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Who Blabs Here?

Hi, I'm a child and adult psychiatrist, a mom, and a firm believer that life is better with loads of time fireside with a book (or computer), a pot of tea, and a neurotic border collie at the feet. I promote a holistic perspective, while not throwing out the baby with the bath towel, so absolutely using what is reasonable, practical and data-based in traditional medical and psychiatric care. I'll also ramble, because that's my way. Thanks for stopping by.

Wednesday, August 14, 2019

Supplements to avoid!

Just belatedly ran into this fascinating Consumer Reports article 15 Supplement Ingredients to Always Avoid. Worth a read!

Thursday, August 8, 2019

L-methylfolate for depression?

Folate is a naturally occurring vitamin, otherwise known as vitamin B 9, that's necessary for all sorts of processes in your body, including healthy cell growth and function. It's key for making DNA itself, that recipe for life that exists in every single cell in our bodies. It's also key in early pregnancy to decrease the risk of birth defects especially to the baby's brain and spinal cord!

After chowing down on food rich in folate like dark green leafy veggies, the gut changes folate  into its brain-useful version called L-methylfolate, the only form of folate that can cross the the so-called blood brain barrier and enter the brain. And it needs to get in the brain to help make the brain chemicals important for happiness (amongst other things). L-methylfolate helps the enzyme co-factor BH4 (tetrahydrobiopterin) work with the all-important rate-limiting enzymes tryptophan hydroxylase and tyrosine hydroxylase to make the all important monoamines neurotransmitters serotonin, dopamine, and norepinephrine.

Folic acid (pteroylmonoglutamic acid) is often confused with folate, its cousin. Folic acid is the synthesized version (the oxidized mono glutamate form of the vitamin used in dietary supplements and fortified foods) that's used as a supplement or to enrich foods. The FDA has filled our diets with it, requiring food companies to add it to enriched bread, flour, cornmeal, pasta, rice and other grain products sold in the USA. But the poor gut can struggle to transform the folic acid version into the brain-useful version L-methylfolate.

After eating folate, most is changed into L-methylfolate in the gut before entering the bloodstream via a lovely enzyme called methylenetetrahydrofolate reductase  (MTHFR).  But, a lot of patients who suffer from depression seem to have weak MTHFR, thanks to a MTHFR genetic polymorphism. In other words, depressed folks often own a less effective variation of the enzyme (MTHFR) that is needed to make L-methylfolate.

So the marketing of L-methylfolate as an anti-depressant supplement. I.e. Depressed people can be short on L-methylfolate that is key in making those important-to-happiness chemicals called serotonin, dopamine and norepinephrine in your brain, so give them some more of it.
But do supplements of L-methylfolate really help?

The data is not yet clear.  However, a review supports L methylfolate supplementation for depression, and some data supports L-methylfolate  as adjuvant to SSRI antidepressants in depression.  Perhaps, there are sub-groups of those with depression who it is especially helpful for, including (not surprisingly!) those who don't metabolize folate effectively. There is even an intriguing case series showing L-methylfolate helpful in alleviating depression, anxiety and irritability in the majority of depressed adolescents followed, although worth noting --  most of the kids had known mutations causing low MTHFR activity (and so low L-methylfolate production).

Of course, first I suggest patients look at their dietary folate choices!  That is, before supplementing, check the diet! Are patients eating enough folate, in case they are, indeed, one of the many who can transform the stuff into lovely L-methylfolate? In other words, are they eating loads and loads of those lovely dark green leafy veggies and friends that are so rich in folate? Like asparagus, avocados, Brussel sprouts, spinach, mustard greens and lettuce? Or how about lemons, bananas, melons, strawberries, oranges and orange juice? Or nuts beans and peas? Have they googled healthy, whole food folate sources and enriched their diet with whatever healthy folate-rich items appeal? If not, I generally suggest that route first!  The only side effect to extra veggies being better health!

And, of course, patients need to talk to their docs about their folate levels and folate intake before changing a thing. Those with gut absorption problems like those with celiac disease, inflammatory bowel disease or alcohol abuse, might be especially low in folate and so especially need to get in there and talk to their docs about this stuff!

Why don't we all just starting chowing down on L-methylfolate supplements willy nilly? Truth is, many supplements over time eventually are found to have negative impacts of some sort.

For example, specific concerns have been raised about folic acid, L-methlfolate's cousin. Some have suggested folic acid can have a negative impact on vitamin B12, on cognitive functioning in the elderly, on cancer risks and more. "The biological activity or longtime health implications of higher unmetabolized folic acid exposures are not clear." The lovely Mayo Clinic medical website RE folic acid supplements warns:

Still, don't throw the baby out with the bathwater. L-methylfolate might not carry the same risks, and L-methylfolate might help!  So talk to your doc about trying the stuff out. And, either way, eat more of those dark green leafy veggies!

And, good luck out there.

Tuesday, August 6, 2019

Don't forget PANDAS! (Not the bear)

PANDAS is a sudden onset neuropsychiatric condition involving overnight appearance of anxiety and movement related symptoms like tics following strep infections, i.e. invasions of the body by the little one celled creatures called Streptococcal Group A bacteria (strep).  PANDAS is controversial, but not to me, not anymore.

Strep bacteria often climb in the body via the throat ("strep throat"), although not infrequently via the skin ("cellulitis"), or other spots. Such bacteria are bitty creatures, but don't underestimate strep or its single-celled organism friends.  These microscopic guys live nearly everywhere on earth from the bottom of the ocean to inside living organisms, and strep alone causes 1/2 a million-ish deaths a year!

PANDAS -- pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection -- is hypothesized to be caused by the body misfiring in response to such a strep infection and so mistakenly attacking the brain. I.e. the child's body's attempt to protect itself from strep via activating his or her immune system, ends up misfiring and setting the immune system to attack his or her own brain in addition to the intended target of Group A streptococci invaders. And so brain symptoms occur.   I.e. "Molecular mimicry, in which antibodies targeting bacterial antigens cross-react with brain (basal ganglia) antigens, was proposed as the pathogenic basis of post-streptococcal neuropsychiatric disorders..."  Some see it as vaguely similar to Sydenham's chorea -- another neurological disease caused by an autoimmune response following strep infection. 

I learned about PANDAS in residency, when it was a new-fangled, radical idea, proposed by Swedos in 1998 in the American Journal of Psychiatry - Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections: clinical description of the first 50 cases. PANDAS was just one of those super rare medical illnesses that are interesting and possibly real, but mostly irrelevant to clinical practice. A disease we call a zebra

But zebras happen. 

And the PANDAS zebra came after my kid.  Amidst a recent illness where my son had a vague sore throat, mild shortness of breath, low grade fevers, dry cough, persistent red cheeks and red ears, suddenly things got worse, and weird. My mellow, sweet son suddenly couldn't stop squirming or moving his arms up to his neck repetitively in a jerky way and pressing on his neck and chest, or clearing his throat repetitively, or dry coughing, or obsessively worrying about his breathing (despite a normal respiratory rate and good blood oxygenation). All symptoms he'd never shown a whiff of ever before. He was no physically sicker than he'd been for days, but he also was no longer himself. He couldn't focus on his computer programming or even on computer games. He was too restless (for no clear reason) even to eat Haagen-dazs vanilla ice cream. That's when I took him to the emergency room, where, thank goodness,  the doc (a pediatrician taking an ER shift, rather than an ER doc) took an extensive history and considered PANDAS. She sent off his strep titers, which came back positive.  And, after being given high dose Augmentin (Amoxocillin/Clavulanic acid) by his attentive pediatrician, he became quickly well, symptoms gone, like a switch turned off. (NOTE: talk to your doc before taking any medication or giving anyone any medication! This medication generally is NOT safe for those penicillin allergic!)

The important take home point -- in my opinion -- get kids checked for strep every time they have even a vague sore throat -- even if the classic swollen tonsils with gunk on them is missing. And, if a child changes suddenly -- with anxiety and movement symptoms out of the blue -- have his or her doc check for strep and consider PANDAS. 

Take care out there. 


Sunday, July 7, 2019

Just say no!

Despite its massive entry into the cultural norm, recreational pot use doesn't look good for us. I'm not saying whether or not to keep cannabis locked up; this isn't a politics blog, thank goodness.  I'm just saying that I strongly suggest choosing to "just say no"

Here are a few reasons I worry about pot.

1. Pot messes with your endocannabinoid (EC) system.
This is my primary concern about pot use.  How the stuff works. THC (an active chemical in cannabis) binds to the very same receptors as endogenous (body made) chemicals named endocannabinoids (EC).  And pot today does this more than your grandmother's pot because  today's pot has 2-3 times more tetrahydrocannabinol (THC) than back then! 

ECs bind to cannabinoid receptors (CB1 and CB2) to cause numerous, widely varying effects throughout the brain and body. These effects include impacting how your nerves grow and change. The EC system impacts neural stem cell (sort of infant brain cell) survival, neuron proliferation (brain cell multiplication) and migration and axonal growth, as well as synaptogenesis and synaptic pruning (changing connections between nerve cells).  Sounds important, right? And no surprise the EC system can be especially important for those with developing brains -- those who are doing the most brain cell making, growing and changing -- like babies especially, but also children, adolescents and even young adults! This is worth consideration. Do we want to even slightly muck around with a system involved in making our brains be, well, our brains? 

And the EC system impacts a host of other body systems --including  heart rate, appetite and memory. The EC system also can kick into gear powerfully to counter severe stress and/or pain

Pot works on this same system but with a sledgehammer rather than with the finely tuned, specific, body-made endocannabinoids.  So, no wonder, pot can mess up the EC system, especially if used heavily, long term.  Cannabis can bind to the same CB receptors as endocannabinoids, so mimicking or disrupting the EC system. This can be nice short term but long term can throw off the fine tuning of the EC system. With cannabis exposure, the EC system can down regulate, meaning you need more to have the same effect over time.  With cannabis exposure, your body's EC levels can lower and there can become fewer EC receptors. Long term this can cause the opposite of the relaxing, pain-relieving effect the pot-user was probably going for.

Although for those with end-stage disease and looking to hijack their stress and pain management system via cannabis, who cares about the long term effects? For these suffering souls on death's doorstep, hijacking the EC system can be totally worth it. Specifics matter!  

2. Pot messes with your thinking.
Pot can mess with thinking, learning and remembering.  It can have a negative influence on cognition, and also on motivation for doing things, like schoolwork and work. No surprise these can suffer.  And, no surprise then, that those who use pot are less likely to get a college degree, or even to finish high school.  

3. Pot messes with driving.
Like all mind-altering substances, pot can mess with driving skills, so can be lethal. It specifically can influence perception, coordination, and thinking. It can also cause daytime fatigue.  Of course all of this can increase the likelihood of other sorts of accidents, too.

4. Pot can mess with mental health.
Pot has been associated with increased mental illnesses including schizophrenia, depression and anxiety disordersPot can worsen symptoms and course of schizophrenia if you already have it.   And one huge (across 11 countries), superb study found that daily pot users had 3-fold increased odds for getting a psychotic disorder. Those daily users of high potency versions of pot were a breath-taking five times more likely to have a first psychosis than non cannabis users! So, no surprise, in countries where high potency cannabis is very available a huge proportion of new psychosis is associated with cannabis use -- like 1/2 of all new cases of psychosis in Amsterdam!  

5. Pot can be dulling.
This one is just my opinion, not like I have studies to show it. Heavy pot users who choose to keep using over the years sometimes somehow have their volume turned down. They can care less and can be less intense.  Sometimes seems to be what they're looking for, but I think it's often a shame.

6. Pot is not so easy to quit.
Unfortunately, even if you want to quit, it's not altogether easy to do, despite pot's benign reputation.  Like other substances of abuse, pot stimulates release of dopamine in the brain's reward centers, and that's hard to give up. We all love some dopamine in our reward centers. So talk to a professional. Get help, especially if quitting is not happening readily. And, if you choose to stop using pot, good luck, especially to one special young person who I'm writing this post for. 


What is Wellness Anyway?

"The state of being in good health, especially as an actively pursued goal."