Mood Madness

By Deborah Rudacille




Psychiatrist Julie Holland has a simple prescription for today’s overworked, over-scheduled and in her view, overmedicated American women. Make a goal to go natural over time. Jettison your plastics and your iPads and start to reduce your pill’s potency little by little. Turn off the TV, toke up and make love. Eat vegetables, preferably raw. Sleep more. Take a walk in the woods. Tune in to your body and rock your natural hormonal ebb and flow rather than aiming first to flatten it out with pharmaceuticals.

Holland’s just-published manifesto, “Moody Bitches: The Truth About the Drugs You’re Taking, the Sex You’re Not Having and What’s Really Making You Crazy,” promotes the traditional view of women as caregivers and nurturers. Women are hard-wired to respond to the needs of others and are moody by nature, Holland says.

But the 1 in 4 American women she says are currently taking antidepressants, anxiolytics and sleep aids are not mentally ill. They are just overworked and exhausted, frazzled and burned out by the competing demands of contemporary life.

According to Holland, too many are popping pills to numb out and get through their hectic days and restless nights, aided and abetted by aggressive pharmaceutical marketing and harried primary care physicians. But not everyone is buying Holland’s diagnosis or her prescription for a more natural life.

Elizabeth Hazen, a 36-year-old private schoolteacher and writer in Baltimore, has been taking antidepressants since she was 19. As a freshman at Yale, “I stopped eating and got really depressed,” she says. She went to the university health center, staffed by graduate students in psychology, who were not helpful. “My first psychiatrist said, ‘You’re so smart and pretty. Why are you sad?’”

Another psychiatrist wrote her a prescription for the antidepressant Prozac that she’s been using ever since, save for the nine months of her pregnancy.

“It was a really tough time for me,” Hazen says of her college days. She started on Zoloft, after her son was born, “because I read that it was safer for nursing,” before returning to Prozac after he was weaned. She also has a prescription for the anti-anxiety drug Ativan though “I rarely take that now because it makes me tired,” she says.

Hazen compares her use of anti-depressants to people who take statins to regulate their cholesterol or antihypertensives for high blood pressure. “I’m not conflicted about it,” she says. “I’m a firm believer in better living through chemistry.”

Her strong family history of depression plays a role in Hazen’s unfazed acceptance of the fact that she may need to be on medication for the rest of her life. Hazen’s severely depressed maternal grandmother was hospitalized and underwent electro-convulsive therapy on multiple occasions. “I remember two or three times when she would go into deep depressions,” Hazen says. “It’s like she wasn’t even there.”

Hazen’s mother, Margaret, says that her mother, a brilliant introverted woman, had her first depressive episode in college but “it really kicked in after the birth of my brother. Time didn’t heal it. She was periodically suicidal.”

Those who have never experienced depression think that you can talk yourself or a family member out of it, she says. “But you can’t. Trying to distract her didn’t work at all.”

Like her daughter, Margaret Hazen is grateful for modern psychopharmacology. She herself suffers from mild depression, for which she takes Zoloft.

“My brother has it too, but he’s determined to tough it out,” she says. Given that four of her mother’s grandchildren are affected as well, “I’m sure there is a very strong genetic component.”

Dr. Jennifer Payne, director of the Women’s Mood Disorders Center at Johns Hopkins Medicine, backs that assessment, pointing out that “psychiatric illness is a marriage between biological vulnerability and environment, with stress being one of the big environmental factors.”

Life these days is extremely stressful for everyone—men and women, Payne says. But she hasn’t seen any evidence that the prevalence of mood disorders is increasing.

So, what explains the jump Holland identifies in the number of people, especially women, who appear to be using psychiatric medications?

In “Moody Bitches” Holland points to two catalysts for medicated conversion: pharmaceutical companies and primary care physicians. Direct-to-consumer advertising by Big Pharma encourages women to see their natural moodiness as a psychiatric problem, Holland says in the book, and handing over a prescription is “the easiest, quickest way for doctors to get someone out of their office so they can see their next patient.”

Payne finds that assessment a bit harsh. Though it’s possible that on occasion internists and other primary care providers might prescribe antidepressants for “what I would say is an adjustment disorder or being stressed.” It’s also likely that increased use of prescription medications may simply be due to better screening and diagnosis of the disorder, she says. “It’s true that a lot of people are on meds these days. But that may be because more people are aware of depression and are aware that there is help for it.”

Some states have now mandated screening for postpartum depression, Payne also points out, and both primary care providers and OB/GYNS are urged to be on the lookout for symptoms of
depression in their patients.

In addition, we talked with women who’ve had trouble finding psychiatrists in Baltimore who accept their insurance and are accepting new patients. So out-of-pocket expenses can be a deterrent from seeking a specialist.

“Certainly there are some people on meds who shouldn’t be, but there are a heck of a lot of people who should be on meds who are not,” says Payne. “Most people who could benefit from psychiatric care are not getting it.”

Last year Payne reviewed a study that found that only 6 percent of pregnant women diagnosed with depression in regular OB/GYN care were treated for the disorder. Like Hazen, many women choose to go off their medications during pregnancy, fearful of negative effects on the fetus. Payne is currently seeking grant-funding for a study of the effectiveness of light therapy—exposure to daylight or specific wavelengths of light—as an alternative treatment for depression in pregnant women.

“Doing studies of pregnant women makes people really anxious but that’s really where you want to have good data to know how to manage patients,” she says.

Large-scale epidemiological studies have shown that 10 to 20 percent of women will have a major depressive episode during their lifetime, a rate that is double that of men. The reason for women’s higher rate of depression remains unclear. Hormonal fluctuations can affect levels of serotonin, a neurotransmitter that helps regulate mood. But other neurotransmitters are also involved in mood regulation—in particular dopamine and norepinephrine.

This is the reason that some people may require a “cocktail” of psychiatric medications to get relief, says Payne. “What we call depression is likely multiple diseases. We know that serotonin, norepinephrine and dopamine are all involved, and different medications affect those neurotransmitters in different ways.”

There is some evidence, she says, that certain medications may be more helpful than others at various stages of a woman’s life span. A recent study found that before menopause, women on average respond better to selective serotonin reuptake inhibitors or SSRIs (e.g. Prozac, Paxil, Zoloft, Lexapro) while after menopause an older class of antidepressants called tricyclics seem to be more effective. That study needs to be validated, says Payne, but the findings make sense to her.

“For symptoms of PMS we know that you have to affect serotonin,” she says. “If someone is having PMS symptoms, wake up and realize they are moody, and take an SSRI, they feel better within hours.”  There’s also some evidence that SSRIs may be more effective in treating postpartum depression, she says.

Women who experience two or more major depressive episodes will likely have to take some sort of antidepressant throughout their lives to prevent recurrence, Payne adds—and that’s OK in her view. “There is no evidence in the literature that taking antidepressants long-term causes any sort of problem,” she says. By contrast, “recurrent mood disorders are bad for the brain.”

What about women who don’t have a strong family history of mood disorders or multiple episodes of depression? How does someone who has run into a bad patch and started taking habit-forming anti-anxiety drugs like Ativan and Xanax or sleep aids like Ambien get off those medications?

Dr. LaShaun Williams, a psychologist in private practice in Baltimore, says that about 60 percent of her clients are not on medications at present though they may have a history of using medications.

“A common story I hear is that they got their first prescription from a primary care provider when they presented with complaints of anxiety or trouble sleeping,” Williams says. “My experience is that psychotherapy helps them to develop alternative coping skills and increased tolerance or acceptance of stress.”

Williams says that she has seen many clients who don’t have severe disorders come off their meds over time by making changes in their diets, exercising more and improving their sleep hygiene in addition to psychotherapy.

“The length of time you should be on medications depends on the disorder,” Williams says. “A lot of time the medications are a bridge. Initially people are overwhelmed by their symptoms and the meds can help them get through.”

Williams uses cognitive behavioral therapy to help her clients identify and challenge the kinds of thought distortions that fuel panic attacks, and the ways that current interactions mirror childhood patterns. “Psychodynamic interpretations can be helpful in developing insight,” she says. Working with clients on problem-solving also can be helpful. “The whole process is empowering. You become a more functional adult.”

It can take time for psychotherapy to have an effect and for a client to make the type of changes that will alleviate the life stressors that are causing them to feel depressed or anxious. But Williams has seen even patients with serious diagnoses like post-traumatic stress disorder lower their dosage over time as they learn to manage their symptoms.

Women who would like to wean themselves from their medications should work with a psychiatrist to lower their dosage and encourage collaboration among their health care providers, she says. “I wouldn’t suggest that someone do it on their own.”

Abrupt withdrawal of anxiolytics and antidepressants can lead to a host of negative effects including irritability, insomnia, decreased memory and concentration and in rare cases, psychoses and seizures. Also, some women (and men) experience withdrawal symptoms that can last from weeks to months—even when following the suggested titration plan suggested by their doctor and the pharmaceutical companies.

Integrative health practices like yoga and acupuncture may help ease the transition and help women regulate their moods in general. “Mindfulness, acupuncture, yoga—all help relax you and make you feel more in control of your emotions,” says Payne. “They are incredibly helpful as adjunctive treatments and if you are trying to get off antidepressants, it’s a great time to do them.”

Mary Lauttamus, director of the Master of Science Yoga Therapy program at the Maryland University of Integrative Health in Laurel (formerly the Tai Sophia Institute), has worked with many women using medications for anxiety and depression. Some choose to work with their psychiatrists to wean themselves from the medications after developing a committed yoga practice and experiencing a reduction in symptoms, she says. “We hear from our clients that they have improved outcomes when they practice yoga regularly.”

She and other yoga therapists help clients increase self-awareness through daily meditation practice, daily posture practice and daily breathing exercises. “The breath tells a story,” Lauttamus says. “With fear and anxiety, the breath is shallow and rapid. Yoga teaches us to notice the breath and use it to calm the body by engaging the parasympathetic nervous system. Longer breaths, more extended exhales.”

By contrast, people with a diagnosis of depression may need to be energized.

“If I’m working with someone with low energy and we want to lift energy, I teach a more warming, energizing breathing practice,” Lauttamus says.

Yoga also can help people who’ve been in talk therapy for a long time, “and are ready to stop thinking and start doing,” she says. Massage therapy too can encourage relaxation and help people develop an increased awareness of what’s going on in their bodies.

“We spend so much time in our heads that the somatic practice—bringing a person into their body—is a gateway to opening up an understanding of all sorts of integrative practices,” Lauttamus says.  “It really is about self-care and feeling empowered—and learning how to understand the mind-body connection on a deeper level.”

Women who have used integrative practices like yoga and acupuncture, and made other lifestyle changes to wean themselves from medication or to avoid taking meds in the first place, strongly endorse these practices.

J., a 38-year-old homemaker and mother of two, says that she developed severe anxiety after giving birth.

“I started experiencing panic attacks and sleep problems. I’d be up all night,” she says. A psychologist recommended that she go on antidepressants and anxiety meds and wrote her a prescription for the sleep aid Ambien. “It helped me to go to sleep if not stay asleep,” she says, “but I didn’t like the way it made me feel.”

After about two months her doctor again recommended antidepressants and anxiolytics. “That time she actually wrote a prescription and that scared the shit out of me,” says J. “I didn’t want to be that woman. So I spoke to my GP and she recommended that I change my diet, exercise habits and pretty much my whole way of life.”

J. put the prescriptions in a Mason jar in her kitchen to remind herself every day of the alternative to making lifestyle changes. “I started running, joined a gym and weeded some people out of my life,” she says. “It made a huge difference. I’ve also started yoga recently even though I’ve never been a spiritual person. It took almost a year for me to get to this place but I don’t even use the Ambien anymore. I’m a completely different person.”

Although J. was able to pull herself out of a bad place without using (much) medication, V., a 40-year-old professional who experienced her first bout of depression in her late 20s, believes she absolutely needed psych meds at that time. “When I see depression commercials today, I totally empathize because that’s the way I felt. I wasn’t suicidal but I had uncontrollable crying, reclusiveness. I just couldn’t get myself out of it.”

Lexapro and psychotherapy helped. But she didn’t like the side effects, including inorgasmia. “There were sexual side effects, but that wasn’t my motivation for going off it. It was more the general apathy and feeling neutral,” she says. Her primary care provider recommended Wellbutrin, an SSRI with fewer sexual side effects, and as an added bonus, weight loss. “The first time she offered it, I didn’t take it. But around 2011, I could feel that I was getting depressed again so I took it.”

It helped, but once again she was bothered by the emotional blunting she experienced while on the drug. “I wasn’t a zombie but I didn’t feel like myself,” V. says. “So I talked to my doctor about getting off.”

Working together, they slowly decreased her dosage around the same time that she discovered community acupuncture.

“I’d done acupuncture before and found it helpful during a very stressful time in my life, but community acupuncture is much more affordable,” she says.

Instead of a private room, clients sit in an open room with six to eight other clients, paying $15 to $20 per session. “At first I went once a week but now I’ve tapered off,” V. says. “It’s made an enormous difference for me. It’s so nice not to take a pill.”

Both V. and J. asked not to be identified by name, a measure of the stigma that still prevents some people from seeking help for mental health issues. But Dr. Tamara Sobel, an internist in private practice in Owings Mills, says that stigma may be lessening. “I’ve seen an increase in both men and women complaining of symptoms of anxiety and depression. People may be more inclined to mention symptoms to their doctors.”

About 25 to 30 percent of people coming into her office present with symptoms of anxiety and/or depression. Some definitely need antidepressants and anxiolytics—“and thank God we have them,” she says—but she will not prescribe medications for stress alone. Instead, she recommends reducing stressors, increasing exercise, a healthy diet, and yoga and meditation.

“A lot of people are looking for a quick fix these days,” says Sobel. “They think ‘I’ll take a pill and I’ll feel better tomorrow,’ but it doesn’t work that way. You need to change your lifestyle.”

Natural Woman

Want some not-so-nutty advice on improving mood—with or without modern pharmacology? “Moody Bitches” author Julie Holland recently cribbed a few tips from her new book. Here are a few we’re willing to try.

EAT CLEAN. One study showed people who ate processed foods were 58 percent more likely to feel depressed. Holland says: Opt for whole foods and eat more lean protein and avoid complex carbs (choose fruits, veggies instead).

GO FISH.
All hail fish oil, salmon, halibut and flaxseeds—or however you get your omega-3 fix. Holland isn’t alone on this one. Many integrative docs say these healthy fats improve brain functionality and improve mood. Also mix in some anti-inflammatory treats like dark chocolate and red wine—in moderation, naturally.

SUNNY D. Sure, you’ve got a gym membership. But do you get outside for 20 minutes (or more) at least three days a week? If not, start walking the walk. In fact, rip off your Ray-Bans and let the sun sink in for a bit. Holland says the rays have to reach your retinas to kick in the anti-depressant effect.

RUNNER RUNNER. Research says doing cardio can be as effective as antidepressants for some patients. Holland suggests getting your heart rate up at least three times a week for at least 30 minutes.

SLUMBER PARTY. You’ve heard this before—sleep seven to nine hours nightly. But here’s a twist: If you’re craving a nap, snooze for 25 or 90 minutes. “Nothing in between,” Holland says, “and try to be done napping by 3 p.m.” so you can doze off easier at bedtime.

MILK IT. Did you know that calcium can reduce irritability? Whether or not you do dairy, that’s one more reason to incorporate the bone-building phenom. More insights from the author/doc: L-tryptophan, L-hydroxy-tryptophan and B6 can help boost serotonin production. And taking a magnesium supplement before your period may make for less anxiety, better sleep and less bloating.

TALK TO YOUR DOC.
If your PMS remains intractable, Holland says you might want to try Lexapro—or another Rx. Don’t feel better once your period starts? You may be clinically depressed. Then the conversation changes. —BETSY BOYD

 

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