Jun 28, 2018

Psychiatrist Ask-Me-Anything - Week 2

4 comments

I'm aiming to make this a regular series, so please ask any questions below -- about psychiatry, mental health, or whatever (it does say anything in the title).

 

Until other users add Qs here, I'll continue to add some that are frequently asked to me.

 

Q: Are chemical imbalances a real thing?

A: Yes and no. It's quite a bit more complex. The myth of a deficiency of a chemical such as serotonin (SSRIs such as prozac raise serotonin) being the sole cause of depression is definitely incomplete. SSRIs do raise serotonin levels, but that's probably not how they help with depression.

 

Instead after raising serotonin, that causes a drop in serotonin receptors (the things that serotonin attaches to), which changes something else, which changes something else, and eventually gets to something called BDNF. This is a signal that your brain already has that it uses to tell itself to make new brain cells. When someone is depressed (or chronically anxious/stressed), that signal is lower. Antidepressants, regardless of whether they work on serotonin or any number of other mechanisms, leads to increased BDNF. It's like helping the brain rebound from stress. As a note, exercise can also raise BDNF, but much more transiently.

 

Yet even this isn't a complete picture. The brain "state" is just one angle. Everytime we have a thought, or some particularly new experience, or behavior, or probably diet, in some way we're changing our brain state including the chemicals inside. Changing our thoughts affects the chemicals, and changing the chemicals affects our thoughts.

 

Thus therapy is very important.

Jul 3, 2018

Hey Paul - What about chronic pain? The emotional trials of going through chronic pain can be really difficult, isolating, and your mental health can spiral into a negative. Are there ways of working through the struggle of depression when going through chronic pain? The future can be really difficult to navigate if you're worried about your health. It seems like sometimes the pain and depression can compound on top of each other making it difficult to over come. Any tips on how to either subside those bouts of depression & anxiety or overcome them in general?

Jul 3, 2018

Paul - thanks for this AMA. You mentioned exercise as a natural way to raise BDNF. Can you provide some other natural ways one can do this?

Jul 3, 2018

Good question, Ravi. Aerobic exercise is definitely the best studied way to boost BDNF. There's some mixed research on meditation and yoga. It appears to help for some but not all, and there's even some research that that might be due to genetic differences between people.

 

It also seems that it could be the exercise aspect of yoga that's helping, while the meditation doesn't. As a big proponent of meditation, I know it has many other benefits, of course. Raising BDNF just doesn't appear to be one of them. BDNF is a clear factor in depression, but is only one of many biomarkers in mental health problems.

 

And then of course there's therapy, which does seem to raise BDNF levels, though it's far less researched than it should be.

Jul 21, 2018

On the topic of chronic pain -- it can absolutely be challenging, draining, distracting, infuriating. Anytime your body seems to turn against you, there's a deep sense of betrayal that can be felt.

 

I think to start that is helpful to acknowledge. Accept that some of this is out of your control. Practically speaking, there are a host of approaches that can be used. Medications can help for certain kinds of pain, particularly neuropathic pain. Other types of pain may have other interventions, and it's always a fair idea to at least do a consultation with a pain expert. They are usually anesthesiologists that specialize in managing pain, and can offer options like injections that could help, or certain medications. There are also things like spinal stimulators, lidocaine patches and the like. I usually recommend avoiding major surgeries or narcotics (vicodin, fentanyl, etc), as they rarely seem to solve the problem -- though I may only be seeing the people who have failed those options -- aka a selection bias.

 

After those options there are interventions like hypnosis, which has a fairly good evidence base for managing chronic pain. In addition, sometimes pain conditions are a manifestation of something psychological. It may not have started that way, but something unconscious seems to maintain it. In those cases therapy can be beneficial (and may be necessary even to test this out and see if there's something there). Therapy can also help in just dealing with all the emotions of the pain, coming to grips with the difficult reality of it all.

 

Finally, there's mindfulness. This of course comes from Zen meditation originally, and I often simplify it as an awareness without reacting, staying in an observer role. For chronic pain that can sometimes be quite helpful to adopt such a mindset -- and there are specialized programs for using mindfulness to deal with the pain. Rather than removing it, accepting it is what is there at this moment, and not having to DO more things but just be aware.

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