Ask the Doctor Q & A

Do you have a question for a mental healthcare provider? We will be accepting questions for our clinical panel and will publish a select question and answer in each of the DBSA monthly eUpdates. Submit your question here for future eUpdates.

View questions and answers that were featured in previous eUpdates below.

January 2012

My husband has chronic joint pain and is clinically depressed. To help him with his discomfort he became licensed to use medical marijuana. Can the use of pot intensify depression? I feel uncomfortable with his use of marijuana, especially since we have a teenager with bipolar disorder in the house. - Harriet

You are right to be concerned about how marijuana affects people who live with depression and bipolar disorder—especially younger people.

Using marijuana can certainly contribute to or worsen depression. Low motivation, fatigue, and withdrawal from positive activities are central features of depression and marijuana can worsen each of those problems. Some people do say that marijuana dulls anxiety or negative feelings. But it also dulls energy and motivation.  And we know that activation and engagement are key parts of recovery from depression.

Marijuana can be even more troublesome for people—especially younger people—who live with bipolar disorder. In addition to worsening depression, marijuana can increase the likelihood of experiencing symptoms of psychosis—like hallucinations or paranoid ideas. In younger people who are at higher risk for bipolar disorder or schizophrenia, using marijuana increases the chances of developing a severe or disabling mental illness.

You’ll want to express your concerns to your husband in a way that feels caring rather than confrontational. If you talk to him about negative effects of marijuana use, the old advice about “I statements” definitely applies. You can say things like: “I notice that you seem less active and more withdrawn when you use marijuana” or “I’m concerned that using marijuana keeps you from doing positive things that would help you to feel better.”

Dr. David Miklowitz

Thank you to Dr. Greg Simon, Chair of the DBSA Scientific Advisory Board, for contributing his expertise to this month’s Q & A.

Greg Simon, MD, MPH, is a psychiatrist and researcher at Group Health Cooperative at the Center for Health Studies in Seattle. His research focuses on improving the quality and availability of mental health services for people living with mood disorders, and he has a specific interest in activating consumers to expect and demand more effective mental health care.

November 2011

I've been through ECT treatments for 2 years. I worry about the treatments causing long-term damage to my brain. Can any of the current or upcoming treatments replace ECT for treatment of medication-resistant medication illness?

It's clear that ECT affects short-term memory. If you think of your brain as a computer, ECT can erase anything that you haven't yet saved to your hard disk. Some people can't remember events from the day of each treatment. Some people lose memory for the previous few days. For people receiving ECT treatments two or three times a week, that can mean remembering very little of the whole treatment.

It's less clear if ECT causes ongoing memory problems. To continue the computer anaology, the question is whether ECT damages your hard disk so you can't save information in the future. Most research says that ECT doesn't cause long-term memory problems. But some people do describe long-term problems with memory after ECT.

Concerns about risks of ECT (memory problems or other risks of anesthesia) were a major motivation to develop alternative treatments. These alternatives - transcranial magnetic stimulation (TMS) and vagus nerve stimulation (VNS) - were hoped to have the effectiveness of ECT without the risks or side effects. Both TMS and VNS have both been approved for treatment of major depression that does not improve with standard antidepressant medications. But it is not clear that either VNS or TMS is as effective as ECT for severe depression that has not responded to treatment with several medications. For the most severe and treatment-resistant depression, ECT still has the strongest evidence for effectiveness.

Dr. David Miklowitz

Thank you to Dr. Greg Simon, Chair of the DBSA Scientific Advisory Board, for contributing his expertise to this month’s Q & A.

Greg Simon, MD, MPH, is a psychiatrist and researcher at Group Health Cooperative at the Center for Health Studies in Seattle. His research focuses on improving the quality and availability of mental health services for people living with mood disorders, and he has a specific interest in activating consumers to expect and demand more effective mental health care.

October 2011

When I saw a doctor about weight loss surgery, he said I had to have a mental health evaluation from my psychiatrist. What is that for? If I did go ahead with the surgery, how might that affect the medications I take? Is there anything specific I would have to watch out for?

Bariatric surgery programs often ask for a pre-operative mental health evaluation. The main purpose is to identify any barriers to success after surgery, especially barriers that can be effectively addressed or overcome. We do know that people with some specific mental health conditions such as an active eating disorder, active drug or alcohol problems, severe mood symptoms, or psychotic symptoms - can be barriers to recovery from surgery and losing weight. In these situations, delaying surgery and getting effective treatment can increase the chances of success. Another purpose of a pre-operative mental health evaluation is to understand the psychological factors that may interfere with success, such as using food as a coping mechanism. Counseling focused on these issues can increase the chance of successful weight loss after surgery. It is important to emphasize that having a diagnosis of depression or bipolar disorder does not mean that bariatric surgery is not safe or effective. Research shows that people with depression are just as successful losing weight after surgery. And losing weight often leads to improvement in depression.

While bariatric surgery is more and more common, we lack good research about how surgery affects the dosing, effectiveness, or side effects of mental health medications. Bariatric surgery can certainly change or reduce absorption of medications - so they are less effective. This may be a bigger problem with sustained- or slow-release medications. With some medications, your doctor may want to measure blood levels before surgery and again after to see if doses need to be adjusted. Monitoring of lithium is particularly important, because large changes in weight can affect how your kidneys clear lithium from your body. If you are planning weight loss surgery, you’ll want to discuss these issues with your health care providers well in advance. And you’ll want to make sure that your different health care providers (psychiatrist, therapist, surgeon) communicate clearly with each other. They will usually need your written permission to do that.

Depression and Bipolar Support Alliance

Thank you to Dr. David Kemp for contributing his expertise to this month’s Q & A.

David E. Kemp, MD, is an assistant professor of psychiatry and director of the Mood & Metabolic Clinic at the University Hospitals Case Medical Center of Case Western Reserve University. Dr. Kemp’s research focuses on improving psychiatric outcomes by targeting the treatment of comorbid medical conditions, particularly obesity, pre-diabetes, and metabolic syndrome. He is currently investigating whether insulin sensitizers can reduce the severity of depression symptoms by acting on novel pathophysiological targets that influence mood. Dr. Kemp is a recipient of the International Society for Bipolar Disorders Research Fellowship Award and the DBSA Klerman Young Investigator Award. His research is currently supported by NARSAD and the Cleveland Foundation.

September Question 2011

"My son is 9 and has been diagnosed as bipolar, adhd, and ocd. When he is having one of his melt downs do you have any suggestions to help him get thru it and if he needs to be disciplined what's the best way?"

The first task is to try to determine what’s driving the meltdown.  Is it part of a bipolar episode (or a signal of one that’s approaching)?  Is it difficulty with changing tasks, typical of both bipolar disorder and ADHD? Does it stem from OCD-related frustration?  You may not always be able to tell, but you’ll have an easier time if you are monitoring your kid’s symptoms on a daily basis with a mood chart (for example, look at If the child’s mood has been getting steadily more irritable over the past few days, and his or her sleep is getting irregular, you may be seeing the beginnings of a manic or hypomanic episode. Look for accompanying signs of excessive energy, unrealistic thoughts. On the other side, for depression, look for fatigue, pessimism, excessive sleeping, or suicidal ideation.

Let’s start with the possibility that this is a manic or hypomanic episode. If this fits, then your options can include:

Use collaborative problem-solving early in the escalation. Start by validating your child’s needs (“I know you really want to play video games now, I’m sure that would be fun”), but also set limits and point him/her toward problem-solving (“it’s time to do homework. What are we going to do about this? What options do you think we have?”).

It’s harder to use this approach as the kid gets angrier (see a great discussion of these issues in Ross Greene’s book, The Explosive Child). If he keeps escalating, make clear your point of view, but keep in mind the three-volley rule: after you and your son/daughter have gone back and forth three times, your side of the argument ends, even if s/he keeps it going.  Walk away, and give yourself a time out. Use ignoring as much as possible: close your door and let him yell and scream as long as he doesn’t hurt himself or anyone else.

Sometimes, it can be helpful to change the scene. Take him for a drive, or ask your spouse or an older sibling to take him somewhere. Call a relative to “spell you” for a time.   Make sure you take care of yourself so that you don’t let anger get the better of you. If your child is older, you should call the police if you feel in any way threatened or if you fear for others in the household.

If it is OCD that’s driving the meltdown, an important consideration is whether the child is receiving (or has received) treatment for OCD, particularly exposure-based cognitive-behavioral therapy.  If not, he or she may have limited skills for managing the frustration.  If your child is in treatment for OCD, perhaps the best response would be, “Do you think that’s your OCD talking?” If your child says yes, prompt him/her with, “Is there a skill you can use to fight back/resist?”  If she continues to be upset, disengage (walk away) and let your child simmer down on her own.  The back and forth when kids are activated typically just gets everyone more upset.   Say something like, “I know this is hard, but I know you can do it.  I’m going to give you a chance to work on this on your own.”

In either case, it’s good to debrief later on when everyone is feeling calm and to think about prevention.  Ask your child what you think set him off, and what skills he could have used (deep breathing? Distraction? Self-talk?). Ask him what others could have done (other than give in to his demands) that would have made things easier.  Make sure your child’s therapist is aware of her problems with regulating emotions and is working with her on self-care skills. 

Some children with ADHD do much better when they know the exact order of their evening routines dinner, homework, games, bath, bedtime.  Writing down the expected routine in a place where everyone can find it may help prevent these disagreements.

As always, consider whether your child is getting the right medication regimen. If meltdowns are occurring frequently, his or her psychiatrist may add an atypical antipsychotic medication or increase the dosage, or, if ADHD is present but untreated, a stimulant medication like Ritalin.

Dr. David Miklowitz

Thank you to Dr. David Miklowitz, DBSA Scientific Advisory Board member, and Dr. Tara Peris for contributing their expertise to this month’s Q & A.

David Miklowitz, Ph.D., is a professor of psychiatry in the Division of Child and Adolescent Psychiatry at the Semel Institute at the University of California, Los Angeles (UCLA), and a senior clinical researcher in Oxford University’s Department of Psychiatry in Oxford, UK. His research focuses on family environmental factors and family psycho educational treatments for adult-onset and childhood-onset bipolar disorder.

Dr. Miklowitz has published over 200 research articles and book chapters on bipolar disorder and schizophrenia, and six books. His most recently published books, The Bipolar Disorder Survival Guide: 2nd Edition (Guilford) and The Bipolar Teen (Guilford), are both best sellers.

Tara Peris, Ph.D., is an Assistant Professor of Psychiatry in the Division of Child and Adolescent Psychiatry and the Semel Institute at the University of California, Los Angeles.  Her research focuses on family features that influence treatment outcome for child and adolescent anxiety and OCD and on developing family-based interventions for these disorders.

August Questions 2011

Is there any evidence in support of fish oil supplements to help depression in bipolar disorder?

The evidence for the benefits of fish oil (or omega-3 fatty acids) in the treatment of depression is mixed.  Some studies show moderate benefit, and some show no more benefit than a placebo.  But no studies show harm from fish oil supplements, and (unlike antidepressant medications) fish oil supplements do not seem to increase risk of mania or greater mood instability.  We would like to have more evidence, but the evidence we have now indicates that fish oil is safe and may be helpful to some people in reducing symptoms of depression.

I got really depressed in April and have been off work. The depression has just started to lift, but now I am phobic. I find going out and socializing hard work. Is this the tail end of the depression?

Losing interest in things you used to enjoy is a central part of depression. Withdrawing from positive activities can keep you feeling depressed.  As you feel better, you should start to feel more interested in things.  And pushing yourself to do things you used to enjoy will help you to feel better faster.  Phobia or phobic anxiety adds another layer.  The core of phobia is avoiding things because doing them (or even thinking about doing them) makes you feel anxious.  Phobias tend to be self-reinforcing.  When you avoid situations because of anxiety, the avoidance helps the anxiety to grow stronger.  The surest cure for phobic anxiety is pushing yourself to gradually overcome the anxiety.  That's easier said than done, but it helps to follow a specific plan.  Pick an activity that is important to you - something you would enjoy or something that you need to do to move forward in life. Chose a small and specific first step, then practice that step over and over until it doesn't make you anxious.  Once you master the first step, choose a second step that's a little more of a stretch.  And practice that one until you master it.  For example, if you're feeling anxious about social situations, your first step could be as simple as going to the grocery store every day and saying something positive to the checker every time.  They certainly won't mind.  If you have trouble making a plan or sticking with it, a therapist who knows about anxiety problems can be very helpful.

Dr. David Miklowitz

Thank you to Dr. Greg Simon, Chair of the DBSA Scientific Advisory Board, for contributing his expertise to this month’s Q & A.

Greg Simon, MD, MPH, is a psychiatrist and researcher at Group Health Cooperative at the Center for Health Studies in Seattle. His research focuses on improving the quality and availability of mental health services for people living with mood disorders, and he has a specific interest in activating consumers to expect and demand more effective mental health care.