Winter Blues: Seasonal Affective Disorder (SAD)

Winter Blues: Seasonal Affective Disorder (SAD)

Seasonal Affective Disorder (SAD)

Depression can occur at any time of year. However, for many, winter represents the most vulnerable time. Changes in sunlight, temperature, changes in the brain and body’s internal chemistry, and the stress of the Holidays can all play a role. In some ways, Winter Depression is built into our biology – just think of bears that hibernate during the winter. Indeed, symptoms of winter depression can mimic hibernation, with lack of energy, sleepiness with difficulty getting out of bed, and an increased appetite with carb-cravings. Difficulty with concentration and focus can also be a symptom. Because of the physical symptoms, some describe seasonal affective disorder (SAD) as “vegging out.”

Some individuals only experience depression during the winter while others may experience it any time of year but more so during the winter.

Some specific findings associated with winter depression include:

1) Lower available levels of the brain chemical messenger serotonin. There is evidence that serotonin remains less available to stimulate neurons for people with SAD. This is because after serotonin is released from a neuron, thereby making it available to attach to and activate docking stations (known as receptors) on surrounding neurons, it is sucked back in by the releasing neuron too quickly in people with Seasonal Affective Disorder (SAD).

2) People with SAD may make too much melatonin, a hormone that promotes sleepiness. Excess melatonin levels can cause daytime fatigue. This can also throw off a person’s day-night cycle (circadian rhythm).

3) Insufficient Vitamin D levels may play a role in SAD. Vitamin D may be involved in the action of serotonin.

4) Activity of a structure deep in the brain called the hypothalamus may be uniquely sensitive to sunlight in people with SAD. The Hypothalamus controls sleep and appetite, and also may play a role in mood.

Treatment for Seasonal Affective Disorder (SAD):

First, it is important to rule out other possible causes, such as low thyroid or anemia as examples. I have had a number of patients where these were uncovered as causes of fatigue.

Very effective treatment for SAD is available. Bright Light therapy, Cognitive-Behavioral Therapy (CBT), and antidepressants are the most evidence-based. These and others that are often helpful are listed below.

Bright Light therapy

There are lots of different styles and price points of bright light lamps or boxes. Specific levels of luminosity (often 10,000 lux is recommended) and timing of bright light are important components. The timing of bright light may depend on the type of depression. For pure SAD or winter worsening of depression, the morning is usually best. Morning bright light resets circadian rhythm, activates the hypothalamus, and suppresses melatonin secretion. Melatonin release is regulated by light. Melatonin is always primed to be released in the brain but held back or suppressed by bright light. This is why melatonin is released at night (and also why you shouldn’t bring your phone or laptop into bed at night!).
(Note that although using bright light later in the day can make SAD worse by messing up circadian rhythm, there are always exceptions. I occasionally find that bright light later in the day whether exclusively or in addition to morning light paradoxically is more beneficial. Also, mid-day bright light is better for Bipolar depression).


Many antidepressants are used for winter depression but one is specifically FDA approved for it. However, your doctor needs to make sure this is the right antidepressant for you (for example, it’s not as good for some symptoms of depression or anxiety).

Cognitive-Behavioral therapy (CBT)

This can help change unhelpful behaviors and negative thinking, help change perspectives on the winter, and teach stress-reduction techniques.

Exercise. For those who are not inclined towards exercise, thinking of this recommendation simply as “getting the blood flowing” can be helpful, as even 10 minutes of physical activity a day can be beneficial. Outdoor activities can be especially helpful.

Vitamin D. Consult your doctor for Vitamin D dosing for SAD.

This article was originally published on Dr. Neal Ranen, Baltimore Psychiatric Services

How to Break Out of Default Mode

How to Break Out of Default Mode

What Depression Looks Like in the Brain:  Stuck in Default Mode (and How to Break Out of It)

Even though depression is usually referred to as a chemical imbalance, it is actually an imbalance in networks of interconnecting regions of the brain. Specifically, sophisticated new brain imaging studies reveal that depression shows up in the brain as being stuck in “Default Mode.”  This is a looping network deep in the middle portion of the brain that, in depression, is more active than the other major networks.  The Default Mode (DMN) has strong connections to the emotional, anxiety, and fear centers of the brain, and parts of the brain that reflect thoughts about self, the past and the future.  It is also involved in thinking about the intentions behind others’ behavior.  So, a disproportionately active DMN results in a hyper-connection to the depression, anxiety, and fear centers of the brain, causes people to be sensitized about how they’re feeling, and whether other people are acting with bad intentions towards them or thinking that they’ve disappointed others.

Also, when the DMN is disproportionately active, the other important networks can’t function normally.  One of these other networks is called the Executive Network. The Executive Network is also sometimes termed the “Task Positive” Network because it is activated when we need to effectively interact with the outside world to get things done or look at things rationally.  It is more on the outer, more advanced part of the brain, rather than buried deep like the DMN, and involves important areas of the Frontal Lobes (by the way, the EN is impaired in ADHD, but that’s for another blog!). In contrast, the DMN is often referred to as the “Task Negative” network because it involves an internally-oriented focus.  This overactive Default Mode Network causes you to literally and figuratively “be in your own head.”

Importantly, with depression, not only is the DMN overactive, it also cannot be deactivated when the brain is trying to activate the Executive Network. Deactivating the DMN is essential to allow the Executive Network to work effectively and not be straining against or clashing with the DMN, again because the EN is Task Positive and the DMN is Task Negative. This is why, in addition to depressed mood, lack of enjoyment, and pessimism, people with depression also have trouble concentrating and getting things done – it is because of an overactive DMN that cannot be deactivated.

So, the DMN causes negative emotions and thoughts and prevents clearheaded thinking and productivity.  In addition, recent evidence reveals connections between this network and the brainstem that controls things like sleep, appetite, sex drive and a sense of physical sluggishness.  So, we can see how a disproportionately active DMN can contribute to all three domains of clinical depression – 1) mood and self-attitude, 2) concentration and productivity, and 3) physical symptoms like lack of energy and changes in sleep and appetite.  One can see why depression causes everything to feel so effortful.

The most effective way to treat depression, and rebalance the brain networks, is through therapy and the targeted, judicious use of medication.  So, break out of Default Mode and start the path towards feeling better!

If you are battling with depression, contact Dr. Neal Ranen to set up an appointment today!

This article was originally posted on DrNealRanenBaltimorePsychiatrist.com

Newer Antidepressants: The “Reuptake-Plus” Antidepressants

Newer Antidepressants: The “Reuptake-Plus” Antidepressants

The “Reuptake-Plus” Antidepressants by Dr. Neal Ranen, M.D. Baltimore Psychiatrist

I previously reviewed antidepressants known as SSRI’s and SNRI’s that work as reuptake inhibitors (see June 27, 2010 blog). This mechanism of action allows serotonin and norepinephrine to remain available long after release, increasing the likelihood that they will occupy docking stations, or receptors, on surrounding neurons, and exert an effect.  There are a couple of newer antidepressants that work not only as reuptake inhibitors but also directly occupy receptors.  I reviewed one of these, vilazodone, or Viibryd, in a previous blog, and since then a newer “Reuptake-Plus” antidepressant has become available, called Trintellix.  This medication acts as a serotonin-reuptake inhibitor plus directly occupies serotonin receptors, either stimulating or inhibiting them, creating additional effects.  There are many types of serotonin receptors, and Trintellix has effects on 5 of them. As above, Trintellix activates some of these receptors but inhibits others. This may sound confusing, but the inhibitory effect can actually activate certain other chemical messenger pathways in the brain. To understand this, it is important to know a couple of pieces of information.  The first is that some chemical messengers in the brain (known as neurotransmitters) activate neurons (known as being excitatory) and some inhibit them (known as being inhibitory). They do this by having stimulating or inhibiting effects when they attach to receptors on surrounding neurons. Serotonin, for example, is an excitatory neurotransmitter.

The next layer of complexity is that serotonin neurons can connect to a second neuron that itself is either excitatory or inhibitory.  So, if serotonin attaches to a receptor on an excitatory neuron, more excitatory activity will be triggered, but if it attaches to a receptor on an inhibitory neuron then there will be more inhibition of brain pathways because it is activating the inhibition.

The next level of understanding is that there are a lot of intermediary neurons in the brain that function as connections between two other neurons.  There will be a first neuron that will connect to the intermediary neuron, known as an interneuron, which will, in turn, connect to the third neuron. These interneurons are usually inhibitory – they hold back activity in the third neuron. The first neuron is usually excitatory – the neurotransmitter it releases, like serotonin, will activate this inhibitory interneuron which results in suppressing the activity of the third neuron. So, serotonin receptors, although always excitatory, can either suppress activity if it is on an inhibitory interneuron or stimulate activity if it is on another neuron that itself is excitatory.  Now we can understand how Trintellix can increase activity in the brain even though it stimulates some and blocks other serotonin receptors: the receptors it stimulates are on neurons that are also activating, and the receptors it blocks are on neurons that are inhibitory.  In the latter case, this will prevent activation of the inhibitory neuron, thereby taking away the brake on activity in the next neuron. This may or may not be associated with certain advantages  (or disadvantages) depending on the type of symptoms of depression a person is experiencing.  For example, in addition to its overall antidepressant effect, this may result in an increase in cognitive processing speed and be less associated with weight gain, but in my experience not work as well if there is a high level of anxiety or irritability associated with the depression. So, a lot may depend on the person’s specific symptom pattern. This is why a careful psychiatric assessment is critical to determine what antidepressant might be right for any particular individual.

To learn more or to make an appointment with Dr. Neal Ranen, M.D. call 410-413-2145.

This article was originally posted on Dr. Neal Ranen

Stress Can Have a Direct Impact on Your Mental Health and Overall Well-Being

Stress Can Have a Direct Impact on Your Mental Health and Overall Well-Being

Effects of Stress on Your Mental Health – Baltimore Psychiatry

Many people make daily comments about being completely stressed out or under so much stress. Even though there are common themes when it comes to stressors, these can really vary from person to person. In other words, what stresses one person may not stress another.

It is known that stress can result in severe physical and mental health consequences.  Physically, the onset of stress can be observed as a result of getting too little sleep or rest, poor eating habits, or too many things to do in very little time. Internally, stress can negatively affect the nervous, cardiovascular, immune and endocrine (hormone) systems, amongst other biological effects.  Mentally, the onset of stress comes with constantly worrying about finances, children, your health or the health of other family, retirement, or the occurrence of a traumatic event.

A great deal of stress occurs as a result of everyday tasks and responsibilities. There is often a collective set of issues that could possibly lead to the onset of stress. These issues typically stem from tasks and responsibilities being piled on an individual.

Internally, our bodies often react to these everyday constant stressors of modern society similar to if they were immediate dangers or catastrophic events because physically we have limited hardwired ways of responding to stress.

Consistent bouts with stress without making the necessary changes to eliminate the effects can eventually cause your mental health to suffer. It is important to understand that external events can result in stress. This results in a feeling of not being in control.

How to Get Your Stress Levels Under Control

The good news is there are tools to combat stress. The process is not a lengthy one, but change will not occur overnight. There are cases of chronic stress, which may require major lifestyle changes or psychiatric attention. Individuals can attempt to find their level of tolerance for stress and make honest attempts to remain within those limitations. It is advisable to avoid stressful situations whenever possible, and minimize the effects of stress when not possible.

Here are a few tips to help control stress:

  • Maintain a Realistic Attitude. Setting expectations are critical. Don’t be afraid to simply say NO to activities or situations that stress you out (and are not absolutely necessary –although expectations sometimes come into play in determining what is absolutely necessary). Any situations or events that make you anxious or overly nervous, or cause you to be overextended, could eventually cause stress to build-up. Take a realistic approach to responsibilities and shy away from those that seem to be overwhelming. Make changes and see if you can reassign responsibilities to others if executing them will cause you to stress out.
  • Execute tasks at a comfortable pace. There are no perfect people and you should know that no one expects you to be perfect. The pressure of perfectionism can backfire, as stated well by the aphorism: “The perfect is the enemy of the good.” If certain tasks or activities seem to be too overwhelming, spread them out or get help with completing them. You don’t have to do everything on your own. Some things can be put off to a later date or treated as a group task. The key is to decrease the amount of stress associated with completing the task.
  • Reevaluate your workload to make necessary changes. If stress has occurred as a result of work, reassess your job duties. If possible, you may need to decrease the number of hours you work or completely change the industry in which you work. Although the latter option sounds extreme, think about how much time you spend at work. There have been numerous cases where employees have become so stressed with work that it becomes the main factor contributing to poor mental and physical health.
  • Engage in stress-reducing behaviors like exercise and meditation. Exercise can chew up excess adrenaline that would otherwise be manifest as anxiety. meditation helps to build up the relaxation pathways of the nervous system, which prevents the alarm system pathways from being constantly active.
  • Talk to a Professional such as a Psychiatrist. If your stress is a result of something that you can’t change in life, or the symptoms of stress are distressing, speak with a mental health specialist. As a psychiatrist, because I am a physician, I can evaluate both the emotional and physical symptoms of stress. For example, I focus on cognitive-behavior therapy and problem-solving therapies for stress, but can also offer medication, prescribed gently for targeted symptom relief. I conduct an evaluation of your situation to provide helpful information on how to alleviate stress in your life, either by modifying the stress or changing the response to it. Professional help can be invaluable because I know that some of the above suggestions are easier said than done, especially when you’re in the midst of the stress!

The onset of stress can easily manipulate the behavior of an individual. They become irritable, difficult to work or associate with, and may find that just getting through the day has become effortful. Stress-related disorders are more common than most people know. Failure to treat stress-related symptoms could lead to severe depression, panic attacks, or aggravate bipolar disorder. The good news is there are helpful proven approaches that provide relief, which is why it is so important to reach out for help and not blame yourself when your own efforts don’t seem to be helping.

Dr. Neal Ranen can assist you with stress and anxiety treatment in Baltimore.  Contact us today to set up an appointment!

This article was originally published on Dr. Neal Ranen, Baltimore Psychiatric Services

Symptoms to Warrant a Psychiatrist Evaluation

Symptoms to Warrant a Psychiatrist Evaluation

These Symptoms May Warrant an Evaluation by a Psychiatrist in Baltimore

Life’s changes and challenges often make many people feel overwhelmed. Obstacles and circumstances can cause a stir of emotions or changes in attitude that can be difficult to understand and even more difficult to explain. There is a chance that negative thinking and an overflow of mixed emotions will vanish with time. Then, there are instances where these feelings linger, perhaps even for months or even years. It is then that a closer look or examination of the mental state must be taken. Even one to two weeks of a number of symptoms occurring at the same time, like changes in mood, sleep, self-attitude, energy level, anxiety level, behavior, and mental sharpness can indicate a psychiatric condition amenable to treatment.

Self-diagnosis is not uncommon, as is the view that challenges or changes will simply rid themselves. Symptoms might be explained away, even when the person has had similar recurring feelings in the past under completely different circumstances. Failure to identify symptoms and diagnose the core of the problem can easily lead to more severe, recurrent, and sometimes dangerous consequences. Failure to identify symptoms and diagnose the core of the problem can easily lead to more severe and recurrent consequences.

Mental distress is more common now than ever before. Research and treatment is widespread and ongoing. Psychiatrists have various approaches based on the dynamic of the illness. The key is to notice the symptoms and not ignore them, and then move forward to have them assessed.

Here are 5 signs that an evaluation by a psychiatrist is warranted:

1. Excessive fatigue or depression:

It is common for changes and unexpected occurrences in life to sometimes cause a downward shift in feelings. The need to compete for positions, attention and social status is a feeling that can easily get people down. This can contribute to becoming depressed or overwhelmed. These feelings can also come out of the blue, even when things objectively are going pretty well in the person’s life. Symptoms that come out of the blue can be associated with a family history of depression or other mental health conditions. The depression can be accompanied by low self-esteem, loss of appetite, decline in mood, hopelessness, irritability, and loss of interest in activities that were previously enjoyed. These are things that can lead to problems at work and with relationships, negative feelings about life, and much more. They make life feel difficult to enjoy, and everything may feel effortful. A psychiatric evaluation will assess these signs of depression.

2. Thoughts that life isn’t worth living:

Some who are depressed feel that they just want to run away or escape. This can take on a stronger tone of someone wishing they wouldn’t wake up the next morning, that they would just be taken in their sleep. Some express that they’re a burden and no longer feel needed on this earth. These are referred to as passive death wishes. Others have specific thoughts of ending their life by their own hands. It is important to take any mention of suicide seriously. An evaluation by a psychiatrist would be recommended in this case. (*Of course, any discussion of this topic warrants noting that with any immediate safety concerns the person should seek out care in the emergency room or call 911).

3. Emotional distress, altered moods, risky conduct, and strong emotional actions:

People who display frequent or constant changes in mood, emotional turmoil, signs of distress, and engage in frequent self-defeating or risky behavior may be displaying signs of mental illness. These signs may be sporadic and brushed off by the individual, or have already escalated to obvious levels of severity. In either case, a psychiatric evaluation should be pursued to rule out or diagnose a mental illness.

4. Constant Worry, Anxiety, or Panic Attacks:

These can occur in the context of different actual stress levels:

a) Regular everyday stressors but constant or disproportionate worry about them.
b) An elevated but not extreme increase in stressful circumstances but with an all-encompassing worry about them. There may have been a bothersome situation that others are telling the person to just put behind them but that they just can’t shake.
c) Objectively extreme high-stress levels causing constant fear and worry. This can be issues at work or in an individual’s personal life and can include traumatic events. Interestingly, a research article was just published showing that treatment with a well-tolerated group of medication, the SSRI’s, after a traumatic event can reduce the likelihood of certain general medical problems in the future. This certainly shows a mind-body connection, and further emphasizes the importance of psychiatric care.
d) Generalized anxiety and panic attacks can also come out of the blue. Anxiety or panic can even wake a person from sleep.

Regardless of the context, the symptoms of constant worry, anxiety or panic are treatable and an evaluation is highly recommended. Both psychotherapy and medication can be effective, and a psychiatric evaluation can best determine what approach or approaches would be best suited for the person.

5. Constant irritability or anger attacks:

Some people seem to have a naturally aggressive disposition that is easily set off by the simplest things. Others find they are constantly irritable out of character for them. Sometimes there are major things going on in the person’s life that are triggering these feelings and behaviors, and at other times they are in reaction to normal everyday circumstances. The reactions may seem warranted to the individual in response to others who have crossed them or unfair situations but are seen by others as unhealthy or disproportionate. Loved ones or friends may be afraid to point out the problem out of fear of becoming the focus of anger — they may find they are walking on eggshells. The irritable person may not recognize the problem because their reactions can seem justified to them. On the other hand, the person may hate that they are feeling irritable all the time. In any case, these emotions and behaviors can cause harm to relationships, or put jobs and careers at risk. And, the irritable or angry person, again, may themselves feel lousy most of the time and are not necessarily dealing effectively with situations. In addition, anger causes unhealthy physical stress reactions in the body, including in the cardiovascular, nervous and immune systems. An evaluation by a psychiatrist could identify if there is an underlying issue and determine what method of treatment would be most effective.

Of course, there are many other conditions that benefit from care from a psychiatrist, such as OCD and ADD/ADHD! Please see my previous blogs and information under “Conditions Treated” on the website for more info on these and others!

Unfortunately, it often isn’t until signs and symptoms such as the ones listed above have spiraled out of control that people begin to seek answers. This can be because of denial (recognizing but explaining away, or not themselves recognizing a problem) or stigma. It is obviously critical to seek care at that point, but it is also really important to proactively seek out an assessment by a psychiatrist before symptoms reach that level. We often refer to medical conditions as “disease,” that at its root means lack of sense of ease (“dis” “ease”), connoting that with these conditions there is a level of distress, or that things just seem so effortful. Psychiatric care aims to rectify this, alleviate symptoms, improve quality of life, and get to the root of the problem to prevent recurrences.

This article was originally posted on Dr. Neal Ranen M.D.

Photo Copyright: bialasiewicz / 123RF Stock Photo

Mood Disorders are Common but Treatment Options Vary

Mood Disorders are Common but Treatment Options Vary

Treatment Options for Mood Disorders

Mood swings, we all experience them on occasion. The key is to know, without a shadow of a doubt, that what you are experiencing are actually mood swings and not mood disorders. There is a big difference between the two. While one may require a simple change of scenery or environment, the other will only respond to effective treatment. A psychiatrist is able to help you distinguish between the two.

The important point is that mood disorders are highly treatable.

To better understand the significance of mood disorders, further details follow. I’ll be focusing mostly on conditions associated with depression but will touch on Bipolar too particularly Bipolar Depression.

Mood Disorders

A mood disorder is defined as a class of mental health conditions that include all levels of bipolar conditions and depression. These disorders can be experienced by all ages including kids, teenagers, adults and older adults. Mood disorders can be treated with antidepressants and mood stabilizers, lifestyle changes, and therapy methods, amongst others.

Categories of Mood Disorders

Mood disorders are not simply categorized underneath a single umbrella. They are broken down into several categories. Here are a few of the most known and treated mood disorders:

  • Chronic Depression or Dysthymia: is classified as a persistent, low-grade, irritable state of depression that lingers for two or more years. It is important to recognize this treatable condition because people may struggle with this lifelong and think it is just their personality.
  • “Major” Depression: Here, “Major” is not a description of severity but rather a type of depression that includes a combination of symptoms, usually in mood, physical and thinking/concentrating areas. Symptoms may include loss of interest in activities that are usually enjoyable, feelings of doubt or sadness, sluggishness or alternatively feeling anxious/agitated, and the feeling that things aren’t going to get better.  By definition, symptoms have been present for at least two weeks (and often longer). Major Depression can be Mild, Moderate or Severe.
  • Bipolar Depression: one of the most common categories is bipolar depression, which defines stages of depression that alternate with mild or pronounced highs or irritable/agitated states. It is important to recognize this type of depression because the depressed phase can look exactly like non-Bipolar Depression but the treatment is very different (The full spectrum of Bipolar disorder, including the manic phase is described under “Conditions Treated”).
  • “Adjustment Disorder” is the official term for a situational depression. Psychotherapy and lifestyle changes are important consideration for this condition.
  • Substance-induced: This category of mood disorders includes those symptoms that occur as a side effect of medication, toxin exposure, abuse of drugs (prescribed or illegal) or alcohol.
  • Some medical and neurological conditions themselves can cause depression. Sometimes it is a reaction to having the illness but other times the medical or neurological condition directly causes the depression by creating a chemical imbalance. Contrary to popular belief, these depressions are also very treatable.

Why Do Mood Disorders Occur?

There are several contributing factors that lead to mood disorders. Ultimately, they occur due to the disproportion of brain chemicals and imbalance of brain pathways. Stressful life events can cause these altered mood states. Depression can also happen when there is little life stress. When feelings of depression are triggered or worsened by stressful life events, the depression can make it more difficult to manage the stress that’s precipitating the depression in the first place.

Both biological factors and life stress may be important within an individual; for example, a person may have a genetic susceptibility towards depression but a stressor is necessary to trigger the condition.

Mood disorders have the tendency occur among relatives.  A genetic contribution to depression is now very well established.  This is why we see that children who have parents or other family members who suffer from mood disorders have a greater chance of experiencing them also.

Who can suffer from mood disorders?

Mood disorders can affect anyone. Some develop depression when objectively everything is great in their lives.  For others, it occurs in the context of significant stress.  Sometimes the depression will cause people to experience their stress as worse than it practically is — cognitive therapy, with or without medication depending on the severity, is extremely helpful in this case. Therapy is helpful because it can be hard for people to problem-solve when they are depressed. Also, therapy can help people see hidden influences in their personal psychology that contribute to the depression.

Mood disorders occur more often in females than males but spares neither sex. Any major life change, whether good or bad, such as employee termination, change in careers (forced or unforced), financial issues, marital status changes, or the death of family or a loved one can contribute to mood disorders.

Symptoms of Mood Disorders

The signs and symptoms that accompany mood disorders will vary. The symptoms occur according to age group and the category of mood disorder. Here are a few of the most common symptoms:

  • Ongoing or continuous feelings of guilt
  • Excessive sadness, anxiety, or flattened mood
  • Low self-esteem and self-blame
  • Relationship issues
  • Lack of interest in hobbies or previously enjoyed activities
  • Changes in eating habits, weight loss or gain
  • Feeling helpless or hopeless
  • Feelings of inadequacy or lack of self-worth
  • Unhealthy change in sleep habits
  • Loss of energy
  • Lingering thoughts of suicide or suicide attempts
  • Difficulty concentrating
  • Feelings of wanting to escape or just not wake up the next morning
  • Sensitive response to failing or being rejected
  • Highly irritable, aggressive or extreme hostility
  • Problems focusing or concentrating
  • Frequent complaints of physical ailments such as headaches, fatigue, or stomachaches that are not related to other medical conditions

Mood disorders can easily mimic other health conditions or problems of mental health. A psychiatrist can help you arrive at a precise diagnosis.

Treatment of mood disorders

Mood disorders can be successfully and effectively treated. Following are a few treatment options:

  • Antidepressant medications: the combination of effective medicines and psychotherapy treatment work to treat depression and various mood disorders. At times, either one alone can be effective.
  • There are specific medications that are proven treatment for Bipolar Depression. It is important to recognize the condition because traditional antidepressants may not work here and, in fact, make the condition worse. Sometimes people who find themselves just very moody have been inadvertently treated with standard antidepressants when they actually have Bipolar Depression.  Mood Stabilizers are used for people with Bipolar who are having both highs and lows.
  • Other Medical Therapies: other types of therapy are available for effective treatment. They include certain supplements that can work as complementary treatments
  • TMS, and ECT.
  • Psychotherapy: There are many types of effective therapies including Cognitive-Behavioral (CBT), insight-oriented, practical problem-solving, interpersonal (enhancement of interpersonal interactions with others), amongst others. These should be tailored to the specific person and situation. Examples include focusing on helping the patient to change the negative outlook or opinion they have of themselves and give tools to improve their symptoms or circumstances. Correct and ongoing treatment of mood disorders helps sufferers resume and lead stable and healthy lives.


This article was originally posted on DrNealRanen.com

Photo Copyright: shidlovski / 123RF Stock Photo

Can Coffee Rev Up Your Workout?

Can Coffee Rev Up Your Workout?

See my New York Times letter commenting on the effects of caffeine on exercise!

Your inherent (genetically coded) rate of metabolizing caffeine has an influence on its effect on exercise.  That rate is determined by how rapidly or slowly working the enzyme is that processes caffeine.  The particular enzyme responsible is known as CYP4501A2 (catchy name!). Our genetic makeup determines the exact configuration of that enzyme, which in turn controls whether it is fast or slow. However, other outside factors may influence the products of our genes, like CYP4501A2.  For example, I was aware that cigarette smoking induces (or speeds up) this enzyme.  So, as the Times article showed that fast 1A2 metabolizers got more of an oomph from caffeine, I added an observation about cigarette smoking and caffeine consumption. Here’s the letter!


By the way, when I do genetic testing, this is one of many items that I look at because this same enzyme is also responsible for processing some medication. Also, some medications can speed up or slow down this and other enzymes, affecting the levels of other medication you might be on. So, applying clinical knowledge to the results of genetic testing is important in optimizing treatment for conditions like depression, anxiety and ADD/ADHD!

In the best of mental health!

Dr. Ranen

This post was originated on Dr. Neal Ranen.com April 2018

Treatment for Excessive Worry

Treatment for Excessive Worry

Dr. Neal Ranen, M.D. Offers Anxiety Treatment in Baltimore

Fear serves as a filter that assists in the recognition of danger. It heightens the reflexes and increases mental alertness. The fear response was particularly important in the early days of humankind when there was a need to be vigilant for mortal threats, such as suddenly encountering a mountain lion. However, our anxiety system is not as well-adapted to the stressors of modern life. Although some degree of worry can be helpful (like not being too blasé about work deadlines) when fears present themselves constantly and evolve into unescapable alarm or a lingering worry, they can have a negative impact on everyday life. This is a sign or indication that one may be dealing with a form of anxiety or an anxiety disorder. Almost 30 million Americans suffer from disorders such as this, and more than 10 percent of the population experience severe symptoms of anxiety that are in one way or another connected to physical ailments. Anxiety is believed to an underlying factor in at least 20 percent of existing medical conditions in people who seek primary health care.

Anxiety manifests in a variety of different ways. For example, phobic disorders are out of the ordinary, horrific fears about a certain thing or object, places or social circumstances. Psychiatrists classify phobic disorders into different groups, such as social, specific or agoraphobia.

Social phobias are fears of an irrational nature that cause the person to avoid being in a particular situation where others may watch or notice them. This can include performance anxiety or phobia, but the social phobia terminology describes signs that exceed simple nervousness prior to a performance in front of a group or crowd of people. People who combat this form of anxiety have a strong fear of people watching, and often judging them, when they are doing certain things. These can be simple things such as having a conversation with someone, checking out at the grocery store, ordering a coffee at Starbucks, eating in a restaurant or attending a fitness class. Social phobia can reach a point that makes it almost challenging for people to attend school, go to work or interact socially with others at all. These phobias occur with both women and men, typically occur after puberty and typically hit their peak after they turn 30 years of age.

Specific phobias are quite common. This particular disorder is reflective of its name, in that it is a fear that people may have of a specific object or situation. If the object of fear is something typical, the results can be devastating. This category generally involves a fear of animals such as snakes, cats, dogs or insects. Then there is a fear that some may have of being in closed spaces, also referred to as claustrophobia or a fear of heights, acrophobia. These phobias generally arise during the younger years and may at some point go away. However, if the phobia carries into adulthood, it tends to persist without treatment.

Agoraphobia literally translates into a fear of the marketplace. It is a fear and avoidance of public or crowded spaces or places from where the person feels they cannot easily exit or escape. It can be related to a fear of having severe anxiety or a panic attack outside of one’s safe zone, typically the home. This phobia occurs in women more than men and is the most impairing of the group. Those suffering from this phobia have a fear of being stuck or alone in a place from which they feel will be difficult to escape. They simply believe that there would be no help if they became entrapped or have a panic attack in a space or area. Of course, ironically, a person would be much better off falling ill around a group of people than alone at home. Misplaced fear of embarrassment over becoming ill or having an anxiety attack around others can be part of this. This group of people tries their best to avoid places with crowds such as sporting events, churches, movie theaters and other similar spaces. This causes them to miss out on several events or social engagements. They withdraw from social activities by avoiding them completely. It causes such a fear in them that they literally become a prisoner in their own home. If circumstances lead them into places they fear, they can be completely overwhelmed with distress. Rarely will they enter this type of environment alone and, rather, they are in the company of a friend or a family member.

Psychotherapy and medication are appropriate and effective treatments for excessive worry and phobias. Psychiatrists utilize special techniques that have been researched and proven to help those suffering from phobic conditions. These include forms of Cognitive-Behavioral therapy and Exposure/Response Prevention. Many patients undergo desensitization treatment with great results. Techniques such as deep muscle relaxation help those with phobias to detect and relieve anxiety. This is followed by mental relaxation. Relaxation shifts the nervous system from a baseline of hyper-arousal to a relaxed resting mode. Then, the person learns to overcome their fears through progressive exposure in imagination and then in real life. This is done gently to achieve a relaxed, non-anxious state at every stage. After several treatments, the circumstance or object that caused the fear to generate eventually diminishes and no longer provokes fear in the person. Eventually, people can learn to put themselves into a relaxation state at their will, even when out and about, or when faced with a stress or trigger. Interestingly, the Biathlon in the Winter Olympics is a great example of the power of relaxation training. These athletes spend a lot of time doing relaxation exercises to help slow their heart-rate when they transition from the cross-country skiing portion to target shooting. The slower heart rate allows for more accuracy by reducing the bobbing of the rifle scope.

Tendencies towards automatic negative thoughts and the beliefs that underlie them can also be explored.

As above, the combination of psychotherapy and medication (particularly non-habit-forming, non-addictive medication) can be highly effective. There are several medications that are proven treatments, and specifically FDA-approved, for Anxiety Disorders, including phobias. So, the judicious use of medication can be extremely helpful.

There are a variety of theories as to why phobias occur in people. Some studies support that there may be imbalances in the chemistry of the brain, while others propose that phobias may be the result of negative messages or a traumatic event from childhood that has been buried emotionally and mentally. Genetic factors have been demonstrated, and, as such, anxiety often runs in families. An individual’s disposition may also play a role. For example, many people are much more concerned with avoiding bad things happening or making mistakes, rather than being influenced by positive experiences or successes. Stress in life or a significant loss can lead to certain phobias also. It is imperative to seek medical attention when phobias occur and lead to excessive anxiety.

When seeing individuals, I sort all this out and design the optimal treatment approach — one that is best for them. Contact me, Dr. Neal Ranen, M.D. to set up an appointment for an evaluation.

This article was originally posted on drnealranenbaltimorepsychiatrist.com 2/28/2018

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Effective Management of ADHD

Effective Management of ADHD

Resume Normalcy in Life with ADHD Management

Living with ADHD presents a set of challenges that are difficult for many to understand. This is particularly so if you haven’t personally experienced the symptoms and circumstances surrounding the condition. Parents, students, instructors, professionals, athletes and people from many other walks of life live with ADHD each day. They become overwhelmed with daily life tasks such as paying bills, organizing family schedules and interacting with social circles.

It is possible to effectively manage ADHD symptoms and regain control of the tasks that easily frustrate or overwhelm you. Psychiatric care can be extremely beneficial in managing ADHD. Targeted use of medication can be very helpful in normalizing brain pathways responsible for focus and productivity. Medications include stimulant and non-stimulant options. It is also wise to practice self-help techniques for efficiency in managing the condition. Not only do these techniques help you feel better, they also help improve the way you feel about yourself overall.

There are skills you can implement into daily habits that will assist in controlling the symptoms. Your habits will become improved, strengths recognized, and it will become easier to interact with other people at home, work or life in general. Self-help techniques also involve educating those around you to give them a better perspective of what you are experiencing.

I describe a number of techniques below. In my practice, I offer ADHD treatment in Baltimore, and I would be helping you design strategies for being successful with these approaches, and discussing a number of others approaches to customize the best plan. Note that you may have tried some of these techniques but found them frustrating to implement without the medication piece. This is why the combination of medication and behavioral strategies represents the best approach – medication can allow you to more successfully employ these approaches.

Maintain structure and neatness – get organized by creating a space for things in your home, office, car and anywhere else you frequently occupy. Sort objects into a category to specify what is used often or daily and what is seldom used. Arrange those objects that you rarely use into a space that is easily accessible but out of the way. Most importantly, declutter. If you don’t use it, get rid of it. Designate a space for bills, keys, writing utensils and similar objects.

Planning Apps – utilize your smartphone’s calendar or personal app to record appointments or important tasks that need to be remembered. This is a great way to help remember deadlines, especially when the reminders are utilized. You can also use the daily planners to write important events or tasks if you prefer those over the digital apps. Sometime plain-old pen and paper is the best reminder – like putting a note on the front door to not forget something when you leave in the morning.

Face Tasks Head-On – the easiest way to avoid clutter or forgetfulness is by taking care of these things as they arise. File important papers when you receive them. This is referred to as the “OHIO” rule – Only Handle It Once. Return important phone calls ASAP. Things that only require a couple of minutes of your time could turn into something more if put off until later.

Prioritize – many people living with ADHD have challenges with impulse control and sometimes navigate from one subject to another. It can be difficult to complete one task before starting another and the mention of a large project can be extremely antagonizing. Consider these points to help you prioritize:

• Complete the most important tasks first
• One step at a time is the key to completing large tasks
• Don’t become sidetracked (utilize a timer if necessary)

One of the biggest issues associated with prioritizing is that most people who have ADHD don’t know how to just say no to certain things or people. It is easy to accept too many social engagements, projects or tasks. This can leave you feeling overwhelmed with things to do, which can have an impact on the quality of your input or work. It’s okay to turn things down, which will allow you to give your best towards those activities or appointments.

Financial Management – it is essential to budget and plan as part of the organization plan to reduce stress with ADHD. Find a simple management plan that doesn’t require too much attention to detail. It may be necessary to create one of your own that is easy to manage. Doing so helps to prevent spending more than your budget allows, late payment on bills and penalties for late payments.

Eliminate Distractions – it is important to remain focused and attentive to the task at hand. This has tremendous effect on the quality of the result of your work. Consider working in an empty space, away from people or things that may distract you. It is likely that while working, the biggest and best ideas enter your head. Write those down and consider them later. Don’t allow these ideas to become a distraction, which will prevent you from completing the task at hand. Also, try to limit time surfing the web.

Failure to have or implement effective management tools can quickly lead to a setback or cause a negative impact on your self-esteem. Interject an active and effective strategy to deter the possibility of feeling down, anxious, irritable or frustrated, or not completing a task.

ADHD may enter your life, but it doesn’t have to consume your life. Regain control of your life immediately!  Schedule a consultation with Dr. Neal Ranen, your Baltimore Psychiatrist, today.

This article was originally posted on drnealranenbaltimorepsychiatrist.com January 2018

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Holidays Cause Social Anxiety to Surface

Holidays Cause Social Anxiety to Surface

Dealing With Anxiety During the Holidays

The holiday season is accompanied by many emotions and expectations. Gifting, family gatherings, office parties, school programs, social events and more are at an all-time high during this time of year. It is quite common for social butterflies to surface and make a grand attempt to attend almost every festivity. This is not the case for those who live with social anxiety. While some may encourage sufferers of the disorder to simply get over it, those who experience it understand that it is not an easy thing to do.

When does Perfection become Unbearable?

Adaptive perfection has been defined as striving for reasonable and realistic standards. Socially this would mean that one follows the rules of conduct and adapts to different social situations in a flexible manner without being too concerned about minor slip-ups.

In nonadaptive perfection, there is a tendency to strive for excessively high standards which is motivated by fear of failure. Socially this would mean that rules of conduct are applied in a very rigid manner which is driven by fear of being judged. As a result, social interactions become very stressful. Higher the distress the greater the indication that nonadaptive perfection is playing a role.

The Costs of Nonadaptive Perfection

Imagine facing the stress of going on a first date, especially during the holidays, and also having to ensure that you meet very high standards to ensure that nothing about you could be judged whether it is your weight, appearance, grooming, quality of your conversation, etc. Trying to be perfect in this manner is exhausting and can make one feel tense and anxious.

When one is trying to be perfect, the tendency to be hypervigilant of one’s errors increases. The focus on one’s imperfections can cause them to seem much worse than they really are. It will not allow one to get absorbed in or enjoy conversations.

The process of self-monitoring to ensure high standards results in conversations that lack spontaneity. People who experience social anxiety are usually trapped in a situation where they want to have closer connections but all that they do to make sure it happens tends to actually prevent it from happening. Their need for perfection inhibits them from being themselves which hinders authentic connections that lead to belonging and acceptance.

What people with Social Anxiety are often not too cognizant of is the fact that everyone has deficiencies. They do not really see others as flawed and human as they are. They make unfair comparisons and their thinking is often distorted.

The Adjustment from Nonadaptive to Adaptive

It is clear that nonadaptive perfection has several costs. Reducing high standards of perfection can be scary but if done in gradual stages the costs of the unhealthy perfection will diminish and you will gain the freedom to be yourself.

Seeking the help of a professional like Dr. Neal Ranen, M.D. in Baltimore County would be good, since you will have an ally and an expert in your corner who will guide and cheer you on.

Acknowledge your imperfections and make them uniquely perfect for you!

Originally posted on drnealranenbaltimorepsychiatrist.com