Today I am taking a seminar with William Sieber calling Calming an Overactive Brain. He’s an excellent presenter, with a good sense of humor, a down to earth speaker. He’s got a nice balance of enough confidence to be a an excellent speaker without being arrogant. This is quite rare in the seminar business. Even though there’s a lot of stuff I already know I’ve learned a number of  interesting things. The seminar is on the ocean in Pacifica, and outside the windows of the meeting hall I can see the waves crashing on the sand.

One funny thing happened at lunch. I had hurried out to the next door cafe so I could get a table before the crowds hit. Dr. Sieber showed up, looking for a table. I invited him to join me at my table. We started talking and discovered some remarkable commonalities! Both of us had attended Yale for training, me for undergrad, and he for graduate school. He had worked closely with Judith Rodin and Peter Salovey while there. Judy Rodin had been my first psychology professor, and probably the one that influenced me to go into psychology. Peter I had known while teaching at the Bridge, Stanford’s peer counseling center, many years before, and in whose book I have a chapter on Listening Skills. Eventually he went on to teach at Yale, and now is Yale’s president. More surprisingly, Dr. Sieber and I both interned at the Palo Alto Veterans Hospital, in different years! We had a fun lunch reminiscing.

About the seminar. He spoke at length about sleep and it’s impacts on health and wellness. For instance, one study showed that those who got less than 6 hours of sleep were 42% more likely to get diabetes. Or that those with the most disturbed sleep were 97% more likely to die in the next 20 years. Poor sleep makes you more prone to pre-diabetes, anxiety, upsetting emotions, not to mention lowering overall mood and vitality.

Less sleep also affects appetite and eating. Leptin is the hormone that lowers our appetite, and ghrelin is the hormone that increases appetite. With sleep deprivation our leptin goes down, and our ghrelin goes up, and on average we consume 250 calories more on days after a bad night’s sleep. This doesn’t sound like much, but it adds up to about 25 pounds of extra weight per year if you chronically sleep poorly.

I also learned how to assess sleep. The key metric is “sleep efficiency”. This means what percent of the time you are in  bed trying to sleep are you actually asleep. A good number is 90-95%. This is hard.  It means if I am in bed for 8 hours a night, I am asleep 95% of the time, or all except 24 minutes. What is your sleep efficiency? He went over how to use the sleep efficiency log to diagnose sleep problems and guide treatment.

One other interesting factoid for all of you pet lovers. Fifty-three percent of pet owners have disturbed sleep due to their pets.  Maybe we should all shut the door at night and train our pets to sleep somewhere else other than in bed with us.

He discussed how to fix common sleep problems. One such pattern is mine, the delayed sleep cycle. This is the night-owl pattern, going to bed late and getting up late. To fix it, he suggested a short term use of sleep aids to shift the cycle to earlier bedtimes, combined with bright light in the mornings, and no screen light for an hour before bedtime. Cutting back on caffeine use is also helpful.

Others suffer the early phase shift, those who fall asleep too early, and get up too early. To shift these people he recommended getting bright light exposure in the early evening so the melatonin production is suppressed until later in the evening.

In the afternoon we got into discussion of moods and control. Discussing anxiety, he explained the key role that perceived control over situations plays in creating or ameliorating anxiety. Exercise turns out to be a strong treatment for anxiety. Most people with anxiety disorders do not exercise more than once a week, and those who exercise 3 or more times a week rarely have anxiety disorders.

Then he turned to relaxation training for anxiety. He made a great point—that even if you train people to relax deeply, the probability of them continuing to practice even four weeks later is very low. So instead, he shared a 20 second relaxation. Take two deep and slow belly breaths, exhaling for longer than you inhale. While doing that go somewhere relaxing in your mind, and experience that place (ie the beach) in the sensory modality of your preference—seeing, hearing, smelling, or feeling. Make up a two word description of that sensory experience, i.e. “Warm sun”. Repeat that phrase as you take your 2 deep breaths, during the exhale.

He suggested pairing this relaxation practice with something you do multiple times a day. So for instance, pair it with hitting the Send button on your email. That way you will remember to practice a quick relaxation many times a day.

He also shared James Pennebaker’s work, which I often use with patients. Pennebaker found that writing about traumatic events for just 30 minutes a day for 4 days in a row had a fairly profound impact on future emotional and physical health. Interestingly, the initial impact was negative, more anxiety and upset, and more susceptibility to illness. But after three to six months, the pattern reversed, with people showing less upset and anxiety, and better health.

Finally, he shared some info about new findings about heart rate variability (HRV). HRV is the change in the rate of your heartbeat over each beat and each several seconds. It turns out that having MORE HRV is better for both mental and physical health. People with anxiety disorders have less HRV. And it turns out the the three factors that most predict low HRV are: sedentary lifestyle, a cynical and hostile view of life, and anxiety.

Can you retrain your heart rate variability? Yes, with both breathing retraining, and with biofeedback. And it turns out that when you learn to increase your HRV, your anxiety goes down. Very interesting and cool stuff.

The final part of the workshop was about mindfulness. I won’t even try to summarize this part of the seminar, as it was very detailed, and even profound. Perhaps I’ll blog about it later.

Overall, it was a good learning experience, with a wonderful view of the ocean the whole time!

Now I need to go to sleep early….

So you’ve got a teenage child who’s depressed. What do you do? A new study published in the Journal JAMA Internal Medicine suggests what NOT to do. In this study, conducted at Harvard, the authors looked at 162,625 people from ages of 10 to 64 years old who took selective serotonin reuptake inhibitors (SSRIs) for depression. (These are drugs like Paxil, Prozac, Celexa, Zoloft, Lexapro, and Luvox, and their generic equivalents.)

The researchers looked at the relationship between initial starting dose and the rate of deliberate self harm and suicidal behavior. What they found was shocking. They found that for people under the age of 25 starting SSRI medication at a higher than normal dose more than doubled the risk of self harm behavior! This translated into one additional occurrence of self harm behavior for every 136 patients who were treated with high-dose SSRIs. This is a lot of additional suicide attempts!

Interestingly enough, for adults 25 to 64 years old, there was only a very small increase in self harm behavior with high-dose SSRI treatment, and the overall risk of self harm behavior was much lower.

Delving more deeply into the data is interesting. In the under 25-year-old range, 142 patients attempted suicide within one year. The rate was 14.7 suicide events per 1000 person-years for those who started SSRIs at average doses, and 31.5 suicide events per 1000 person-years in those who started at high doses. For the older adults the rates were 2.8 per 1000 person-years for average doses, and 3.2 suicide events per 1000 person-years for those who started at high doses.  These numbers translated into seven more suicide events per 1000 for patients under 25 during the first 90 days of treatment with high dose SSRIs.

Also, disturbingly, the study found that 18% of all patients were started on high initial doses of antidepressants, despite clinical guidelines that specifically recommend starting at a low dose and titrating the dose upwards slowly.  The typical doses of common antidepressants are 20 mg for Prozac, 20 mg for Paxil, 20 mg for Celexa, 50 mg for Zoloft, and 10 mg for Lexapro. For unknown reasons, almost one in five patients were started at higher doses than these.

Why were almost one in five patients started at higher doses than these? I suspect I know the answer, although it wasn’t discussed in the study. Unfortunately, the vast majority of patients are given antidepressants by their internist or family physician or pediatrician. In contrast to psychiatrists, these practitioners do not have the time or bandwidth see patients every week. So they are more likely to start the patient at a higher dose.

Most psychiatrists will start patients at subclinical doses and gradually increase the dosage to avoid side effects. It certainly has been my clinical experience that some general medicine doctors do not do a very good job of administering antidepressants. That is why with most of my patients, especially if they can afford it or have good insurance coverage, I suggest that they seek the advice of a psychopharmacologist or psychiatrist for psychoactive drugs.

The authors of this paper point out that recent research suggests that antidepressant medication is at best only slightly effective in young people and that the dosage of antidepressants are typically unrelated to their effectiveness. Given these two research findings, it certainly does not make any sense to start antidepressant treatment at a higher than average dose.

But I would go one step further. I would argue more strongly that in most cases it does not make sense to use antidepressant medications in young people at all. Why expose a young person to the heightened risk of suicide for what is at best a relatively modest improvement in mood?

This is even more relevant when you consider that there is an alternative treatment that has no side effects and has been shown to be effective. That is cognitive behavioral therapy (CBT) for depression. And there is even a specific cognitive behavioral therapy for suicide prevention that has been developed. (CBT-SP). This is a 12 week focused CBT program that in one study demonstrated that it significantly lowered the probability of a suicide event in suicidal adolescents.

If medication is going to be used, one recommendation that follows from all of this research is that it is good idea for doctors to follow the guideline of “start low and slow” when prescribing antidepressant medications to people under 25. Start at lower than typical doses, and very slowly and gradually increase the doses. While this is happening the patient should be followed on a weekly basis.

If the prescribing doctor is not a psychiatrist who sees the young person weekly, it’s a good idea to pair this with weekly psychotherapy sessions. The weekly psychotherapy session, especially when conducted by someone skilled in cognitive behavioral therapy who evaluates mood and suicidal ideation at every session, can be an essential safety measure when prescribing antidepressants to young people. Or consider treating with CBT alone,  which may very well be just as effective.

Because this is so important, I am listing some references below.

No jokes today, as suicide is not a laughing matter…

References

http://www.clinicalpsychiatrynews.com/home/article/suicide-doubles-in-young-patients-starting-high-dose-ssris/3c57e41e724244599c16d5a565ac8ce3.html

https://archinte.jamanetwork.com/article.aspx?articleid=1863925

http://www.intechopen.com/books/mental-disorders-theoretical-and-empirical-perspectives/cognitive-behavioral-therapy-approach-for-suicidal-thinking-and-behaviors-in-depression

http://www.texassuicideprevention.org/wp-content/uploads/2013/06/AdolescentSuicideAttemptersLatestResearchPromisingInterventionsCharlotteHaleyJenniferHughes.pdf  (CBT-SP)

http://www.nimh.nih.gov/news/science-news/2009/new-approach-to-reducing-suicide-attempts-among-depressed-teens.shtml

http://www.clinicalpsychiatrynews.com/home/article/suicide-doubles-in-young-patients-starting-high-dose-ssris/3c57e41e724244599c16d5a565ac8ce3.html