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Emotional Distress: Counseling or Medication

Emotional distress comes in many forms and shapes. There are no x-rays or blood tests to explain what is going on or what is wrong, just your verbal description. The two most common mental health problems are anxiety and depression. However, there are many other diagnostic conditions such as problems with anger, concentration, mood and/or thinking.

Anxiety and depression come in varying degrees with different causes. They may arise from situational problems.  These may include difficulties in a relationship such as marriage, problems with money, and performance problems in school or work that may produce anxiety, depression or both. Family difficulties are also often a source of distress. It is hard to believe 50% of marriages end in divorce, but only 40% of people get divorced. How is that difference possible? Some people get divorced, two, three or more times, so the statistics on divorce go up but the people are the same.

Some people have anxiety or depression or both and yet nothing in their life experience appears to be the cause. For some, emotional problems are genetic in origin and there is a history of the difficulty in the family. The depression or anxiety seems to hit like lightening, seemingly out of no where. In other cases a trauma is the cause of problems precipitating either or both anxiety and depression. Trauma may come from witnessing a tragedy, violence, or being hit on the head in a car crash. X-Rays, EEG, cat-scan may reveal nothing, yet emotional problems emerge.

So what do you do?  Most people initially go to their primary care doctor. Some primary care doctors will take time to talk to their patients and family. Pediatricians are often better than doctors of internal medicine at talking with their patients and parents. Whether you are depressed or anxious, the most common medicine prescribed will be an antidepressant. Most antidepressants are prescribed by primary care physicians, not psychiatrists. Unfortunately, over-burdened primary care physicians often do not follow up but leave it to their patient to set up another appointment if something is not working. Further, most patients I have seen are not aware of side effects that they may be having from their medication.

The most common prescribed antidepressant last month was Lexapro simply because it was the newest. Next month it may not be. Lexapro has three virtues. It helps both anxiety and depression. It works within five days, not the eight weeks it takes many of the older antidepressants, and one tablet a day works as well as two or three. It has only two frequent draw backs: weight gain and in both men and women, interference with sexual performance and interest.

Many physicians are reluctant to prescribe anti-anxiety pills. They worry it is addicting and I have seen patients addicted to Xanax. Unfortunately, Xanax lasts only three hours. As it leaves your system you may have a resurgence of anxiety as a result of withdrawal and take another one immediately. If you are afraid of flying that is no problem. You take one pill, perhaps Xanax, ½ hour before flight time. The plane takes off you are fine. The pill wears off but you know you are landing in one hour and there is no further anxiety. Another common anxiety medication is Klonopin. It starts in thirty minutes and lasts eight hours. It wears off slowly and you don’t have rebound anxiety and so don’t need another one immediately.  Knowing you have the pill is itself reassuring so you may not even bother to take it. Every antidepressant has to be taken every day and the doctor will tell you to stay on it for a year. I have seen patients on Paxil or Zoloft who have been on the medication for four years, gained forty pounds, but thought it was just a part of the depression. Prozac, Paxil, Zoloft have remission rates of 35%. But 70% of people have some degree of relief though not a total loss of symptoms. So it is easy to misinterpret what is going on.

You may choose to see a psychiatrist to help you with your emotional concerns. Most psychiatrists will see you for 45 minutes the first time and tell you to come back in two weeks. They will then see you for twenty minutes to follow up. The third time they may see you for 15 minutes. Follow-up visits allow the doctor to assess symptoms and side effects and titrate your medicine.  Picking an antidepressant is not obvious. They vary person to person both in effectiveness and side effects and only trial and error provides a clue.  Fifty percent of people who start an anti-depressant will switch to another.

You may have gone to see a mental health professional. Psychologists will have Dr. in front of their name. Social workers, nurses or professional counselors will be called Mr. or Ms. Some mental health professionals may discuss medication with you and others may think it is not their responsibility. You may have started with a counselor and the presenting problem lessened quickly. The average length of psychotherapy, to use a more technical term, is six sessions. Many individuals are helped to better cope through a long-term involvement. Many people see a therapist as well as take medication and all evidence is that for depression the combination of the two is more effective than either one alone.For some people an antidepressant or tranquillizer is sufficient. They may have not had that much to say and they thought the therapist was boring. In other cases they might have liked the therapist and felt it just wasn’t necessary to return. For some the experience with psychotherapy is profound.

Does therapy help? It depends who you ask. There are many different theoretical orientations to psychotherapy. Some tell you that you should have “evidence-based-therapy”. They maintain cognitive-behavioral therapy, a type of evidence-based therapy, has been shown to be the best. Cognitive therapy was radical in that it disposed of psychoanalytic therapy which involved exploring your childhood. Cognitive therapists maintain that you need to identify the ideas that are generating the distress and change your thinking. I am sure that works as well as anything else. Whatever the orientation, if your therapist has common sense and is responsive and warm, then you will feel helped. That is the only real evidence present in research as to what works. Talk helps when you are in distress and some conversations will be more constructive than others; especially the chance to discuss current problems, feelings and life experiences with a competent mental health professional.  There are individuals who despite taking multiple psychiatric medications participate in long term psychotherapy yet struggle with intermittent emotional difficulty. Without medication and psychotherapy their lives would be more profoundly compromised. The science is not yet complete and we do not all have the same emotional barometers in a challenging world.

Dr. Jeremy Kisch is a licensed clinical psychologist and has diplomate status with the Amerian Board of Professional Psychology.

About the author: Charlie

1 Comment.Leave a comment»

  1. by Jonathan Hillman
    July 25, 2011
    11:26 am

    With extreme emotional distress that accompanies dealing with PTSD, would mood stabilizers such as for Bi-Polar be appropriate? I am seeing a female friend of mine go from rational to paranoid anxiety within hours. She has been diagnosed with PTSD due to childhood trama and abusive (ex) husband.

    Is there a bi-polar that is not manic/depressive, but more of calm/rational to paranoid/distressed?

    Thanks for your help.

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Dream a Little Dream

It is common practice in psychoanalysis for the patient to report the content of dreams as part of treatment. Sigmund Freud believed that dreams were a window into the unconscious mind. Therefor, by understanding and interpreting the content of dreams the patient would reveal thoughts and images that would possibly clarify current or past experiences, feelings and actions.

Dream analysis, once in vogue for both patients and doctors, has given way to what is termed cognitive-behavioral therapy, or CBT. A CBT approach to treatment might view dream content as random neural activity. However, if one considers the complexity of our dreams and the fact that there are repetitive themes and images,frankly, that hardly seems “random.” CBT examines cognition,our manner of thinking about issues. It also evaluates and treats behavioral concerns, like nail biting, smoking or other compulsive behaviors. Dream analysis is more within the realm of psychotherapeutic approaches that incorporate a deeper analysis of the complex developmental issues, or psychodynamics, which are the causal basis of personality and cognitive concerns.

The dream is divided into two components. The first level of analysis is the manifest content ( which is the actual experience of the dream). “I was driving my car down a mountain road and I had no brakes!” The second level is the latent content of the dream,( what the dream really means). In this case it might be a feeling of loss of control or an inability to control something. We dream in symbols. If we identify certain people in the dream that image could be a “stand-in” for someone else. Dreaming about snow could represent depression or a desire to “cover up” something or jus a pleasant memory of childhood.. So, how do we know the “correct” interpretation? The symbolic items in the dream can be better understood if interpreted within the context of that particular person. Freud suggested that we dream in symbols to “protect” our sleep. If we see through the symbolic process it can cause anxiety and would awaken us, possibly identified as a nightmare.

Dreams can be viewed as the dreamer’s attempt to “work through” or resolve some conflict that they are experiencing in reality. Another aspect of the dream is “wish fulfillment.” Within a dream one can see themselves mastering a task or problem. Apparently, we experience dreaming several times on most nights, even if we do not recall the experience. However, some medications can interfere with neurological function and inhibit dreaming. Interestingly, we seem to have a need to dream.In a classic study people were awakened as they began to dream.It was easy to identify the dream state since dreams are accompanied by rapid eye movements that can be identified and recorded. This procedure occurred for several days. Finally when the subjects were allowed to sleep, their number and frequency of dreams increased. Deprived of dreams, people began to dream more; possibly to make up for the deficit. Dream deprivation increases dreaming when subjects are permitted to have normal sleep.

Finally, dreaming is the only time that we can really “time travel.” One can be a young child in the dream and instantly become a teen or young adult. While the meanings in dreams may be elusive, they can provide meaningful thoughts and ideas that can help the patient to overcome the challenges and the demands of life that have brought them to treatment.

The Columbia Counseling Center offers an eclectic and integrated approach to treatment. The doctors on our staff are trained in the use of multiple techniques and strategies to relieve anxiety, improve mood and effectively modify coping strategies.

You can call 410 992 1949 for the first available appointment.

The Serotonin – Depression Connection

Recent articles( such as this piece from psychcentral.com have posited the notion that serotonin is not a significant component of the depressive process .Further, that drug companies, having developed serotonin enhancing medicines, began an advertising campaign to “convince” the public that serotonin was the “cure” for depression.The idea that drug companies would conspire to mislead the public is quite questionable ( although I do enjoy a good conspiracy theory). One of the problems is that we cannot measure serotonin in the brain directly. Further, if we manipulate serotonin with an SSRI (selective serotonin re-uptake inhibitor), this also disturbs the balance of norepinephrine and dopamine- two of the major neurotransmitters. Now, it is really more complicated than this. There are many sub-types of each of these substances so it is not a simple matter of manipulating one of these chemicals.There are also many sub-types of receptor sites in the brain. The more we learn about the chemistry and structure of the brain, the more complicated it becomes.

The data from numerous studies indicates that psychotropic medications may only work about 50% of the time. In addition, psychiatrists may have to try a number of different medications in order to gain a positive effect. Of course, patient compliance is always a problem. It is not a good idea to wash your Prozac down with scotch whiskey – but I have had a number of patients who have done just that!

Michael Greger points out that diet ( whole food plant based nutrition) and exercise may be just as effective as some anti-depressants. While there is merit to this assertion, trying to get a depressed patient to exercise and eat properly is quite challenging – to say the least! It is my impression that “comfort foods” carbohydrates, potatoes, bread, mac and cheese act as “comfort foods” because they do, in fact, raise serotonin levels along with a number of other “calming” chemicals (such as tryptophan) that do cross the blood-brain barrier. Unfortunately, a bag of potato chips only increases serotonin levels for a couple of hours.

It does appear that cortisol is a precipitating chemical in the depressive process and influences a decrease in certain neurotransmitters. Indeed, being in a stressful situation for two to six weeks can trigger a depressive episode. This is chemistry, not “psychological” weakness. The notion that neurotransmitters are the causal factors in the depressive process is strengthened by the apparent genetic relationships within families. If we examine the family of origin of a depressed patient we will find both genetic and psychogenic factors that contribute to the depressive process. Further, it is interesting to note that if a particular antidepressant medication is effective for a “blood relative” ( biological parent or sibling) there is a high probability that the medicine will be effective for the patient.

The “holy grail” of treatment for depression will not be easily discerned. Light therapy can be effective. Likewise, trans-cranial stimulation shows promise. Various approaches in psychotherapy can be quite effective. However, anti-depressant medicines will continue to be a major component of treatment.Columbia Counseling Center’s integrated treatment protocol carefully evaluates the multiple causal factors in depression and provides both pharmacological and psychotherapeutic approaches for maximum effective treatment of depression.
Call 410 992 9149 for the next available appointment.

The Most Powerful Treatment for Depression

The title of this 2008 study says it all: “Faster remission of chronic depression with combined psychotherapy and medication than with each therapy alone”. The study of over 650 patients with depression compared medication treatment alone to medication treatment plus psychotherapy. The results were clear: patients on medication and therapy recovered from chronic (meaning repeated episodes of) depression faster than patients on either treatment alone.

Many studies over the years have identified both cognitive-behavioral therapy and interpersonal psychotherapy as being just as effective as medication in reducing symptoms of moderate depression. Other studies have shown that the improvements gained in therapy alone can last longer than the improvements gained from medication alone.

In my opinion, it’s the minority of cases that improve on just medication. The job of antidepressant medicine is to reduce the most immediate and troubling symptoms that interfere with your ability to function at home, at work, and socially: low energy, loss of interests, poor concentration, crying spells, hopelessness, and suicidal thoughts. The job of therapy is to identify the life issues that have led to depression and make changes in how you deal with those issues so they stop depressing you.

Therefore, we have two powerful and effective tools to treat depression. Use them together and you are likely to get the fastest and most enduring relief from your symptoms. At Columbia Counseling Center, the psychiatrists and therapists are all under one roof and we work with each other to ensure that your treatment is coordinated and efficient.

Written by: Dennis Glick, M.D. Board Certified Psychiatrist at The Columbia Counseling Center

Generalized Anxiety Disorder (GAD) is a common and recurring condition. Typical symptoms include near-daily worry, anxiety, tension, feeling on edge, irritability, and sleep disturbance. Features of panic attacks and/or social anxiety may also be present. Your primary care doctor may have already ruled out medical causes such as thyroid, electrolyte, cardiac, or nutritional abnormalities.

Cognitive-behavioral therapy (CBT) is a very effective form of treatment, typically requiring 6 to 12 weekly sessions that may include the use of workbooks and homework. The SSRI and SNRI antidepressant medications (Prozac, Paxil, Zoloft, Celexa, Lexapro, Effexor, Cymbalta, and Pristiq) are highly effective and should be continued for a period of 6 to 12 months following symptom reduction. Benzodiazepines such as Xanax, Ativan, and Klonopin are best used on a temporary basis due to the risks of addiction, memory impairment, physical incoordination, and potentially endangering combinations with alcohol and pain killers. Other medicines such as Buspar, Vistaril, Gabapentin, and Seroquel are occasionally used but are not specifically approved for treatment of GAD.

Many patients will benefit from the combination of CBT and medication. The Columbia Counseling Center is uniquely able to provide coordinated treatment as our staff includes both psychiatrists and psychologists specifically trained to diagnose and treat GAD and other anxiety and mood disorders. Your clinicians work together to ensure you are receiving the most effective treatments for your condition.

Conflict Resolution vs Separation

By Dr. Susan Minsky

Couples often believe the easiest solution to frequent arguments that appear unresolvable is to threaten separation and divorce. Divorce is the last choice to resolve what initially may appear as unreconcilable differences. Marriages require the willingness on both parties to rebalance needs, expectations, hopes, on a consistent basis at various stress points and change which occur throughout a long term relationship. Clear, direct communication, hearing each other in an accurate manner is necessary to produce effective changes for both parties. Couples often require refresher courses and new skills to promote a growth oriented exchange during stressful times, in particular.

Come join the Columbia Counseling Center team who provide an integrated approach to promoting and strengthening the bonds between partners in relationships. Individual and couples therapy are offered simultaneously to promote more rapid and productive identification of issues that require resolution to enhance the lost intimacy and positive communication and interaction between partners.