Mar 31

It was NOT the depression

by Dr. Micaela Wexler

As a psychiatrist who treats people with depression on a daily basis it is disheartening to see news story after news story referring to depression in relation to the Lufthansa Germanwings Airbus crash. The latest news story I’ve seen is one titled “Lufthansa’s Deadly Confession,” and it reveals that Lufthansa (gasp) knew Andreas Lubitz was depressed and continued training him.

People do NOT murder because of DEPRESSION. People do not do much of anything because of depression. That’s the problem with depression: it prevents people from taking actions, from accomplishing, from participating. People with depression are unable to do things they could previously do before a depressive episode. They lack interest, energy, concentration. People with depression do not suddenly get an urge to go out and do something evil that takes a great deal of skill and planning.

Perhaps there is confusion about what depression is. If so, then it is up to people like me, a psychiatrist who is intimately acquainted with depression, to educate about what depression is. The mnemonic device DIGSPACES (Depression, loss of Interest, Guilt, Sleep disturbance, Psychomotor agitation/retardation, Appetite changes, loss of Energy, Suicidal thoughts) is a helpful way to remember these key symptoms of Major Depressive Disorder. To be diagnosed, the person has to have had FIVE or more present over the previous two week period, and it has to reflect a change from the previous level of functioning.

Does any of this sound like someone is focused and energetic enough to go plan the murder of 149 people?

It is stigmatizing to the many people I see who courageously struggle with their depression to see the media continuing to relate this tragedy to depression. I am not saying Andreas Lubitz did not suffer from depression at some point. Evidence shows that he did, and that is very sad. What I am simply saying is that the depression is not why he did what he did. Yes, depressed people can be capable of evil things, they are capable of hurting others, of causing damage, of lying, stealing, just like anyone else. But, it isn’t the DEPRESSION that makes them do this. Their motivations would be the same as anyone else committing evil, violent acts.

It’s hard enough to get people who struggle with depression to get help. Let’s not make it worse by stigmatizing them. This will not only serve to further marginalize the mentally ill, but it will do nothing to get to the root of what really caused Andreas Lubitz to crash a plane full of innocent people. And, both of those situations hurt all of us.

Appointment information for Dr. Micaela Wexler: wexlerpsych.com

Mar 15

Dementia Treatment Guide

By Dr. Micaela Wexler

One size does not fit all!WexlerPsychiatryDementia1

The treatment of dementia is a skill that is becoming more urgent for the primary care physician. While it is essential to treat dementia early, it is equally important to remember that one size does not fit all. For example, Aricept, a medication ideal for Alzheimer’s Disease (AD) may be detrimental for Frontotemporal Lobar Dementia (FTLD).

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What follows is a Dementia Treatment Guide, a short description of the most common forms of dementia, and their treatments. This is meant to be a quick guide, not all-encompassing. Please read disclaimer before using this guide.

Alzheimer’s Disease (AD) – most common form of dementia, begins with memory loss followed by language difficulties. As AD progresses from mild to moderate, people lose executive function. Severe AD is characterized by imbalance, decreased movement and complete lack of communication.

AD Treatment:

Mild to moderate AD – acetylcholinesterase inhibitors (Aricept, Exelon, Razadyne)

Moderate to severe AD – NamendaWexlerPsychiatryDementia3

Research shows that targeted lifestyle choices can decrease cognitive decline associated with AD: elimination of simple carbohydrates and gluten, increased consumption of fruits and vegetables, fasting for 12 hours between dinner and breakfast, 7-8 hours of sleep each night, exercising 30 minutes a day 6 days a week, yoga, mediation and stress reduction.

Vascular Dementia (VD) – the second most common type of dementia characterized by a step-wise decline in memory and cognitive functioning caused by decreased blood flow to the brain due to strokes.

VD Treatment: stroke prevention to stop progression; lifestyle modifications to target heart disease, hypertension and diabetes; Namenda is both neuroprotective and improves cognition, preferred over Aricept.

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Dementia with Lewy Bodies (DLB) – movement problems EARLY, memory problems LATER (opposite of AD); rapid progression; visual hallucinations; REM sleep disorder; 3-minute test to screen for LBDWexlerPsychiatryDementia6

DLB Tx: very responsive to Aricept and Exelon, for both memory and behavior; Klonopin for REM sleep disorder; extreme caution using anti-psychotics

Frontotemporal Lobar Dementia (FTLD) – strikes YOUNG people; memory normal in early stages, behavior and mood problems prominent, loss of impulse control; misdiagnosed as Bipolar Disorder; rapidly progressiveWexlerPsychiatryDementia7

FTLD Tx: behavior problems – use Depakote, Tegretol; memory – use Namenda, AVOID Aricept and Exelon; speech therapy preserves function, avoid benzodiazepines

Parkinson’s Disease Dementia a (PPD) – 1 of 5 patients with Parkinson’s Disease gets PPD, 4 of 10 patients with PD get AD.

PPD Tx: Namenda or Aricept for memory, Aricept does not affect movement; extreme caution using anti-psychotics; use Seroquel if needed

Wernicke-Korsakoff Dementia - confabulation, often preceded by Wernicke’s encephalopathy which is characterized by confusion, ataxia and nystagmus. Caused by thiamine deficiency, which can result from alcohol dependence, eating disorders, AIDS, malnutrition.

WKD Tx: thiamine, Namenda, Aricept, Exelon. Namenda neuroprotective. Anti-psychotics do NOT decrease confabulation.

This Dementia Treatment Guide was originally created as a supplement for a CME course given at the Missouri Association of Osteopathic Physicians and Surgeons Annual Convention in Branson, Missouri on May 1, 2015.

Note: photos do not represent people with dementia; they are photos of actors and models, go to 123rf.com for information on releases and credits.
References:
10 Warning Signs of Alzheimer’s

Vascular Dementia: Signs, Symptoms and Treatment

Frontotemporal Lobar Dementia

Lewy Body Dementia Association

The value of clock drawing in identifying executive cognitive dysfunction in people with a normal Mini-Mental State Examination score

Toothbrushing, inflammation, and risk of cardiovascular disease: results from Scottish Health Survey

Poor Dental Health May Lead to Alzheimer’s Disease

Treatment of Frontotemporal Dementia

Clock-drawing: is it the ideal cognitive screening test?

Treatment of behavioral and psychological symptoms of AD with Yokukansan

Aricept beneficial in mod-severe AD and comparable to Namenda in mod-severe AD. No improvement in combining both for Mod-severe AD.

Long term use of donepezil in DLB 108 patients enrolled in 52 week study – improvement in cognitive function, reduced caregiver burden lasted 52 weeks with few adverse events

Risperidone Versus Yokukansan in the Treatment of Severe Alzheimer’s Disease

Atypical antipsychotic drugs in the treatment of behavioural and psychological symptoms of dementia: systematic review

ACETYLCHOLINESTERASE INHIBITORS FOR THE TREATMENT OF WERNICKE–KORSAKOFF SYNDROME−THREE FURTHER CASES SHOW RESPONSE TO DONEPEZIL

Consensus guidelines for the clinical and pathologic diagnosis of dementia with Lewy bodies (DLB): report of the consortium on DLB international workshop

Reversal of cognitive decline – a novel therapeutic program

Results of a large, federally funded trial showed that 10 milligrams of donepezil (Aricept) daily reduced the risk of progressing from amnestic MCI to Alzheimer’s disease for about a year, but the benefit disappeared within three years.

Early diagnosis beneficial in AD
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Appointment information for Dr. Micaela Wexler: wexlerpsych.com