Today women have more opportunities than at any prior time but still are expected to fill an almost comically large number of roles”, writes psychiatrist Anna Fels, author of the book "Necessary Dreams: ambition in women’s changing lives". 

Fels notes that:

• Women view ambition as selfishness, self-aggrandizement, egotism, or manipulation of others for one’s own ends  • Women who deplored ambition in reference to their own lives freely admitted to admiring it in men  • Today’s women of accomplishment in the public eye often repeat the same self-abnegating stance of women of earlier times  • Women’s source of identity and affirmation is heavily drawn from private relationships rather than talent, skill, or hard work  • Lack of a romantic heterosexual relationship de-sexes a woman since the existence and quality of her attachments define her femininity  • Women speak less than their male counterparts in conversations, classes, business gatherings, or conferences when men are present  • Decades of studies suggest that women’s deferential behavior in regards to recognition is not “natural” but is socially conditioned.

While Fels’ does not in any way diminish the role of motherhood, given the points she makes, should we celebrate ‘Women’s Day’ to expand on our appreciation and affirmation of women for the many roles they fulfill, not only the role of mother?  I’d like to hear your thoughts on the matter.

I am a bit naïve. Yes, I am a psychiatrist, a Clinical Professor of Psychiatry, and the founder of the National Center for Whole Psychiatry. Given my experience, I should, you would think, know better. Yet I was in practice for probably 20 or more years before I realized that some times my patients lie to me about how they are doing, and whether they are following our jointly agreed upon recommendations. I am prompted to write about this, because a week ago I had an experience where a patient told me that she was lying to her other doctor.

Now, using the word ‘lying’ seems a bit strong, but I use it to get the point across. In fact, it is more like hiding the truth, not wanting to disappoint the doctor, avoiding shame, judgment, criticism, or the doctor’s expected anger.  Any reason that might inspire a child or adolescent to lie to their parent can probably be operative here because, understandably, being a patient is a vulnerable state for many.

My patient’s name is Joan.  Joan is a 58-year old married accountant who has, for the past 15 months, been having odd symptoms—feeling like the walls are closing in on her, feeling unsteady on her feet all the time, as if she just got off a boat, seeing faces “melting”. A thorough medical and psychiatric work has revealed some underlying hormonal, nutritional, and immunological dysfunctions, which are contributing to the symptoms.  As part of the medical work-up I referred her to a neurologist (Dr. Blandt), who prescribed a medication for Joan.  When I next met with Joan, I asked her if the medication worked and discovered her lie.  Our conversation went like this:

“Joan, what did Dr. Blandt say when you saw her last week?”

“ Well not that much, she had given me the Scopolamine, but I didn’t like it.”

“Did you tell her that?”

“Yes.”

“What did Dr. Blandt say?”

“She said I should try different drug.”

“How long did you take the Scopolamine for?”

“Not very long, I took it once or twice.”

“Did you tell Dr. Blandt that?”

“No.”

“Why not?”

“I didn’t want her to be upset with me.  I don’t want more drugs.”

“Joan, you have a right to not take a medicine, but you need to tell Dr. Blandt the whole truth and your concerns.  Dr. Blandt may well conclude that the Scopolamine didn’t help you, and so it’s not helpful for the type of symptoms you have and other patients like you have.  She will be less likely to prescribe it for other patients, based on the experience she believes you had.  Dr. Blandt’s ability to help people is somewhat diminished by such erroneous information.  When this happens enough a doctor’s ability to help their patients is compromised.  You need to be more direct.”

I explained to Joan how her inaccurate reporting to Dr. Blandt could easily effect her ability to get relief through proper diagnosis and treatment her problem.  A patient’s reaction to medication tells the physician something about the patient’s biology and clarifies the diagnosis.  

Inaccurate reporting leads to inaccurate treatment not just for you, but for others with similar conditions or symptoms. If you fear telling your doctor the whole truth when you are face to face, consider writing her a note before you see her telling the doctor ALL the facts of your situation – whatever they are.  You can certainly tell the doctor in the note that you have some fear or concern about telling him the whole truth. An understanding physician will appreciate your concerns and your honesty.

Antidepressants have a role in clinical practice but they are grossly over-utilized.  As a certified psychopharmacologist, practitioner of Whole Psychiatry (Functional Medicine and traditional psychiatry) and Clinical Professor of Psychiatry at Georgetown School of Medicine, I prescribe antidepressants, but  only after a thorough multi-faceted  evaluation of the patient.

We rely on drugs as a solution rather than deal with root causes of illness, and the pills generally are not as effective as we would be led to believe by the pharmaceutical companies (publically acknowledged as distorted in peer reviewed journals such as New England Journal of Medicine, Eric Turner, 2008). Nor are these drugs without financial costs and side effects.  I suggest that the solution is to develop better assessments of the metabolic factors leading to the syndrome of depression. The psycho-social-spiritual risk factors are reasonably well spelled out, and we have excellent targeted psychotherapeutic techniques available now.

The fact that the head and brain are connected to the body by something called the neck may be relevant.  In fact, there is a great deal of basic science and a good deal of clinical science indicating the very significant role played in subjective and objective mental health by at least six metabolic systems: nutrition, gastrointestinal physiology, immune/inflammatory/infectious processes, methylation processes, oxidative stress, and all hormonal systems.  This list excludes other factors such as circulatory problems, physical-structural problems, age, gender, and lifestyle factors.

Assessing these metabolic systems, and their mediators in a careful comprehensive manner, and re-establishing multi-system reserves not only helps depression with less medication, but at the same time reduces the side effect burden imposed by medication, and reduces the incidence of known co-morbidities such as diabetes, cardiovascular disease, osteoporosis, sexual dysfunction.  Psychopharmacology is only one small tool in our toolbox.  As Confucius once said, “To do good work, one must first have good tools.”  Anti-depressants are somewhat useful tools; they are just not the best or the only ones.  We have other tools at our disposal.  Why not use them?

Vitamin B12 deficiency and its detection have been in the news lately from the New York Times and The Dr. Oz Show.

B12 Deficiency Effects Widespread
The effects of vitamin B12 deficiency are widespread.  Vitamin B12 has a major influence on the function of neurons and also on the ability of the bone marrow to make red blood cells.

B12 Causes Psychiatric Symptoms
B12 deficiency can cause almost any psychiatric symptom—from anxiety, and panic to depression and hallucinations.  This is because B12 deficiencies trigger symptoms in the nervous system and red blood cells.

Diagnosing B12 Deficiency
While it is not possible to go into the details of the diagnosis and how to interpret these tests, it is important to understand that assessing vitamin B status involves understanding A DYNAMIC (moving & interacting changes in these parameters) not static assessment of the metabolic systems involved.  And because it is a dynamic system, a static measurement (e.g., B12 level) does not suffice.

As an example of the interactive dynamics, a low iron level makes red blood cells smaller; and, low vitamin B12 makes red blood cells larger. Thus, normal red blood cell size can present a false normal because low iron and low b12 counterbalance each other. If one assesses the size of the red blood cells alone once would miss this fact. However if one also looks at the iron and homocysteine, one would not miss it.  Similarly, a homocysteine level is the result of B12, folate, and mercury levels and therefore a normal homocysteine does not necessarily mean an absence of of B12 or folic acid deficiency.  In turn, all must be assessed to understand the homocysteine.

Early Detection Is Critical
It is critical that a vitamin B12 deficiency be detected as early as possible in order to prevent permanent damage to the nervous system.

The Best Way to Assess for B12 Deficiency
Unfortunately a simple B12 blood level is NOT a sensitive test for detection of B12 deficiency.  A variety of studies have shown that a simple B12 blood level misses vitamin B12 deficiency over 80% of time.  There is no one perfect test for the diagnosis of vitamin B12 deficiency.  Therefore, to determine a vitamin B12 deficiency a thorough assessment involves the following tests and other factors:

Tests

1.    Homocysteine level

2.    Red blood cell count

3.    MCV which (mean corpuscular volume)

4.    Iron & ferritin

5.   MTHFR - a genetic test

Other Factors

1.         One’s age and dietary history (the elderly and vegetarians most often have B 12 deficiencies)

2.        Medications used (people on Glucophage/Metformin, and proton pump inhibitors are often deficient)  

3.        Findings from a physical examination

(Methylmalonic acid testing is commonly thought to be useful, however a little known fact is that less than 20% of the variation in the blood or urine level is accounted for by B12 metabolism, so this test is not useful.)

If you think you have a B12 deficiency, get yourself assessed and treated right away.  

I was wandering around the internet last night, looking for scholarly articles on something called ‘methylation pathways’, when I came across a very disturbing article on the potentially quite toxic interaction between nitrous oxide (NO2) and certain states of B12 deficiency. Before getting into the nitty gritty, bottom line, let me give you some background.

Nitrous Oxide (NO2)-commonly referred to as ‘laughing gas’ was used for years in the practice of dentistry.  It is used currently as part of general anesthesia, and recently has been gaining popularity as a ‘recreational drug’.  An article in Popular Science in the late 1940’s demonstrates how easy it is to make NO2 with an at ‘home laboratory’.

The methylation pathway I refer to above is a fundamental biochemical pathway occurring billions of times per second in the human body.  It’s like the dollar bill of our economy-it keeps things moving.  Methylation plays a key role in the building up and breaking down of molecules.  For example, methylation helps make and break down neurotransmitters (serotonin, dopamine, norepinephrine), estrogens, and histamine (think allergy); methylation helps turn certain genes on and others off, and methylation is involved in protecting nerve cells, making blood cells, strengthening collagen (fewer wrinkles), etc.

The methylation pathways work well when we get enough B12 in our diet (vegans are very vulnerable to B12 deficiencies), enough folic acid (spinach, kale, Swiss chard), and B6.  Additionally selenium (nuts), vitamin B2 (riboflavin), magnesium (Brazil nuts and almonds), and some amino acids (methionine, cysteine, serine, glycine, taurine) are needed to keep the methylation cycle running smoothly.

In addition to these nutrients, we must have genes that can make the enzymes that ‘grease the wheels’ of these pathways.  These enzymes allow things to flow smoothly, and allow methylation to meet the demands of the body and environment.  There are several genes involved in the methylation pathways, and abnormalities of one or more of these genes are quite common (e.g., MTHFR C677T).  These abnormalities slow down the methylation pathways, and connected detoxification and free-radical pathways.

So here is the punch line:

Laughing gas (N02)―nitrous oxide―stops the methylation pathway in its tracks by deactivating B12, and stopping the activity of a certain enzyme for days to weeks. When someone is already deficient in B12/folate (e.g., due to diet, medications such as proton pump inhibitors or Metformin),  or has genes that are not functioning properly, the B12 deficiency is suddenly worsened, and weeks later neurological and psychiatric problems develop. They can be subtle (e.g., trouble with balance) or they can be severe (cognitive problems); any psychiatric syndrome (e.g., panic, depression) can develop.  It is unlikely that anyone will make a correlation of cause and effect between the NO2 and the symptoms, because of the delayed toxicity, and the fact that not every one is effected. Symptoms can be subtle.

NO2 is a very serious danger to your health. The risk is unappreciated by college students who are using NO2 as a recreational drug, and the risk needs to be assessed before use of anesthesia (by testing homocysteine and methionine in the blood, looking for risk factors for B12 deficiency such as a vegan diet or the use of certain medications, as well as the genetic MTHFR test) when possible.  Please raise people awareness of this risk by passing this information along.

Your Biologic Clock

Your Biologic Clock keeps our body rhythms and sleep –wake cycles in synch with the light-day cycle of the earth. It is located in the suprachiasmatic nucleus (SCN) in the hormone control center of the brain, the hypothalamus.  When light enters the eye, it activates this part of the brain and reduces production of the sleep hormone (melatonin) produced in the pineal gland of the brain.  The light also acts to the release of a variety of other hormones and affects body temperature. 

Interestingly, we are programmed to cycle every 24.2 hours―but our exposure to light on a regular basis keeps us linked closely to the earth’s rhythms.  Four neurotransmitters (dopamine, norepinephrine, glutamate, and GABA) have roles in controlling the biological clock.  Importantly, melatonin cannot be produced if thyroid hormone levels are not adequate.  So, if you have sleeping problems, in addition to noting the amount of light you get each day, have your thyroid hormone levels checked.
 
Generally, the more bright light one gets during the day (especially earlier in the day), the more likely one is to make more melatonin (sleep hormone) during the night, and the less sensitive one is to minor light exposure in the evening or night time.

Light Therapy

Light therapy uses specialized artificial light to treat mood disorders, shift one’s biological clock, or synchronize one’s sleep-wake cycle with the day/light cycle.  
It may also be useful in normalizing sleep and behavior in people with dementia, although more research is needed.

The artificial light consists of either a light box which emits up to 10,000 lux  of light, much brighter than a customary incandescent lamp, or a lower intensity of specific wavelengths of light from the blue (470 nm ) to the green (525 nm) areas of the visible spectrum.

Application and Timing of Light Therapy

Synchronizing and/or Shifting Sleep/Wake Cycle
If one wants to delay sleep onset, it is best to give light therapy in the hours before bedtime, when core body temperature is beginning to go down.  On the other hand if one wants to move sleep earlier in the day/night cycle, it is best to administer light therapy in the second half of the night.
 
For Mood Disorders
Seasonal Affective Disorder [SAD] is strictly defined as present when a person has a mood disorder which occurs during a particular time/season of the year, and then clears completely at other times of the year. Current criteria require that this occur for 2 years, consecutively.  In practice, most people have a seasonal component to their depression, but do not fit strict criteria.  Nevertheless, people with a seasonal component do benefit from light therapy.  Light therapy is not a substitute for other treatments in non-seasonal depression, and is probably only an adjunct in those who only have a seasonal component to their mood disorder.  People with a tendency to oversleep and overeat are more likely to respond to light therapy than others.

If one is treating a mood disorder, light therapy is best given for duration of 30 minutes for every hour one sleeps beyond 6 hours.  So for example, if one sleeps 8 hours, they would require one hour of light therapy given one hour before they would normally wake.  Since this is unlikely to be done by people who already feel the need for more sleep, it is best to use a dawn simulator light.
 
Light therapy for mood disorders should usually begin about one week before depressive symptoms tend to begin (based on your past experience), or as soon as they begin.  It should be tapered as the day lengthens.  The transition dates are around the spring and fall equinox (March 20/21 and September 22/23 each year.)

For Dementia
It is possible that bright light between 7-9 PM may help people with dementia sleep better, have fewer nighttime awakenings, reduce the decrease cognitive functioning and orientation (called ‘sun-downing’) which occurs at night.

What Kind of Light Is Best?

Early studies used 10,000 lux (a measure of light intensity) broad spectrum light, kept one to two feet from the eyes. However, newer data indicates that low lux light (500 lux―which is about 1/10 as strong as the light at dawn) may be just as effective.  Short wavelength light (blue part of the light spectrum) seems to be the most active part of the light spectrum, in terms of shifting sleep/wake cycles.  Nevertheless most lights available for SAD are 5,000 - 10,000 lux.

Placement of Light [Dawn Simulator]

A dawn simulator is placed above the head (on a headboard), with the light facing the pillow.  It is set to go on very gradually–starting about three hours before the normal waking time, and peaking in intensity at the normal waking time.  It then shuts off within 10-15 minutes.  The advantage of the dawn simulator is that the treatment is administered while you are asleep, and simulates conditions on a normal spring day.

Are There Side Effects of Light Therapy?

 
Light therapy is similar to drug therapy in that the response depends on dose, timing of dose, and duration of use.  There can be mild side effects as well (agitation, insomnia, and rarely nausea or headache).  If side effects do occur it is usually best to reduce the amount of light therapy, after discussion with your doctor.  One need not look directly into the light to obtain benefits.  If you have an eye condition, you should consult your ophthalmologist before using light therapy.

Yes!  Over the last 20 years, ample evidence has accumulated to prove that inflammation in the body causes changes in the brain that lead to depression, anxiety, sleep problems, and memory problems. Inflammation comes from the Latin  ‘inflammare’ -- to set on fire.  Our brain is ‘on fire’ when it is inflamed, or when our body is inflamed.

What sets your brain on fire?

Your body experiences inflammation the way your skin reacts to a cut:  The area becomes swollen, warmer, and it may hurt.  (This happens because there is increased blood flow, increased immune activity, and a change in the chemistry in the area.)

When there is inflammation any where in the body, signals are sent to the brain via various cytokines. The cytokines send signals to the brain via the vagus nerve and other pathways.  These cytokine signals then block the brain from making serotonin.

What does the fire do to your brain?

Inflammation affects hormones and other neurotransmitters in your brain. Inflammation drives down the level of serotonin, which can lead to feelings of depression or anxiety, and problems with memory.  It prevents melatonin from being produced, which causes insomnia.  It causes dopamine levels to rise, which contributes to insomnia, and feelings of anxiety and agitation.  The excitatory neurotransmitter, glutamate, goes up. Over time or with excessive levels of glutamate, anxiety can result. In extreme amounts, glutamate can be toxic to brain cells.

In fact, in depression, a certain type of brain cell-called an astrocyte, actually deteriorates under these circumstance, which permits the inflammation to continue. Now you have a brain that is, if not on fire, at least smoldering.

You too can prevent brain fires!

It’s not as complicated as you might think!  Try these suggestions (with your doctors approval of course.)

A) Clean up your diet by eliminating food common allergies –

¨    breads

¨    gluten

¨    milk and dairy products

¨    eggs 

¨    sugar

B) Balance your diet

¨    Try the Barry Sear’s “Zone” diet, or one of the diets in my book-“The Anti-depressant Survival Guide”

C) Keep exercise moderate,

D) Make sure your air is clean

¨    No mold, or things you are allergic to-such as dust mites

E) Reduce your stress so your adrenal glands can recover their anti-inflammatory function

F) Clear up all gut issues

¨    70% of inflammation comes from the gut-such as bloating, gassiness, diarrhea, constipation and reflux.

G) Be sure you do not have any hidden infections.

H) Drink lots of water

I) Eat lots of anti-oxidant rich foods

¨    Lots of organic colorful veggies, with a bit of fruit

Many people would be surprised that the immune system, the gastro-intestinal tract and stress interact, but that is what the most recent of a number of studies shows. In this study on mice, (Brain, Behavior, and Immunity Volume 25, Issue 3, March 2011, Pages 397-407. http://www.ncbi.nlm.nih.gov/pubmed/21040780)  researchers demonstrated that  psychological stress causes almost immediate changes to the gut bacterial population, and that some of these affected sub-populations strongly influence the effect that stress has on immunity. In the study, the researchers exposed mice to social disruption, which is known to cause increases in circulating cytokines ('hormones of the immune system), which themselves induce enhanced reactivity in the immune system.  The researchers found that social disruption altered bacterial counts of some gut bacteria sub-populations, particularly when the bacteria were assessed immediately after stress exposure. Stress exposure  increased the relative abundance of bacteria in the genus Clostridium, which often causes prolonged and severe diarrhea (generally after antibiotc use). The stressor also increased circulating levels of IL-6  which was significantly correlated with stressor-induced changes to certain other sub-populations. In a second experiment, these researchers found that a combination of antbiotics prevented the stress induced increase IL-6. This means that certain gut bacteria are necessary for stressor-induced increases in circulating cytokines.So, not only does stress affect the gut bacterial population, but these organisms are also required for  activation of the immune system.

This information becomes even more relevant for psychiatric disorders such as OCD, and depression, as activation of IL-6 has clearly been associated with depression. In fact blockers of IL-6 (eg etanercept) have been shown to reduce depression scores. Furthermore, we can now see, that stress, via its effect on gut bacteria, and hence the immune system (IL-6) can change brain function. We know this because IL-6 activates a certain enzyme (IDO), which actually 'steals' or syphons-off  tryptophan from its normal metabolic pathway ( ie conversion into serotonin and then melatonin) and instead converts it into chemicals that increase activity of glutamate (in depression) at an excitatory-and some times toxic- receptor (NMDA) in the brain. The result of all of this is increased depression, anxiety, and reduced memory. In mice this effect can take moths to reverse. The upshot of all of this, is that stress, the gut, the brain and the immune system are really intimately linked, and inseparable. While this might be news to most psychiatrists, it is not news when one understands the Whole Psychiatry model.

With the ongoing release of radiation into the atmosphere from the damaged Japanese nuclear facilities, many people are wondering whether they should protect themselves as well as what they can do to protect themselves and their families.  Some authorities expect the radiation to spread from Japan in an easterly direction, to the west coast of the United States, while others state that the thousands of miles between Japan and the west coast, will protect the US population from any harmful effects. It seems very likely, that the thousands of miles will in fact dilute the radiation significantly.  

In the United States the Three Mile Island nuclear accident was the worst nuclear disaster we have experienced.  To determine the effect of this radiation exposure on the population a 2002 study conducted by the University of Pittsburgh determined that the average radiation dose to individuals was less than the average annual radiation people receive on a routine basis. Twenty-five years after the accident, the researchers concluded that there was no increase in cancer deaths.  However, another analysis conducted by the Radiation and Health Project has found that death rates for infants, children, and the elderly rose significantly in the two years after the accident.

Based on the above and other conflicting opinions, there remains a question about the real effects of nuclear accidents in the short and long term.  In Japan, the accident has involved five nuclear reactors.  So, it is worth educating oneself about the potential risks.  There is no question that large amounts of radiation over time can increase one's risk of cancer.  Acute release of radiation can cause radiation sickness, which affects the most rapidly dividing cells in the body-the gut, hair, the thyroid, the blood system, the reproductive system and the heart.  The most vulnerable are infants, young children, young adults, pregnant women, and the elderly.

One of the measures recommended to protect oneself from radiation's negative effects, is the use of potassium iodide.  This will protect one from thyroid cancer, when taken quickly after exposure.  This is most likely to benefit those who are in the immediate and surrounding areas of the nuclear event. The further away from the exposure the lower one's risk, and therefore the "cost benefit ratio" shifts against using the potassium iodide. Excessive doses of potassium iodide can cause severe illness, and people who are allergic to iodine should not take it.  People with some skin conditions can be harmed by it, and should consult their doctors regarding the safety of use.  Check out the FDA website (under emergency preparedness) for more information.

According to a new study discussed on Health.com "about 2.4% of people around the world have had a diagnosis of bipolar disorder at some point in their lifetime, according to the first comprehensive international figures on the topic.The United States has the highest lifetime rate of bipolar disorder at 4.4%, and India the lowest, with 0.1%". 

Bipolar disorder has a strong genetic component. Depending on which studies you look at, the  gentics acount for anywhere from 40-60% of the vulnerability. While that seems like a high number it also means 40-60% of the risk of developing the disorder  despite having the same genes comes from the environment. Only 40-60% of  every set of identical twins will develop the disorder. So what is it that could be triggering this high rate of bipolar disorder in the US?

Let's look at this problem from the 'macro' to the micro' levels. On a socio-economic macro level, the US, as the largest and most industrialized Western society, has a somewhat exagerated culture. First, we have the largest gap between rich and poor, so the economic stresses on a large part of thepopulation are greater than in other western societies. This translates into psychological stress, more substance abuse, poorer quality nutrition, and fragmentation of the family. Early child hood rearing is more likely to be by a day care center -which is inherently unstable (people change centers or caregivers change in a center) and impersonal. There is a higher likelihood of bullying and reduced supervision.

The result of all this is impaired social bonding in those who are particularly vulnerable. The poor nutrition results in imparied metabolic functioning (now we are into the micro level), trouble making or breaking down neurotransmitters, more likely infection and inflammation (which change brain chemistry). This is a simple overview, and many books could easily be written about this subject (in fact I have written three books myself on these factors). Suffice it to say that the most vulnerable amoung us pay the price for our imbalanced society. Included in that group are the young, the ill, the genetically vulnerable, and the elderly.