Psychiatric Medication Management Archives - Mindshift Care

Episode 21: What success in mental health looks like on Functional MRI machine images of the brain.

https://vimeo.com/1133014538?share=copy&fl=sv&fe=ci

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The "clean-up and repair" cells in the brain use Brain-Derived Neurotrophic Factor to repair and rebuild new nerve growth in the Central Nervous System. See Figure 1 below from an except from my first book with these images of what the hippocampus looks like before and after treatment. This area of the brain is like a muscle and can be strengthened with new nerve growth, something we were told wasn't possible when my Class of 2007 entered U.T. Houston Medical School.

The Healer Protein: BDNF

Excerpt, Combat PTSD in America: Toward a Permanent Solution (2016)

How we Increase BDNF

Several things increased human BDNF and most of them are lifestyle related. The area of your brain where this is most impactful is an area called the hippocampus. Unfortunately, this is your resilience center, responsible for coping with stress and incorporating new memories into your long-term memory. If you become overwhelmed with life, PTSD or develop clinical depression, you can lose so many neuron connections in the hippocampus that it will shrink.

Here are some of the known ways to increase BDNF:

Meditation & Stretching. Slowing down, taking time for yourself can help.1

Eating more fruit and vegetables. I recommend eating as close to an unprocessed, anti-inflammatory diet as possible (Books: Paleo Diet, Wheat Belly).

Green tea. The caffeine content can be quite high so be careful.2

Resveratrol. Resveratrol is a plant polyphenolic compound.3 

Weight lifting. Fatiguing muscles to the point they are tired with exercise is known to increase BDNF. It also causes the brain to release Growth Hormone at night which is associated with improved sleep.4

Talk therapy. Cognitive behavioral therapy alone, without medications, has been shown to treat PTSD and increase BDNF levels.5

Antidepressant medications. Serotonin and Serotonin/Norepinephrine (adrenaline)-related antidepressant medications increase BDNF and are shown to improve PTSD, depression and anxiety.5

Social connection. Whether it’s work, school, church or volunteer service, establishing a routine with friendly, social interaction is also helpful.6

Prebiotics. Gut bacteria convert prebiotics into butyrate7, a substance that has been shown to increase BDNF.8

Magnesium.9 

N-acetylcysteine.10 Taken as a supplement.

The Ketogenic Diet.11

Dark chocolate.12

And more… (Special thanks to Jordan Fallis’ blog.)

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Notice the subtitle, "toward a permanent solution". A Mindshift Plan is the permanent solution.

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References

1.         Cahn BR, Goodman MS, Peterson CT, Maturi R, Mills PJ. Yoga, Meditation and Mind-Body Health: Increased BDNF, Cortisol Awakening Response, and Altered Inflammatory Marker Expression after a 3-Month Yoga and Meditation Retreat. Front Hum Neurosci. 2017;11:315. doi:10.3389/fnhum.2017.00315

2.         Gundimeda U, McNeill TH, Fan TK, et al. Green tea catechins potentiate the neuritogenic action of brain-derived neurotrophic factor: role of 67-kDa laminin receptor and hydrogen peroxide. Biochem Biophys Res Commun. Feb 28 2014;445(1):218-24. doi:10.1016/j.bbrc.2014.01.166

3.         Rahvar M, Nikseresht M, Shafiee SM, et al. Effect of Oral Resveratrol on the BDNF Gene Expression in the Hippocampus of the Rat Brain. Neurochemical Research. 2011/05/01 2011;36(5):761-765. doi:10.1007/s11064-010-0396-8

4.         Arazi H, Babaei P, Moghimi M, Asadi A. Acute effects of strength and endurance exercise on serum BDNF and IGF-1 levels in older men. BMC Geriatrics. 2021/01/13 2021;21(1):50. doi:10.1186/s12877-020-01937-6

5.         Björkholm C, Monteggia LM. BDNF - a key transducer of antidepressant effects. Neuropharmacology. Mar 2016;102:72-9. doi:10.1016/j.neuropharm.2015.10.034

6.         Salinas J, Beiser A, Himali JJ, et al. Associations between social relationship measures, serum brain-derived neurotrophic factor, and risk of stroke and dementia. Alzheimers Dement (N Y). Jun 2017;3(2):229-237. doi:10.1016/j.trci.2017.03.001

7.         Savignac HM, Corona G, Mills H, et al. Prebiotic feeding elevates central brain derived neurotrophic factor, N-methyl-d-aspartate receptor subunits and d-serine. Neurochemistry International. 2013/12/01/ 2013;63(8):756-764. doi:https://doi.org/10.1016/j.neuint.2013.10.006

8.         Kim HJ, Leeds P, Chuang DM. The HDAC inhibitor, sodium butyrate, stimulates neurogenesis in the ischemic brain. J Neurochem. Aug 2009;110(4):1226-40. doi:10.1111/j.1471-4159.2009.06212.x

9.         Pochwat B, Sowa-Kucma M, Kotarska K, Misztak P, Nowak G, Szewczyk B. Antidepressant-like activity of magnesium in the olfactory bulbectomy model is associated with the AMPA/BDNF pathway. Psychopharmacology (Berl). Jan 2015;232(2):355-67. doi:10.1007/s00213-014-3671-6

10.       Dean O, Giorlando F, Berk M. N-acetylcysteine in psychiatry: current therapeutic evidence and potential mechanisms of action. J Psychiatry Neurosci. Mar 2011;36(2):78-86. doi:10.1503/jpn.100057

11. Masino SA, Rho JM. Mechanisms of Ketogenic Diet Action. In: Noebels JL, Avoli M, Rogawski MA, Olsen RW, Delgado-Escueta AV, eds. Jasper's Basic Mechanisms of the Epilepsies. National Center for Biotechnology Information (US) Copyright © 2012, Michael A Rogawski, Antonio V Delgado-Escueta, Jeffrey L Noebels, Massimo Avoli and Richard W Olsen.; 2012.

12.      Sbarro Health Research Organization (SHRO). "The power of cocoa polyphenols against neurodegenerative diseases." ScienceDaily. ScienceDaily, 12 April 2013. .

Episode 15: Download and Share my Cheat-Sheet for Mixing Dangerous Prescription Medications.

Polypharmacy is a term used to describe the interaction of multiple medications with increased risk of adverse outcomes including disability and death. The most commonly reported definition of polypharmacy was the numerical definition of five or more medications daily (n = 51, 46.4% of articles), with definitions ranging from two or more to 11 or more medicines1. Each class of medication carries different risks that can be additive and potentiate adverse events.

Two Hundred Thousand – 400,000 people die every year due to medical mistakes globally. Pressure from the US government led doctors to drastically cut back the use of opiates in the past several years. The next target is Benzodiazepines sometimes still necessary for relief of severe anxiety, at least until someone decides to start achieving Physical, Mental, Spiritual and Emotional balance.

https://vimeo.com/1129164156?share=copy&fl=sv&fe=ci

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The standard of care for anxiety disorders

The standard of care for anxiety disorders is psychotherapy and an antidepressant. Medications such as benzodiazepine-related (alprazolam, diazepam, lorazepam, clonazepam, zolpidem, etc.), gabapentin, propranolol, hydroxyzine and buspirone are frequently used off-label for breakthrough anxiety or panic episodes. Also, chronic insomnia is best treated with a specific protocol for Cognitive Behavioral Therapy for Insomnia (CBT-I).

Primary care prescribe approximately 90% of all psychiatric medications in the U.S.A., but they take a symptom-based approach to make the anxiety temporarily abate. In psychiatry, the goal is to overcome the emotional dysregulation and improve resiliency for future stressors. Chronic benzodiazepine use no longer has a place in the psychiatric standards of treatment. The risks of dementia, IQ point loss, insomnia, prolonged PTSD, chronic anxiety, dependency, risk of death, and avoidance of psychotherapy outweigh the temporary benefits of this class of nervous system depressants.

Below is a list of contraindications (Do Not Mix) and summary of class-specific side effects in attempt to prevent harm, originally published as an excerpt from Clinical Handbook for Psychiatric Urgent Care in the USA, Daniel M. Williams, M.D., P.A.

List of common side effects in acute settings of polypharmacy. This is what your doctor is worried about:

Why We Fight

Alcohol: Active alcohol use is a risk factor for medication adverse events. Combining medications with alcohol can result in respiratory depression, failure to maintain a secure airway, aspiration pneumonia, respiratory failure, coma and death.

Benzodiazepines: Work on the GABA receptors just like alcohol. As such, they kill brain cells and are associated with insomnia, doubling the risk of dementia at any age, cognitive loss, persistent anxiety, physical and psychological dependence, and addiction. Examples: Ativan (lorazepam), Klonopin (clonazepam), Valium (diazepam), Xanax (alprazolam), Ambien (zolpidem), Temazepam, Oxazepam, Zaleplon.

Benzodiazepines handoutDownload

Buprenorphine: Subutex contains only buprenorphine but Suboxone contains naloxone in addition to buprenorphine (naloxone helps protect people from an inadvertent opioid overdose). So long as there is naloxone present, there is practically no abuse potential, but it makes no sense to take it with a bunch of other controlled substances. I've seen people take full opiates in the parking lot and walk-in to start the buprenorphine induction protocol. Subutex is a sublingual tablet and Suboxone is a film that you put under your tongue. Subutex was approved in 1981 and Suboxone has been available since 2002. Both Subutex and Suboxone can be initiated early by a doctor as part of an opioid treatment program. The brand name Subutex has been discontinued in the U.S. but it is available as generic buprenorphine sublingual tablets.

Methamphetamine: This stimulant can cause psychosis, irritability and anger, and other forms of mood and thought disorders. Acutely, heart attacks, strokes, seizures and psychosis are some of the most dangerous interaction when mixing meth with other substances.

Opiates: Opiates stop the respiratory drive so the diaphragm stops moving, the main way people die on overdoses with fentanyl and heroine, etc. Prescription opiates are just as dangerous when abused or mixed with other medications or alcohol.

Stimulants: Stimulants can include prescription and nonprescription. By definition, they increase adrenaline and dopamine in the frontal cortex in the brain. Therefore, combining stimulants with some other medications can exacerbate the background risk of hypertension, palpitations, arrhythmia, even leading to stroke and death. Examples: Methylphenidate, Adderall, methamphetamine, cocaine. A good example of this is the recently outlawed Dos Locos beer that added a stimulant to an alcoholic beverage that resulted in deaths.

THC. Tetrahydrocannabinol (THC) is the main psychoactive agent and neurologic pain relief from the cannabis plant. There are no known overdoses or deaths due to THC in the history of mankind. There are 500 endocannabinoids and terpenes with ancient, healing benefit. That said, it can cause syncope, dizziness, sleepiness, drowsiness, forgetfulness and amotivational syndrome.

1 Masnoon N, Shakib S, Kalisch-Ellett L, Caughey GE. What is polypharmacy? A systematic review of definitions. BMC Geriatr. 2017 Oct 10;17(1):230. doi: 10.1186/s12877-017-0621-2. PMID: 29017448; PMCID: PMC5635569.

Episode 8: How childhood neurodevelopment turns into road rage, or becomes rewired completely. You decide. (This one will save loss, pain, and lives.)

Intermittent Explosive Disorder (IED) is an official diagnosis for an anger control problem. It is characterized by impulsive, unexpected anger and aggression that is disproportionate to the situation. The diagnosis code is F63.81 in the International Classification of Diseases, Tenth Revision. From the outside, the world sees an angry person, but they are often riddled with guilt about their behavior. If unable to modify the personality and self-care to accommodate for IED, these people burn all their bridges and wind up totally alone. They need to Mindshift.

https://vimeo.com/1054709890

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Trileptal and My 2-Minute Speech

"When a threat is perceived, adrenaline triggers an uncontrollable reaction.

Intermittent explosive disorder is a hard-wired anger reaction, almost always originating from PTSD. This is why traditional cognitive approaches to anger management are often inadequate.

It is exactly the opposite of a trained operator or martial artist. However, if the brain is exposed to enough toxicity, a veteran will slowly lose their brain's ability to inhibit.

A mood-stabilizer is a "10 second fuse". It will let you notice the feeling without impulsively acting on it.

Walk away from the anger-provoking situation the first 5 times you get mad, so you can learn how the medication will help you go calm yourself down. Then, practice talking through your problems knowing you can now walk away if you need to, so eventually you won't have to live in fear of your anger or be made to feel like a doormat."

Trying to overcome IED without help is like dancing stoned on the edge of cliff. By definition, not taking life-threatening behavior seriously is absolutely the most irresponsible decision for mental health. Afterall, mental health equals self-care.

Why won't this work on children?

From the outside, children and adults look the same emotionally with temper tantrums. The adult with IED, however, is overreacting in anger despite a previous decision to keep anger under control. Children haven't yet made decisions on the kind of person they want to be (superego), they are running into a nonstop series of life lessons and reflexively react based upon their hardwired subconscious programming. It's not the kid's fault. By that same logic, it's also technically not the adult's "fault", but it is their responsibility. Adults in the heat-of-the-moment react violently without a conscious choice - the prefrontal cortex is not involved in a decision until after the action has begun. Trying to stop yourself once your anger has progressed to screaming and violence is literally trying to overcome all of your life's pains and griefs that have come to bear, and in the most dangerous and unhealthy way possible. You need to Mindshift.

Notice the division between Oppositional Defiant Disorder (ODD) in children and Intermittent Explosive Disorder (IED) in Adults in Figure 1: Psychotherapy mirrors neurodevelopment across the lifespan. This means that the different psychotherapies that helps these psychiatric diagnoses as we age support our understanding of brain health and its misuse:There are three overall phases in brain development when viewed from the womb to the tomb.

Initial Programming is broken into two stages: womb to age 6 and from age 6 to age 17. The first stage begins in the womb and involves the direct download of the environment into the unconscious body memory (mind) of the child. Gradually, the child learns how to approach the world through choices but faces an uphill battle to rewire the body-lessons learned in very early development. The subconscious mind is already formed. We never completely undo the early, initial programming.

The Neuroplastic Zone reflects the period of our lives when we can really learn, think for ourselves, and have the capacity to change. This ability to change our mind, form new neurons and connections, is referred to as plasticity. This plasticity is lost in the third and final phase.

Psychotherapy for the Three Neurodevelopment Phases

Initial Programming – Behavioral therapy = Parent training, Nutrition, Alpha Stim, Meditation, Meds > age 6.

Neuroplastic Zone – Psychotherapy with behavioral change sufficient to cause rewiring, Meds

Loss of Plasticity – Behavioral therapy, Meds to slow rate of neuron loss

ADHD: primarily medication

ODD: primarily behavioral therapy on the part of the guardians

IED: the patient can begin to rewrite their neural wiring by repetitive behavioral change and extinguishing unhealthy dopamine-raising behaviors.

Anxiety, panic, depression: all have great research for cognitive behavioral therapy

Clinical dementia: and we're back to behavioral therapy only again. Medications slow the progression of memory loss, at best, but don't restore cognitive function once it's lost. Detox does! Check out the supporting End of Alzheimer's research by Dale Bredesen, M.D.

Both groups, children and elderly with dementia, rely on behavioral therapy because their executive function isn't 100%. Thus, they are even more sensitive to neurotoxins in the water supply.

Figure 1: Psychotherapy mirrors neurodevelopment across the lifespan

For children with Oppositional Defiant Disorder, the standard of care treatment is not medications. It is Parent-Child Interaction Therapy, which is essentially a Behavioral Therapy. It seeks to study everything that is being rewarded in the child's life and offer perspective and modeling for how to reward the child differently. It is used in severe neurologic disorders for all ages in which the patients can't reason with you in logical conversation. They do learn by experience, therefore Behavioral Therapy is specialized training in creating experiences for other people. Adults with IED and foster parents of severely traumatized children find out that reactions to maltreatment persist for years even if the environment is truly sound and emotionally healthy, even from electromagnetic waves, toxins in the food and water supply, restriction on the internet, no social media, a healthy support group, good sleep hygiene, access to Brene Brown resources, grounding sheets, bible study - they know it's sometimes not enough. If you have a tough cookie, join me on a live call.

Mood Stabilizers Can Help with Intermittent Explosive Disorder

Trileptal is in an anticonvulsant, in the anti-seizure (when used for Neurology) and mood-stabilizer (when used for Psychiatry) family of medications. They work by changing the electro-potential gradient across the cell membranes of nerves all over the body through the Na+/K+ Pump by inhibiting the ATPase enzyme. The result is it takes a little stronger stimulus to get the nerve to do anything. This results in slightly slower initiation and less firing, so it can stop seizures in high enough doses. Psychiatrists often use about 1/3 the strength of the same medications to get relief of mental health symptoms, than do Neurologists to get relief for epilepsy.

I typically start Oxcarbazepine at 300 mg by mouth twice per day on a scary, full sized adult - half of that if they're smaller framed with not-so-scary episodes.

I typically double it on the next visit if it's helping only somewhat, or go up by 50% if other risk factors are present, at the follow-up appointment.

Weight-based doses should be calculated for people around 100 pounds or less, including children. I've started 75 mg twice per day before.

Note that a careful history of past violent behavior and recent trends is crucial to determining the appropriate level of psychiatric care. True tele-health is typically not an option if Trileptal and a Two-Minute Speech doesn't work. The patient may need an intensive outpatient program that takes them away from their usual routine for at least six weeks.

I like to think mood stabilizers work by slowing down the nervous system so people with fast-conditions of the nervous system could see benefit: intermittent explosive disorder, attention deficit disorder, anxiety, OCD, panic disorder, etc.

The generic name is oxcarbazepine, which is what I practically always prescribe. I like how "Trileptal and a Two-Minute Speech" rolls off the tongue, even though I don't actually prescribe brand name very often (working in the Army, VA, and prisons won't allow). As a psychiatrist, I'm always noticing simpler ways to make things memorable and meaningful. Other medications I've sometimes used for IED in the same family are Tegretol (carbamazepine), Lamictal (lamotrigine), Lithium, Depakote (has a chance of making it worse). Keppra (levetiracetam) is often used for seizures but can worsen anger or cause secondary IED.

In summary, we have covered synaptic plasticity, treatment of Intermittent Explosive Disorder, and discussed childhood Oppositional Defiant Disorder. Trileptal and a Two-Minute speech may slow the IED brain down enough for the adult to change their behaviors sufficient for rewiring. But does it work?

My absolute favorite story of how good mental health treatment (anger management) can help stabilize vulnerable communities (Rural Alaska, pay attention)

While deployed to the Texas-Mexico border in 2022, I simultaneously pulled civilian duty as a tele-psychiatrist for 4 different private, federally-contracted prisons. During such times of stress, Intermittent Explosive Disorder was commonplace among my patients in prison, and the Soldiers and Airmen I would see on the base. I got real fast at giving the same 2-minute speech to angry Soldiers, Airmen, and prisoners (some of which were veterans). The first emotional support animal I trained to be a PTSD service dog, CPT Tigger,...

Episode 7: Teaching tool for medication classes in severe psychiatric illnesses.

Figure 1. This is the table of contents for the Clinical Handbook I wrote as a teaching tool for advance practitioners.

I taped the below graphic on the walls of each office where I supervised a busy psychiatric urgent care. It was helpful in explaining modern medication management approaches in an easy-to-understand format.

The 100-Day Mindshift by Dr. Daniel Williams helps primary care and mental health programs that don't have time to explain the Clinical Practice Guidelines from the American Psychiatric Association.

Figure 2: Treatment Guidelines for Serious Mental Illness.

https://vimeo.com/1054650093

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What is considered a "Serious Mental Illness"?

Major depressive disorder, schizophrenia and bipolar disorder type 1 are considered Serious Mental Illnesses. Lobbyists aren't yet successful with getting PTSD added to the list.

Medications are frequently used to treat dozens of mental health-related symptoms, but this episode will focus on Serious Mental Illnesses.

Summary of Diagnostic Criteria for Serious Mental Illnesses

*Major depressive disorder ~ 2 weeks of a collection of low mood and neurovegetative symptoms (appetite, sleep, energy, concentration, motivation, psychomotor agitation or retardation) with or without suicidal thoughts and psychotic features.

Schizophrenia ~ 6 months of predominantly psychotic symptoms, such as hallucinations, delusions.

Bipolar disorder ~ 7 days of a manic episode ever in life, including the combination of decreased need for sleep, grandiosity, and euphoria. Episodes can be depressed, manic, or mixed.

Schizoaffective disorder ~ Clinically significant depressive or manic episodes, but psychosis remains when the mood episodes are in remission for at least 2 weeks.

Bipolar Disorder is frequently confused with Intermittent Explosive Disorder

Western culture defines "bipolar" as impulsive anger flares. This is nothing like the manic episodes of bipolar disorder and it is possible to have an anger problem too.

Intermittent Explosive Disorder is truly an anger problem diagnosis. Features include unplanned, violent overreactions, such as arguments, punching holes, breaking cell phones and TV remotes. The guilt from the outbursts is often enough to trigger a full major depressive disorder, unless the person is antisocial and has no guilt.

In my practice...

A holistic approach to Intermittent Disorder would include Trileptal and a 2-Minute Speech, energy release work, and the Definite Major Purpose worksheet.

Definite Major Purpose WORKSHEETDownload