Anxiety, depression, schizophrenia, and other mental problems are common and often difficult to deal with. They can create disability and impairment in family structure as serious, and expensive, as most physical illnesses. In our current state of knowledge, therapy mainly involves prescription of sedatives and other psychiatric medications. Drugs, however, do not address cause, have many side effects, often are not effective very long if at all, and are replaced or complemented by other drugs. Frequent side effects are a worsening of the primary condition, fatigue, loss of memory and concentration, loss of libido, increased incidence of accidents and falls, weight gain and diabetes.
In children and adolescents, prescription drugs are often preceded or followed by the use of street drugs. It is uncertain whether prescription drugs promote the use of street drugs because they themselves are addicting (Adderall, Ritalin), fail to achieve sufficient effect, or create a habit of using chemicals to improve an unpleasant state of mind. In our practice we see many adolescents and young adults who self-medicate with street drugs or alcohol in addition to taking prescribed psychiatric drugs. We try to get them off all mind-altering substances. The process often takes months.
It is better to address emotional problems with lifestyle therapies than with drugs. It is a safer and more effective approach.
- Get a thorough history and physical exam, and laboratory studies, always to include blood count, blood chemistries, and thyroid. Many illnesses cause symptoms that mimic mental disturbances, including thyroid disorders, anemia, liver or kidney disease. Hormone deficiency may also be involved, especially the menopause. Anxiety and depression are both common in menopause, often alleviated or resolved with bioidentical estrogen, progesterone, and sometimes testosterone. Testosterone deficiency in men, much more common than we once thought, can cause depression and fatigue, rapidly corrected by the addition of testosterone. We now routinely measure testosterone in men with emotional disturbances. Adrenal dysfunction may also play a role, and we assess this using salivary cortisol measurements.
- Evaluate nutrition and nutrient deficiencies. Caloric deficiency is rare in the United States these days, but many people take in empty calories and lack vitamins, minerals and essential fatty acids that maintain brain health. Some foods may aggravate emotional problems, including refined sugars, chocolate, soft drinks, fast foods, high caffeine intake. We sometimes test for food allergies to identify items that should be withheld. Gluten, a protein in wheat, barley and rye, has been incriminated in emotional disorders.
- Identify and eliminate use of street drugs and alcohol. Addicted individuals, even those with only intermittent use of drugs, are adversely affected. Many will assert that the drugs do not hurt them, and actually help them feel better. This is an aberration. Drug use may be very well hidden. It is important to investigate closely. Many patients have told me their doctors were prescribing sedatives and pain pills, unaware that they were using street drugs. There is also an official sanction for the use of prescription addictive drugs, with the belief that this is an answer to the drug problem. We have widespread methadone and Suboxone/Subutex maintenance programs for narcotics addicts, and a legalized marijuana prescription status. You can see ads for these programs on buildings in Los Angeles. In my experience, any use of mind-altering substances will impair recovery from mental problems.
- Evaluate all prescription medications. Medications used to treat high blood pressure, cardiac disease, and many other conditions may interfere with brain function and cause depression, fatigue, or cognitive impairment. If there is a question about any medication, it should be replaced if possible. Dose reduction may not be sufficient.
- Take nutrient supplements. We recommend supplements freely. Most important are the B vitamins, especially thiamine, B12, and folic acid, as well as omega 3 fatty acids, and magnesium. Other items include the amino acids L-tryptophan, 5-HTP, glycine, theanine, and L-carnitine. Specific items and doses should be recommended by a physician.
- Get exercise. Minimal requirement is a 30 minute walk, twice a day. In some situations much longer walks are recommended. Exercise, especially outside, reduces stress and upset.
- Get enough sleep. Emotional problems are almost universally accompanied by sleep disorders. People either cannot fall asleep, or awaken early and cannot get back to sleep. Without sufficient sleep the situation cannot resolve. Sleep apnea is a common problem, and should be evaluated in suspicious cases- snoring, daytime sleepiness, witnessed cessation of breathing, or obesity. To improve sleep, avoid caffeine or chocolate after 12 noon. Dont eat anything before going to bed. Avoid any disturbing television programs before bed, such as the news, and dont get involved in any upsetting conversations at night. Magnesium and calcium supplements taken just before bed are helpful. L-tryptophan, 5-HTP, theanine, glycine, and melatonin are often helpful. Progesterone taken at night by mouth is often effective for menopausal women with sleep difficulties. When people have unrelenting sleep problems, we may prescribe prescription sedatives, with a plan to discontinue them once sleep improves. Severe insomnia must be addressed before emotional problems can resolve.
- Establish a calm environment. This can be hard to do. Sources of upset, often other people, should be kept away. Time away from work or school may be necessary. In some cases the individual should go away from home to a different place, where upsetting reminders are absent. Often communication itself should be limited, to avoid restimulating unpleasant memories.
Recovery from emotional disturbances may take a long time, sometimes months. The program, once set up, should be closely adhered to. If psychiatric drugs have been employed, we set up schedules to reduce and eliminate them, with the idea that people function best without drugs altering mental functions
Allan Sosin MD