Question:

Dr. Raj,

A close friend of mine has been seeing the same psychologist every other week for over 4 years.  This friend is college educated and intelligent. He does not abuse drugs or alcohol.  He has a problem with anger management, often reacting out of proportion to events.  His reaction can range from melancholy to temper tantrums that include shouting insults.  He can go up to six weeks without having what I call a “melt down”.  How do I know this?  Because I have actually tracked his mood swings on a calendar over 12 months.  The melt downs can last 2 days, 1 week or he may have one very few days for 2 weeks.  Then, he will recover and appear happy and content for 2 to 6 weeks.  I know this is probably bipolar disorder.  Or maybe it is post traumatic stress, since he grew up with domestic violence between his parents.  The point is…my friend does not appear to be “getting better” in light of all the therapy he has gotten.  I can see no changes in his behavior!over the 3 1/2 months I have known him.  I know my friend speaks openly to his doctor and is honest to a fault.  He does realize he has problems with self esteem, depression, mood swings and handling his anger.  I know not every doctor is the same caliber, too.  What type of therapy should my friend be getting? Talk therapy? Cognitive behavior therapy?  What strategies can you suggest?

Answer:

Dear iNTj,

It does seem that you have a lot of insight into your friends problems and that you genuinely care about his well being.  You mentioned that he see’s a therapist every two weeks, how often is he seeing his psychiatrist?  What is the working diagnoses that his psychiatrist is treating?  Is he on any psychiatric medications and have any helped?

We now know that the most effective treatment will address the Biological-Psychological-Social domains individually.  What this means is that once, the presenting problem is understood, a health care practitioner should address each of these domains to get the most effective treatment response. The Biological domain usually involves medication management, the Psychological involves getting into psychotherapy and the Social domain involves looking at and understanding social factors that are contributing to the persons presenting complaint(s) i.e. family dynamics.

Remember that it takes time to correctly diagnoses and understand the dynamics of human behavior.  I know this can be frustrating for many individuals but the number of diagnostic tests in psychiatry are limited.  Our most useful tool is obtaining a through history from our patients and their families in order to come up with a working diagnoses and over time it is verified or adjusted.  Many times I hear from people, “My Psychiatrist only spent 2 minutes with me, how could he have correctly diagnosed me?”  My response to them is usually to find someone else who will spend the time obtaining the proper history to properly formulate a treatment plan.

As far as therapy goes, I think going every other week is not as effective as going every week.  In my opinion, much happens in two weeks and the session usually becomes about “catching up” versus working on insight.  Their are also many different types of therapy that range from working on supporting the individual to working on insight around internal conflicts.  Their are also therapies that focus on one’s thoughts (Cognitive Behavioral Therapy) as well as being more mindful about one’s behaviors (Dialectic Behavioral Therapy).  Which approach is best is dependent on the individual who is entering it.  As a general rule of thumb those in treatemnt do better than those who are not in treatment.

Thus, I commend your efforts in understanding your friend’s current challenges but remember that he must make the commitment to find the appropriate answers.  You can not do his work for him but only support him along the journey.  He’s lucky to have you in his life.

Question:

I hear about people who say they take a “xanax” pill when they fly so they fall to sleep. What is this and can anyone get it?

Answer:

Xanax is a medication that belongs to the class known as benzodiazepines.  The benzodiazepines are considered to be minor tranquilizers with varying hypnotic, sedative, anxiolytic, anticonvulsant, muscle relaxant and amnesic properties.

I think great caution should be taken when using a medication from this class of drugs because of it’s addictive potential.  However, in an individual with minimal abuse potential short term use can be appropriate.  In some situations, such as in your question, some individuals can become very anxious when they fly and require a minor tranquilizer to be able to tolerate the flight.

One aspect that I find very concerning is inappropriate use of this class of medications.  Many persons will go to their physician due to situational anxiety (an anxiety related to a particular stressor in ones life) and want something to relieve their symptoms.  What often happens is the person will find effective symptom relief and begin to psychologically become dependent on the medication.  I have seen many cases in which “pill popping” becomes a coping strategy.  Remember, I said that this class of medications is addictive.  Thus, what would have been a good short term strategy has turned into something that the person is now dependent.

What I suggest is asking your physician about addictive potential for any medications that are prescribed to you (Benzodiazepines are only available by prescription from your physician).  Make sure you ask the questions up front so that you don’t find yourself with a bigger problem down the road.

Question:

Dear Dr. Raj, I am currently struggling with my mental health. Following many years of taking anti-depressants and anti-anxiety meds I decided it was time to detox, and in Jan. discontinued taking Effexor XR and buspar.  I weaned myself with physician guidance, but not necessarily approval.  I’m sure you are aware that discontinuing the Effexor w/o the proper guidelines is awful.  It was difficult enough…since that time I have undergone, treatment by an accupuncturist for my depression.  However I feel like as hard as I try to be “happy” I continually struggle.  I’ve listened to Oprah’s “The Secret”, recently read The Four Agreements, constantly tell myself, I am enough, I have enough, I do enough.

My question and concern are if I do have altered brain chemistry can I correct it through will power, and positive thinking? How do I avoid my dark side?  Should I go back on meds?  If so what’s out there that doesn’t cause sleep disturbances or sexual side effects?  Since currently I feel like my system is clean are there herbs or supplements that you might suggest?  Thank you so much for your time and consideration.

Answer:

Dear Cara,

It seems that you are committed to overcoming your depression which I commend you on; sometimes making the commitment to getting treatment can be one of the hardest steps.

First, it will be important for you to identify and understand what gives rise to your “unhappiness”; it is through this understanding and insight that you will eventually find “Happiness”.  The first question that comes to mind is, what is happiness to you?  It will be important to know what this word exactly means to you, as we all have different definitions. It is important to note that one can be satisfied and “happy” with certain aspects of one’s life while simultaneously discontent or “unhappy” in other areas.  It does not have to be mutually exclusive.

With regards to depression, it has both a biological and a psychological basis and can be a part of a variety of clinical presentations; again, the key is to have a good understanding to what’s giving rise to your symptoms. Medications may be necessary if your symptoms interrupt your normal function; I would suggest you to discuss this with your psychiatrist; if you feel that your psychiatrist does not spend an ample amount of time with you, find another one who will; you deserve to have one that is interested in listening to you and one that is genuinely committed to finding the right diagnosis and treatment.

Remember, prescription medications must be taken under the care of a physician and should be monitored closely for any side effects as well as efficacy; as a category, the Selective Serotonin Reuptake Inhibitors (SSRI’s) have a high association of sexual side effects; this doesn’t mean that they will all cause this as each individual is different; one SSRI may cause sexual side effects in one person and not in the next; there are anti-depressant medications that do not have a high association of sexual side effects; one such anti-depressant is Wellbutrin; again, the decision to be on Wellbutrin should be made with a physician and be taken under his or her guidance.

As far as herbal preparations for mild depression, please read the answer I posted for a question on homeopathic medications for mild depression (on May 27th; you can click on medication? under categories).

Your question about thoughts changing our brain function is an area in which there as been a great deal of interest recently; research has shown that talk therapy does change brain function and hence structure. I find it fascinating that after every conversation we have with someone, our brain has changed in some way; this then means that after every session in therapy, our brain has changed; now keep in mind that talk therapy is more time consuming and requires a great deal of effort but I believe that it gets to the deeper causal layers (psychologically speaking) and is tremendously important to include in a treatment plan.

Thus, I highly recommend finding a good psychiatrist and therapist who you can work with in understanding the biological and psychological underpinnings of your “unhappiness”; this will be fruitful in the long run.  Remember, you are enough, you always have been and you always will be. Healing will take time and will happen as long as you are committed and stay in treatment; if your need support, please send in any questions that I can help you with.

Question:

Kat writes: My 13 y/o niece was just started on Prozac. She seems to have some anxiety and maybe OCD.  What are your thoughts on young teenagers taking antidepressants?

Answer:

Dear Kat,   Prozac is approved for use in pediatric patients with major depressive disorder (MDD) and obsessive compulsive disorder (OCD).  Selective serotonin reuptake inhibitors (SSRIs) can restore the balance of certain brain chemicals that regulate mood. When these brain chemicals are in proper balance, the symptoms MDD and OCD may be relieved.   Antidepressants are used to relieve the obsessive thoughts and subsequent compulsive behaviors in those who have OCD. By increasing the level of serotonin in the brain, antidepressants help to regulate the communication between different parts of the brain. One thing to keep in mind is that there is the following black box warning with Prozac:    Suicidality in Children and Adolescents— Antidepressants increased the risk of suicidal thinking and behavior (suicidality) in short-term studies in children and adolescents with major depressive disorder (MDD) and other psychiatric disorders. Anyone considering the use of Prozac or any other antidepressant in a child or adolescent must balance this risk with the clinical need. With that said, In one 13-week clinical trial in pediatric patients (N=103). Prozac produced a statistically significantly greater mean change from baseline to endpoint than did placebo as measured by the Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS).   I suggest that you and your niece work closely with a child psychiatrist in setting up an appropriate treatment plan that may include some therapeutic element.