Therapy for Mood Disorders1...In bipolar disorder, reduced the rate of mood problems 8-fold after six months. Jump starts therapy for PTSD Lowers inflammation Apps (CBT-i Coach) Mood

Therapy for Mood Disorders

Chris Aiken, MD Instructor, Wake Forest University Dept of Psychiatry Director, Mood Treatment Center Editor-in-Chief, The Carlat Psychiatry Report

Depression and Mood Disorder Certification Training

PESI, 2020

Disclaimer Materials that are included in this course may include interventions and modalities that are beyond the authorized practice of mental health professionals. As a licensed professional, you are responsible for reviewing the scope of practice, including activities that are defined in law as beyond the boundaries of practice in accordance with and in compliance with your professions standards. Conflicts of Interest Book royalties, WW Norton, PESI

Mood Spectrum

Mania Mixed States Depression

“Manic-depression … is an illness that is biological in its origins, yet one that feels psychological in the experience of it.”

—Kay Redfield Jamison, An Unquiet Mind, 1996

Therapy changes the brain and body in ways that medications do not

Moods are not emotions

Mood disorders are not emotional illnesses

Emotions are adaptive responses to life.

There is no such thing as a diseased emotion.

Mood disorders affect the connections between

the brain’s emotional center and action center.

What is a Mood Disorder?

Allen Francis, Chair of DSM-IV

Homeostasis The tendency of the body to seek and

maintain a condition of balance

Negative feedback maintains homeostasis

Psychiatric illness is a break in homeostasis1

1Allen Francis, Saving Normal, 2013

Positive feedback Disrupts homeostasis, so reserved for rare but critical events: Ovulation Childbirth Blood clotting

Broken feedback loops Alcohol, drugs, or binge eating without satiety

Panic attacks Phobia of panic More anxiety More panic

Avoidance Reduced anxiety More avoidance More depression/anxiety

Action Success More action Less sleep More hypomania

Therapy Implications Early intervention in depression and mania can

prevent full episodes.

OEA: Acting the opposite of the emotion.

Empowers clients, destigmatizes.

CBT lead to longer remission when it increased flexible thinking rather than positive thinking1.

1Teasdale et al., 2001

Questions?

The Mood Spectrum

1900’s manic depression

Emile Kraepelin, MD, 1856-1926

1900’s manic depression 1960 bipolar vs. depression 2013 mood spectrum

Jules Angst, MD, 1926-present

major depression depression with mixed features depression with short-duration hypomania cyclothymic disorder bipolar II disorder bipolar I disorder

Depression and bipolar are part of “a continuum, with variable expressions of vulnerability to hypomania or mania” —David Kupfer, Chair of DSM-5, 2013

Diagnosis Rate of Bipolar I, II and Cyclothymia

General Population 3-5% of total population

Primary Care 20-30% of mood/anxiety patients

Outpatient Psychiatry 30-50% of mood/anxiety patients

On average, people with bipolar wait 10 years and visit to 3 different providers before being correctly diagnosed.1

1Hirschfeld RM, J Clin Psychiatry, 2001.

Diagnosis: Youth Rate of Bipolar I, II and Cyclothymia

Adolescents 1-3% of teens

Children of bipolar 15-30% (or 50% if 2 BP parents)

Conversion in adulthood

20-40% of depressed teens

Stages of Bipolar

0: Genetic risk factors only 1: Prodromal (subsyndromal) symptoms + genes 2: First onset of hypomania or mania 3: Recurrence (>90% recur within 5 years) 4: Treatment resistance and disability develop after too many episodes

Ü Family therapy Ü Meds + therapy Ü Meds, therapy, cognitive rehab

Bipolar diagnoses rose in children 2000-2005

Family history matters

When children have a few hypomanic symptoms, which ones will develop full bipolar? A family history of bipolar nearly doubled the risk of conversion to the full disorder.

Hafeman et al, Am J Psychiatry, 2017 Birhamer et al, 2009

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

No family history BP Family history BP

Conversion to bipolar in youth with subsyndromal hypomania

Diagnostic Tools Bipolarity Index

Self rated scales Mood Disorder Questionnaire Bipolar Spectrum Diagnostic Scale Hypomanic Check List

Bipolar II Unipolar Depression Early Onset (age 15-20) Later Onset (age 30-40)

Recurrent depressions (40-60% of lifespan) 50-60% recur

Hypomania present, but rare (10% of lifespan) No hypomania

More comorbidities Fewer comorbidities

Likely to worsen with, or not respond to, antidepressants Improves with antidepressants

Female : Male = 1:1 Female : Male = 3:1

Strong genetic factors Less genetic

Depression Mania Julie Fast, BP Hope, 2017

Sunny hypomania Greater drive and energy

Socializing

Less shy, less inhibited

More plans and ideas

Motivated

Happy, euphoric

Physically active

Faster thoughts, more jokes

Talkative

Laughter, good humored

Less need for sleep

Confident

(Akiskal et al., 2003)

Euphoric mania or hypomania

Clear separation of mania, depression, and normal self

Rare mixed states and rapid cycling

Healthy personality with few comorbid conditions

Very responsive to lithium

Classic Bipolar

Dysphoric mania/hypomania

Mixed states, rapid cycling, rare recovery

Comorbid: anxiety, bulimia, OCD, borderline personality

Higher rates of trauma, head injury, substance abuse

Responds better to: seizure meds and atypical antipsychotics

Atypical Bipolar

Sunny hypomania Dark (mixed) hypomania Greater drive and energy Irritable, impatient

Socializing Excess traveling, imprudent driving

Less shy, less inhibited Unwise or impulsive decisions

More plans and ideas Heightened sex drive

Motivated Distracted

Happy, euphoric Excessive spending

Physically active High anxiety

Faster thoughts, more jokes Urges to self-medicate

Talkative Verbal aggression

Laughter, good humored Disregard for authority

Less need for sleep Careless of responsibilities

Confident Suicidality, self harm


“Tired and Wired”

“Driven but don’t know what to do”

“Irritable, agitated, impatient, frustrated”

Anxiety, panic, non-delusional paranoia

Craves urgent relief (substances, benzos, self-cutting)

Distracted, “like a ping-pong, mind won’t shut off”

Sleep reversal; over- and under-sleeping

More physical symptoms and medication side effects

Elevated risk of suicide

Mixed State Misery

Questions?

“Irregular energy levels” with “intense, variable moods,” where depression predominates but is interspersed by brief periods of “elation... dejection, anxiety, or impulsive anger”

Borderline Personality Disorder Affective Temperaments

Dysthymic Hyperthymic

Irritable Cyclothymic

“The psychiatrist’s aim is to bring out what is positive and desirable in the patient’s temperament” –H. Akiskal

Temperament Mood linked to Features

Depressive Depression Self-critical, “glass half-empty,” avoidant, worried, hard-working, realistic

Hyperthymic Hypomania Energetic, confident, extroverted, charismatic, impatient, hot-headed, impulsive

Irritable Mixed states Quick tempered, skeptical, suspicious, dissatisfied, assertive

Cyclothymic Rapid cycling of all moods

Traits from the other three temperaments cycle frequently, from energized to sluggish, extroverted to withdrawn, and passionate to disinterested. This cycling leads to anxiety, insecurity, and instability in relationships and work – but also to creativity, empathy, intuition, and spontaneity.



















Depressive Dysthymic (DSM-IV) Persistent depressive disorder (DSM-5)

Paul Giamatti, Sideways, 2004

Limitation Strength

Self-doubting, non-assertive

Anxious, worried

Indecisive, avoidant

Sensitive to rejection

Little pleasure in life

Non-spontaneous, difficulty adjusting to change

Low energy, high need for sleep (>9 hours/day)

Depressive

Limitation Strength

Self-doubting, non-assertive Humble, thoughtful

Anxious, worried






Depressive

Limitation Strength


Anxious, worried Realistic






Depressive

Limitation Strength



Indecisive, avoidant Cautious, prudent





Depressive

Limitation Strength




Sensitive to rejection Empathic, considerate, sensitive to other’s pain




Depressive

Limitation Strength





Little pleasure in life Hard-working, conscientious, ethical



Depressive

Limitation Strength






Non-spontaneous, difficulty adjusting to change Dependable, consistent, fair-minded


Depressive

Limitation Strength






Non-spontaneous, difficulty adjusting to change Dependable, consistent, fair-minded

Low energy, high need for sleep (>9 hours/day) Patient, persistent

Depressive

Hyperthymic

Franklin Roosevelt

Limitation Strength

Arrogant, self-assured, egotistical

Risk-taking, impulsive, reckless

Controlling, overbearing, domineering, meddlesome

Overindulges in food, drink, or sex

Unfaithful, unreliable, making spur of the moment plans that can’t be followed through or promises that can’t be kept

Talks over people, socializes to the point that it’s exhausting to others

Though warm and engaging, can also be insensitive and unempathetic

Lacking in self-reflection, which makes it hard to learn from mistakes

Impatient

Decreased need for sleep (<6 hours/day)

Hyperthymic

Limitation Strength

Arrogant, self-assured, egotistical Confident, decisive, a natural leader

Risk-taking, impulsive, reckless







Impatient


Hyperthymic

Limitation Strength


Risk-taking, impulsive, reckless Action-oriented, optimistic, cheerful







Impatient


Hyperthymic

Limitation Strength



Controlling, overbearing, domineering, meddlesome Influential, involved, interested in others






Impatient


Hyperthymic

Limitation Strength




Overindulges in food, drink, or sex Lover of life, spreads joy to others





Impatient


Hyperthymic

Limitation Strength






Spontaneous, fully engaged in the moment




Impatient


Hyperthymic

Limitation Strength








Friendly, extraverted



Impatient


Hyperthymic

Limitation Strength










Thick-skinned, able to take insults in stride like “water off a duck’s back”


Impatient


Hyperthymic

Limitation Strength












Easy going, comfortable, not bogged down by self-conscious worries

Impatient


Hyperthymic

Limitation Strength













Impatient Active, energetic, lots of interests


Hyperthymic

Limitation Strength













Impatient Active, energetic, lots of interests

Decreased need for sleep (<6 hours/day) Can turn into insomnia in middle age

Hyperthymic

Hyperthymic in Therapy

Moderation to balance hedonism.

Realistic assessment to balance impulsivity.

Interpersonal skills: Empathy, listening, patience, humility.

Irritable

Clint Eastwood, Gran Torino, 2008 Archie Bunker

Limitation Strength

Irritable, hot-headed, quick to anger Assertive

Mistrustful, suspicious of others Skeptical, “nobody’s fool,” scientific

Jealous Protective, loyal to their inner circle

Conflicts in relationships, social isolation

Able to take important stands that others are

not comfortable making, original, iconoclastic,

independent

Easily dissatisfied, complaining, sarcastic Honest, frank, not afraid to point out real

problems

Irritable

Limitation Strength







independent


problems

Irritable

Limitation Strength







independent


problems

Irritable

Limitation Strength







independent


problems

Irritable

Limitation Strength







independent


problems

Irritable

Limitation Strength







independent


problems

Irritable

Cyclothymic

Jessica Lange, Blue Sky, 1994

Limitation Strength

Inconsistent, unreliable Spontaneous, flexible, open to new experiences, creative

Rapidly shifting moods Adaptive, have learned how to cope with many moods and can relate to a broad range of people

Emotionally reactive, sensitive to rejection Engaged and responsive to others, able to feel deeply and passionately

Sensitive, easily overwhelmed or over-stimulated Highly attuned to the sensory world, which can lead to artistic gifts and success in music, culinary arts, cosmetology, and the hospitality industry

Tendency to self-medicate with alcohol, drugs, caffeine, or nicotine

Tend to seek professional help when needed and make good use of therapy

Falls in and out of love too easily, impulsive starts and ends relationships

Able to rebuild their social network when things break down

Often have to cover up negative moods, which can lead habitual lying or the feeling that “no one knows the real me”

Able to put on a mask when needed, to “fake it ‘til they make it”

Overly trusting of others; easily drawn into fads, cults, or deceptive marketing schemes

At other times, have the healthy skepticism that comes with experience

Cyclothymic

Limitation Strength













Cyclothymic

Limitation Strength













Cyclothymic

Limitation Strength













Cyclothymic

Limitation Strength













Cyclothymic

Limitation Strength













Cyclothymic

Limitation Strength













Cyclothymic

Limitation Strength













Cyclothymic

Limitation Strength













Cyclothymic

Therapeutic Relationship Approach Therapeutic Stance Therapeutic Pitfalls

Dysthymic Respect them

Realism Encourage open communication Encourage assertion

Dominating, anger, hostility Withdrawing, defeated Cheerleading, overly-positive Missing indirect expressions of anger

Hyperthymic Mirror them Practical focus on the future Action-oriented Tell it like it is Strong-spine

Missing pathology Losing control of sessions Power struggles Boundary violations

Irritable On their side Firm but compassionate Open, honest, genuine Clearly state boundaries Don’t sweat the small stuff

Argument Withdrawing (“got something to hide”) Attacking Reacting personally to attack

Cyclothymic Believe in them Define roles clearly Use active, genuine body language Speak direct, and sometimes directive

Judgmental Overly strict Overly permissive































Cycloid Personality

Original term for borderline personality in the working drafts of DSM-III “Irregular energy levels” with “intense, variable moods,” where depression predominates but is interspersed by brief periods of “elation... dejection, anxiety, or impulsive anger” —T. Millon

“The theory I present is… in many ways similar to that of Millon’s [Cycloid Personality]” —Marsha Linehan, Cognitive-Behavioral Treatment of Borderline Personality Disorder

Common Traits in Cyclothymia and Borderline

high neuroticism, low agreeableness

harm avoidance + novelty seeking

anxiety + impulsivity

Borderline traits can result from the overlap of cyclothymic temperament and bipolar II

impulsive

self harm

irritable

Sunny hypomania Dark (mixed) hypomania Greater drive and energy Irritable, impatient

Socializing Excess traveling, imprudent driving

Less shy, less inhibited Unwise or impulsive decisions

More plans and ideas Heightened sex drive

Motivated Distracted

Happy, euphoric Excessive spending

Physically active High anxiety

Faster thoughts, more jokes Urges to self-medicate

Talkative Verbal aggression

Laughter, good humored Disregard for authority

Less need for sleep Careless of responsibilities

Confident Suicidality, self harm


38% of people with bipolar II have cyclothymia Akiskal et al., 2003

38% of people with bipolar II have borderline personality disorder Fornaro et al., 2016

Borderline Personality Disorder Cyclothymic Disorder H

IGH

OV

ER

LAP

Affective instability due to marked reactivity of mood (e.g., intense episodic depression, irritability, or anxiety lasting hours to days)

Rapid mood swings that cycle between depression, irritability, anxiety, and excitation over days to weeks

Unstable relationships that shift from idealization to devaluation (splitting)

Relationships that vacillate from glowing adoration to hateful paranoia

Unstable identity Insecure identity. Frequent changes in beliefs, religions, and social groups

Impulsivity Impulsivity

Intense anger Intense anger


IGH

OV

ER

LAP








SO

ME

O

VE

RLA

P Frantic efforts to avoid real or imagined

abandonment Intense romantic attachments and sensitivity to rejection

Recurrent suicidal behavior, gestures, threats, and self-injury

Elevated risk of suicide and self-injury


IGH

OV

ER

LAP








SO

ME

O

VE

RLA

P Frantic efforts to avoid real or imagined

abandonment Intense romantic attachments and sensitivity to rejection

Recurrent suicidal behavior, gestures, threats, and self-injury

Elevated risk of suicide and self-injury

LES

S O

VE

RLA

P Chronic feelings of emptiness May occur if there is a significant history of trauma or

neglect

Transient, stress-related paranoid ideation or severe dissociative symptoms

Paranoia can occur during severe mood episodes, and dissociation may be part of the picture if there is a significant trauma history

PTSD Bipolar Trauma: 100% Trauma exposure is 2-3x higher in bipolar2

Interpersonal trauma in bipolar: 30-60%3

PTSD in bipolar: 16%4

Intrusive distressing memories Pressured, intrusive negative thoughts

Nightmares Nightmares more common (REM sleep)

Flashbacks --

Distress with triggers Amygdala hypersensitivity

Avoidance of triggers, memories, emotions Dislikes thinking about painful events

Inability to fully recall trauma

Persistent negative beliefs, distorted cognitions, negative emotions, low activity, detachment from others

Prominent in depression (50% of lifetime)

Irritable, reckless, self-destructive, hypervigilant, startle, poor sleep/concentration

Prominent in mixed states

1Kilpatrick DG, J Trauma Stress, 2013. 2Yuval N, Bipolar Disord, 2008. 3Mauritz MW, Eur J Psychotraumatol, 2013. 4Otto, Bipolar Disord, 2004

ADHD Bipolar hypomania Fidgets, gets up, runs about Hyperactive mood

(irritability common) Euphoric or irritable mood

n/a Inflated self-esteem

(insomnia common from restlessness) Decreased need for sleep

Talks excessively, interrupts others More talkative

Thoughts are easily distracted Flight of ideas

n/a Racing thoughts

Easily distracted Distractibility

“On the go,” “Driven by a motor” Goal-directed activity or motor agitation

(impulsivity part of hyperactive syndrome) Impulsivity

Generalized Anxiety Bipolar Excessive worry about every things Common in depression

Difficulty controlling the worry Rumination common in depression and mania

Restless, keyed up, or on edge Hyper, agitated

Easily fatigued Atypical depression = fatigue

Difficulty concentrating Part of mania and depression

Irritability Part of mania

Muscle tension Motor agitation in mania and depression

Sleep disturbance Part of mania and depression

Anxiety sensitivity is higher in hypomania than depression1

20-50% of people with bipolar have an anxiety disorder at some point2

1Otto M, J Affect Disord, 2005. 2Deckersbach T, Am J Psychiatry, 2014.

1Otto M, J Affect Disord, 2005. 2Deckersbach T, Am J Psychiatry, 2014. Deckersbach T, Am J Psychiatry, 2014.

People with bipolar responded better to psychotherapy if they had anxiety.

CBT Family focused therapy

Social Rhythm (IPSRT)

Psycho- Education

CBT-insomnia-

bipolar

Functional Remed-iation

Psychoeducation Y Y Y Y Y Y Relapse prevention Y Y Y Y Y Mood monitoring Y Y Y Y Y Med adherence Y Y Y Y Y Regular sleep Y Y Y Y Y Communic. skills Y Y Y

Six Effective Therapies for Bipolar

Questions?

The Therapeutic Relationship

Common Themes in Bipolar

Denial of the illness Stigma Developmental delays and emotional immaturity Uneven career or creative life; loss of roles in society Financial problems Burden on the family Risky sexual behavior Marriage, pregnancy, genetics Tempestuous relationships, lovelife, divorce Effects of medications on temperament Fears of return of illness episodes Grieving over years lost due to bipolarity and its complications Self-regulation and regulation of self-esteem —Adapted from Hagop Akiskal, Care of the Bipolar Patient, 2011

Therapy Stance Friendly advisor who works to understand the client’s entire life and educate them on relationships. Role model for relationship skills such as consideration, healthy assertion, gratitude, and understanding. “Cool under stress,” “Not overreact to disappointment,” “Think before acting.” Adapt stance to current mood state.

Judy Beck, CBT for Personality Disorders

“Encouraging grandiosity diminishes it. The best reaction to a grandiose comment is to say: ‘How wonderful! I wish I could feel more that way myself.’" —Ghaemi and Havens, American Journal of Psychotherapy, 2005

Manic Siding

Nassir Ghaemi

Dysthymic To establish trust, be realistic, sensible, and skeptical. Caution with optimism.

Countertransference Therapeutic defeat in chronic depression can lead to…

Anger (assigning lots of homework, challenging) Withdrawal (passive, daydreaming)

Sign: dreading the appointment

Illness Role Depression is an illness.

People lighten their loads and reduce expectations when ill.

You are not responsible for the depression, but you are responsible for doing your part in recovery. (from Interpersonal Therapy for Depression)

Fully whole vs. wholly bipolar “I don’t think my therapist gets it that I have bipolar. He expects me to do things that I just can’t, and acts like I’m not trying hard enough.” “No offense but I really don’t want to hear anymore about bipolar. I want to move beyond that and need a therapist who can help me find myself again.”

Past vs. Future “My therapist only wanted to talk about my father, and that just made me more depressed so I quit.” “I have a lot of baggage and really want a therapist who can help me work through that so I don’t repeat the past.”

Advice vs. Listening “I don’t need someone to nod and say ‘I understand.’ I need some guidance here!” “There’s no one I can talk to about these problems, and have a lot to get off my chest. I’m not looking for simple advice. I need someone who can take the time to understand me.”

Questions?

Cognition

“Functional impairment often persists even in the face of full symptomatic recovery.”

—Goodwin & Jamison, Manic Depressive Illness, 2007

The Cognitive Pole “I lost my sense of competence... Word retrieval was difficult and slow... Clarity of thought, memory and concentration had all left me. I was slowly fading away. [After recovering] I still don’t have full days — I’m only functional mornings to midafternoons.”

—Linda Logan New York Times Magazine 2013

Cognitive Problems

Attention “I’m distracted, can’t follow a movie.”

Memory “I forget what I went in the room for.” “Can’t think of words.” “I repeat conversations… embarrasing!”

Executive “I’m overwhelmed and don’t know where to start.” “I’m impulsive.” “I’m always late.” “My boss is so unfair, she keeps changing the rules on me.”

Social “I don’t trust anyone” “People are always criticizing me.”

Group therapy 21 weekly 1.5 hour sessions

Interactive Clients roll-play and do exercises together

Homework Reading, practicing, word games, puzzles. Can include web-training: www.cognifit.com www.brainhq.com www.rehacom.us

Functional Remediation

What to Tell Clients Cognitive problems affect 30-60% of people with bipolar and often persist after the episode resolves. They are the result of too many past episodes. It is not progressing to dementia.

Medications rarely cause significant cognitive impairment. They can help prevent cognitive problems, but rarely treat them. Aerobic exercise, Mediterannean diet, and skill-building are the best treatments.

Allow extra time Schedule breaks

(5 min/hr) Change tasks Schedule difficult tasks

for times when concentration is optimal

Minimize distractions

Attention

Attention Drink water Build in simple rewards

(chocolate, favorite websites) Summarize as you read Find something personally

relevant in the material

Memory MEMORY AIDS Calendars Apps Alarms DAILY JOURNAL To do list Appointments Important events

ORGANIZE Keep related things in

the same place at home

MEMORY TRICKS Chunk information into

smaller pieces Associate names with

people you know, physical traits, or funny rhymes

Calendars Top Picks Simple Elephant Planner and Panda Planner. Designed with mental health in mind, these include mood-boosting features like a gratitude journal. Simple, affordable options Blue Sky, At-A-Glance® Classic, professional look Moleskin, Lemome, and Ink+Volt

Panda Planner

Task Completion BREAK IT DOWN Break complex tasks into

smaller steps Prioritize each step

TIME MANAGEMENT Practice estimating how it

will take to complete each step

Problem Solving SLOW DOWN

DESCRIBE THE PROBLEM What causes it or makes it persist? Who are the people involved? What is the desired outcome?

BRAINSTORM SOLUTIONS

EDIT, RANK & IMPLEMENT Most likely to work Least likely to backfire Easiest to implement

No solution is too ridiculous

A video

game for ADHD?

Wii Sports

Questions?

Top Causes of Depression

Initial response to stress = Try harder.

Chronic stress (e.g. 6 months) without success = Depression.

Stress + Time

Loss + humiliation = depression

Loss + threat = anxiety

Kendler KS et al, Arch Gen Psychiatry. 2003 Aug;60(8):789-96 Aslund C et al, Eur Child Adolesc Psychiatry. 2007 Aug;16(5):298-304

Like weeds, even minor physical and mental symptoms tend to grow back into full episodes.

Residual symptoms

Antidepressants do not work in depressed mice who are kept in isolation.

Isolation

Aerobic exercise prevents depression 4-times better than an antidepressant.

Depression tends to return 2-4 months after stopping exercise.

Inactivity

BMI > 30 predicts poor response to antidepressants, in part due to inflammation.

Weight

Poor diet is contributes to 30% of the depression risk in large epidemiologic studies

Poor diet

The body’s response to injury and infection

Found in 30% of depression, 50% of treatment-resistant depression

Inflammation

Inflammation Risks Early childhood trauma

Recent significant stress

Treatment resistant depression

Anxiety, depression, neurotic traits

Chronic medical illness

Obesity (BMI ≥ 30), Western diet

Smoking, sedentary lifestyle

Recent chemotherapy or radiation

Recent bodily injury or surgery

Elevated CRP > 3

Chronic pain

Sleep apnea

Thyroid illness

Head injury

Other health problems

Insomnia is a top risk factor of depression or mania.

Anxiety disorders often turn into depression, e.g. by age 30.

Both are risk factors for suicide.

Insomnia and Anxiety

High activity at night, and low in the evening, was associated with depression, bipolar, and cognitive problems 3 years later in a study of 91,000 people

Nocturnal Activity

Lyall LM et al, The Lancet Psychiatry, 2018

Associated with: Depression Sexual dysfunction Obesity GI and Heart disease

Night Shift

Routinely working over 11 hours a day doubles the risk of depression

Long Hours

30 min one-way and longer associated with: Depression Insomnia Obesity Marital stress Chronic pain

Commutes

St-Louis E et al (2014), Transportation Research Part F: Traffic Psychology and Behaviour, 26, 160–170.

Depression in fall or winter

Mixed states or mania in spring

Can worsen around equinox when the light changes rapidly. Or when the amount of light is lowest (Dec-Jan).

Depression in March when daylight savings shifts morning light later.

Seasonality

Sudden changes in sleep, wake times, or timing of daily routines

Rapid changes in outdoor light (Spring or Fall Equinox)

Traveling across more than 2 times zones

Childbirth (for women and men)

Medications: antidepressants, stimulants, steroids, testosterone, weight loss medications

Top Mood Destabilizers

Questions?

“The most noxious assumption that [clinicians] can fulfill is the feeling by patients that we represent the “system,” the status quo of power and privilege. We will label the patient as sick, and then send them through a rigamarole of diagnosis and treatment that will end up with his extrusion as a “patient,” often without an active and productive role in society or a strong sense of self-worth.” —Ghaemi and Havens, American Journal of Psychotherapy, 2005

On Diagnosis

Fragile Circadian Rhythm Disorder

A day in the (ideal)

life

Sound alarms wake us from deep sleep 90% of the time, causing sleep inertia.

This groggy state lasts 15 minutes in most people, but up to 4 hours during depression.

Sleep Inertia

Phillips HF3520/60 $100

TURNS ON Gradually over 30 minutes

IMPROVES Alertness Energy Depression

Dawn Simulator

EXAMPLES Philips morning wake-up

LightenUp (best price)

Apps (Rise & Shine, Lichtwecker )

Seasonal Affective Disorder (SAD) Positive in 8/10 small controlled trials (total n=446) 7/10 of those are placebo-controlled

Other Conditions Sleep inertia SAD in recovered alcoholics Sleep quality in normal adults (cross-over study, n=100) Attention, alertness, and working memory in adolescents and sleep deprived adults (pb-control)

Dawn Simulation

$20 at windhovermfg.com

Products

www.moodtreatmentcenter.com/products

Wake up at the same time each morning (within 15 minutes).

Get out of bed immediately upon waking.

Make the bed so it’s harder to get back in.

Start the day with energizing activity.

Brisk Awakening

Melodic Music Reduces Sleep Inertia

McFarlane SJ et al, PLOS One 2020

Do these upon awakening: Page turners: the more you do them, the more you want to do them

Aromatherapy (citrus, mint, rosemary)

Morning playlist (e.g. dance or exercise music)

Step outside, move around

Cold water

Energizing Activity

Top activities that stabilize mood (zeitgebers*)

Time out of bed Time starting work or chores Time of significant interaction with others Time of dinner

Do these at the same time each day (give or take 15 minutes) *German for “Time givers”

Social Rhythm Therapy

IPSRT: Interpersonal Social Rhythm Therapy

“Awake” = Feet on the Floor

Social Rhythm Chart

Rate the People Factor

0= Alone

1= Others present but not involved

2= Others actively involved

3= Others very stimulating

Social Rhythm Therapy

Avoid overstimulation at night

Bright lights

Crowds

Arguments

Intense conversation

Goal-directed activity

Exciting projects

Is it energizing? Move it to morning

Opposite action for Mania Schedule down time

Stay on one task at a time

Mindfulness

Rhythmic breathing

Limit overstimulation, texting, social media

Avoid stimulant drugs, caffeine

3-Volley rule for arguments

Delay making decisions (wait 3 days or ask 2 people)

Dim lights

Sleep

5 Month Educational Group Therapy for Bipolar

Delle Chiaie R et al, n=20, RCT, 2013

Cortisol Before Cortisol After

Questions?

45 minutes every other day of light aerobics (raise heart rate by 10 bpm)

Brisk Walking

Exercise works as well as an antidepressant, but prevents depression 4-times better. It also improves memory, which antidepressants do not.

Dance Play with kids or animals Cycling or stationary bike Treadmill in front of TV Swimming Active video games

(Wii Sports, Just Dance, Island Run) Happy walk at home video Or even better... In a forest

Creative Aerobics

Island Run

An hour a day in "farming" activity, from gardening to agriculture, was associated with a 50% lower risk of depression

12% of the improvement was related to physical activity, but none was related to age, gender, weight, smoking, drinking, physical health, isolation, education, income, or length of day.

Asai Y et al, J Affect Disord. 2018, 1;241:235-240

How Nature Heals Low threat signals Phytoncides improve immunity Negative air ions lift depression

Sundown Dim the lights Dim the screens (f.lux app)

30 min before bed

Electronic free zone Darkness or warm, yellow light Colder temperature Meditative activity Stretching, muscle relaxation Calming music Lavender, Jasmine

Evening Wind Down

Obesity Diabetes Cancer (breast, prostate) Cardiovascular disease Neurologic diseases Gastrointestinal ulcers Adverse reproductive outcomes

Light at Night (LAN)

Delays, reduces melatonin Impairs neuroplasticity, shrinks dendrites Impairs sleep, cognition, learning Creates night-owls (phase delay)

Light at Night (LAN)

Obayashi K et al, Am J Epidemiol. 2018

Bedroom light above 5 lux associated with double the risk of depression after 2 years. The brighter the light, the greater the risk. (Obayashi, 2018, Longitudinal study of 863 older adults)

Even dim light...

Full moon 0.3 Twilight 5-10 Dark public area 20-50 Living room 50 Dark overcast day 100 Office lighting 320-500 Sunrise/set 400 Overcast day 1,000 Full daylight 10,000-25,000 Direct sunlight 32,000–100,000

Lux

Dark Therapy

Mania (controlled trial) Rapid cycling (case series) Shift-work syndromes (case series) Insomnia (controlled trial, deepened sleep) Next-day cognition

Dark Therapy Treats

Dark therapy improved mania in hospitalized patients. Effect size = 1.8 (3-times greater than most meds). Patients recovered without sleeping more.

Henricksen et al. Bipolar Disorders, 2016

6pm to 8am Virtual darkness (blue-light filters) when out

of bed Total darkness (or eye mask) when in bed Can start later if improved after a week or if

symptoms are mild (Shifting later by 1 hour every 2-3 days) (2 hours before bed is ideal for prevention)

Protocal pm

am

Glasses

Uvex Skyper 3S1933X $7-10 on Amazon

Uvex Ultraspec 2000, S0360X , $7 on Amazon

Lowbluelights.com $70-80

Kayumov et al. J Clin Endocrinol Metabolism, 2005

Melatonin Rises with Dim Light or Blue-Light Filtering Glasses

Blackout curtains (such as ShiftShade, or buy blackout fabric, attach with pins or Velcro)

Aluminum foil against window Electric tape over LED lights Sleep in basement Low blue nightlights: Maxxima MLN-16 Amber LED Night Light Plug SCS Nite-Nite Light Bulb or Sleep-Ready Light lowbluelights.com, somnilight.com Apps: f.lux, Apple Nightshift mode, Kindle Candle

Black out

Computers Windows: f.Lux

Mac: Candlelight by Oliver Denman

Smartphones, Tablets

Apple Nightshift mode

Kindle BlueShade

Android Twilight and Blue Light Filter app

Blue Light Filters

Try and see what works: Weightless, by Marconi Union

Binaural beats (5-7 Hz, theta)

Regular rhythm, bass tones, tranquil melodies, slow tempo (60-80 BPM; songbpm.com)

Classical, celtic, Gregorian chant, New Age, Indian or Chinese Classical, electronic

Familiar songs without lyrics

White noise and pink noise (nature sounds)

Music for Sleep

Top Tools for Bipolar

1. Regimented sleep

2. Reducing alcohol

3. Exercise

4. Lamotrigine (Lamictal)

5. Sunlight

6. Mindfulness

7. Psychotherapy

8. Self-tracking & journaling

9. Reducing caffeine

10. Lithium CureTogether, online survey, 2012

bipolar CBT-i

Harvey et al, 2015

bipolar CBT-i

Harvey et al, 2015

Questions?

CBT Insomnia (CBT-i)

Free app: CBT-I Coach

Doubles the rate of response to antidepressants.

In bipolar disorder, reduced the rate of mood problems 8-fold after six months.

“Jump starts” therapy for PTSD

Lowers inflammation

Apps (CBT-i Coach)

Mood Benefits of CBT-i

Ashworth 2015, Taylor 2007, Harvey 2015

Two forces drive sleep: Sleep Drive:

Increases the longer you’re awake.

Circadian Drive:

Cycles with sunlight and wake times.

Sleep: A 24-hour Cycle

The problem: Sleep-drive is more powerful than sleep

medicine, but one force can override it: Anxiety.

Anxiety about sleep delays sleep drive, causing people to get tired at the wrong times.

Trying to sleep can override sleep-drive because the effort involved activates stress hormones.

Anxiety Disrupts Sleep Drive

Solutions: Only go to bed when you are tired; don’t force it.

If you can’t sleep after 20 minutes, get out of bed. Keep the lights low and do boring or meditative things.

Allow sleep deprivation; it will increase your sleep drive.

While following this strategy, you may worry that limiting your time in bed will cause you to be sleep deprived. That’s true, but remember you are already suffering sleep deprivation from insomnia so either way you will have trouble. With this strategy, the trouble will gradually get better.

Anxiety Disrupts Sleep Drive

The Problem: Oversleeping prevents the circadian clock from setting correctly, resulting in more insomnia.

Solution: Arise out of bed the same time each day regardless of how much you slept.

“CBT-i will help harness your sleep drive and align your circadian rhythm. CBT-i is more effective, and longer lasting, than sleep medicine, but it takes longer to work. You may be more anxious, and more sleep deprived, in the first phase.”

Awake at regular times. Out of bed during the day; only use bed for

sleep and intimacy. Avoid daytime napping. Avoid caffeine after 2pm. Wind-down time in 30 minutes before bed. Only go to bed when tired. If unable to sleep after about 20 minutes

(don’t watch the clock), get up and sit in the dark doing nothing until tired again.

First Aid: Sleep Hygeine

For each day, record how much time you spent in bed awake vs. asleep

At the end of the week, add up the total time asleep and divide by 7 for average time asleep.

Add 30 min to that average time asleep. Over the next week, you can only spend that much time in bed. Choose a regular wake time that fits with it.

Do not restrict time in bed to < 5 hours (or <6.5 hours if bipolar).

Advanced: Bed Restriction

CBT-i Examples

Daytime Napping Napped during the day 4:00 pm to 6:00 pm.

Evening: awake in bed from 11:00 pm to 1:00 am, then slept to 7:00 am. Total sleep = 8 hours. Time awake in bed = 2 hours.

Can’t fall asleep (initiation insomnia) To bed at 10:00 pm, toss and turn for 3.5 hours and fell asleep around 1:30 am.

Sleep through the night and wake up at 9:00 am

Total sleep = 7.5 hours. Time awake in bed = 3.5 hours.

Waking up at night (middle insomnia) To bed at 10:00 pm and fall asleep within 15 minutes.

Woke up twice during the night, each time losing about 30 minutes of sleep.

Awoke a third time at 5:00 am and stayed in bed for 3.5 hours before getting up at 8:30 am.

Total sleep = 6 hours. Time awake in bed = 4.5 hours.

After about a week, or once improvement occurs, you can adjust your allowed time in bed nightly rather than weekly using this formula:

Sleep efficieny = (time asleep) / (time in bed) * 100.

Below 80%: subtract 15 minutes from time in bed.

80-85%: keep time in bed the same.

Above 85%, add 15 minutes to time in bed.

Nightly adjustment

After age 50, people tend to go to bed earlier and wake up earlier.

Waking in the middle of the night is more common.

Sleep becomes more fragmented after age 60, so that people may effectively sleep in two shifts. In that case napping can be normal and health, e.g. 30-90min nap at a regular time (before 5pm). This needs to be individualized – best to add napping in after improvement with basic CBT-i to see whether it destabilizes the sleep cycle.

Modifications for Older Age

Modifications for Bipolar 1. Don’t restrict time in bed by <6.5 hours.

2. Address rewarding aspects of sleep-interfering behaviors.

3. Greater emphasis on circadian rhythms.

4. Morning: light, brisk wake-up, energizing activity.

5. Evening: dim light. Dark therapy if manic.

6. Addresses night-owl nature of bipolar (phase-delay) by gradually moving sleep-time 20-30min earlier each night.

7. Validate the realistic fear that lack of sleep could trigger a mood episode.

8. Use mood chart and connect sleep problems to mood problems.

Yearning for freedom from time constraints may impair adherence to sleep hygeine –Hagop Akiskal

Modifications for Night Owls Adolescents and bipolar clients tend to stay up late and wake up late….

1. Move the wake-up time up by 30-60 minutes each day, while keeping time allowed in bed the same.

2. If society allows, clients are welcome to keep their night-owl routine.

Questions?

Temperature & Sleep Drop in temperature signals

sleep. A Rise signals wake.

A very hot bath (not a shower) 1-2 hours before bed (102-104°F) for 20-30 min causes core body temperature to fall.

Sleep in a colder room (60-65°F)

For morning, program thermostat to increase temp.

Bath Safety Falls and drowning: Avoid alcohol, sleep meds, sedatives.

Blood pressure drops: Stay hydrated. Caution with pulmonary hypertension, emphysema, heart disease, renal disease, elderly, dizziness.

Skin burns, infection, breakdown: Avoid if active skin disease, neuropathy or numbness, any infections. Avoid > 30 min or temp ≥ 110°F.

Fertility: Avoid in pregnant women and men attempting to conceive (sperm count).

Questions?

End Day One

Therapy for Mood Disorders

Chris Aiken, MD Instructor, Wake Forest University Dept of Psychiatry Director, Mood Treatment Center Editor-in-Chief, The Carlat Psychiatry Report

Depression and Mood Disorder Certification Training

PESI, 2020

Social World

Mood disorders alter the perception of facial expressions, even when mood is stable.

=

S/S Gene The short-arm of the serotonin transporter This gene is associated with amygdala hypersensitivity to fearful faces (and fear in general). It also predicts higher rates of depression after stress.

Dark Blue: 2 short arms. Light Blue: 1 short, 1 long. Yellow: 2 long

Family Focused Therapy Free manual: www.semel.ucla.edu/champ

Reduce: Hostility, critical comments, scrutinizing mood, over-involvement Increase: Warmth, optimism, positive comments Communication: Reflective listening Regular family meetings Education: Family learns signs of illness so they can better focus on the person Plan for emergencies

Expressed Emotions

Critical comments Specific negative comments about the client

Expressed Emotions


Hostility

A belief that the client can control their symptoms

but chooses not to.

The client is seen as the cause of all the family’s problems.

Expressed Emotions


Hostility

A belief that the client can control the symptoms of their

disorder but chooses not to.

The client is seen as the cause of all the family’s problems.

Over-involvement Over-protectiveness, enmeshment, poor boundaries,

self-sacrifice, excessive praise or blame

Priebe et al, 1989 8 times more likely

Bipolar relapse in families with high EE…

Families with high EE benefit from communication skills

All received similar family therapy with education, but only the FFT group learned communication skills:

1. Active listening 2. Making requests for changes

in others’ behaviors 3. Offering positive feedback or

constructive criticism about specific behaviors.

4. Problem-solving

Taught through role playing and homework assignments

Milkowitz D et al, JAACAP 2009

Warm, optimistic and positive expressions help.

Angry, hostile, and critical expressions worsen outcomes,

Structured time to give feedback and problem-solve difficult topics.

When criticism is given randomly, it feels like it’s happening 24/7

Weekly meeting

“It is often the mother who carries the brunt of the illness’ burden. Such mothers themselves often go through periods of despair, hope and denial about their adult bipolar children.

This is often a lonely despair, about which kin not living with the family are ignorant of or indifferent to; at worst, such kin may even display critical and angry attitudes towards the caregiving mother (i.e. “You are a bad mother - you are not taking care of your sick child”), or even worse (“Your child's illness is due to you having abandoned her”).

Such criticism toward the mother is also routinely verbalized by the bipolar offspring, but unlike that of kin, may cycle into effusive expression of love and gratitude in a state-dependent fashion.”

—Hagop Akiskal, Care of the Bipolar Patient, 2011

On Mothers

Adult Children with bipolar living in the home If they can do something independently, allow them to.

Seize the day: Don’t avoid opportunities (e.g. college) because of fear of relapse or failing.

Set up realistic expectations with enforceable consequences for living in the home, much like you would with a tenant.

Living at home may be contingent on going to treatment, but not necessarily on taking medication.

Emergency plan

Crisis Plan

Anticipate problems Violence, suicidal behavior, substance abuse, overspending, and

fights that impact children in the home.

Plan Solutions Wellness Recovery Action Plan (WRAP) or Crisis Plan

www.dbsalliance.org/pdfs/wellness_toolbox/crisis_plan.pdf

Allow family to come to appointment or contact providers

Lock away guns, credit cards, extra medication

Temporarily live apart

Partial hospitalization or hospitalization

Young Children what to tell children of parents with mood disorders If over 12, talk about the disorder in specifics.

Otherwise use general terms and compare to physical illness.

Emphasize that their parent loves them.

Tell them it is not their fault.

Empower them: give specific things to do to help the family.

Encourage them to ask questions and talk about how they feel.

Strengthen sources of support outside the home.

Questions?

CBASP Cognitive Behavioral Analysis System of Psychotherapy Easier book: CBASP: A Distinctive Treatment for Persistent Depressive Disorder

CBASP is one of few therapies with efficacy.... > in chronic depression > as antidepressant augmentation

In a large study of chronically depressed people with early childhood abuse or neglect, CBASP was effect while antidepressant (nefazodone) was not.

CBASP: The Data

James McCullough , PhD, Founder of CBASP

CBASP for Chronic Depression

Keller MB et al. New Eng Med. 2000;342:1462-70. (n=681)

Theory of Chronic Depression Childhood maltreatment may have fostered survival skills

that were effective then but not now

Disengaged from their environment

Don’t respond to feedback, can’t learn

Locked in a primitive world-view that blurs the linear sequence of cause and effect

We Overestimate Their Logical Capacity

Reality is the way it is because “I believe it”

Monologue speech. They don’t talk with us. They talk at us. Empathic, bidirectional speech is absent

Ego centric. All roads leads to the client. You don’t exist for the client in any way that could change their behavior

Global thinking. Always, everyone, forever, never, nothing…

CBASP: Strategies Problem-solve desired vs. actual outcomes through

interpersonal exercises.

Pragmatic focus on transference distortions.

Increase client’s awareness of their effect on others.

Which relationships left a mark on you? For each one, how did they react when you...

Asserted your needs?

Expressed negative emotions?

Made mistakes?

Sought to be close to them?

Interpersonal Inventory

CBASP: Interpersonal History

Sought Intimacy Failed, made mistakes Expressed Emotional

Needs Expressed Negative

Affect

Father He goes away He beat me Ignores my feelings He tells me to suck it

up

Mother Uses me to do things for

her Ignores it unless it

effects her Tells me not to be

emotional Gets angry at me

What was the mark each person had on your life?

Disciplined Personal Involvement

Reveal your reaction to the client to help them learn how they effect others.

Hot Spot: when client would expect you to be rejecting, dominating, hostile, or withdrawn… act the opposite way and call attention to the difference.

Use yourself as a tool for the client to learn verbal and non-verbal empathy and give and take.

Interpersonal Discrimination

The way it was then

with my parent

The way it is now

with my therapist

Fearful

Unsafe

Unchanging

Hopeless

Helpless

Safe

Helpful

Hopeful

Empowering

Avoidance Approach

Tell a story about a recent personal interaction. What happened? What did you do? What was said? What were your emotions and perceptions? What did it mean to you?

The story should have a beginning, middle, and end.

What was the actual outcome?

How did you want it to turn out?

How did your perceptions and actions influence the outcome and how could you improve on that?

Situational Analysis

If you don’t like the way you feel, then you must change your behavior

Questions?

Behavioral Activation Easier book: Behavioral Activation by Jonathan Kanter (CBT Distinctive Features)

Behavioral Activation WORKS As well as CBT, and more effective than CBT for severe depreession

WHAT IT IT’S NOT Lists of activities Purely behavioral

WHAT IT IS Identifying avoidance Gradually overcoming anxiety Values-based action

Jacobsen N et al, 1996

BA outperforms CBT in severe depression

Dimidjian S et al, 2006

Remission rates greater with BA in severe depression

Dimidjian S et al, 2006

23% Medication (ADM)

36% Cog Therapy (CT)

56% Behav Activ (BA)

DEPRESSION CAUSES...

Passivity: “Things happen to me,” without a sense of one’s role

Avoidance of unpleasant feelings (anxiety)

Tendency to interpret others as rejecting or critical

Erosion of pleasure, meaning, and values BA HELPS PEOPLE ENGAGE WITH....

Moment-by-moment awareness of actions and choices

Values they can live by

Purposeful action

Behavioral Activation

Behavior is everything a person does...

Actions: Approach, avoidance

Private behaviors: Thinking, feeling

There is no judgment about will or intention


Positive reinforcement Adding a reward makes the behavior more likely

Negative reinforcement Removing something aversive makes the behavior more likely

Punishment Adding something aversive makes the behavior less

Extinction Removing a reward makes the behavior less likely

Reinforcers

Positive Reinforcement

Adding something rewarding (a text message)

makes his cell phone use more likely to happen

Removing something aversive (parents)

makes the behavior more likely to happen

“I can’t stand my parents” Negative Reinforcement

Adding something aversive (wrist pain)

Punishment

makes the behavior less likely to happen

Removing a reward (cell phone)

Extinction

makes the behavior less likely to happen

“I enjoy it.”

“It’s a responsibility I have to take care of.”

“It’s a step towards something better in my future.”

“It’s part of my beliefs and values.”

“I was avoiding uncomfortable feelings or a difficult situation”

Common Reinforcers

Behavior is everything a person does...

Behavior: What are they doing?

Antecedent: What is going on, what’s the context, when they do it?

Consequence: What happens after they do it?


The ABC’s of CBT and BA

Cognitive

Antecedent Invited to a dinner, anxious

Belief “I’m not likeable”

Consequence More depressed, stay at home

Behavioral

Antecedent Invited to a dinner, anxious

Behavior Stay at home

Consequence Reduced anxiety

Target for change What reinforces Behavior

Diverse and stable rewards

DEPRESSION RESULTS FROM LACK OF CONTACT WITH

Increase contact with diverse, stable, meaningful rewards

THE GOAL

Devotion to a single pursuit with unstable reward, e.g.

Artistic fame

Creating ideas

Composing

Collaborating

Public performance

Mastery of instrument

Recording & Technology

Marketing

Depression is an adaptive response to loss of rewards

Problem solve

Elicit support

Signal retreat

so as to avoid conflict and further loss

ORIENT THE CLIENT

Take history

Link behavioral model to history

Explain nature of sessions

Depressive behaviors are normal, understandable responses

Goal is to learn to take action even in the face of negative thoughts and difficult feelings.

Often this means to act the opposite of your feelings and knowingly approach unwanted experiences

This is a skill; the therapist is a supportive coach.

Opening Session

ORIENT YOURSELF

There are no failures – goal is understanding. It’s rare for clients to complete homework 100%

Your interest is in understanding behavior – what the client does – and what makes it more or less likely. Not their intentions or will power.

Your interest is in the function of their thoughts – what their thoughts lead to – not in their validity or content.

Opening Session

CALENDAR WEEK 1

“The heart of this therapy is in understanding what you do each day and how that affects your mood and life. To help me get a better picture of that, I’d like you to record as much as possible of what you do each over the next week. Include things that seem like “nothing” – if you are sitting and worrying write that. Don’t try to make it look better than it is. I want to know how badly this depression is for you.”

Any form of calendar that gets the information will do.

Optional: Rate mood 0-10 throughout day

First assignment

Always Decide on a time and place for activation assignments

REVIEW CALENDAR

Positively reinforce any completed effort

Look for times of low activity, avoidance, approach

ACTIVITY ASSIGNMENTS

Develop list of approach activities with client, have them rate by difficulty, and schedule in upcoming week.

Choose activities collaboratively – What is easiest? Are basic daily routines missing? What is most likely to be rewarding, especially with diverse and stable rewards.

Anticipate difficulties in completing assignments.

You’ll be interested in how the assignment goes – whether they do it or not – you’ll want to know the details

Session 2

Antidepressant Activity

1. Time flies

2. Un-self-conscious

3. Challenging enough

4. Sensory involvement

5. Clear goals, quick feedback

6. Slightly addictive

7. For the love of the game

8. A higher cause

Mindful Media

1. Limit screen time

2. Use it as a reward

3. Watch with intention

4. Get absorbed, but avoid binge watching

5. Move around and laugh a little

Mindless Media

1. Social comparisons

2. An unruly social media circle

3. Advertisements

4. Gratuitous violence

5. Daily news

6. Reality TV

7. Binge watching

FUNCTIONAL ASSESSMENT OF ASSIGNMENTS

If successful, continue to build activations

If not successful, problem-solve

Ask about the context/triggers, the immediate result, and the long-term result. How did it work? How did it affect their mood?

Session 3+

Forgot Stimulus control:

Post-it notes in place that’s relevant to the action.

Smartphone, family or friends for reminders.

Skill deficit Non-social skills

Courses, learning, practice

Social skills

Borrow skills modules from other therapies, e.g. DBT

Skill deficit 1. Break it down into simpler steps

2. Practice and prepare

3. Focus on the process, not the outcome

4. Imagine how you’ll feel when it’s done

External consequences

How would family or friends respond if you did this?

Contract with others and client together to change reaction.

Internal consequences

Experiential avoidance is default reason if no other comes up. If client is vague about reasons, they may be avoiding in session.

These activations will take longer work.

Internal consequences Distress tolerance

Mindfulness

Sensory-based skills (music, aromatherapy, deep breathing)

Values

Values-based action is easier to sustain in absence of rewards

Marriage, dating, intimate relationships

Parenting

Other family relationships

Job, meaningful work

Education, training, life-long learning

Recreation, hobbies

Creative and artistic expression

Spirituality

Citizenship, community, activism, altruism

Health, nutrition, self-care

Life organization, time management, discipline, finances

Values

“What is important to you?”

“What used to give your life purpose?”

“Do these goals reflect any one else’s values?”

“Would these goals still be important to you if no one else was aware of your success or failure?” “Would you be happy – or unhappy – if you

achieved this goal?”

“Would this goal still be important if it did not lead to certain outcomes, such as praise, success, promotion, money?”

Core Values

“What goals would you like to work towards in treatment?”

“In what ways would you like things to be different?”

“What would you most like to change about your circumstances?”

“What things have you stopped doing since you became depressed that you would like to resume?”

“Are there any things you have started doing since you became depressed that you would like to change?”

“What would you be doing differently if you were not depressed?

Goal Questions

Functional goals are…

Specific: concrete, broken into steps

Measurable: pursuing something, rather than avoiding something

Achievable: within their control

Realistic: adjust if not

Time-limited: time-line with outcome

Goal conflict

“I want people to do things the right way…”

“I don’t want to disagree with people”

S.M.A.R.T. Goals

Putting values into practice

Reminders

Pictures, quotes in relevant places

Morning walk Start the day by reflecting on values

Rumination

Staying in bed

Staying at home

Avoiding conflict

Avoiding risk, challenge, and responsibility

Putting off jobs

Avoiding people

Avoiding promotion at work

Avoiding evaluation or judgment by others (e.g. tests, exams, interviews)

Abstract thinking

Distraction

Analyzing events over and over for certainty and control

Reassurance seeking

Complaining

Emotional avoidance (blocking or suppressing emotions)

Avoidance Behaviors

Direct action

Asking people for help and support

Being assertive

Taking risks

Trying new things

Making decisions and plans

Taking responsibility

Expressing feelings to others

Social contact

Scheduling activities

Testing things out by trial and error in the world

Problem solving

Learning and developing skills

Allowing oneself to experience feelings

Staying with details of memories

Approach Behaviors

Warm, supportive, validating, patient, understanding

Bring the abstract into the concrete

Address in-session behaviors that are relevant to activation: Avoidance, non-assertiveness

Therapist as reinforcement: e.g. If client completes assignment, they can use session time to talk about what they want; otherwise will talk about assignment

Act natural. Natural reinforcers are more generalizable. Avoid artificial praise.

Therapeutic Relationship

What are you feeling right now?

I see that you are struggling with your emotions at this

experience rather than fighting it and, without judgment, tell me what you are feeling.

Where do you feel it? In your chest? Behind your eyes? In your shoulders?

Take your time with this and mindfully explore this feeling for me if you are able. I will be here for you and I am open to anything you may experience.

─ JW Kanter et al, Behavioral Activation, 2009

How does therapy reinforce activation? Can it continue in its absence?

Gradually space out sessions, shorten their duration

Prepare for future risk periods, like major life changes, holidays and other disruptors of routines, and early signs of depression

Ending Therapy

Activation Guide Skills

Awareness of environment

Self-assessment

Self-activation

Tools

List early warning signs, activities, values, obstacles and ways to overcome them

Questions?

Rumination Focused Cognitive Behavioral Therapy

Recognize the Types

Dwelling, brooding, worry, obsessing, pondering, over-analyzing, stewing, “stinkin’ thinking”

“Yes, but…”

Rumination about rumination

Rumination about therapy

Co-rumination with the therapist

Rumination

Risk factors

Unreachable goals

Poorly defined goals

Goals that are hard to let go of

Inadequate skills to reach goals

Rumination

A gap that won’t close

Validate!

Thoughts that lead to a decision or plan

Specifics, like “What? Where? When?”, rather than abstract or general terms

Answerable questions

“How” rather than “Why”

Helpful Rumination

but I never walk backwards

I walk slowly

Stephen Spielberg’s

Scary Whispers

Stop Ruminating!

Habit Reversal Recognize early signs and risks

Intervene early with actions that are incompatible with rumination

Identify rewards of rumination

Goal is to reduce frequency, not eliminate it

Environmental risks…

Early in the morning

Late at night

When alone, tired, bored, or unoccupied

Pain, tension, or physical symptoms

Feeling pressured or disorganized

Withdrawing when upset (often to the bedroom)

Early Signs

Internal thoughts:

The self: mental and physical symptoms

The past: upsetting events, unresolved conflicts

The future: catastrophizing, worry

Social: other people’s intentions

Early Signs

Tracking Like a treasure hunt… “What new cues of rumination did you discover?”

Choose two situations with opposite outcomes; one a success and one a failure. For each one…

What? Include goals, events, actions, feelings, physical state, outcome

Where? Location, setting

When? Time, day, what came before the situation

How? Step by step how the event unfolded, your approach during the situation

Who was involved?

Functional Analysis

Avoidance

> Thinking about a problem rather than confronting it

> Anticipating rejection rather than facing the risk

> Avoiding painful details by abstracting

Feels like you’re solving or understanding a problem

Rehearse future events, worry to prevent errors

Revenge fantasies in angry rumination

The Rewards of Rumination

Anti-Ruminators

Conversation

Sports, board games, puzzles

Comedy, entertainment

Researching

Spiritual or religious activity

Music or dance

Art project, cooking, or knitting

A warm bath

Exercise, walking, biking

A pager-turner

Engaging activity

Behavioral Activation Quiets the Default Mode Network

RCT of 5 session of BA in adolescents, n=40, Yokoyamaa et al, 2018

Before After

A 90-minute walk in the woods reduced rumination more than a walk in the city

RCT of 38 healthy adults (Bratman GM et al, 2015)

Drop in Rumination Drop in Default Mode

After a Forest Walk

Take your time…

One thing at a time

Reduce demands

Allow adequate time to complete things

Simplify

Deliberately attending to the present in a friendly, nonjudgmental way.

Notice ruminative thoughts without trying to change, run from, or get caught up in them.

Mindfulness

The awareness of what is, at the level of direct and immediate experience, separate from concepts, category, and expectation.

-Dimidjian and Linehan

Allowing ourselves to be moved by suffering,

and experiencing the motivation to help.

Compassion

Do you relate to your struggle with…

Self-criticism, attack, shame, thinking you’re a problem,

Physical reactions of threat (fight/flight)….OR

Supporting, reassuring, encouraging yourself

Wisdom, kindness, courage

Acceptance and tolerance

Create a compassionate voice and script: “This too shall pass,” “I’m doing the best I can.”

Compassion

Recall painful memories in full sensory detail.

Watch for abstraction and rumination, which are ways to avoid the experience.

Allow self to be moved by the memory, letting go of the desire to change or avoid it.

Immersion in Memories

Questions?

CBT for Suicidality

CBT for Suicide Prevention (CBT-SP)

CBT-SP reduces suicide attempts by 50%*

10-16 sessions after a suicide attempt

Suicidal behavior is an understandable reaction given their

circumstances and frame of reference, but one that is

ultimately disadvantagous to the client

*metaanalysis of 10 controlled studies, 1,241 patients (Gøtzsche, 2017)

Key Ingredients

1. Attention to drop-out: Engage client quickly

2. Hope

3. Problem-solving: Suicidal patients jump quickly to a most

extreme solution

4. Social supports

5. Emotion regulation (self soothing)

6. Impulsivity

7. Hope box, Coping cards, Safety plan

8. Imaginal exposure to practice new learning

Structure of Sessions

1. Set agenda

2. Check symptoms (mood, suicidal ideation, etc)

3. Monitor substance use

4. Monitor adherence to psych meds and physical health care

5. Build bridges between past sessions with a particular focus on

beliefs related to the suicide attempt

6. Make capsule summaries

7. Elicit feedback throughout the session

8. Assign homework

Therapeutic Relationship

Flexibility

Empathic, validating, while at the same time

keeping the focus on the problem at hand

Prioritize Autonomy

Client cannot change their life if they aren’t in the drivers seat.

Put them there explicitly.

“I cannot prevent you from suicide,”

but acknowledge reality of involuntary commitment

Early Phase

Early Phase Goals

1. Engage client

2. Have them tell their story about the suicide attempt

3. Assess risk collaboratively

4. Safety plan for emergencies

5. Orient to CBT model

6. Collaboratively develop a cognitive conceptualization of the

suicide attempt, problem list, and goals (skills, life stressors)

7. Convey hope

Engage the patient

1. Simply scheduling an appointment is usually inadequate

2. Reminder calls

3. Discuss factors that would prevent them from attending

4. Discuss ways you’ll reach them if no-show

5. Conduct no-show sessions by phone

Tell the story

1. Thoughts, feelings, mental images, and events leading up

to the attempt

2. Empathy. Listen. Bear witness. They should feel heard.

3. May be first time they’ve shared the full details with another

Safety plan for crises

1. Clients cannot think straight when suicidal

2. Collaboratively develop list of strategies for emergency

3. At a minimum, include phone numbers of

Supportive people

Therapist and on-call providers

24-hour emergency psychiatric center

Other services that handle emergency calls

National Suicide Prevention Lifeline, 1-800-273-TALK

Coming soon: Dial 988

Cognitive model

1. Teach about how interpretations

influence feelings, and behavior.

2. Homework (skill based, or book

Choosing to Live)

3. Chain analysis of attempt

Stressors

Skill deficits and problems with

processing information

Dysfunctional core beliefs

Problem solving

What problem(s) lead to the attempt?

Can the attempt be reframed as an effort to solve that problem?

To escape from pain that seems unbearable and unending

To change something in their environment

Make a full problem list, divide into solvable and unsolvable

“Help clients adopt a more flexible approach to problem-solving and

modify beliefs that their problems are unsolvable or unbearable”

Hope

Hope in the face of adversity is more functional than hopelessness

No cheer-leading, Pollyanna, however

Middle Phase

Coping cards

Side 1: Automatic reaction

When stressed, slow down and notice your thoughts,

feelings, or impulsive. Write on front of card.

Side 2: Adaptive response

Work in session to develop an alternative to side 1

Coping Cards

Side 1

“This is hopeless

and will never get

better”

Side 2

“I have solved

problems that looked

unsolvable at first

before, like when I

moved here with no

one and found friends”

“Getting hopeless

does not help, I need

to talk with someone

who can help me get a

more objective view”

“Although I am overwhelmed now, I know this is temporary”

Hope Kit

1. A memory aid of reasons to live and adaptive strategies

developed in session

2. A box with items in it, e.g. pictures of family or pets, sentimental

gifts or objects, an award from school, a letter from a friend,

passage from a spiritual text, a prayer card, and a coping card

3. Put it in a conspicuous or easy to find place

“Many clients

report that the

Hope Kit is the

most

meaningful part

of cognitive

therapy.”

Virtual Hope Box

1. Relax: Breathing, muscle relaxation, guided

meditations

2. Distract: Puzzles, word games, solitaire

3. Inspire: 100 inspirational quotes

4. Coping: Cards, and activity planner

5. Phone contact list

6. Favorite songs

Though practical and portable, it lacks the

sentimental touch of real objects.

But it’s got music.

Distress Tolerance Skills

1. Self soothing

2. Exercise

3. Progressive Muscle Relaxation

4. Breathing exercises

5. Recall positive memories or pleasant scenes

6. Distraction techniques (Count 7 things in the room)

7. Aromatherapy, hot bath

8. Apps: Stress Free, Panic Relief, Breath2Relax

Aromatherapy

Calming scents

Lavender

Jasmine

Chamomile

Sweet marjoram

Frankincense

Bergamot

Impulsivity

1. Suicidal impulses come and go in waves

2. Goal is to wait them out

3. Safe-guard environment to make action more difficult

4. Hierarchy of strategies for impulsive times

Call or visit a friend

Engage in a task (clean, sing along with music, start a puzzle)

Sleep

Call therapist

5. Short-term solutions for impulsivity. Long-term solutions for life.

Long term goals

1. What have they been meaning

to do with their life?

2. Homework

Create a list of these and write

down why each is important

Social supports

1. Who is most caring in your life or willing to help?

2. Clients often believe no one cares, so use detailed questions or

family meeting to identify sources of support.

3. Are institutional supports in place?

Primary care physician, social services, church

Ending Therapy

Imaginal exposure of past attempt

1. Recall events leading up to past attempt with all senses.

Relive the pain and distress they experienced

2. Then… imagine using coping strategies instead of suicide

3. Important to explain rationale (consolidating learning) and warn

that they may have intense emotional reactions to the imaginal

exposure

Imaginal exposure with relapse prevention drill

1. Imagine future situation that might lead to suicide

2. See if they can use alternative coping in that situation

3. When they do, praise client but offer additional challenges to see

if they can continue to respond adaptively

Afterwards, debrief, check in.

Explore any suicidal ideation activated by the task.

Client remains in the session until all such thoughts have subsided.

Moving on

1. Discuss how the future will look

2. Support realistic expectations

Life has ups and downs, but that’s not the same as relapse

Modifications for adolescents

1. Psychoeducation for family on nature of depression, suicide

attempts, and treatment. Address problematic beliefs.

2. Family check-ins (5–15 minutes) are optional, but most session

time is for client.

3. Longer sessions with family to encourage their support and teach

Problem-solving skills

Emotion-regulation

Communication skills

Behavioral activation as a family

Modifications for adolescents

1. “No questions asked” turn in policy to get rid of pills/razors/etc.

2. Make a plan with relatives for room checks

3. Create a “safe space” in bedroom

(i.e., removing any upsetting pictures, posters, music, etc.)

Step 1: Look for Solutions

A crisis is a major stress that can’t be readily fixed or easily ignored, but there may be aspects that can be solved or worked on for part of each day

Step 2: Distress Tolerance

Improve the moment with distractions, ACCEPTS

Step 3: Avoid making it worse

If you can’t make it better, shift your goal – avoid making it worse

Irregular sleep, inactivity, poor diet, intoxication, self-harm, heated arguments, and other destructive behaviors

Crisis Survival

Questions?

Diet

Vegetables Daily servings ≥ 6

One servings = ½ cup

Aim for variety of colors. Include green leafy vegetable or tomatoes in at least one of those servings.

Frozen is fine. Mushrooms count. Limit potatoes to one serving a day unless it’s a sweet potato.

Fruit Daily servings ≥ 3

One servings = ½ cup

Include berries in at least one of those servings.

Dried fruit fine but watch for added sugar.

Limit fruit juice to no more than one of those servings.

Nuts, seeds, olives

Daily servings ≥ 1

One servings = ¼ cup nuts or seeds, ½ cup olives

Minimize salt.

Peanut butter and other spreadable nuts count, but look for low sugar options.

100% whole grains

Daily servings ≥ 5-8

One serving = 1 slice bread ½ cup cooked rice or pasta ¼ cup oats or muesli

Bread, brown rice, whole wheat pasta, oatmeal, muesli cereal, whole wheat crackers, quinoa.

The bran and germ has the healthy stuff: Antioxidants, B vitamins, fiber, and other nutrients

Not that! Eat this

Not that! Eat this

Not that! Eat this

Home Popcorn Ingredients

1/3 cup popcorn

3 tab extra virgin olive oil

Directions

Place olive oil in heavy bottom pot on high heat. Add 3 kernels of popcorn. When they pop, add the rest.

Cover and turn off heat for 30 seconds.

Turn head back to high and shake pot every few seconds. Lift the cover slightly ever 15 seconds to let out steam.

When popping slows, turn off heat and add popcorn salt or seasonings to taste.

Fish Weekly servings ≥ 2

One serving = 3 oz cooked.

“Fresh” fish is often defrosted, so frozen is a wise buy.

Costco’s frozen Kirkland Atlantic salmon preferred by chefs.

Beans

Weekly servings ≥ 4

One serving = ½ cup beans, or 1/3 cup hummus or tofu.

Edamame, humus, tofu, and falafel count.

Extra Virgin Olive Oil Daily servings = 3 tab

Olive oil is low in saturated fats, and extra virgin has brain-healthy antioxidants.

EV olive oil burns ≥ 325-400°F. For high-temperature cooking, use regular olive oil (465°F), safflower oil (510°F), or avocado oil (520°F)

“Extra virgin olive oil [is] the most stable oil when heated, followed closely by coconut oil and other virgin oils such as avocado and high oleic acid seed oils.” -Guillaume C, 2018

Phenols and antioxidants protect it from breaking down when heated. Reusing olive oil can increase the trans fats.

Guillaume C., et al, Acta Scientific Nutritional Health 2.6 (2018): 02-11.

g g

Safety line 25%

Low polar compounds

High oxidative stability

Lean red meat Max weekly servings = 3-4

One serving = 3 oz.

Poultry Max weekly servings = 2-3

One serving = 3 oz.

Milk, cheese, yogurt Max daily servings = 3-4

One serving: Milk: 1 cup milk (250 mL)

Yogurt: 200 grams

Hard cheese: 40 grams

Soft cheese: 120 grams

Eggs Max weekly servings = 6

Less if high cholesterol

Eat in Moderation

Questions?

Processed foods Fried foods Fast foods Sweets Sodas White bread/pasta Deli meats Bacon, beef jerky Butter, condiments

Max weekly servings = 3

One serving = 120 cal.

Eat less of

Purchasing tips

Highly processed foods:

Packaged meals, hotdogs, cold cuts, bacon, sausage, soda, chips, microwave popcorn, candy, frozen desserts, sugary breakfast cereals, energy bars, bottled drinks, Frappuccinos, pre-mixed baking items, margarine, and premade sauces.

Choose packaged foods with

Fewer chemical ingredients Lower salt Lower added sugars

Limit added sugars to

Women: 25g a day Men: 36g a day

Coffee or Tea?

Dong X et al, 2015

3 cups of tea a day lowers risk of depression by 37%

11 studies, 23,000 people

Green, black and white tea from the Camellia sinensis plant.

Brain benefits from Epigallocatechin gallate, catechins, flavonoids, polyphenols, and L-theanine. Risks: Renal stones, cancer if throat burn

Grosso et al, 2016

Depression risk falls with moderate coffee use, but rises with more than 1-2 mugs a day

12 studies, 347,000 people

Risks: Insomnia, dependence, tremor, anxiety, reflux, diarrhea, headaches, high blood pressure (but protects against heart/liver disease & diabetes)

Max cups/day of caffeinated beverages for brain health

Beverage Max metric cups/day

Brewed Coffee 2

Latte or mocha 2.5

Espresso 0.5

Instant Coffee 5

Brewed black tea 6

Brewed green tea 10

Bottled tea 8

Cola 6

Energy drink 1.5

Energy shot 0.3

Alcohol ≤ 1.5 standard drinks/day:

6.8 ounces wine

2 bottles beer

1 bottle high gravity beer

2 ounces spirits

5 ounces sherry or port

Red wine is best

Fish Oil (1-2,000mg of DHA + EPA, EPA should be at least 60% of total)

Salmon (10 oz/week farm-raised) Trout, herring, caviar, anchovies, mussels,

Albacore (white) tuna, anchovy Walnuts, flax seed, edamame, kiwi

Omega-3

Risks: Bleeding if taken before surgery

Turmeric MENTAL BENEFITS Depression: 1,000mg daily with curcumin BCM-95

6 controlled trials; in one it was equal to fluoxetine (Prozac) Particularly for middle-age and older adults Cognition May prevent dementia

PHYSICAL BENEFITS Arthritis Anti-inflammatory Anti-cancer Diabetes, high cholesterol RISKS: Kidney stones 1 teaspoon a day in young adult study

Cinnamon Protects the brain’s memory center

(hippocampus) and may improve cognition Improves diabetes, cholesterol Dose 1/8 to 1.5 teaspoon daily Ceylon cinnamon safer than the more

common Cassia type (for liver)

1 teaspoon a day in young adult study

Dark Chocolate Brain and heart benefits for a few

ounces per day of at least 70% cocoa

May prevent diabetes, weight gain, and improve cholesterol

CocoaVia, a flavanol extract of dark chocolate, improved age-related memory loss (by 30 years) and protected hippocampal cells (dose 900mg daily, equal to 8 bars of dark chocolate per day)

Based on cross-sectional study of 13,000 adults Average intake: ½ ounce of > 45% cocoa Controlled for physical activity, smoking, alcohol, and total sugar and caloric intake, gender, marital status, education, income, weight, and presence of chronic medical problems.

Jackson SE et al, 2019

Risk of Depression by Chocolate Intake

Probiotics Improved anxiety,

depression, cognition, mania in dozens of studies, but only about half are positive

Also aid weight loss, irritable bowel syndrome, and fatty liver

Diet and Mania

High fructose corn syrup caused manic-depressive behavior and bipolar brain-changes in rats

In humans it impairs memory

Diet and Mania Beef jerky associated with 3-fold increase in mania in 2018. Animal studies pinned this down to nitrates in the meat that caused bipolar-like changes in the brain.

Unknown if bacon, hot dogs, and deli meats will do the same.

Cookbooks America’s Test Kitchen. The

Complete Mediterranean Cookbook (2016).

Christy Ellingsworth and Murdoc Khaleghi M.D. The Everything Guide to the MIND Diet (2016)

Maggie Moon, MS, RDN. The MIND Diet (2016)

Rebecca Katz. The Healthy Mind Cookbook (2015)

Leslie Korn. The Good Mood Kitchen (2017)

Free: moodtreatmentcenter.com/antidepressantcookbook.pdf

Measure Start Diet Off On Off Diet

Questions?

Natural Supplements

Omega 3 Fish oil, 30% of the brain

Improves flexibility of brain cell membranes

Treats: depression, bipolar, irritability, borderline, emotional features of ADHD. Prevents psychosis and dementia.

Dosage 1-3,000mg daily, with EPA = at least 1.5 times DHA amount

Omega 3 Physical Benefits: Reduce cholesterol, blood pressure, and inflammation.

Lower the risk of cancer, stroke, osteoporosis, psoriasis, inflammatory bowel disease, macular degeneration, and asthma.

Recommended products at www.moodtreatmentcenter.com click Brochures

Vayarin, Vayacog FDA approved for emotional symptoms of ADHD (Vayrin) and cognitive decline (Vaycog).

Combines omega-3 (EPA+DHA) with another component of brain membranes: Phosphatidylserine.

N-Acetylcysteine (NAC) Main antioxidant in the brain.

Improves low-grade depression in bipolar and schizophrenia.

Treats trichotillomania (compulsive hair pulling), skin picking, self-cutting, and nail biting, OCD.

Addictions (e.g., marijuana, cocaine, nicotine, gambling).

Dementia.

Dose 2,000mg daily.


L-Methylfolate (Deplin) FDA approved to augment antidepressants.

Works preferentially in obesity, inflammation, elderly, and people with MTHFR c-677t gene.

Small study showed efficacy in bipolar depression.

Involved in production of neurotransmitters.

Vitamins Folate 2mg daily with vitamin B12 400–600 mg daily. Prevents depression, improves SSRI efficacy.

Vitamin D for unipolar and bipolar.

SAM-e Natural methyl-donor, involved in serotonin, dopamine, norepinephrine.

Best-studied natural supplement for depression; worked as well as a tricyclic antidepressant.

Dose 400–1,600 mg daily.

Can trigger mania.

Lavender (Silexan) Prescription medicine in Germany.

Improved Generalized Anxiety Disorder better than paroxetine (Paxil).


Chamomile Improves anxiety and sleep.

Dose 220mg/day, with 1.2% apigenin


Melatonin Naturally increases in darkness and shuts off

with bright/blue light.

Mild benefits in sleep, 0.2-5 mg at night, can use SR version.

Can take with zinc 11.25mg and magnesium 225mg, which enhance natural release.

Sustained release melatonin

Reliable Brands Time release: Natrol Melatonin, Sam’s Club

Member’s Mark, REMFresh, Source Naturals time release. Instant release: Swanson’s natural

Dr. Wurtman’s combines instant release and sustained release

Melatonin

Dr. Wurtman’s Melatonin

Melatonin Useful in elderly, shift-work, and jet-lag.

Prevents weight gain on antipsychotics (3-5mg/night), migraines, and possibly tinnitus.

Possible treatment for depression (e.g. taken with buspirone, as melatonin agonists: ramelteon or agomelatine).

Other For Unipolar: Chromium picolinate (600 mcg daily)

Saffron (30 mg daily)

Creatine (5 grams daily; effect when used with an SSRI antidepressant in women)

Acetyl-L-carnitine 1,000–3,00 daily

St. John’s Wort (Hypericum perforatum) 900–1,800 mg daily

Rhodiola rosea (200–400 mg daily)

For Bipolar: Inositol

Magnesium

EMPowerPlus

Some natural treatments for unipolar can worsen mood in bipolar.

Lightbox Treats depression as well as an antidepressant.

Can work in summer as well.

Typically started early in morning (use AutoMEQ test at cet.org to optimize timing) for 30-60min per day.

For bipolar can start at noon.

Need to sit close to it, and box should be above head.

Can be combined with Wake Therapy and lithium (triple chronotherapy).

Uplift Daylight XL and Recommended products at www.moodtreatmentcenter.com click Brochures

Negative Air Ions Prevalent in beaches, waterfalls, humid forests.

Depleted by air conditioning and dehumidifiers.

Filters dust, smoke, pollen, and mold spores.

Treats depression in 5 controlled studies1

Possibly safe/effective in mania2

1Perez, BMC Psychiatry, 2013. 2Giannini, Psychol Rep, 2007

Negative Air Ionizer Sit beside it 30min in morning, or have it

auto-turn on/off 90min before awakening.

Some models produce unhealthy ozone.

Can be used 24/7.

Instructions at cet.org

Wein Room Air Purifier $75 on Amazon.

Questions?

Medication

Top Ten Updates 1. Medication increases lifespan in mood disorders, ADHD, and schizophrenia

Causes of Premature Death in Bipolar

Heart disease Stroke Cancer Diabetes mellitus Chronic obstructive pulmonary disease (COPD) Pneumonia and influenza Accidental injuries Suicide

Top Ten Updates 1. Medication increases lifespan in mood

disorders, ADHD, and schizophrenia. 2. Lithium lowers rate of suicide attempts,

completion, and suicidal thinking.1

1Based on data from 100,000 people. Goodwin & Jamison, Manic Depressive Illness, 2007.

Top Ten Updates 3. Lithium prevents dementia and has other

health benefits, lowering the risk of: Dementia Cancer Heart disease Stroke Neurologic illnesses Protects telomeres in the genes Enhances growth in the brain

Top Ten Updates 1. Medication increases lifespan in mood disorders, ADHD, and schizophrenia. 2. Lithium prevents dementia and has other health benefits 3. Lithium lowers rate of suicide attempts, completion, and suicidal thinking 4. Latuda (lurisidone) and Vryalar (cariprazine) FDA-approved for bipolar

depression. 5. Ingrezza and Austedo are first FDA-approved treatment for tardive dyskinesia. 6. New antidepressant vortioxetine (Trintellix) improves cognition and lacks

sexual side effects.

Top Ten Updates 1. Medication increases lifespan in mood disorders, ADHD, and schizophrenia. 2. Lithium prevents dementia and has other health benefits 3. Lithium lowers rate of suicide attempts, completion, and suicidal thinking 4. Latuda (lurisidone) FDA-approved for bipolar depression. Vryalar (cariprazine)

may be next. 5. Ingrezza is first FDA-approved treatment for tardive dyskinesia. 6. New antidepressant vortioxetine (Trintellix) improves cognition and lacks

sexual side effects 7. Don’t take with food (slows them down): Sleep meds and Adderall-XR 8. Warning placed on Abilify (aripiprazole) for gambling risk 9. Trazodone associated with suicidal risk 10. Varenicline (Chantix) relative safe for smoking cessation in psychiatric patients

Therapy and Meds 1. Benzodiazepines may slow learning if taken during CBT or exposure

therapy. 2. Cycloserine (an older antibiotic that’s hard to find) speeds learning if

taken before exposure exercises. 3. Benzodiazepines (and alcohol) increase risk of PTSD if taken after a

trauma. 4. Hydrocortisone (a steroid) and possibly propranolol (blood-pressure

med) reduce risk of PTSD if given after a trauma.

Antidepressants Buproprion (wellbutrin), fluoxetine (prozac), ?emsam patch (MAOI).

Mood stabilizers Lamotrigine (lamictal), carbamazepine, ?lithium.

Atypical Antipsychotics Best: Ziprasidone (geodon) best. Worst: Quetiapine (seroquel), olanzapine (zyprexa, symbyax), clozapine (clozaril).

Low Weight Gain

Antidepressants Buproprion (wellbutrin), fluoxetine (prozac), emsam patch (MAOI) SNRIs: Desvenlafaxine (pristiq), duloxetine (cymbalta), levomilnacipran (fetzima), milnacipran (savella), venlafaxine (effexor).

Mood stabilizers Lamotrigine (lamictal), lithium.

Atypical Antipsychotics Low risk: Aripiprazole (abilify), brexpiprazole (rexulti), paliperidone (invega), lurisidone (latuda), cariprazine (vraylar). Higher risk: Quetiapine (seroquel), olanzapine (zyprexa, symbyax), ziprasidone (geodon), clozapine (clozaril).

Low Fatigue

Antidepressants Buproprion (wellbutrin), mirtazapine (remeron), vortioxetine (trintellix), vilazodone (viibryd), ?emsam patch (MAOI).

Mood stabilizers Lamotrigine (lamictal).

Atypical Antipsychotics need data Low risk: Aripiprazole (abilify), brexpiprazole (rexulti), paliperidone (invega), lurisidone (latuda), cariprazine (vraylar). Higher risk: Quetiapine (seroquel), olanzapine (zyprexa, symbyax), ziprasidone (geodon), clozapine (clozaril).

Low Sexual Side Effects

Antidepressants Buproprion (wellbutrin), vortioxetine (trintellix) improve cognition. Most others are neutral.

Mood stabilizers Lamotrigine (lamictal) best.

Also lacking weight gain, sexual dysfunction, cognitive problems: Pramipexole (mirapex) treats restless leg syndrome and both bipolar and unipolar depression. It can cause fatigue. Modafinil (provigil/nuvigil) treats fatigue, ADHD, and partially helps both bipolar and unipolar depression.

Low Cognitive Effects

The main reason people with bipolar stop meds is not because they miss the mania; it’s because they don’t think they are working. Chance of bipolar episodes returning: 95% in next 5 years after stopping Chance of unipolar depression returning:

Prevention is necessary. Meds are one tool in prevention.

Can I Stop Meds?

Past depressions Chance of relapse

1 50% 2 70% 3 90%

One at a time.

Slowly; at least 2 weeks. 2-6 months may be better.

Only after symptom-free for 6-12 months (depending on diagnosis).

Preferably after making lifestyle changes to prevent depression.

How to Stop Meds

It takes 7-10 years for a med to go generic, and another year for the cost to drop. Generics have the same blood levels as brands, plus or minus 10%. Generics with release coatings (SR, CR, XR) may have more issues. Solutions for Medication Costs

Price check if paying out-of-pocket: Costco or www.goodrx.com Assistance if uninsured: www.pparx.org, www.togetherrxacces.com, www.rxassist.org

Meds and Cost

Lean-forward for caps

Swallowing Meds

Read more at www.moodtreatmentcenter.com/brochures.htm. Source: Schiele JT, Annals of Family Medicine, 2014.

Squeeze bottle for tabs

Questions?

Mood and Technology

Mood Charting MoodLog Look for apps that measure mood or energy, not emotions Automatic trackers: The Future

Sleep Monitors Monitor Breathing Temperature Movements Sound

Versions Apps: Sleep Cycle, SleepBot, Sleep Time FitBit, Jawbone ResMED S+

Mental Health Apps Mindfulness Headspace ($), Insight Timer, Smiling Mind, iMindfulness ($), and Mindfulness Daily Breath2Relax

Behavioral Activation Ginsberg, Moodivate ($), Happify ($), and Activities Mood Tracker Intellicare CBT App Suite

Sleep CBT-i Coach (free)

Stress Management Stress Free and Virtual Hope Box DBT Diary Card and Skills Coach

Questions?

Strengths

“Many bipolar patients have considerable psychological assets, such as personal charm, affective warmth, creative bent and a high drive to fight for or advance various causes.

These assets can often he capitalized in attempts to reconstruct lives that have been shattered because of impulsiveness and poor social judgment.”

—Hagop Akiskal, Care of the Bipolar Patient, 2011 “Work on two fronts, one for treating their illness and one for encouraging their strengths.” —L. Havens and N. Ghaemi

Strengths

Artistic sensitivity, intellectual curiosity, creativity, love of variety, flexible thinking, and a nonjudgmental attitude.

Associated with better response to psychotherapy1.

Openness

1Bagby, 2008. Carrie Fisher, Actor & Author, 1956-2016

Warmth, assertiveness, expressive, leadership. People with bipolar tend to have more friends than those with unipolar1. In the military, those whose relatives have bipolar are more likely to be in leadership positions.

Extraversion

1Poradowska-Trzos, 2007.

Lyndon Johnson, 1908-1973.

Both higher and lower IQ are more common in bipolar1. Greater creativity and verbal abilities2,3.

Intelligence

1Meyer, 2015. 2Kyaga, 2011. 3MacCabe, 2010 Ernest Hemmingway, 1899-1961

People with bipolar may recover faster after a trauma1.

Resilience

1Galvez, 2011. Winston Churchill, 1874-1965

People with depression tend to see the world (and themselves) more accurately. Empathy may be a strength when not in an episode. Three leaders who were suicidal in their early 30s: Abraham Lincoln, Martin Luther King, Jr., and Mahatma Gandhi.

Depressive Realism

Questions?

Documents

Therapy for Mood Disorders1...In bipolar disorder, reduced the rate of mood problems 8-fold after six months. Jump starts therapy for PTSD Lowers inflammation Apps (CBT-i Coach) Mood