SPRAVATO An Alternative For Treatment-Resistant Depression

An Alternative For Treatment-Resistant Depression- SPRAVATO

Spravato Brochure

SPRAVATO™ is the only NMDA receptor antagonist approved in conjunction with an oral antidepressant for treatment-resistant depression. It contains esketamine, an alternative for treatment-resistant depression, and is a schedule III-controlled substance, related to ketamine, an anesthetic that also has been studied to help in the treatment of depression.

What Is Treatment-Resistant Depression?

The depression is considered resistant to treatment after failing to respond to two trials of antidepressants. About 30 percent of the patients suffering from depression do not respond to the standard treatments. Ketamine and esketamine are similar but not identical. They are enantiomers, meaning that their chemical structures are mirror images of each other. Both can be used as anesthetics but esketamine has more potency acting on the brain receptors.

Research On Ketamine And Esketamine

Ketamine IV has been extensively studied and there are numerous clinics throughout the US offering ketamine IV as a treatment for depression even though it does not have an FDA approval. The administration is done over a period of 40 minutes, at a subanesthetic dose.  We prefer to use Eskatemine Spravato because of its improved safety and FDA endorsement.

Administration Of Esketamine And Possible Side Effects

Esketamine can be administered intranasally, it is FDA approved and has less potential for dissociation and hopefully will be covered soon by the insurance carriers, has less potential for dissociation and hopefully will be covered soon by the insurance carriers. Because esketamine, like ketamine, has abuse potential, there are very strict rules related to its administration. It must be done in the doctor’s office, under direct supervision, followed by a period of two hours of observation. Following the administration, dissociative episodes can happen; therefore, the patient should not engage in driving or operating any machinery. The most common side effects are feeling dissociated from one’s body, dizziness, nausea, sedation, vertigo, anxiety, increased blood pressure, vomiting and feeling drunk.

Learn More

If you’d like to learn more about SPRAVATO for treatment-resistant depression and esketamine- call us to set up an appointment at 713-426-3100. If you’d like a brochure click here.

Learn more about Spravato here.

Psychiatrists And Mental Health Counseling Options Houston

Who Provides Mental Health Counseling and Treatment?


In my last blog article, I talked about The Importance Of A Correct Diagnosis of Mental Illness.  I spoke about the importance of getting a thorough medical screening by your primary care provider, first, to rule out any medical conditions that might cause physical or emotional symptoms. In this article, I will discuss some options for getting help by exploring the role of various psychiatric care providers so that you can make informed choices about getting help.


Medical and Other History Is Needed

Initially, when I talk to my patients, I will ask them about the history of their symptoms, and any prior diagnoses and treatment. In many cases, the clients are confused about who was a mental health provider and who was a medical provider delivering mental health treatment, since many providers can participate in their healthcare.


Who Provides The Diagnosis?

A diagnosis of a mental illness can be made by a physician who is familiar with the current diagnostic criteria for psychiatric conditions. Sometimes primary care or family practitioners feel comfortable doing that- but in many cases, they would refer to a specialist, a psychiatrist for confirmation and treatment.


What is a Psychiatrist?

A psychiatrist is a medical doctor, MD who has been trained in recognizing, diagnosing and treating mental conditions using various pharmacological treatment, psychotherapy or a combination of both. To become a psychiatrist one must complete medical school and take a written examination for a state license to practice medicine. They then must complete a 4-year psychiatry residency program. The first year of residency training is typically in a hospital setting working with patients with a wide range of medical illnesses, but at least three of the four years are spent specifically in the practice of psychiatry.


Split Treatment Model

However, even if the psychiatrists are trained to deliver both forms of treatment, most commonly the psychiatrist oversees the pharmacological treatment and another professional provides the therapy. This model is known as split treatment. This form of therapy works best when the psychiatrist and the therapist collaborate during the treatment. The psychiatrist should be versed in different types of therapies to make the appropriate referral to a professional, according to the patient’s condition that needs to be treated, the emotional strengths of the patient as well the patient’s receptivity for a long or short term therapy all matched with the professional’s specialty.  For example, if a patient has an obsessive type of disorder, I can either refer them to an exposure prevention therapy trained professional or to insight-oriented therapy trained one. Some professionals train in one or more types of therapy.


Psychiatric Advanced Nurse Practitioner

In many clinics, a Psychiatric Advanced Nurse Practitioner can also diagnose, and treat mental health conditions and they work under the supervision of a Psychiatrist. They can deliver pharmacological treatment as well as some forms of therapy according to their training.

The different types of psychotherapies include psychodynamic expressive therapy, supportive therapy, cognitive behavior therapy, motivational interviewing, etc. Each of them can be even more specialized in attempt to focus on one type of mental health condition, such as exposure prevention therapy for OCD type disorders, dialectical behavior therapy primarily for borderline personality disorder or Eye Movement Desensitization and Reprocessing for PTSD.


What Is Counseling?

Counseling is the process through which a professional counsels on how to approach and solve different problems/situations, such as difficulties with school, marriage, relationship, work, etc. Depending on the credentials and training of the counselor, that can take the form of various therapies. Counseling often can focus on the past and how it influences the future. The therapist will focus on Identifying and treating disorders and pathologies, and the goal of treatment is typically to alleviate symptoms through behavioral, cognitive or analytic interventions. Most of the time the therapeutic process is longer, and deeper than the coaching process since it looks to change deeply rooted unconscious processes.


What is Coaching?

Coaching is different from therapy since it does not actively look for a connection between the past of the patient and the way he or she constructs the present but is more geared towards finding immediate solutions, using goals and timelines. Coaching is results-based, whereas therapy most of the time looks for a genuine understanding of how the past of a person influences the way the present decisions and choices are made.

Some of the professionals doing counseling or therapy, but not pharmacological treatment are psychologists (Ph.D.), social workers (SW), or counselors (LPC).


What is a Psychologist?

A psychologist has a graduate university degree in recognizing different states of mind, normal or abnormal, also able to do psychological testing to record and interpret cognitive performances and deliver various forms of therapy.


What is a Social Worker?

A social worker is a professional who has a Bachelor degree of Social Worker ( BSW) or a master degree of social work ( MSW). The primary focus is to deliver social services, social welfare, public health, and mental health counseling. Some of the BSW and MSW graduates specialize in various forms of therapy, counseling and/or coaching.


What Is A Licensed Professional Counselor (LPC)?

LPCs are doctoral and master’s level mental health providers trained to work with individuals, families, and groups who also can specialize in different forms of therapies or coaching.


Which Professional Should I Choose For My Mental Illness?

Since all of the above could appear complicated and confusing- what is somebody who first encounters depressive, anxious, or other symptoms supposed to do?

Do not disregard or ignore the symptoms! While friends and family can be a source of support, the best person to ask for professional help is your physician. A family practice MD who is comfortable and has training and experience with mental health conditions can diagnose you and even initiate treatment. However, as with other conditions, they might need to refer you to a specialist, a psychiatrist, like they would refer to an endocrinologist for a thyroid condition that they do not feel comfortable treating.

If you have a family history of mental illness, you should look for a psychiatrist when you too start having symptoms of anxiety, depression or another disorder.

If you begin to seek help from a mental health professional and have trouble managing your symptoms then discuss your condition with them and decide if you need another form of treatment such as medication, or an alternative approach.


Be Mindful And Seek Help If You Experience Side Effects

Please understand that even over the counter remedies, including herbal therapies could have side effects. So make sure that the person who recommends any to you is aware of them and of the potential health or interactions that they could have with medications you take for other illnesses such as hypertension, diabetes,  as this may affect the treatment outcome of your mental illness.


Seek A Specialist When Needed But Be Specific In Your Request

Discuss with your psychiatrist the course of treatment according to the severity of your condition. Given the fact that a lot of mental health providers do not take insurance, it might be difficult to find professionals highly trained in what you need. Should you choose to call the insurance providers for guidance, be specific in what your request is: i.e. ” my psychiatrist recommended (Eye Movement Desensitization and Reprocessing Therapy (EMDR)… is there anybody on your provider list who specializes in that?”


For Questions Or To Schedule A Psychiatric Consultation

Please call Midtown Psychiatry at 713-426-3100 or check us out online at www.midtownpsychiatrytms.com

The Importance Of A Correct Diagnosis of Mental Illness

Why A Good (Correct) Diagnosis Is So Important

Good Diagnosis

One of the most important things in treating mental illness successfully is a correct diagnosis. That can sometimes be a difficult task since there are some medical issues that can present as a mental illness or a psychiatric symptom. Diagnosis is also challenging because a psychiatric symptom can be present in more than one psychiatric disorder. Why is a correct diagnosis so important? Because a correct diagnosis helps the psychiatrist formulate the most effective treatment that will result in remission. For example, one symptom like irritability can be a common presentation in depression, anxiety, Attention Deficit and Hyperactivity Disorder, mania, hypomania, impulsive disorders, Post Traumatic Stress Disorder and even in Obsessive Compulsive Disorder, to name a few. Sadness, another common psychiatric complaint can be a sign of a Major Depressive Disorder or Bipolar disorder, and be seen in Schizophrenia in some cases; all severe mental illnesses with completely different types of treatment.


Examples of Misdiagnosis

To illustrate some of the challenges in forming a diagnosis, I have a couple of examples from our Clinic.

Patient A.

A 29 y/o male was referred by his therapist for an evaluation after increased concern that he might have Bipolar Disorder. The patient described periods of time when he worked more than 60 hours per week, reporting that people close to him would notice that he was increasingly irritable and also had a decreased desire for sleep.  He did not have any concerns about his behavior but said his family was increasingly worried about his mood swings, and his proneness to get into fights.  He had sought Christian counseling at his father’s urging. During his examination, he was very polite, friendly, but somewhat reserved and slow in establishing rapport. He reported that he was previously diagnosed and treated by his Primary Care Doctor for ADHD for many years and was treated with a number of medications over the years, but said he preferred Adderall XR. After the interview process and a routine check of his prescription across Texas database, we discovered that he was prescribed 30 mg of Adderall XR twice a day, with no early refills. However, we also learned that he was using the entire 30-day supply during a 7-10 day period each month, amounting to an average of 180-270 mg of Adderall per day. When I spoke with him about it-he was truthful, saying that he was not addicted to the direct effects of Adderall but to how much work he was able to accomplish during that time. Given this additional information, the correct diagnosis was not Bipolar Disorder and as a result he did not need a mood stabilizer. The correct diagnosis was amphetamine drug use, and substance-induced bipolar disorder that needed an addiction treatment and reevaluation of his prior diagnosis and treatment for ADHD.


Patient B

A 48 y/o, divorced, mother of one child, employed professional, was treated for depression with fluoxetine. Her symptoms responded to an initial dose of 20 mg of fluoxetine and almost got to remission with an increased dose of 40 mg. She continued to complain of persistent tiredness and lack of energy in doing things that she was interested in. Her blood work report did not show anything significant except for a low T3 on the Thyroid function panel and a high C reactive protein. As a psychiatrist, I recommended supplementation with liothyronine, which improved her energy level dramatically. At the same time, she was referred to an endocrinologist for further testing that came back suggesting an autoimmune thyroiditis disease. A new treatment plan was created to target both her depression as well as her thyroid condition.


Patient C

A 32 y/o recently married woman was referred for worsening mood that was not responding to the lamotrigine and bupropion that were started a few months prior to her initial visit to a psychiatrist by her Primary Care Doctor. She was in couple’s therapy to address difficulties in her relationship that started a month prior to her wedding. The therapist suggested a mood stabilizer because the patient had increased irritability, insomnia, and crying spells as the wedding was approaching. The response to the medication was minimum, she continued to be depressed, still cried a lot, felt anxious, and the tension in the relationship was not helping her symptoms. A new medication, Wellbutrin, was added to lamotrigine and her mood was slightly better. After the wedding her mood continued to be unstable, initially with insomnia and then she started having panic attacks.  In my initial psychiatric interview, she appeared to be very anxious but there was no history of clinical symptoms of mania, nor any history of bipolar disorder in her family. Her pattern of insomnia was suggestive of an anxiety disorder that neither medication addressed. We discussed options and I recommended that she add Trintellix and start a slow tapering of her Lamotrigine first and then her Wellbutrin. Over the next two appointments, both her anxiety and depressive symptoms were in remission and she said that she finally felt like she got back to feeling like her normal self, despite the continued difficulties in her marriage on which she continued to work in therapy.  In this situation, it was clear that she was misdiagnosed with a mood disorder and the treatment that was chosen was not addressing her anxiety which was her main presenting problem.


Prevent Undue Suffering By Getting A Proper Diagnosis Quickly

Any delay in obtaining a correct diagnosis can prolong the period that the patient suffers, and, in some situations, the treatment that is chosen for a different condition can worsen the presenting problem, like in the last case where the medical provider was treating a depressive episode of a bipolar disorder with an antidepressant. Please note that even though people might have the same diagnosis each person’s experiences and health conditions are different- so what works for one person may not work for another.  Any diagnosis of mental illness should include a full history of your both your mental and physical health.

Research indicates that if you get the right diagnosis early in the treatment process you will get better faster and experience fewer treatment-induced side effects.

If we can help in any way- call us at 713.426.3100  to schedule an appointment.

Psychiatrist For Anxiety and Depression Houston

Psychiatrist For Anxiety and Depression Houston Shares Facts About Mental Illness

psychiatrist for Anxiety and depression

Research On Anxiety and Depression

Research on mental illness shows that mental illnesses are common in the United States.  According to the National Institute of Mental Health, tens of millions of people experience depression and anxiety each year. In fact, some research even suggests that mental illnesses are so common that almost everyone will develop at least one diagnosable mental disorder at some point in their life. However, estimates indicate that only half of those with mental illnesses receive treatment.

Facts About Anxiety Disorders

According to the World Health Organization (WHO), 1 in 13 people, globally, suffers from anxiety. The WHO reports that anxiety disorders are the most common mental disorders worldwide. Anxiety disorders are the most common mental illness in the U.S., affecting 40 million adults in the United States age 18 and older, or 18.1% of the population every year.

Anxiety disorders are highly treatable, yet only 36.9% of those suffering receive treatment.

People with anxiety disorders are three to five times more likely to go to the doctor and six times more likely to be hospitalized for psychiatric disorders than those who do not suffer from anxiety disorders.

Anxiety disorders develop from a complex set of risk factors, including genetics, brain chemistry, personality, and life events.

Feelings of anxiety can interfere with daily activities such as work performance, school, and relationships.

There are several different types of anxiety disorders such as social anxiety disorder, panic disorder, generalized anxiety disorder, and specific phobias.

Anxiety and Depression Can Occur Together

It is common for someone with an anxiety disorder to also suffer from depression and vice versa. Nearly one-half of those diagnosed with depression are also diagnosed with an anxiety disorder. Accordingly, there is significant overlap in symptoms between anxiety and depression. Comorbid anxiety and depression are often more resistant to pharmacologic treatment, and patients with coexisting disorders have a poorer medical prognosis than do patients with either mental illness alone.

Facts About Depressive Disorders

Depression is believed to be the leading cause of disability worldwide. Almost 75% of people with mental disorders remain untreated in developing countries with almost 1 million people taking their lives each year.


Major Depressive Disorder (MDD)

Major Depressive Disorder is the leading cause of disability in the U.S. for ages 15 to 44.3.  MDD affects more than 16.1 million American adults or about 6.7% of the U.S. population age 18 and older in a given year. While major depressive disorder can develop at any age, the median age at onset is 32.5 years old. Only 61.7% of adults with MDD are receiving treatment. The average age of onset is 31 years old. (Source: National Institute of Mental Health).

Depressive Disorders are more prevalent in women than in men.

Persistent depressive disorder or PDD, (formerly called dysthymia) is a form of depression that usually continues for at least two years.


Treatment Options

Anxiety and Depressive disorders are treatable, and the vast majority of people with these disorders can be helped with professional care. Several standard approaches and lifestyle changes have proved effective:

  • Therapy
  • Medication
  • Complementary and alternative treatment
  • Self-Help or Support Groups
  • Exercise
  • Diet
  • Stress-Management Techniques
  • Transcranial Magnetic Stimulation(TMS)*Note that TMS has been researched and shown effective for anxiety but it’s not FDA approved or covered by insurance for anything except Major Depression.


Get Help As Soon As Possible

It is crucial for those who experience depression and anxiety to seek treatment as soon as possible. Aggressive and professional management of depression, as untreated or inadequately treated patients are more likely to have negative medical consequences of their depression, including a substantial risk of suicide and longer, more treatment-resistant episodes of depression.

Fortunately, many new medications are available to help. The newer antidepressants, in particular, are playing an increasingly important role in the treatment of both depression and anxiety disorders alone as well as comorbid anxiety and depression.


The Challenge of Diagnosis

Thus, the challenge for clinicians is to make a quick and accurate diagnosis and then to ensure proper and effective treatment.

One reason it is essential to obtain a diagnosis from a medical professional is so they can rule out any medical issues that might be causing physical symptoms as we know that somatic complaints can affect an individual’s mood and emotional state. In conjunction with your primary care doctor, a psychiatrist for anxiety and depression can help rule out any physical causes of mental illness.

Our Psychiatrist For Anxiety and Depression Houston, Daniela White, MD, is located at Midtown Psychiatric and TMS Center, a mental health clinic located in Houston, Texas. All of the clinical staff at Midtown Psychiatry are caring and knowledgeable professionals who are committed to using the most up-to-date treatments for anxiety and depression and other mental health disorders. Give us a call at 713-426-3100 or visit our website at https://www.midtownpsychiatrytms.com to learn more.


References and further reading:






Can Magnets Really Help Depression? TMS Therapy Results

TMS Therapy and Depression Treatment

TMS and Depression Treatment

If you are suffering from major depression, you know that every day can seem difficult and hopeless. And you are not alone. The Latest Statistics on Major Depression from the National Institute of Mental Health(NIMH) in 2016 show that:

  • In the United States, an estimated 16.2 million adults in the United States had at least one major depressive episode. This number represents almost 7% of the United States population.
  • The prevalence of adults with a major depressive episode was highest among individuals aged 18-25 (10.9%).
  • The prevalence of major depressive episode was higher among adolescent females (19.4%) compared to males (6.4%).

Symptoms of Major Depressive Disorder

There are many different types of major depressive disorder. Each type can have a different cause, however, they all involve the same feeling of disinterest in activities you once enjoyed and feelings of hopelessness, sadness or anxiousness as well as other symptoms. See a mental health professional for a formal diagnosis, but to have a formal diagnosis of major depressive disorder you will need to experience a primarily depressed mood for two weeks or more, as well as other symptoms as outlined below.


Although the number and intensity of symptoms will vary for each individual, they are typically as follows:

  • Persistent sad, anxious, or “empty” mood
  • Feelings of hopelessness, or pessimism
  • Irritability
  • Feelings of guilt, worthlessness, or helplessness
  • Loss of interest or pleasure in hobbies and activities
  • Decreased energy or fatigue
  • Moving or talking more slowly
  • Feeling restless or having trouble sitting still
  • Difficulty concentrating, remembering, or making decisions
  • Difficulty sleeping, early-morning awakening, or oversleeping
  • Appetite and/or weight changes
  • Thoughts of death or suicide, or suicide attempts
  • Aches or pains, headaches, cramps, or digestive problems without a clear physical cause and/or that do not ease even with treatment


Major Depression Can Cause Severe Impairment

In 2016, an estimated 10.3 million U.S. adults aged 18 or older had at least one major depressive episode with severe impairment. Severe impairment was indicated if their depression caused severe problems with their ability to manage at home, manage well at work, have relationships with others, or have a social life. Those adults who had major depression with severe impairment represented 4.3% of all U.S. adults.

For adolescents aged 12 to 17, approximately 9.0 percent had a Major Depressive Episode with severe impairment. Adolescents were defined as having a Major Depressive Episode with severe impairment if their depression caused severe problems with their ability to do chores at home, do well at work or school, get along with their family, or have a social life.


Depression Treatment Options

Common treatments for a major depressive episode may include antidepressants,  psychotherapy, exercise, TMS and electroconvulsive treatment (ECT). A prescribing psychiatrist can provide both psychotherapy services and prescribe antidepressants, which may differ for each person based on their individual considerations. However, ECT is generally avoided, except in extreme circumstances, in favor of both psychotherapy and antidepressants. ECT is generally avoided because the patient typically needs to be in the hospital and receive anesthesia. ECT may also cause some side effects, including confusion, disorientation, and memory loss. Unlike the TMS treatment that is noninvasive and done with the patient being awake, without any need for anesthesia.


Depression Treatment With TMS Therapy

What Is TMS Therapy?

tms machine depression treatmentTranscranial magnetic stimulation (TMS) is a non-invasive method for using a magnetic field to cause an electric current to flow in a small region of the brain via electromagnetic induction, which causes the excitation of neurons in the brain. During a TMS procedure, a magnetic field generator, or “coil”, is placed near the head of the person receiving the treatment. The neuron excitation is caused by the electric currents induced in the tissue by the rapidly alternating magnetic fields, a process called electromagnetic induction. The TMS machine triggers activity in the brain without applying electrodes on the brain and without surgery.


Who Is A Good Candidate For TMS?

A doctor can help decide if NeuroStar TMS Therapy is right for you. TMS Therapy has been approved for the treatment of Major Depressive Disorder in adult patients who have failed to receive satisfactory improvement from prior antidepressant medication in the current episode.

NeuroStar TMS Therapy is only available by prescription.


What Happens In A Typical TMS Procedure?

A typical TMS session lasts approximately 30-50 minutes and does not require anesthesia. Patients come to the office five times per week. The treatment goes on for six to eight weeks, for an average of 20-30 total treatments. The TMS treatment is time-intensive, but research shows it can provide long-lasting improvements.


What Happens During The TMS Procedure:

An electromagnetic coil is held against the forehead near an area of the brain that is thought to be involved in mood regulation.

Short electromagnetic pulses are administered through the coil. The magnetic pulses easily pass through the skull, and causes small electrical currents that stimulate nerve cells in the targeted brain region.

Generally, the person feels and hears a slight knocking or tapping on the head as the pulses are administered.


Side Effects of TMS

For those who experience side effects, the most common side effect they have reported is a headache and/or pain or discomfort (tenderness) on the scalp, at or near the treatment site. However, this is usually transient; it occurs typically during the TMS treatment course and does not occur for most patients after the first week of treatment. There is a rare risk of seizure associated with the use of NeuroStar TMS (less than 0.1% per patient).


Who Is Not A Candidate For TMS

NeuroStar TMS Therapy should not be used with patients who have non-removable conductive metal in or near the head. NeuroStar TMS Therapy has not been studied in patients who have not received prior antidepressant treatment.


How To Pay For TMS Therapy Treatment

Insurance Coverage For TMS Therapy

Insurance coverage for TMS is expanding due to the increasing recognition by the insurance companies of the effectiveness of TMS. In Texas, TMS treatment is covered by Blue Cross Blue Shield, Cigna, and Optum (formerly United Behavioral Health).

If you don’t have these carriers, TMS Therapy® may be covered by your health insurance provider on a case-by-case basis.  Currently, insurance coverage for the TMS procedure varies and individual carriers and plans may determine coverage on a case-by-case basis.

Most insurers will only cover members after they have tried 3 or 4 medications without success, although this may change in the future, as was seen with Medicare when they changed this approval to 1 failure of medication. Although anyone can pay for the treatment out of pocket. Research shows that taking fewer medications before TMS can reduce the number of side effects of these medications, and increase the success rate of the TMS treatment.


Success Rate Using TMS With Major Depression

Repetitive transcranial magnetic stimulation, known as rTMS, may produce long-lasting changes in electro-cortical function. According to researchers, the pulses are thought to increase blood flow and encourage the growth of connections between brain cells. TMS can also cause the release of the neurotransmitters dopamine, serotonin and norepinephrine, which are chemicals that help send signals between cells. The magnetic field is about the same strength as that of a magnetic resonance imaging (MRI) scan.

Midtown Psychiatry Experience With TMS

At Midtown Psychiatry and TMS Center, Dr White has been using TMS to help people with Major Depression since 2014. She has seen a success rate of  54% percent for patients who’ve tried TMS at her office that have seen improvements in their depression symptoms.

“For the people who do see an improvement, it can be life-changing, as many of those patients have suffered from Major Depression for years,” Dr. White says. The success stories of those helped using TMS can be seen in the note cards that Dr. White has posted on a bulletin board in her office.

The results Dr. White has seen in her office are similar to studies announced at the American Psychiatric Association meetings, which report that 53 percent of patients with medication-resistant depression who were treated with TMS reported no or mild depression following six weeks of treatment, according to results.

The TMS patients achieved better results than depressed patients who tried a different medication after failing to improve from past medication. Among patients trying a new medication, 38 percent saw improvements, according to study results.

However impressive the studies are, the studies and Dr. White caution that TMS does not work for everyone. In more serious cases of major depression, intensive outpatient treatment or hospitalization may be required.


TMS For Other Conditions

Research is ongoing into whether transcranial magnetic stimulation, or TMS, can help people with autism, schizophrenia, tinnitus, and a host of other conditions involving the brain. Although the FDA has approved TMS only for medication-resistant depression, the treatment has been approved in Europe for bipolar disorder, post-traumatic stress disorder, chronic pain, obsessive-compulsive disorder and adult ADHD, according to transcranialmagneticstimulation.com.


Integrative Treatment And Major Depression

Dr. White uses what she calls Integrative treatment, which, after a comprehensive evaluation, may include a combination of various therapeutic modalities such as relaxation, psychotherapy, yoga, medication, meditation, exercise, TMS therapy, nutritional supplementation, herbal medicine, vitamins, dietary changes, light therapy, and others. If you find yourself experiencing any of the symptoms of a major depressive disorder, you should seek assistance from a medical professional. Thankfully, in recent years, there is much less of a stigma for a major depressive disorder, and there is plenty of in-depth information available about depression online that you can discuss with your doctor.


What Our Patients Are Saying About TMS Treatment At Midtown Psychiatry

We have a bulletin board in our office which has note cards posted from people who have experienced TMS treatment in our Houston TMS Psychiatrist Office. Here are a few:

“As someone who has struggled with depression on and off my whole life and struggling with another long term episode I was excited to find a new treatment. After completing the TMS treatment I’ve been able to climb out of that depressive state and start doing the things I need to do to continue to enjoy my life. I would recommend the treatment.”

“My experience with TMS was very helpful. I went from being tired all day and not finding much pleasure in life to seeing hope for the future.”

“TMS help with my depression symptoms better than any medication ever has with no side effects. I would definitely recommend TMS to those suffering from depression and/or anxiety.”




You can hear from some of our patients as they discuss the real impact of TMS on their lives by watching Dr. White in a television video interview about TMS.


About Midtown Psychiatry & TMS Center

Midtown Psychiatry and TMS Center was created to provide the best possible mental health care available. With each patient, we strive to identify and treat the underlying causes of distress and symptoms of anxiety, depression, and other mental health issues. We work closely with patients and their families to create a treatment plan that addresses any imbalances we find. This may include addressing nutritional, lifestyle, and other core imbalances. Our treatment team, directed by Dr. Daniela White, MD, is dedicated to providing the best in diagnosis and treatment possible for a wide range of psychiatric issues, using an integrative treatment approach that improves the quality of life for our patients.

To that end, Midtown TMS and Psychiatry Center works in partnership with our patients and their families, advising them on options for treatment, such as psychotherapy, medication, TMS therapy, nutritional supplementation, vitamins, dietary changes, light therapy, yoga, meditation, exercise, herbal medicine, and others.

To learn more about TMS and our integrative treatment approach–make an appointment using the button or form on this page or call us directly at 713.426.3100.












The Best Treatment When You Have Both Anxiety and Depression

When To Get Help For Anxiety and Depression

Best Treatment When You Have Both Anxiety and Depression

Anxiety is a normal reaction to the stress and worry that is part of modern-day life. One can feel “stressed out,” nervous, or fearful, at times, given the demands of everyday life. If, however, it lasts for a long time or if it becomes severe, it could be suggestive of an underlying mental illness. Depression, on the other hand, can appear as sadness, hopelessness, and loss of interest in life. Some surveys show that 50% of those with anxiety also have depression, and a slightly greater number of those with depression have clinical symptoms of anxiety. The distinguishing attribute of these conditions is that they can last a long time and are likely to get worse if not treated.


Causes of Anxiety And Depression

Some people are more at risk of getting anxiety attacks, as well as depression. A history of either of the conditions in the family can predispose you to also be affected. Sometimes, anxiety is triggered by an event outside the control of the affected person. A terminal illness or death of a close friend or relative can cause a high level of anxiety and later, depression. Other situations like a serious illness, an accident, divorce, separation or drug abuse can also lead someone to experience anxiety and depression.

Clinical depression can be expressed in anxiety attacks. Continuous anxiety can also lead to depression. This has led some psychiatrists to view the two conditions as different sides of the same coin. With anxiety, one will live in fear of bad occurrences happening in the future; whether in an hour or year to come. Depression, in some cases, can manifest itself as a feeling of giving up because you do not think you can cope. This can sometimes lead to self-destructive behavior whose consequence could turn out tragic as in the case of suicide.


What Is Comorbidity?

Comorbidity refers to a situation where a person has both anxiety and depression. An example is persons suffering from Post-Traumatic Stress Disorder (PTSD) whose anxiety attacks could develop into depression.


Signs And Symptoms Of Anxiety And Depression

  • Unrelenting, irrational fear and worry
  • Insomnia
  • Erratic eating habits that could include bingeing and self-starvation
  • Memory difficulties, erratic decision-making, difficulties with attention
  • Feeling tense
  • Panic attacks
  • Constant fatigue and irritability
  • Loss of interest in social activity and hobbies
  • Sadness and feeling of loss of worth
  • Physical symptoms include headaches, rapid heartbeat, sweating, abdominal pain, and labored breathing


Because depression and anxiety are related conditions, the two conditions require a treatment regimen that addresses both. A suggested treatment often entails a combination of medication, exercise, therapy, relaxation techniques, and support groups.



A good number of people who come to see me have already tried a number of the non-medication alternatives and have not received enough relief from symptoms. Medication can be used to manage the symptoms of anxiety or depression. Often, the same drugs are used for both conditions. The main effect of the medication is to help you to relax and not feel so sad or anxious.

An experienced psychiatrist will prescribe the best pharmacological treatment in addition to the lifestyle changes recommended. Ruling out biological causes of the presentation, such as thyroid disorders, vitamin deficiencies, or inflammation should be part of an initial evaluation so they can be addressed as part of a comprehensive treatment. The pharmacological treatment requires frequent visits at least initially to determine what are the best options since there are different classes of agents that can be used in addressing anxiety and depressive symptoms. Some of the medications used to treat anxiety could be addictive and need consistent monitoring to detect early signs of developing tolerance. In that case, the psychiatrist will discuss further options for treatment.

Medication for both depression and anxiety symptoms include SSRI (selective serotonin reuptake inhibitor) and SNRI (serotonin-norepinephrine reuptake inhibitor). Your psychiatrist can review with you the advantages and possible side effects of various medications to come up with a treatment that is best for you.


Therapy For Anxiety And Depression

There are a number of treatments for these conditions. Interpersonal therapy improves your ability to relate to other people through developing your communication and other social skills. Problem-solving aims to give you the skills needed to handle your symptoms. Exposure therapy aims to have a person confront their fears by being exposed to the situations or people that trigger their anxiety attacks. This is done gradually so that you can develop coping mechanisms.
Cognitive behavioral therapy (CBT) involves the therapist helping you to change your thoughts and actions. By taking charge of your emotions, you are empowered to control your fears and anxieties since you learn to identify what causes them. The CBT approach is one of the best treatment options if performed well and in accordance with a set of procedures. People who get treated using this method are also less likely to relapse because of the sense of responsibility it develops.



It is well known that exercise leads to a change in your mood. It can also bolster your self-esteem and confidence, which in turn can have a positive impact on how you relate to others. Endorphins, the feel-good chemicals in the brain can be released by exercise. For this reason, mild to moderate depression can be impacted by the use of workouts. The best approach is to have a regular high energy exercise program. Joining a group or friends for exercise can also be beneficial in offering support and motivation.


Relaxation Techniques

Meditation is a good way to cope with anxiety attacks. Learning yoga and deep breathing can help one keep anxiety under control. Meditation can also help you to replace the images that cause your anxiety with more calming and self-soothing alternatives. Other people find repeating mantras (usually any repeated word or phrase) helpful in gaining more control of their response to anxiety. Mantras are sacred statements, sounds or group of words in Sanskrit that practitioners believe to bear spiritual and psychological powers.


Diet And Mental Illness

A healthy diet and a regular meal plan are important for your physical and mental health. Anxiety or depression can manifest in seeking comfort from eating. Eating any foods you like can activate the release of endorphins in the brain, and can lead to compulsive eating so it is important to be on a regular schedule and maintain a healthy diet. The other extreme is where depression makes you think that you look overweight and unattractive. If you have feelings of worthlessness, shame, and sadness directly coming before or after binges you may want to seek help and be evaluated for an eating disorder.


Get Support

Family and friends can be helpful in facing the challenges stemming from anxiety or depression. It can sometimes help to inform them of your condition if you feel they can offer support and encouragement. Some people also opt for support from the community, such as church groups, clubs. If your depression is linked to drug or alcohol addiction, groups such as the Alcoholics Anonymous can also provide support.

What You Can Do

Other than the assistance you receive from professionals, you can also carry out some activities to lessen your depression or anxiety. These could include:

    • De-cluttering your life and physical surroundings. This will help keep the feeling of being overwhelmed to a minimum.
    • Get involved in a purposeful activity. A purpose helps you focus your energies and can remove the hopelessness.
    • Set new achievable goals to keep your mind away from thoughts of failure. Create a plan that can be broken down into achievable steps.
    • Creative activity such as painting, writing, crafts, or even reading is also constructive and can improve your self-worth.

If you are experiencing any of the symptoms mentioned above we recommend you speak to your primary care doctor to rule out a medical condition and get a referral to a trained mental health professional. If you live in the Houston area and need any assistance, feel free to contact us at 713-426-3100.



How Anxiety and/or Depression Comes With ADHD

Comorbidity of ADHD and Anxiety or Depression

ADHD Depression

People often picture a person with ADHD as someone who is extremely hyperactive. They rarely picture someone who is anxious or depressed. However, a person who suffers from ADHD and anxiety and/or depression is a common scenario. Anxiety and depression are often comorbid with ADHD, which means they often occur in conjunction with ADHD. Adults with ADHD are mostly the ones who suffer from anxiety and/or depression simultaneously. The symptoms of ADHD in adults include:

• Impulsiveness
• Trouble listening and focusing
• Interrupting other people’s conversations or activities
• Excessive talking
• Restlessness
• Getting easily distracted
• Fidgeting
• Forgetfulness of important information
• Losing essential items
• Has a strong disdain of work, school, driving, or other activities that require extensive focus and sitting.

Diagnosing Anxiety and/or Depression with ADHD

Diagnosing someone who has ADHD with anxiety and/or depression can be complicated because anxiety and ADHD share many symptoms. When mental health professionals are questioning whether an ADHD patient is suffering from anxiety and/or depression in conjunction with ADHD, they need to consider two factors:
• Whether or not the patient’s symptoms are severe enough to be indicative of a coexisting disorder.
• Whether or not the patient’s symptoms will improve if treated for anxiety and depression.

Why Anxiety and Depression Tend to Be Comorbid with ADHD

The distress caused by ADHD symptoms can often lead to anxiety and depression. Though hyperactivity tends to cease once an ADHD sufferer reaches adulthood, many of the symptoms such as impulsiveness and trouble focusing linger if the ADHD is untreated or improperly treated, which will cause an ADHD sufferer to struggle with everyday life. An example of ADHD symptoms causing anxiety is a college-aged ADHD sufferer being anxious about their academic performance because he or she has trouble focusing on studying and has trouble remembering important details. An example of ADHD symptoms causing depression is an ADHD sufferer being depressed because he or she does not have any friends due to struggling with interrupting others and talking a mile a minute.

People can easily be misdiagnosed with ADHD when they actually have anxiety and/or depression because ADHD, anxiety, and, depression because of the similarity of the symptoms. In addition, anxiety and/or depression can give the illusion of a more severe form of ADHD. Once it is established that a patient has anxiety and/or depression that is comorbid with ADHD, it is possible that it will be discovered that his or her case of ADHD is not as severe as previously thought.

The Best Treatment for Anxiety and/or Depression that is Comorbid with ADHD

A mental health professional will take one of two approaches to treating anxiety and/or depression that is comorbid with ADHD, depending on the patient’s unique case:

• If the anxiety and/or depression is caused by ADHD symptoms, the mental health professional will focus on managing the ADHD before addressing the anxiety and/or depression.

• If the person was misdiagnosed with ADHD or the anxiety and/or depression significantly worsens the case of ADHD, the mental health professional will focus on managing the anxiety and/or depression first. If the person still has ADHD, the mental health professional will address the ADHD after the anxiety and/or depression is under control.
ADHD and anxiety treatment or ADHD and depression treatment can consist of a medication and other methods of treatment. The best treatment for comorbid ADHD and anxiety and/or depression is an integrative approach that combines medication and non-medication methods. Medication is helpful in the short-term while the person is learning non-medication methods to managing their ADHD, anxiety, and/or depression for the long-term. The different treatments for comorbid ADHD and anxiety and/or depression consist of:

• Medication (benzodiazepines, anti-depressants, serotonin, beta blockers, stimulants)
• Cognitive Behavioral Therapy (CBT)
• TMS Therapy
• Relaxation techniques (deep breathing, yoga, meditation, etc.)
• Hypnosis
• Journaling
• Identifying triggers
• Lifestyle changes (getting enough sleep, adhering to a schedule, diet, and exercise).

Proper Treatment is Key to Treating Comorbid ADHD and Anxiety and/or Depression

Mental health issues can be just as painful and serious as physical health issues. Living with ADHD by itself is a battle; therefore, living with comorbid ADHD and anxiety and/or depression is double the battle. Approximately eight million adults are living with ADHD in the United States of America. Sixty percent of those eight million adults have a comorbid condition, so sufferers of comorbid ADHD and anxiety and/or depression are not alone.

Proper ADHD and anxiety treatment or ADHD and depression treatment offer sufferers a chance of living a successful, fulfilling life. Effective treatment is the key to success, and effective treatment comes from an effective mental health professional. In addition, a strong support system of family and friends is helpful. Sufferers of comorbid ADHD and anxiety and/or depression are not different, less, or mentally ill; they simply have a struggle just like everyone else in the world. Recovery is possible for those struggling with comorbid ADHD and anxiety and/or depression.

Midtown Psychiatric and TMS center is a mental health clinic that is located in Houston, Texas. Our staff is a group of knowledgeable, caring individuals who are committed to using the best treatment for ADHD and other mental health disorders. Give us a call at 712-426-3100 or visit our website at https://www.midtownpsychiatrytms.com if you think we can help you.




ADHD Treatment For Children: What Works

Why And When Do We Need To Treat ADHD

ADHD Treatment For Children

Start With Your Primary Care Doctor

If you are concerned that you have ADHD or that your child has it, the first step is to talk to a professional. We recommend that you speak with someone who has experience assessing and treating ADHD and who can do a thorough assessment. These professionals include psychiatrists, psychologists, psychiatric nurses, and social workers.

Diagnosing ADHD

The process of diagnosis is one of exclusion, because many other disorders such as anxiety, depression, or sleep disorder can have similar symptoms.
Psychological testing is not required to make the diagnosis. The AAP (American Academy of Pediatrics), APA (American Psychiatric Association) and AACAP (American Association of Child and Adolescent Psychiatry) guidelines recommend that the healthcare professionals ask the patient, the parents, the teachers or other adults involved in the interactions with the patient about changes in the behavior in at least two areas (for school age children it is at home and at school).

ADHD and Executive Function

By and large ADHD can be conceptualized as a disorder of “executive function.” Individuals with ADHD show a reduced ability to exert and maintain cognitive control of their behavior. Compared to their peers, individuals with ADHD have a lower ability to react to insignificant external or internal stimuli. The MRI studies of individuals with ADHD show thinning of the cortex in the areas associated with working memory and attention. (Molecular Neuropharmacology; Nestle, Hyman 321-323).
ADHD is diagnosed based on the DSM 5(Diagnostic and Statistical Manual of Mental Disorders, 5th edition) diagnosis criteria. Here are the criteria below in shortened form. Please note that they are presented just for your information and not to be used for self-diagnosis. Only trained health care providers can properly diagnose or treat ADHD.

DSM-5 Criteria for ADHD

People with ADHD show a persistent pattern of inattention and/or hyperactivity–impulsivity that interferes with functioning or development in these areas:

1. Inattention: Six or more symptoms of inattention for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of inattention have been present for at least 6 months and they are inappropriate for developmental level:
o Often fails to give close attention to details or makes careless mistakes in schoolwork, at work, or with other activities.
o Often has trouble holding attention on tasks or play activities.
o Often does not seem to listen when spoken to directly.
o Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (e.g., loses focus, side-tracked).
o Often has trouble organizing tasks and activities.
o Often avoids, dislikes, or is reluctant to do tasks that require mental effort over a long period of time (such as schoolwork or homework).
o Often loses things necessary for tasks and activities (e.g. school materials, pencils, books, tools, wallets, keys, paperwork, eyeglasses, mobile telephones).
o Is often easily distracted
o Is often forgetful in daily activities.

2. Hyperactivity and Impulsivity: Six or more symptoms of hyperactivity-impulsivity for children up to age 16, or five or more for adolescents 17 and older and adults; symptoms of hyperactivity-impulsivity have been present for at least 6 months to an extent that is disruptive and inappropriate for the person’s developmental level:
• Often fidgets with or taps hands or feet, or squirms in seat.
• Often leaves seat in situations when remaining seated is expected.
• Often runs about or climbs in situations where it is not appropriate (adolescents or adults may be limited to feeling restless).
• Often unable to play or take part in leisure activities quietly.
• Is often “on the go” acting as if “driven by a motor”.
• Often talks excessively.
• Often blurts out an answer before a question has been completed.
• Often has trouble waiting his/her turn.
• Often interrupts or intrudes on others (e.g., butts into conversations or games)

In addition, the following conditions must be met:
• Several inattentive or hyperactive-impulsive symptoms were present before age 12 years.
• Several symptoms are present in two or more setting, (such as at home, school or work; with friends or relatives; in other activities).
• There is clear evidence that the symptoms interfere with, or reduce the quality of, social, school, or work functioning.
• The symptoms are not better explained by another mental disorder (such as a mood disorder, anxiety disorder, dissociative disorder, or a personality disorder). The symptoms do not happen only during the course of schizophrenia or another psychotic disorder.

Types Of ADHD

Based on the types of symptoms, three kinds (presentations) of ADHD can occur:
Combined Presentation: if enough symptoms of both criteria inattention and hyperactivity-impulsivity were present for the past 6 months
Predominantly Inattentive Presentation: if enough symptoms of inattention, but not hyperactivity-impulsivity, were present for the past six months
Predominantly Hyperactive-Impulsive Presentation: if enough symptoms of hyperactivity-impulsivity but not inattention were present for the past six months.
Because symptoms can change over time, the presentation may change over time as well.

ADHD in Adults

ADHD often lasts into adulthood. About 65% of individuals diagnosed as children with ADHD will have persistent impairing symptoms by age 25. (Parikh MD, Baker, MD Adult ADHD: Pharmacology in the DSM -5 era, Current psychiatry, Oct 2016)

Changes In The DSM-5

The fifth edition of the DSM was released in May 2013 and replaces the previous version, the text revision of the fourth edition (DSM-IV-TR). There were some changes in the DSM-5 for the diagnosis of ADHD:
• Symptoms can now occur by age 12 rather than by age 6;
• Several symptoms now need to be present in more than one setting rather than just some impairment in more than one setting;
• New descriptions were added to show what symptoms might look like at older ages; and
• For adults and adolescents age 17 or older, only 5 symptoms are needed instead of the 6 needed for younger children.

Obstacles In The Treatment OF ADHD

One of the obstacles I see in my practice to effectively treat ADHD is the fear of addiction to the medication. This is a myth. In fact, a multi-cohort national study sampling of about 40 000 individuals, recently published in the journal of the AACAP in June 2016 showed that starting the treatment for ADHD early and continuing it for more than 6 years was associated with a rate of substance use which was lower than in the general population. Also, individuals who started the treatment later, and taking the medication for less than 2 years had similar rates of substance use with the general population.

Relative immaturity is one of the challenges that ADHD brings with it. It has been shown that children and adolescents with ADHD tend to be less mature than their peers. (JACCAP 2016;55(10):886-895). The female gender is more protected against developing ADHD than the male gender (JAACAP 2016;55(6):504-512), and that also explains the higher prevalence in males than in females.

ADHD Treatment

1. Medications
a. amphetamine preparations come in short acting and long acting formulations that can be combined according to the individual response. They act through increasing the release of norepinephrine and dopamine that are essential for the frontal brain circuits.
b. methyphenidate preparations also come in short and long acting formulations. Together with the amphetamines they are by far the most effective medications for ADHD. They have common side effects such as insomnia, decreased appetite, growth delay. Combining them would increase the likelihood of the side effects.
c. atomoxetine increases the availability of norepinephrine, is not as effective as a stimulant and can be used as an alternative for people who do not tolerate the amphetamines or methylphenidine.
d. alpha-adrenergic agonist, clonidine and guanfacine also have short and long acting formulations, and can be used by themselves or in combination with the stimulants;
e. bupropion, considered a third line of treatment for individuals who do not tolerate the amphetamines or methylphenidate or can be added to them to enhance the response.

2. Neurofeedback
Evidence from well-controlled studies failed to support neurofeedback as an effective treatment for ADHD (Cortese and collab JAACAP 2016;55(6):444-455).

3. Brain Training Games
Brain training games did not gather solid scientific evidence that it works for ADHD, however these programs are early in their development and it is believed that the future will bring new possibilities. At the present time they are being used for cognitive rehabilitation. (Psychiatric Times, June 2014: The Evidence and Application of Brain Training Games: Science or Sales, Larry Brooks).

Myths About The Treatment Of ADHD

(Strawn, MD/Current Psychiatry October 2016)
1. Contrary to the popular belief that treatment with stimulants would worsen anxiety, a meta-analysis of about 3000 patients showed that a stimulant treatment has a low relative risk for anxiety and many patients experience improvement in their anxiety while some of them could experience an increase in anxiety level.
2. A meta-analysis of 22 studies including 2400 patients showed a lack of association between stimulant treatment and a new onset or worsening of tics despite the ‘contraindication’ included in the package insert.
3. Polypharmacy(the simultaneous use of multiple drugs to treat a single ailment or condition) in ADHD is beneficial because it allows synergistic effects of different medications and does not represent a treatment ‘failure’.

Consequences Of Not Treating ADHD

Here is what the research says about the consequence of not treating ADHD.
1. School failure, peer rejection, and subsequent association with a delinquent peer group can increase the likelihood of substance use, especially in the presence of comorbid conduct disorder (Molecular Neuropharmacology, Nestle, Heyman pg 321-323)
2. ADHD in childhood and adolescence predicted homelessness in adulthood, maybe partly for the high degree of comorbidities with conduct, SUD, arrest, and school dropouts. (Garcia Murillo and colab/JAACAP 2016;55(11):931-936
3. The degree of severity of ADHD symptoms in adults is related to not addressing the symptoms during childhood. In other words, treating ADHD during childhood and adolescence minimizes the symptoms persistent into adulthood. (Roy and colab JCAAP 2016;55(11):937-944
4. Adult functioning is worse, when less ADHD symptoms persist from the adolescence period. (Hechtman, MD and collab/JAACAP 2016;55(11):945-952). It is important to identify ADHD symptoms early and intervene in a timely manner to promote better functional outcomes
5. Adults with ADHD have more traffic violations and accidents and a higher rate of incarcerations and convictions
6. A mortality rate almost 2 times higher with great differences in suicide and accidents (Parikh, Baker Current Psychiatry 2016, October)

Further References
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th edition. Arlington, VA., American Psychiatric Association, 2013.
CDC website: https://www.cdc.gov/ncbddd/adhd/diagnosis.html

Get Help For The Warning Signs Of Depression And Suicide In Children And Young Adults

Suicide Is The Number One Cause Of Death In Young People


Sadly, suicide is the number one cause of death in young people, 15-24 years old, and by 2020 depression will become the number one cause of disability worldwide. It should be noted that 1 in 5 teens will suffer from depression before they reach adulthood. And In 2014, around 15.7 million adults age 18 or older in the U.S.A had experienced at least one episode of major depression in the past year. This represented 6.7 percent of all American adults.

Communicate With Your Child Openly

It is a common belief that if you ask someone if they are considering suicide, you may actually instill that idea in them. However, it has been found that being open and unafraid of inquiring about it when somebody seems depressed might be the only way to get help, and therefore, be more likely to prevent suicide.

A Window Of Opportunity

In the mind of the patient suffering from depression, there is a window of opportunity that allows for intervention. It is during this time that a decision to do something to kill themselves has not been made yet. Teenagers, as we all know, have a more difficult time to talk about how they feel than adults. The most common answer to the question ‘how was your day?’ is typically ‘fine’. That is a normal response from a teenager who is preoccupied with his or her own developmental challenges. However, that should not discourage parents to ask questions which can create opportunities for a dialogue to occur. Just because your teen might signal that he or she does not want to talk about things that preoccupy them- does not mean that you, as a parent, must accept the notion that there is nothing to talk about.

Your Attitude About Psychiatric Treatment Makes A Difference

Before I review several signs that could alert parents that something more serious than normal development may be happening with their teen, I have to share some of my concerns about parents’ attitude with regard to psychiatric treatment.  More often than not, your child will mimic your attitude about mental illness, and model your understanding and acceptance of it. When you, as a parent, have been disparaging about people with mental illness and/or treatment of it, either denying its existence or denigrating those with mental illness who seek help as weak- do not be surprised to learn that your child might not be forthcoming with their feelings or concerns.

Young Adult Body And Mind Changes

Because young adults are still growing and developing, many teens and young adults do not have the language necessary to discuss their emotional states in words. Especially with their parents, teens are even more unlikely to talk about their insecurities or feelings for fear of being considered ‘crazy’, or ‘weak’ or ‘not worthy’ of your love.

Play It Safe-Take Your Child Seriously

Unfortunately, I see way too many parents who do not take seriously their children’s complaints of sadness, lack of interest, energy or extreme worries. These symptoms need to be evaluated by a professional to explore their seriousness so that, if needed, they can be addressed in treatment; either with medication, therapy, or both. Since parents are the decision makers in the administration of their children’s treatment- they need to keep in mind that they are not the ones who are directly experiencing the pain of depression, anxiety or other mental illness.

Resources That Can Help Your Child

A good resource for understanding when to become concerned about your teen is the ‘Facts For Families,’ guide which details the signs that could alert a parent about the possibility of a suicide. These are as follows:

  • change in eating and sleeping habits
  • withdrawal from friends, family, and regular activities
  • violent actions, rebellious behavior, or running away
  • drug and alcohol use
  • unusual neglect of personal appearance
  • marked personality change
  • persistent boredom, difficulty concentrating, or a decline in the quality of schoolwork
  • frequent complaints about physical symptoms, often related to emotions, such as stomachaches, headaches, fatigue, etc
  • loss of interest in pleasurable activities
  • not tolerating praise or rewards

As it is noted in the ‘Facts for Families’ guide, the above are also signs of depression and the parents should attempt to get help to prevent a suicide attempt by getting the teen or young adult to participate in a psychiatric consultation.

Other Signs To Look For In Your Child

There are some other changes to look for in your child that may signal imminent danger. These include teen or young adult communicating the following thoughts:

  • complain of being a bad person or feeling rotten inside
  • give verbal hints with statements such as: I won’t be a problem for you much longer, nothing matters, It’s no use, and I won’t see you again
  • put his or her affairs in order, for example, give away favorite possessions, clean his or her room, throw away important belongings, etc.
  • become suddenly cheerful after a period of depression
  • have signs of psychosis (hallucinations or bizarre thoughts)

There Is Hope If You Take Action

What is important to know, and to remember, is that depression is a treatable disorder, and so is suicidal ideation, as long as we act fast. As I mentioned above, we must act within the window of time that precedes the decision to move from suicidal ‘idea’ to ‘plan’.  As also previously stated, once the teen has made the decision to kill himself or herself, their mood usually lifts, becomes less obviously gloomy and more peaceful. This is not an unusual behavior for people, adults or teens alike, who shift their mindset from ‘contemplative’ or more ‘passive’ thoughts of death to an actual active plan for completion of the suicidal act. The bottom line here is that you don’t have to make this decision as to what is safe or not by yourself. It is better to err on the side of caution and discuss with your child the decision to have them evaluated, not as a punishment, but, as a way to help them sort out their thoughts and feelings and begin to find ways to make them feel better.





Same Sadness, So Why Different Types Of Depression?

If It’s The Same Sadness, Why Are There Different Types Of Depression?

And How Does This Affect Your Treatment?

By Daniela M. White, MD

 depression treatment houston


It Is The Same Illness, So Why Different Medications?

I’m sure that some of you wonder that after seeing your psychiatrist that you received a different medication than your friend, coworker, or even family member. You have many of the same complaints of feeling sad, lacking interest and the energy to do much, isolating, crying at the drop of a hat and having ruminating bad thoughts that sometimes life is not worth living. You appear to have the same feelings, the same complaints, but are receiving different treatments and sometimes, a different diagnosis. This article describes why this might be the case.
From the beginning, it is worth noting that feeling sad, and crying when something bad and unexpected happens is perfectly normal, and oftentimes is expected.  Feeling of sadness by themselves, does not result in a diagnosis of clinical depression, unless several conditions are met at the same time.


Different Types of Depression

Even if the criteria for clinical depression is met, there are different types of depression, and they need to be approached with different treatments to obtain a response and eventually remission.

Response, in clinical terms, means that the treatment provides some relief.

Remission means that the symptoms become absent.


What is The Commonality Within A Depression Diagnosis?

In all the different types of depression, sadness is the main complaint, usually associated with low self-esteem, sometimes irritability and difficulties enjoying life and increased tendency to cry very easily. However, there are differences in duration, intensity and severity as well as the way these episodes are triggered that make the diagnosis and therefore treatment, different.

According to the Mayo Clinic, to get a diagnosis of clinical depression, one must meet the symptom criteria for major depressive disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM), which is published by the American Psychiatric Association. The DSM is also used by mental health providers to provide a diagnosis of mental health conditions and by insurance companies to provide reimbursement for mental health treatment.

To get a diagnosis of clinical depression, you must have five or more of the following symptoms over a two-week period, most of the day, and nearly every day. At least one of the symptoms must be either a depressed mood or a loss of pleasure or interest. Signs and symptoms may include the following:

  • Depressed mood, such as feeling sad, empty or tearful (in children and teens, depressed mood can appear as constant irritability)
  • Feelings of worthlessness, or excessive or inappropriate guilt
  • Fatigue or loss of energy
  • Significantly reduced interest or feeling no pleasure in all or most activities
  • Insomnia or increased desire to sleep
  • Significant weight loss when not dieting, weight gain, or decrease or increase in appetite (in children, failure to gain weight as expected)
  • Either restlessness or slowed behavior that can be observed by others
  • Trouble making decisions, or trouble thinking or concentrating
  • Recurrent thoughts of death or suicide, or a suicide attempt

For a diagnosis of clinical depression, your symptoms must be severe enough to cause noticeable problems in relationships with others, or interfere with your day-to-day activities, such as school, work, or social activities. Symptoms may be based on your own feelings, or on the observations of someone else.

Clinical depression can affect people of all ages, including children. However, clinical depression symptoms, even if they are severe, can usually get better with counseling, antidepressant medications or a combination of the two.


Types of Depression Diagnoses

The following list of diagnoses that most mental health clinicians might choose from when determining a diagnosis. The diagnosis is important because proper treatment depends on an accurate diagnosis:

  • Persistent Depressive Disorder (or dysthymia): 
  • Major Depressive Disorder, unipolar
  • Bipolar disorder, Depressed (bipolar disorder I, II and cyclothymia
  • Postpartum Depression
  • Premenstrual Dysphoric Disorder
  • Adjustment Disorder with depressive symptoms
  • Bereavement
  • Depression secondary to medical conditions
  • Substance Induced Depression

As an example of the difference between two types of depression, a lot of times people who have bipolar disorder spend most of their sick time depressed and not hypomanic, or in a state of elation. However, the treatment for a depressed episode of a bipolar disorder is typically a mood stabilizer and not an antidepressant that might make symptoms worse.  Having one episode of mania or hypomania, indicates a diagnosis of bipolar disorder and the treatment should focus on that, avoiding as much as possible an antidepressant without a mood stabilizer to start with.


How To Get The Most Out Of An Appointment With Your Care Provider

The best thing that a patient can do is to be as open as possible during the psychiatric evaluation and be willing to work with your doctor without leaving information out that might be essential not only in treating the symptoms but to avoid causing new ones.


Diagnoses Can Change Over Time

It is also worth remembering that your initial diagnosis is a working one that can evolve over time as more clinical information becomes available from the sessions. It is also important to see your psychiatrist often before the diagnosis is fully defined and until remission is achieved.


See Your Doctor And Psychiatrist Regularly, Even If You Are Feeling Better

Your primary health care and mental health care should be given in a coordinated manner. That is to say, your primary care doctor and mental health provider should be aware of the care the other is providing.  If you haven’t already done so, and you are feeling sad or depressed, we recommend that you first speak with your primary care doctor and get a complete physical exam. The goal of the physical exam would be to try and rule out a physical cause for your depression. During the physical exam, the doctor typically will focus on the most likely causes of depression, the endocrine and neurological systems of your body. The doctor will look for any health concerns that may be contributing to clinical depression symptoms. For example, hypothyroidism is typically caused by an under-active thyroid gland. The under-active thyroid is the most common medical condition that is associated with symptoms of depression. Other endocrine disorders that are associated with depression include hyperthyroidism, caused by an overactive thyroid, and Cushing’s disease, which is a disorder of the adrenal gland. Oftentimes, treating these issues can alleviate symptoms of depression. Also, your doctor might look at other medications that you are taking to see if any of the side effects include depression.

Not seeing your treating physician and mental health care provider regularly can leave side effects unaddressed or allow symptoms to progress or worsen.


Monotherapy Vs. Combination Drug Therapy

There are multiple medications and therapies now available. In psychiatry for bringing mental illness to remission, and it is not uncommon to try several medications before finding one or more that are effective. Combination drug therapy is a type of treatment that many doctors and psychiatrists have been increasingly utilizing during the past decade, especially for Major Depressive Disorder, where there is some research to suggest that taking antidepressants from multiple classes may be the best way to treat Major Depression.



Combination of Antidepressant Medications From Treatment Initiation for Major Depressive Disorder: A Double-Blind Randomized Study   Pierre Blier, M.D., Ph.D., Herbert E. Ward, M.D., Philippe Tremblay, M.D., Louise Laberge, M.D., Chantal Hébert, R.N., and Richard Bergeron, M.D., Ph.D.  March 1, 2010, American Journal of Psychiatry March 2010, Vol. 167, No. 3, pp. 281 – 288


http://www.webmd.com/depression/guide/depression-tests – 1