The Mental Health Review
By Dr. Herb Wagemaker

Dr. Herbert Wagemaker is a board-certified psychiatrist.

He taught in the Department of Psychiatry at the University of Louisville from 1975 to 1986.

While there, he was the medical director of Central State Hospital, Louisville, KY.

While at the University of Louisville, his research in schizophrenia was funded by the National Institutes of Mental Health.

Later, Dr. Wagemaker joined the faculty of the Department of Psychiatry at the University of Florida's teaching hospital, Shands Jacksonville, where he was director of inpatient psychiatry.

At the present time, Dr. Wagemaker is in private practice in Ponte Vedra Beach, Fla., and is involved in research with children suffering from autism.

He is also the director of Ponte Vedra Publishing, which publishes mental health books and mental disorder educational videos.

Order Dr. Wagemaker’s

www.mentaldisorders.com

Do chronic pain and depression go together? The answer to that question is yes. I often see them together in my patients. I am convinced that what goes on in the body is often influenced by the mind, and what goes on in the mind is influenced by the body. Pain causes depression and depression causes pain. Pain is a complex experience that affects thought, mood and also behavior. This is especially true if pain has been a daily experience for a long time. Pain is depressing.

Often, I see patients with vague pains. They may suffer from headaches, neck pains, or joint pains. Their muscles may ache. They may get up in the morning with back pain. Their pain is very real; they feel it. It complicates their lives. They are bothered by it and cannot get around as well as they used to. Pain robs them of energy and creativity. It is something they live with and put up with every day. They go to sleep with it and wake up with it. Pain wears them down and depresses them.

Many patients that I see have been to their family physicians or internists. Usually, the tests, including MRIs, come back negative. Out of desperation, they come to me.

Patients who come to me with chronic pain are often angry. Their pain is real to them. They live with it every day. Now, they sit in my office. Someone thinks their pain is in their head, somehow contained by their subconscious. More often than not, they would rather have a specific diagnosis, something medical, a cause. When I explain to them that they have the signs of depression, they are not satisfied.

Depression not only causes pain, it intensifies it. I have seen this relationship in my patients for the past 35 years. People with chronic pain develop psychiatric problems 3 times as often as people with no chronic pain. Usually this is depression or anxiety disorders. Depressed patients have 3 times the chance of developing chronic pain as people who are not depressed.

Depression contributes greatly to the disability caused by backaches, headaches, or arthritis. Some estimate that 50% of depressed patients who visit their family physician complain only of physical symptoms that include pain.

Depression makes pain more difficult to treat. Pain also makes depression more difficult to treat and to diagnose. If, however, depression is diagnosed and treated in patients who suffer from chronic pain, pain is relieved, or may even disappear.

Depression is treatable. Not only do antidepressants lift depression, they reduce pain. We have known for a long time that the tricyclic antidepressants are effective in the management of pain. Elavil, a tricyclic, has been used in this capacity. The SSRIs probably are not as effective as the tricyclics, but they are effective also. Neurontin, an anticonvulsant medication, may also be effective in treating pain.

There is a mind body connection. Depression and pain are connected. There is a good chance that patients who are clinically suffering from pain are also depressed. Depression can present as pain. The connection is real. Pain has to do with neuroreceptors and neurotransmitters - so does depression. As a clinician, I must be aware of that fact. I try to help my patients become aware of that also.

Common symptoms of depression:

• Feeling sad or blue
• Changes in sleep patterns
• Eating problems, usually loss of appetite
• A decrease in sexual activity
• Loss of energy
• Difficulties with memory, concentration
• Irritability, anger
• Very emotional, cries easily
• Feelings of hopelessness, helplessness
• Suicidal thoughts
  

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ADHD: Are medications safe for my child?

My child has been diagnosed with ADHD. The psychologist recommended that I take him to a psychiatrist for medication. Are medications safe and effective?

We have been using stimulants since the late 1960s in children who suffer from ADHD or ADD. There is a lot of scientific information about these medications. I think they are both safe and effective. I advise parents to become informed about the medications their children are taking. They have the final decision on the use of medications in their children.

What happens to patients who are successfully treated for panic disorder with medication and then stop taking their medication?

Dr. P. King and colleagues studied two groups of patients who had been on medications for two or three years for panic disorder. One group continued on their medications, and the other was taken off medications. The probability of relapse was much higher in the group that stopped taking their medications.

This points to the probability that panic disorder patients need to be treated with medications longer than three years. It goes along with the idea that panic disorder tends to be a chronic illness and that medications are effective in treating panic disorder symptoms but do not change basic brain chemistry.

I tend to keep patients on medications for at least 18 to 24 months while treating panic disorder. I find that the tricyclic antidepressants desipramine and imepramine are very effective in the treatment of panic disorder. The SSRI's have also been shown to be effective in the treatment of panic disorder.

The bad news is that panic disorder seems to be a chronic illness. The good news is that we have medications that treat panic disorder very effectively.

To order these books by

Dr. Wagemaker, go to

www.mentaldisorders.com

Ponte Vedra Publishers, PO Box 773, Ponte Vedra Beach, FL 32004-0773

Depression and pain

Don Evans is in my office. He doesn't want to be there, but his mom insisted. He is 17 years old, tall, and good-looking. Up until recently, he received good grades in school, rarely got into trouble, and had many friends. All that changed six weeks ago.

"Don had always been a happy-go-lucky kid. We had no real problems with him," his mother told me. "Now, he's not like that. He is sullen and angry all the time. Everything is an argument. He comes home from school and doesn't say much. Then he goes into his room and doesn't come out until suppertime. He was an A-B student all through high school. No more. He had 2 C's and 3 D's on his mid-semester report card. Don has really changed. He's like a different kid. We just don't know what's going on."

Don told me when we were alone, "I don't know what's going on either. Every little thing makes me angry. I can't stand to be around anyone. My parents are always on my back. I avoid them as much as possible. I don't hang out with my friends much anymore either. I'd rather be alone. I've lost interest in almost everything. Nothing seems to be worth the effort. My grades are dropping, and I don't have the energy to study. When I try to study, I can't concentrate. I can't remember what I've read. I don't understand why I'm sad all the time. This just isn't like me."

Don had all the signs I see in an adolescent who suffers from depression. I asked Don if he was suicidal. He told me he wasn't; he hadn't thought about it.

The diagnosis was easy, but the difficult part was the treatment. The use of antidepressants in depressed kids has been questioned of late. Some studies have shown that suicidal thinking increases when adolescents are given antidepressants. Some have stated that therapy, cognitive behavior therapy (CBT), is effective in treating depression in kids like Don.

As a clinician, I have several questions about treatment. Double-blind studies have demonstrated that antidepressants work in this age group, and my personal experience of using antidepressants in this age group has also demonstrated this. But are these medications safe? Do they cause more suicidal thinking when adolescents take them?

We know that 25%, 1 in 4 adolescents, think about suicide. In depressed kids, this figure is higher. We also know that 35% of patients in a double-blind study do not respond to the antidepressant. Some in this group of patients will develop suicidal thoughts. I have used antidepressants in my practice for 35 years in this age group. My patients have not reported an increase in suicidal thoughts while they are on antidepressants. As a matter of fact, they report the opposite - they are less suicidal.

T he next question I have as a clinician is how effective is cognitive behavior therapy (CBT)? Does it work? Is it as effective as medications?

A recent study conducted by the National Institutes of Mental Health (NIMH) compared the efficiency of Prozac and CBT alone and together against a placebo during a 12-week treatment trial. 439 adolescents between 12 and 17 years of age with major depressive disorder were in the study.

There were four groups in the study. One group received Prozac for 12 weeks. A second group received CBT. They received 15 sessions that lasted 50 to 60 minutes during the course of 12 weeks. A third group received a placebo or sugar pill. The fourth group received both the Prozac and CBT.

Patients who were at a high risk for suicide were excluded from the study. 29% of patients did report significant suicidal thinking at base line. No patients committed suicide during the study, although 7 (1.6%) attempted suicide during the study.

T he results of the study were interesting. When Prozac was compared with CBT, the improvement on Prozac was greater than 60.6% to 43.2%. The placebo response was 34.8%. When Prozac is combined with CBT, the improvement was 71%. What this means is that Prozac was effective in treating depression in this age group. The combination of CBT and Prozac was most effective, but the use of CBT alone was not very effective. CBT is not a viable alternative treatment when used by itself in this age group. It was also reported that in all groups, the suicidal ideation was reduced.

I advised Don's mom that he should be treated with medication and CBT. Ten weeks later, Don's mom reported, "We have our son back. Things are so much better." Don told me the same thing. Treatment with medication in this age group is both safe and effective.

Strokes are caused when arteries to the brain are blocked or when they burst. Brain cells are robbed of oxygen and die. The brain can be mildly damaged or greatly damaged. Symptoms range from tingling sensations in the fingers to loss of movement in the arms or legs. Patients can also have problems speaking and difficulty understanding. Strokes can also affect the mental state of the patient.

In the United States, there are more than 500,000 new stroke victims each year and there are also five million stroke survivors. About one-third of these survivors suffer from depression.

Depression and stroke are related. Depressed patients are at higher risk for a stroke, and they suffer more cognitive problems and loss of functioning after a stroke. Depression reduces the quality of life in the stroke survivor, and is associated with an earlier death. In a study out of Australia, stroke patients were eight times more likely to die within 15 months if they were depressed.

Depression can also follow a stroke. This is understandable. Depression can be caused by an inability to function or an inability to communicate to family members. It can also be caused by brain cell damage in the nerve circuits that regulate mood.

The right treatment can help. Rehabilitation can improve functioning. Adding an antidepressant can not only treat depression, it can even improve cognitive functioning. It is not a bad idea to give antidepressants to stroke victims even before they get depressed. This can prevent depression.

Studies also show that giving antidepressants improves cognition and daily functioning quicker and sustains it over the long haul. Stroke patients also live longer if they are started on antidepressants during the first three months after a stroke. The SSRI's, like Zoloft, Celexa, and Prozac are used most frequently in the treatment of stroke patients. Using them in stroke patients is not a bad idea.

Because of the FDA's warning about antidepressant use in kids causing suicidal thoughts, pediatricians and family practitioners are reluctant to prescribe these medications. This poses a problem: Where do parents get these medications for their children?

Child psychiatrists are seeing a surge of referrals from primary care physicians, but there are not enough trained specialists to meet their demands. Parents are scrambling to find physicians who will prescribe these medications, but at times, the wait is long - 3, 4, even 6 months. Parent advocacy groups are getting calls from frustrated parents who have to deal with them. Family physicians and pediatricians also have a hard time getting their patients into see child psychiatrists. They are frustrated also. There are not enough child psychiatrists to go around, and, until recently, many of the physicians were reluctant to medicate kids.

Will all the controversy about antidepressants, there are still many child psychiatrists who will prescribe them. A phone call will tell you if a physician will prescribe them. Community mental health center physicians may also prescribe antidepressants. If you have a medical school in your city, you can get antidepressants from their psychiatric outpatient clinics.

Be persistent; make phone calls; get on waiting lists. Once you make it through the door, follow-up visits are available. The key is to be persistent. Antidepressants work in this age group. I have seen this happen again and again in my practice. I feel these medications are also safe. I have advised the parents of kids I treat to keep them on these medications. Depression in this age group needs to be treated. Medications are the foundations stone of treatment.

Contact Dr. Wagemaker:

hwagemd@aol.com

Health Canada has decided to suspend the sale of Adderall XRÒ in Canada due to information about product safety. There have been reports of deaths in kids taking Adderall and Adderall XR. The reports are hard to interpret and could not be linked to the use of Adderall. The patients who died were on other medications. Many of them had other preexisting health issues.

News like this scares us. I prescribe Adderall to kids who suffer from ADD or ADHD. From my experience, I have not had a problem. I recommend that my patients get an EKG when they are started on Adderall. I also have parents check with their pharmacist if there are any drug-drug interactions that may be problematical.

Every medication that I prescribe has risks. If the risks outweigh the benefits, I don't prescribe the medication. I try to inform parents about the risks, and they make the final decision about using medications in their children.

I feel Adderall is safe and effective. But parents need to know the risks to make an informed decision. Visit this site: www.fda.gov/cder/drug/advisory/adderall.htm