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.

 

References:

https://www.healthline.com/health/adhd-and-anxiety#overview1
https://www.medscape.com/viewarticle/736281
http://impactadhd.com/manage-emotions-and-impulses/recognize-treat-depression-anxiety-disorder-adhd/
https://adaa.org/understanding-anxiety/related-illnesses/other-related-conditions/adult-adhd

How Do Stress, Emotion, and Diet Affect the Gut?

Stress, Emotion, Diet and the Gut

dietstressgut

photo by Shira Gal

The Gut – Brain Connection

It has becoming more accepted in the psychiatric literature as well as in the functional medicine that there is a bidirectional connection between the brain (central nervous system) and the gut (the gastrointestinal tract) through endocrine pathways.

Stress Affects The Gut

Stressors of various nature, either psychological or physiological, can alter the gut microbiota’s composition and the changes in the microbiota, represented through metabolic activities can influence the brain response.1

Emotion and the Limbic System

The limbic system plays a central role in regulating emotion and also is the center of the gut control.2 The generation of emotions and attached physiological reactions are most likely generated at this brain level (a very primitive part of the brain).

Depression and The Gut

In more recent scientific communications it has been suggested that depression can promote intestinal permeability as a result of chronic inflammation leading to a condition known as ‘leaky gut’. Leaky gut is another name for intestinal hyper-permeability that allows different substances (such as toxins, microbes and undigested food particles) to pass into the blood stream.

Diet and the Gut

Diet plays an important role in addressing the condition, such as ingestion of probiotics and prebiotics. Probiotics are beneficial forms of gut bacteria that helps the intestine to function properly. Examples of probiotic foods include: yogurt, kefir, sauerkraut, dark chocolate, microalgae, miso soup, pickles, tempeh (made from soy, a great source of vitamin B12 too), kimchi (an Asian form of pickled sauerkraut), Kombucha (fermented tea). For those who don’t find any of these appealing, tablets of probiotics are also good.

Prebiotics and the Gut

The prebiotics are enzymes that help the good bacteria to grow in the intestine. They are found in asparagus, Jerusalem artichokes, bananas, garlic, onions, oatmeal and legumes. They are also available in forms of supplements.

Non-Celiac Gluten Sensitivity

Another source of interest in affective disorders as well as in autism, and schizophrenia has been the Non-Celiac Gluten sensitivity (NCGS). The literature and studies are limited on the subject but it has been suggested that there is a relationship between the NCGS and neuropsychiatric disorders. Some studies point at the inflammation triggered by the gliadin in people sensitive to it and the ‘leaky gut syndrome’ associated with it.  The IgA detected in affected individuals suggest an inflammatory response to the gliadin that is found in wheat, barley, rice, and an exclusion of these products could reduce the neuropsychiatric symptoms associated with the “leaky gut” (migraines, Irritable Bowel syndrome, tiredness, chronic fatigue, etc).3

Listen To Your Body

Because research on diet and gut is still in it’s infancy it is important that you monitor how you feel after you eat certain foods. Obviously, if a food makes you feel bad you can reduce or eliminate it and see how you feel.

Integrative Treatment in Psychiatry

We take an integrative treatment approach with all our clients because we believe that any treatment that we recommend should be based on a very thorough history, questionnaires, targeted laboratory testing, and results from a physical exam.

Examples of core imbalances we assess for include:

  • Structural, boundary, and membrane imbalances
  • Genetic Mutations
  • Psychological and Spiritual
  • Hormonal and neurotransmitter imbalances
  • Oxidation-reduction imbalances and mitochondrial dysfunction
  • Detoxification, neurotoxicity, and biotransformation imbalances
  • Immune imbalances (Cytokine hypothesis)
  • Inflammatory imbalances
  • Digestive, absorptive, and microbiological imbalances

If you like this article on How Do Stress, Emotion, and Diet Affect the Gut, or have questions, schedule your first session by calling us at 713.426.3100

 

References:

1 Inflammation:Depression Fans and Flames and Feasts on the Heat: Kiecolt-Glase PhD, and colab, Am J Psychiatry, 172:11, November 2015, pg 1075-1091

2 Brain–gut connections in functional GI disorders: anatomic and physiologic relationships: Jones, MD and colab, Neurogastrointestinal Motil, 2006, 18, 91-103.

3 Non-Celiac Gluten Sensitivity: The New Frontier of Gluten Related Disorders,  Catassi and colab, Nutrients 2013, 5, 3839-3853.

Can Exercise Help Depression?

Physical Activity and Lifestyle Changes as Adjunctive Treatment for Mental Illness

exerciseanddepressionWhen it comes to helping people cope with depression, the most commonly recommended treatments for most are usually either therapy alone, or counseling combined with prescription medications. These forms of treatment are often effective in helping people to manage the symptoms.

Research on Depression: What Works?

However, research on depression, anxiety, and exercise shows that the psychological and physical benefits of exercise can also help reduce symptoms of depression and anxiety, and even help people manage other conditions such as diabetes, high blood pressure, and arthritis.

A study by S. Rosenbaum et al. published in the Journal of Clinical Psychiatry (Sept 2014) showed that physical activity reduced depressive symptoms in people with mental illness. Physical activity has been researched more in recent years showing that when incorporated in a holistic approach to the treatment of mental illness it has the result of augmenting the action of the antidepressants, and speeding up the response to treatment.

What I See In My Practice In Patients With Depression

While some studies suggest that exercise can be a substitute to the pharmacological treatment, what I found in my clinic is that only a certain subset of patients with depression respond to physical activity only; those with depression that is milder in severity. However for moderate to severe depression I find that the addition of exercise to the medication regimen and other changes in lifestyle, make the recovery more robust and sustainable.

Physical Activity Defined

Physical activity was defined for the purpose of the above study as ‘any body movement that is produced by the contraction of the skeletal muscles that increases body energy expenditure’ and exercise as ‘a subset of activities that is planned, structured, and deliberate’. The simplest form of regular exercise that could still make a change in the treatment of depression is walking at a brisk pace, for at least 25 minute a day for a minimum of five days per week.

Challenges for People With Depression

People who struggle with depression know that what may seem to be a simple task, taking a walk, or working out, becomes a difficult one. Especially those with moderate to severe depression, due to the fact that some of the common symptoms include: lack of initiative, decreased energy, difficulty making decisions, thoughts of life not being worth living, etc. These symptoms make taking that first step toward regular exercise extremely difficult.

More Challenges Seen In Depression

Another common form of resistance for those with depression is the reluctance to initiate a change, even one that could potentially be helpful. I hear a recurrent complaint of ‘the lack of time’. For the depressed patient in the midst of their depression, it becomes increasingly difficult to attend to the required activities of going to work, attending to the children, cleaning the house, and taking care of themselves. Usually, they are the last ones to take care of themselves, especially if they are feeling mentally tired and physically exhausted.

Ways to Break Through The Challenges of Depression

Get Support and Encouragement

 

Rather than add exercise as one more task to add to the ‘to do list’, what I find the most helpful is to ask the patient to rely on a friend or a family member to support and encourage them to set a goal and start working towards it.

Schedule Exercise; Start Small And Build

Usually, I recommend people start with just allocating 10 minutes a day in their daily schedule for ‘exercise’. Even for a short distance of 100 yards is enough to start, but keep the mind aligned with a final goal of walking 25 minutes at a brisk pace every morning, if possible. I ask them to start with this small step, dividing the main goal into smaller ones that are more easily attainable. Accomplishing a small task becomes rewarding, and initiating it is less overwhelming. What I found is that when the window of time allocated for exercise exists in one’s schedule, increasing the amount of time or the intensity of the exercise is easy to adjust in a stepwise approach.

Take Time For Yourself

We all know that we can best help others if we take care of ourselves- so it is important that we make the time for ourselves a priority. Walking is really helpful in increasing the sense of planning, and actually doing something for one self which is extremely healing for the depressed patient who perceives him/herself as not worth it, a burden, and contemplating death.

Take Time To Reconnect With Others

Walking can also provide distraction from our negative thoughts- especially when done with a companion. It helps create a sense of connection with people and with our surroundings as well.

Physical Effects of Exercise

When done at a fast pace, exercise increases the heart rate high enough to provide aerobic benefits, including the production of the endorphins that often help you feel happier and more relaxed. When exercising regularly, people also begin feel better about their appearance which can boost confidence and improve self-esteem. And most importantly, exercise improves your chances of living a longer and healthier life.

Holistic Approaches to Treatment; Other Ways to Manage Depression

In addition to exercise, I encourage my patients to consider other lifestyle changes that can help manage depression. These include healthy nutrition practices, getting good sleep, increasing their social support, and practicing stress reduction techniques. I will talk more about these practices in future articles. So to answer the question can exercise help depression, yes it can, but also explore other options to maintain improvement in mood, energy level, and overall health.

Contact us to learn more about can exercise help depression and treatment options by calling us at 713-426-3100.

 

 

References:

http://www.psychiatrist.com/JCP/article/Pages/2014/v75n09/v75n0915.aspx

http://www.mayoclinic.org/healthy-living/fitness/in-depth/exercise/art-20048389

Integrative Treatment In Psychiatry: A Path To Wellness

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Case Study N.Y.

Main Symptoms

When N.Y. 20, came in for an evaluation with her family, her main complaint was that she could not retain information and was worried about starting school and her performance in college. Her family noticed that she was also very tired, slept a lot and did not seem to follow through on her goals. She complained of very low energy and increased appetite, and was concerned about the weight that she gained and could not lose. She felt sad and worried most of the time- especially about her starting school again and not feeling up for it.

History

N.Y. was never seen by a psychiatrist before and was not aware of any mental illness running in her family. She had been a good student in her country of origin, came to United States when she was in 9th grade and once here, her academic performance gradually deteriorated. She found that she needed more time to accomplish her tasks; she was easily distracted in class, and seemed that she worked twice as hard as her peers to achieve the same results.

Diagnosis

During the first meeting with her-it became clear that based on the clinical history and the self-reported questionnaires that she was suffering from significant depression and anxiety symptoms. At the same time, while her concentration could have been impaired by the presence of an affective disorder, I considered the presence of a comorbid ADHD. At the same time, her lethargy, decreased energy and mental cloudiness could have been explained by an atypical form of depression but I was also concerned about the possible comorbidity with a thyroid deficiency, vitamins deficiencies, or anemia.

I created a customized treatment plan and discussed the plan with N.Y. and her family and decided to start the treatment for the most obvious complaint, the low depressed mood, and test for ADHD when the mood was better through a Continuous Performance test. At the same time, I recommended we run a set of lab tests to address possible biological causes of her symptoms.

The laboratory results confirmed my clinical suspicions by showing signs of microcytic anemia, and significant deficits in Vitamin D, B12, and folate, with an increased homocysteine level that is a marker for a generalized inflammatory state.

The Continuous Performance Test (CPT) test for ADHD showed that she was having a lot of difficulties with maintaining attention, and increased distractibility.

Integrative Psychiatric Treatment For N.Y.

We created a customized Integrative psychiatric treatment program which began to help N.Y. see improvements. N.Y. showed significant improvements on a combination of a medication (an SSRI) for her depressive symptoms and anxiety, Strattera (for ADHD) and targeted supplementation including Vitamin B12, Vitamin D, folate(Vitamin B9), and B-Complex. She was also referred for further testing and follow up with her primary care physician for her microcytic anemia. I also recommended that she start exercising by going for a walk regularly, at least 25 minutes a day at a fast pace. To help her lose the extra weight she wanted to lose we talked about her trying a low-glycemic index diet.

It is possible that with an improved regimen of regular exercise, improved nutrition and supplementation with the appropriate vitamins she might be able to get off the antidepressant in about 6 months. At that time- we plan on repeating the CPT test to assess her ability to concentrate on and off medication, and decide if further treatment is necessary.

Integrative treatment in Psychiatry is becoming more and more popular and effective because it provides a more comprehensive analysis of the potential factors that may influence an individual’s health and mental health. It also provides a more customized plan of treatment that incorporates the interplay of body, mind and spirit and therefore can be much more effective than traditional medicine which takes a narrower view.

If you like this article on integrative treatment in psychiatry, or have questions, schedule your first session by calling us at 713.426.3100.

WHAT IS INTEGRATIVE PSYCHIATRY?

integrative psychiatry treatment

 

Integrative Treatment in Psychiatry

Integrative psychiatry integrates traditional modalities of treatment (pharmacological agents, cognitive behavioral therapy, psychodynamic therapy) with complementary and alternative treatment approaches (CAM), attempting to create an individualized treatment approach that takes into account the individualized needs of the patient.

The classic treatment of depression, for example, would include pharmacotherapy and talk therapy. However, there are more facets that relate to its successful treatment, and resources that would be helpful to all patients struggling with depression, especially to those who encounter their own resistance to try medications or therapy.

Examples of Complementary Modalities of Treatment

For the minor to moderate depressive disorders, exercise has been proven to be an effective treatment if it’s done ‘effectively.’ Combining that, with a good nutrition and adequate supplements, will help the brain to restore adequate production and preservation of neurotransmitters (serotonine, dopamine, and norepinephrine) that are involved in mood modulation. The patient frequently hears their doctor’s advice on starting exercising, but frankly this task sometimes seems insurmountable to depressed patients who struggle with decreased energy, initiative and interest. It has also been shown that a person who has never had a rigorous or disciplined exercise schedule has a difficult time starting one. Therefore, it makes sense to receive that more detailed guidance at the same time as a prescription for medication or traditional therapy.

Most people also are told by their medical practitioner to maintain a “healthy diet.” However, unless the psychiatrist takes interest in understanding the patient’s eating habits and how they are affected by depression and goes through the education of how a poor diet delays the recovery from depression, most patients would not know where to start to make changes.

A Comprehensive Approach to Assessment

For the treatment of depression, besides just evaluating the way that the patient forms and maintains relationships and address that in traditional therapy, it would be equally as important to engage the spiritual resources, if any, that the patient has at his/her disposal. Sometimes participating in the religious rituals of the community can help speed recovery by providing a direction to the healing. We also explore resources like meditation and yoga to new a few.

Vitamin/Supplement Research and Depression

More studies show that there is a relationship between vitamin deficiencies and anxiety or depressive symptoms. For example, Vitamin D deficiency, along with B complex deficits are known causes for some of the symptoms we target with antidepressants. A significant number of depressed patients are testing positive for genetic mutations that prevent appropriate incorporation of folic acid in the metabolic process of manufacturing neurotransmitters. Therefore, it is important to identify this mutation, and if found, provide supplements with methylfolate that could be an easy treatment for refractory depression.

Other Non-Invasive Treatment for Depression

Along the same lines, light therapy and transcranial magnetical stimulation (TMS) are noninvasive methods of treatment for people who suffer from depression that traditional medications do not help, or create side effects. These non-invasive therapies would also make more sense for pregnant women, who are reluctant, for obvious reasons, to start antidepressants- especially in their first trimester of pregnancy.

Integrative Treatment Case Example

In summarizing with an example, the treatment for a moderate single episode of depression could change from an SSRI prescription and referral to weekly therapy, to a more individualized treatment plan that would include: Omega 3 supplements (fatty acids), tryptophan and 5 HTPT supplements, Vitamin B complex with or without vitamin D and/or B12 replacement therapy, a scheduled aerobic exercise 20-30 minutes a day for 5 days a week, dietary changes towards a more balanced approach of ingredients, light therapy ( for seasonal depression) or TMS therapy for patients who could not tolerate the medication’s side effects. Supplementing with SAMe, Methylfolate and NAC would also help to boost the initial response to the treatment as well.

If you like this article on what is integrative psychiatry, or have questions, schedule your first session by calling us at 713.426.3100.

Taking Care of Your Brain: What Does It Mean

Brain and Mental Health

Indisputably the brain is the master organ of the body, which holds the mapping of our daily functioning. Psychiatry treats the mental illnesses that result from its malfunctioning. There is an interesting relationship between the brain and the mind, so complicated that science can’t quite explain it the way it does with other organs of our body. The liver’s function as complex as it is, offers less unanswerable questions regarding its massive role in metabolism and digestion. The brain- mind connection is far less understood.

As complex as the issue is, one fact is certain: a physiological malfunction of the brain’s circuits produces alteration of the mind processes. We do know that if the norepinephrine, serotonin or dopamine driven circuits don’t work properly, people end up feeling sad, depressed or anxious, having negative thoughts, beliefs and outcomes.

The mind on the other hand can influence the way that people ‘navigate’ through the darkness of mental illness because the brain –mind connection, is a double way street: a positive mind setting

speeds up the recovery from a depressive or anxiety episode, and a healthy brain produces a healthy mind.

So, what can people do to keep their brain as healthy as possible?

  1. Exercise, especially aerobic releases body manufactured substances that improve the sense of wellbeing, increase energy, improve cognition, stimulate brain regeneration process ( BDNF,
  2. endocannabinoids, endorphins, different regenerative stimulating growth factors) .
  3. Healthy diet provide the right kind of proteins ( vegetable type protein), fatty acids, vitamins and amino acids that are needed in rebuilding the brain cells;
  4. Medication that have a targeted action at the receptor levels serotonin reuptake inhibitors, serotonin/norepinephrine reuptake inhibitors, etc
  5. Light therapy can help some forms of depression, such as the Seasonal type of Affective Disorders
  6. Neuromodulation: depressed patients who do not tolerate the medication side effects could achieve relief through Transcranial Magnetical Stimulation, ECT or vagal nerve stimulation.

So what can people do to keep their mind healthy or to heal from anxiety and depression?

  1. Meditation helps to give the brain a break from daily worries triggered by real or perceived problems;
  2. Spirituality helps by making people feel part of the bigger universe, relieving them from mundane struggles;
  3. Positive programing, i.e. NLP techniques helps by replacing negative expectations with positive ones through reframing;
  4. Therapy: cognitive, insight oriented, individual therapy, etc helps addressing the cause or the pathological responses to the stress

The possibilities of creating an individualized approach and treatment are multiple when the individual needs of the patients are taking into account. The best way to create a successful treatment program is to seek professional help from a psychiatrist or licensed therapist as soon as symptoms appear (sadness, irritability, inability to enjoy life etc). Waiting too long makes it more difficult to get to a remission state.

If you like this article on taking care of your brain, or have questions, schedule your first session by calling us at 713.426.3100.

Case Studies: Integrative Treatment In Psychiatry

How To Treat the Patient AND Address the Diagnosis

 

The Integrative Treatment Model

integrative treatment

When James came to see me for the first time he was accompanied by his wife. When an adult brings their spouse with them at the first visit with the psychiatrist, it almost always means that things are not going well. As they sat on the couch next to each other, I knew James’ wife, Mary, was a strong emotional support for him and that she was there to make the message to me more compelling: James needed help, and he needed it fast!

I noticed that James moved very slowly, with reduced balance of his arms while walking, but as he sat down, he started moving his right leg in a fast, tapping motion.

I heard from James that he was highly functional until three years ago, when he started declining, feeling depressed and losing his ability to enjoy things. His wife Mary told me she noticed a marked change from his usual bubbly personality. During the last three years he had two psychiatric hospitalizations, tried ‘many medications’ and was engaged in weekly therapy.

Referral for Transcranial Magnetic Stimulation (TMS)

Due to his lack of response to medications, his therapist referred him to me to evaluate James for possible Transcranial Magnetic Stimulation (TMS) treatment. His therapist told me on the phone that James was so depressed and that nothing seemed to help him and she did not know what else to suggest.

 

Integrative Treatment Model Assessment

For all my patients, I do a thorough assessment that looks at many physical and mental health issues, so that I can rule out possible medical and health issues that could be contributing to symptoms. This approach is called an Integrative Treatment Model. As part of my integrative treatment assessment, I began to explore whether there was an organic cause to any of his symptoms. Both James and Mary assured me that he was recently evaluated by his Primary Care Physician, who told him that everything was normal, and prescribed him Xanax to help him manage his anxiety. Mary was very concerned that for a period of time, James was taking three of them every day, and she was concerned that he was developing an addiction because he was waking up in the middle of the night to take more pills. James on the other hand, told me that the Xanax was the only thing that was helping him to stop his leg from moving. James reported being very bothered by the fact that his leg would start shaking uncontrollably the moment he woke up in the middle of the night. To prevent him from abusing the Xanax, Mary and James decided she would dispense the Xanax as prescribed. James medication was Prozac 20 mg once daily, Seroquel 100 mg once daily and Xanax 1 mg twice a day.

 

The Correct Diagnosis Leads To The Best Treatment

My initial thoughts in regard to his correct diagnosis were multiple and varied covering different areas, including a neurological condition, a possible bipolar disorder, or a withdrawal from benzodiazepines.

I began to explore a detailed history with James to try to understand what might be causing his symptoms. The more I learned about James‘ depression, the more I believed that it fit the diagnosis of bipolar disorder. This diagnosis was communicated to him in the past, by previous treatment providers, but his current treatment regimen was not adequately addressing his depression.

His cognitive abilities, as seen by a mental exam were too impaired for his age, and for somebody who was very successful in sales, and I was extremely concerned about an early onset of a neuro-degenerative disorder.

I also explored a possible correlation I observed with bipolar disorder or major depression disorder, which results in a highly inflammatory state. This inflammation has been reported, more and more in the recent research and scholarly journals, and so I requested a blood test that would help us understand what might be going on.

 

Treatment Based On The Assessment

Both James and Mary felt very pressed by time because James’ poor performance at work was jeopardizing his job. They were convinced that if his condition were not addressed correctly he would soon become unemployed. They really wanted him to try Transcranial Magnetic Stimulation, but that intervention did not seem to be indicated given the fact that James’ diagnosis was not Major Depressive Disorder, the only diagnosis for which there has been FDA approval for TMS treatment.

My decision was instead to initiate Lithium treatment as a good mood stabilizer. James had not tried this medication in the past, and it is a good antidepressant for bipolar disorder, especially in the depression phase. I also ordered more lab work to rule out some other issues I observed. The blood work came back with very low levels of testosterone, very low levels of vitamin D, high cholesterol, and Triglycerides, high homocysteine levels, and very low therapeutic level of Lithium.

Over the next month, with regular visits every couple of weeks, and numerous calls to my office requiring reassurance, James received testosterone supplementation, vitamin D supplementation, folate, zinc and magnesium supplementation ( to address the high homocysteine levels). I also made adjustments of his lithium dosage until James got to the best therapeutic level of lithium. At the same time, I treated his anxiety by increasing his Prozac dosage to 60 mg per day.

At his third and last visit, six weeks after his initial visit, James reported that he was back to work full time, that he was sleeping well, and had reduced his Xanax use to only one pill at bedtime to help him sleep. He also reported that his leg movements had stopped completely. James reported that he was feeling well, and his concentration was back on track. When he came for his follow up visit, he came without his wife, and told he that he felt that I had saved their marriage and conveyed Mary’s appreciation for bringing him back to his normal self.

If you are concerned about yourself or a loved one who may need help- give us a call to set up an appointment at 713-426-3100.