​Published in Authority Magazine...

"One of the consequences of the pandemic is the dramatic growth of Telehealth and Telemedicine. But how can doctors and providers best care for their patients when they are not physically in front of them? What do doctors wish patients knew in order to make sure they are getting the best results even though they are not actually in the office? How can Telehealth approximate and even improve upon the healthcare that traditional doctors’ visits can provide?

In this interview series, called “Telehealth Best Practices; How To Best Care For Your Patients When They Are Not Physically In Front Of You” we are talking to successful Doctors, Dentists, Psychotherapists, Counselors, and other medical and wellness professionals who share lessons and stories from their experience about the best practices in Telehealth. As a part of this series, I had the pleasure of interviewing Dr. Joshua Stein.
Joshua Stein, MD is the clinical director and an attending clinician at Minnesota-based psychiatric health system, PrairieCare’s partial hospitalization program (PHP). He also operates a clinic that serves as a bridge for patients leaving PHP until they can see their outpatient provider. Dr. Stein practices with a focus on patient centered care to improve his patients’ functioning at home, in school and in social settings, with the goal of not only addressing immediate obstacles and gains, but improving long term trajectory as well. Dr. Stein completed medical school, a general psychiatry residency and a child adolescent psychiatry fellowship at the University of Minnesota.

Thank you so much for joining us in this interview series! Before we dive in, our readers would love to “get to know you” a bit better. Can you tell us a bit about your ‘backstory’ and how you got started?
Medical school was always on the table, but somehow, I had no idea I would end up in psychiatry. I was raised by a talented clinical social worker; and in hindsight, our dinner table conversation shaped my awareness of psychology, attachments and character. During my required core clerkship in psychiatry, it clicked, and I realized the connection between medicine and those dinner table conversations of emotional awareness would lead to a career in the field. Since then, I am honored to have numerous mentors who shaped my path and led me to child psychiatry. Currently I am lucky enough to teach, work in the hospital, consult to pediatricians and have a long-term continuity clinic. Also looking back, I did a bit of theatre growing up. My comfort on stage has led to teaching and lecturing as a physician. It has become an increasingly joyful part of my career.

Can you share the most interesting story that happened to you since you began your career?
Although there are of course unique or eye-catching stories, I think generally the most interesting aspect is the aspect of time. Time allows growth and development. Patients have gone from crisis to having families, careers, and vast talents. It illustrates the striking importance of treatment and the value of time.

Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?
“Life deserves purpose.” My grandfather who survived the holocaust told me this in high school and it stuck. The seriousness of his life built this perspective, but it many ways it applies to all of us. In my life I interpret it to mean — whether with family, work or play — be thoughtful and aware. Exploration of self or world can be purpose. Developing can be purpose. In the therapy side of my practice, this concept shifts care from: “I want to feel better,” to “my hope is to graduate high school” or “learn to love again,” or “play baseball again.” It moves care past “just be healthy” to regaining specific functioning in areas of meaning.

None of us are able to achieve success without some help along the way. Is there a particular person who you are grateful towards who helped get you to where you are? Can you share a story about that?
Drs. Joel Oberstar and Jonathan Jensen at the University of Minnesota were mentors in child adolescent psychiatry that demonstrated how joyful this field could be. They both showed how to engage patients through humor and play, allowing treatment to be silly. The moments learning from them have allowed me to bring play and silliness to my interactions that in many ways defines how I build rapport. Awful “dad jokes,” running football routes, Pokémon trivia and Harry Potter house assignments are examples of how my career gets to be goofy and fun, which it should be, when you work with children.

​Ok wonderful. Let’s now shift to the main focus of our interview. The pandemic has changed so many things about the way we behave. One of them of course, is how doctors treat their patients. Many doctors have started treating their patients remotely. Telehealth can of course be very different than working with a patient that is in front of you. This provides great opportunity because it allows more people access to medical professionals, but it can also create unique challenges. To begin, can you articulate for our readers a few of the main benefits of having a patient in front of you?
Similar to the experience many have had after the world has moved to virtual, with telehealth, there is the loss of connection that can only occur in person. In psychiatry, an extensive exam takes place called the “Mental Status Exam.” While the physician does not palpate the stomach or utilize a stethoscope, we do pay extensive attention to aspects of interaction and functioning. It is hard to complete this or build rapport in the same way virtually.
Additionally, there is an affective feel to a visit that speaks wonders. By meeting in person, the family dynamics are palpable, the stress levels are evident, and conflict is hard to ignore. This can be lost when meeting virtually.

On the flip side, can you articulate for our readers a few of the main challenges that arise when a patient is not in the same space as the doctor?
At times, virtual visits can lack the necessary formality of a doctor’s appointment. Patients can try and squeeze in an appointment from the car or a crowded restaurant. As your doctor, my goal is to give you my utmost attention and help care progress. Situational informality can lead to wasted time often to the detriment of care.
Additionally, diagnostics become difficult. Children are appropriately shy and may not like to see themselves on the screen. Many grandparents have found this fact frustrating as they have tried to maintain a virtual relationship over the pandemic. In medicine avoidance, lack of engagement and why those things are occurring help to understand the clinical diagnosis of the patient. When the patient is in the office these abstract aspects are readily clear. Virtually, it becomes quite difficult to understand why they “won’t come to the screen.”

Fantastic. Here is the main question of our interview. Based on your experience, what can one do to address or redress each of those challenges? What are your “5 Things You Need to Know To Best Care For Your Patients When They Are Not Physically In Front Of You? (Please share a story or example for each.)

1. Set effective ground rules before care: While this has always been necessary, it is strikingly important in virtual health. This includes arrive on time, no driving while in an appointment and be in a private area that feels comfortable for candid discussion. The physician needs to know who is in the room ahead of time. In my practice when I have not taken these steps it leads to lost time, risks confidentiality, or at worst — a patient may not disclose what concerns them. An example from my practice is when a mother of an anxious patient presented for a virtual appointment from the public pool. The child was embarrassed and uncomfortable. The session was ended after a review of appropriate formats for meeting. Future appointments were much more successful.
2. Both patient and provider should prepare internally for the appointment ahead of time. Often given the ease of technological access means there is not the classic preparation time in the car or even walking through a clinic during which the patient may center and focus on goals for the appointment. Take a few minutes to reflect prior to appointment to make sure it is worthwhile. The switch to virtual has led to many appointments where patients arrive without awareness of direction or needs.
3. Prepare externally for the appointment: The same screen that provides access for the clinical connection is a site of constant distraction. Shut off email, alerts, etc. These distractions can at best undermine therapeutic connection and at worst render an appointment useless. In my practice I regularly ask patients to shut off email reminders, social media, etc. My teenage patients often reflect that it is a relief not to have constant alerts and have space to connect.
4. Find a quiet, confidential space. A cubicle or the kitchen table often limits the discourse due to concern for who can hear. Countless times patients will present from an inappropriate place and then be hesitant throughout. By picking a private room or a locked car, the normal disclosure can occur, leading to the necessary treatment and healing. I have had patients try and whisper about the family member across the room or imply concerns without saying them while at a coffee shop. A confidential place of focus is needed.
5. Let patients share their life: Classically, appointments occur in the formal medical setting. Home virtual appointments allow a chance to meet the furry friends, see trophies, meet the other siblings, and see favorite possessions.
6. Recognize when virtual is not working and an in-person appointment is needed. In my practice, autism and ADHD evaluations are much more effective in person. As we move into year three of the pandemic, every provider has a different comfort level with when to meet in person. If the virtual appointment is stagnating care, consider shifting patient back to an in-person setting whether in the same clinic or not.

Can you share a few ways that Telehealth can create opportunities or benefits that traditional in-office visits cannot provide? Can you please share a story or give an example?
Access to care no longer requiring physical proximity is a huge advantage of telehealth. Child psychiatrists and many other specialized physicians commonly live and practice in larger cities or their suburbs. Rural patients have always struggled with the choice of long drives or not being able to see the most appropriate clinician for their symptoms. In my practice I see many children right after a hospitalization, but then they return to their home and cannot be seen further by a child psychiatrist due to distance. Over the last two years telehealth has allowed the care to conclude based on illness course rather than physical proximity.
Additionally, there is a large “time cost” of doctors’ appointments. This includes: the interruption to school, the drive time, potentially a parent needing to take the whole day from work, etc. Telehealth can allow less disruption in the day as there is little extra time needed other than the appointment time.
Telehealth also allows numerous parties to be present that may be hard to gather in person. In my practice, this allows case managers, therapist, separated parents, and/or complex families to be present all at the same. That “coming together” can happen in person, but often rarely. With telehealth, this occurs with greater frequency.

Let’s zoom in a bit. Many tools have been developed to help facilitate Telehealth. In your personal experiences which tools have been most effective in helping to replicate the benefits of being together in the same space?
As simple as it sounds, good lighting and a couple books to prop up the phone or tablet being utilized. Handheld devices in poor lighting can make the entire experience frustrating. By removing the camera from the hands, patients can speak freely and use body language effectively. It allows a shift towards forgetting the virtual nature of the visit and getting down to business. Overall appointments via desktop computers with built-in cameras seem to be the most effective overall. Finally, good Wi-Fi is needed. If patient has struggled with connection issues in the past, consider encouraging them to use a private room at the local library.

If you could design the perfect Telehealth feature or system to help your patients, what would it be?
A screen a few feet from the patient would be helpful to allow them to settle into the conversation without the overt issues a cell phone or tablet presents. Often the camera is facing the ceiling or aimed at the chin. If a parent is present, they may only be half in the screen. The device that captures the image often starts to take up its own space in the appointment. The simpler the device, that allows connection without dominating the interaction, all the better.
Also, the potential for a noise deadening microphone would be beneficial. Although the patient may not realize, many steps are taken in the therapist’s or physician’s office to maintain confidentiality. Thick walls, white noise and other tools are used to maintain privacy. Virtual care often requires a patient sneaking away to their car for a confidential visit. A tool to increase confidentiality would be helpful.

Are there things that you wish patients knew in order to make sure they are getting the best results even though they are not actually in the office?

1. Prepare briefly ahead of time, focus on what you would like to accomplish in the session.
2. Find a quiet, confidential space.
3. Plan ahead. Virtual appointments allow numerous people across numerous settings to be present. Would it be beneficial if a social worker, a therapist, a teacher, or a family member join the appointment? This new tool allows for a more collaborative appointment.
4. Children need to be present for their appointments. This is a regulation, but also allows the completion of the mental status evaluation which informs psychiatric care.
5. Used a fixed-point camera. Handhelds shift and often end up filming chins, ceilings, floors. By setting the camera down, it allows increased engagement and comfort.

The technology is rapidly evolving and new tools like VR, AR, and Mixed Reality are being developed to help bring people together in a shared virtual space. Is there any technology coming down the pipeline that excites you?
Recently, both Amazon and Facebook released devices that sit on a table and allow virtual connection at the highest degree. Sound quality and imaging are excellent. The camera will follow a pacing patient. A shift to make these devices covered for mental health would be appreciated.
Also, schools and offices may consider new confidential virtual health rooms. Patients could book these for appointments to allow easy access for a setting that allows earnest communication without the risk of being overheard.

Is there a part of this future vision that concerns you? Can you explain?
While technology allows improved access to individual interests it comes at the cost of actual interaction. We need real interaction to develop. Humans need to learn to be flexible, compromise and build resilience. This growth comes through faced obstacles initially small and then larger. First, we learn the alphabet, next we learn to read and then perhaps understand the rhetoric of Shakespeare. Virtual life certainly has some advantages, but I am fearful that it limits real life stress tolerance.

Ok wonderful. We are nearly done. Here is our last “meaty” question. You are a person of great influence. If you could inspire a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger. :-)
I would say, a push to allow “growing up” to be expected allowed and appropriate. We need to let children, adolescents and young adults make mistakes. Growing pains will occur but help them learn what they are capable of. A push to allow children this space and time is warranted.

How can our readers further follow your work online?
https://www.mnpsychconsult.com/ is the home website of the Psychiatric Assistance Line. We offer education, and in real time psychiatric consults to primary care physicians. I regularly blog on this site and future trainings are available in the calendar.
https://www.prairie-care.com/ is the website for my clinical practice. Additionally, numerous PrairieCare Education Series links are available including my past and future lectures.

​Thank you so much for joining us. This was very inspirational, and we wish you continued success in your important work.

PAL Psychiatrist, Dr. Stein, was invited to "Talking Pediatrics," a podcast by Children's Minnesota, to offer guidance on how to address and prevent suicidality in primary care.

"As those of us in clinical practice know, we have seen soaring rates of mental health challenges among children, adolescents and their families during the course of the COVID pandemic, exacerbating the already tenuous situation that existed for child and adolescent mental health. We have seen rates of childhood mental health concerns and suicide rise steadily over the last decade. Across the country, we have seen dramatic increases in ED visits for acute mental health emergencies, including suspected suicide attempts. Here to talk to us today about these increasing mental health challenges, and provide us with some strategies for addressing and preventing suicidality in primary care, is child and adolescent psychiatrist Dr. Joshua Stein." - Children's Minnesota

Listen to podcast recording or view transcript version here:
​https://www.childrensmn.org/for-health-professionals/talking-pediatrics-podcast/talking-pediatrics-addressing-child-adolescent-suicidality-self-harm-1-21-22/
​

​Isotretinoin, trade name Accutane, is a medication for severe acne vulgaris which was released in 1982. The possible relationship with depression symptoms was first reported in 1983. The FDA issued a warning in 1998 regarding “possible associations of isotretinoin with depression, psychosis, suicidal ideation, and suicide.” (1). Isotretinoin is a fat-soluble compound, crossing the blood-brain barrier, and can affect dopaminergic and serotonergic systems. A 2008 case crossover study published in the Journal of Clinical Psychiatry found a statistically significant association between isotretinoin and depression.
However, a competing viewpoint that treatment of severe acne with isotretinoin actually improves depression symptoms. Several studies have failed to show an increased risk for depression or suicide with isotretinoin.
A more recent meta-analysis published in 2017 did not find any statistically significant or causal relationship. In this study pooled results of 1411 patients who received depression evaluations at baseline and after treatment revealed significant improvement in depression scores. A controlled trial (3) new onset depression was noted in both isotretinoin and antibiotic groups, implying depression is associated with acne. There do not appear to be randomized controlled trials investigating this possible phenomenon.
In sum, there does not appear to be enough data to establish a causal link between isotretinoin and depression, psychosis, or suicide. There may be evidence that treating acne successfully can improve depression, which may be more prevalent in people with severe acne. I would not hesitate to use isotretinoin for a person with severe acne and previously identified depression, but the patient should be made aware of the possible relationship and closely monitored.
 
Sources:

1. Chang, Yu-Chen et al. Isotretinoin treatment for acne and risk of depression: A systematic review and meta-analysis. American Academy of Dermatology. 2017
2. Bigby, M et al. Does Isotretinoin increase the risk of depression? J Clinical psychiatry. 2008
3. Halvorson JA, et al. Suicidal ideation, mental health problems, and social impairment and increased in adolescent swith acen: a population-based study. J Invest Dermatol. 2011. 

- By Todd Archbold, LSW MBA

Studies consistently show nearly one out of five people will experience diagnosable symptoms of a mental illness in their lifetime, and less than half of them will ever seek the treatment they need.

According to polls from organizations like the American Psychiatric Association (APA) and National Alliance on Mental Illness (NAMI), a majority of adults reported increased symptoms of anxiety and depression throughout the pandemic, adversely impacting their daily lives. Parents are now reporting more worry and anxiety related to their children’s health. The necessary safety restrictions, such as social distancing, have exacerbated social stressors including financial distress, job instability and food insecurity. These subsequent stressors have disproportionately impacted our BIPOC communities. More people are feeling isolated and disconnected as mental health providers are overwhelmed with referrals.

With mental illnesses so prevalent, why don’t more people get help? Nearly one in 13 people suffer from asthma and nearly one in 10 from diabetes; almost all get care or help managing their symptoms. Nearly one in 10 people suffer from depression, and more alarmingly, nearly one in five adults suffer from some form of anxiety, yet less than half will get professional care. At least half of all cases of mental illness onset before age 14, meaning many people struggle with symptoms from a very early age.

We can all become advocates and speak out against stigma.

Comparatively speaking, most people will never experience the breathing difficulties associated with asthma or the tingling hands and feet that diabetes may cause. Yet everyone knows what it is like to feel depressed and anxious. It is when these feelings begin to impact our daily functioning that we need to get professional help. An acquaintance recently shared with me that she wanted to get involved in mental health advocacy, but had a hard time relating since she did not know anyone with a mental illness. I simply told her, “Yes, you do actually know several people with a mental illness; you may just not know they have an illness.” Many people may be effectively managing their symptoms, but sadly, many are not getting any help at all and are not talking about it. There are three main reasons people don’t get the mental health care they need, when they need it.

Access Barriers
These are real, often tangible barriers that prevent someone from getting help. They can range from such things as financial barriers, lack of reliable transportation, geographical isolation, poor internet and more. Some of these barriers can be more easily overcome than others, but in general they only add to functional impairment and create more frustration. Some access barriers may simply be not knowing who to call or where to go. Sadly, many individuals access care only through a crisis with an emergency room as their entry point.

Across the nation, we estimate that there is one mental health professional for every 378 people. This includes psychiatrists, psychologists, psychotherapists, advance practice nurses and drug and alcohol counselors. Of course, many of these are specialists and not trained to treat all conditions. Some specialties may focus on treating certain age range or certain conditions, while some are focused on research and may not care for patients directly. On average, psychotherapists carry caseloads of 40 to 60 patients, while psychiatrists carry caseloads closer to 400 and even upwards of 1,000 patients. Minnesota ranks in the middle of the nation, with an average of one mental health professional for every 365 people. Minnesota also ranks above the national average in alcohol and drug abuse, as well as racial inequities. Furthermore, our state has comparatively vast rural areas endearingly referred to as greater Minnesota. In these rural areas, the ratio of mental health providers to the population is close to one for every 1,500 people. Many people in these regions will struggle to find the right mental health provider, if any at all. While telehealth services have been extremely successful in many places, it requires reliable internet and tech-savvy patients.

Unlike other health care providers, mental health providers are more likely to be out-of-network with insurance plans as a result of poor reimbursement rates. Many people report being underinsured, so the costs of care become a barrier. It is estimated that nearly one of four psychotherapists do not accept insurance plans, and even fewer psychiatrists are in-network. Paying out-of-pocket for regular health care is a luxury that very few can afford. Financial insecurity can only exacerbate feelings of depression or anxiety about financial matters. In addition, poverty and low income are risk factors for mental illness. This inequity is widening a gap in our communities, disproportionately impacting BIPOC individuals.

Accessing some services, such as residential treatment or substance use disorder (SUD) treatment, can require extra steps for approval and are subject to scrutiny of utilization throughout treatment. At the end of 2020, a monumental lawsuit found one of the nation’s most profitable insurance companies was intentionally and methodically denying coverage for psychiatric services. The investigation revealed denials for care led to people dying as a result of an identified, but untreated mental illness. There is little oversight of mental health parity laws, and the behavior of insurance companies to ensure comparable coverage between medical and mental health services is discriminatory at best. A large part of the access problem is that insurance companies pay so poorly for mental health care that many providers cannot afford to be in-network.

Life as Usual
For many, we just feel the way we feel, and that is normal for us. The symptoms of a mental illness or deterioration of mental health may be something we don’t realize is different. We just get used to the mild but chronic pain in our hip or we learn to cope with dry skin in the winter. Just as easily, we may struggle to get out of bed each morning or we may fear meeting new people, and we assume that is just life as usual. We can tolerate these things for at least a short while, and often we are not aware that effective treatments exist. Studies have shown that upwards of 20%-50% of the population experience symptoms of a mental illness in a given year, but never identify it as such. This can be due to lack of information or educational resources. It can also be cultural or a familial tradition. We may not talk about feeling depressed, we just deal with it. This is different than stigma which is rooted in fear or shame. In these instances, people simply are unaware that things can be different.

Some may be aware of their mental health struggles, but be unaware that help is available. There are a variety of treatment methods for all conditions, ranging from psychotherapy and medication management to transcranial magnetic stimulation (TMS), equestrian programs, and more homeopathic approaches. More than 75% of individuals receiving psychotherapy report improved symptoms. The APA cites numerous studies that have identified brain changes in people with mental illness (including depression, panic disorder, PTSD and other conditions) as a result of undergoing psychotherapy. In most cases, the brain changes resulting from psychotherapy were similar to changes resulting from medication.

50%-70% of primary care visits involve a mental health concern.

We can combat this by normalizing conversations about mental health and feelings so we can gain deeper perspectives about our own. Studies have shown younger generations are more apt to talk about mental health and subsequently find treatment. The APA published a report showing that members of Generation Z were more likely to receive treatment or therapy than any other generation, and nearly twice as likely as Baby Boomers. This is largely due to increased awareness and because these kinds of conversations are more normal for them. When we don’t engage in these conversations, we lack the revelation that others may also feel this way and it can be different for us. 

Stigma and Fear
While we have made significant progress in debunking myths of mental illness that have contributed to stigma, this is still a significant factor that prevents many from talking about mental health and getting treatment. Stigma can lead to discrimination resulting in barriers to care, confusion/frustration, physical harm and worsening symptoms. In some cases, stigma may stem from misunderstanding, misinformation or lack of education in our communities.

While stigma is often seen as an external factor or public force, some create their own self-doubt and shame that is equally as harmful. They may feel that mental illness is a sign of weakness or something they are unable to control. It is important for people not to become isolated and to connect with others who may also be experiencing similar feelings or symptoms. Primary care providers, school counselors and even human resource departments can help connect people with resources and care they need. This may include support groups and even trusted online forums. Learning to accept our condition is a powerful first step in allowing us to access care.

Similar to how younger generations have helped to normalize conversations about mental health, their outward advocacy and openness have made talking about mental health more of a strength than a weakness, as it used to be seen. This has been helped by social media and online apps designed to build resiliency, diagnose and even treat mental illnesses. We can all become advocates and speak out against stigma. This will help support all of those around us and provide a safe conversation if we need support ourselves.

Helping Your Patients
All health care systems and providers have a responsibility to respond to mental health needs of patients. This requires more training in mental health, including identification of symptoms, crisis management, and providing basic care to those experiencing symptoms. This also means awareness of the reasons people don’t access care when they need it. It is estimated that nearly 50%-70% of primary care visits involve a mental health concern, but it is rarely discovered. Some providers hesitate to hear the story because connecting their patients with mental health resources can be difficult. This is a systemic issue–our network of mental health resources is not broken, because it has not yet been built. When we don’t listen to the patient’s story, we erode engagement in care and we miss things.

It is estimated that nearly 70% of people with a chronic health condition also struggle with their mental health. These conditions are almost always treated separately, and the referral follow-through to a mental health provider is about 50%. This drives up costs and decreases the quality of care. For example, one common comorbidity is diabetes and depression. If treated separately, the costs of care could be three times more than if they were treated at the same time. Diet, exercise and insulin are all critical factors for both conditions, but absence of the other’s treatment plan results in different independent recommendations. Failure to effectively care for diabetes can exacerbate depressive symptoms, and increased depression can lead to worse follow-through on medical recommendations for diabetes. We need to treat them together. Local integrated health care models have shown to increase patient follow-through by 52%. In some cases, co-located therapists were able to care for 250% more patients in the integrated setting than in a stand-alone clinic by themselves.

Minnesota offers a Psychiatric Assistance Line (PAL) for any health care provider seeking consultation on a specific case. This free on-demand service is managed by clinical social workers and staffed by board-certified psychiatrists. This helps alleviate numerous access barriers and helps primary care providers treat psychiatric conditions directly in their own care setting.

While this list is not exhaustive or detailed, it helps to summarize the main factors that prevent many from getting mental health treatment when they need it. We can help connect people with service by advocating for parity and fairness in access and by talking about the signs and prevalence of mental illness. This will help to increase awareness and the likelihood that someone will get help when struggling.

Todd Archbold, LSW, MBA, is a licensed social worker and the Chief Executive Officer at PrairieCare.

Sexual Dysfunction and SSRIs:
 
SSRI medications including Lexapro, Zoloft and Prozac are a common first line treatment for depression and anxiety.  SSRI medications are well tolerated and useful, however sexual dysfunction in both men and women is a common concern and a notable reason for discontinuation. Below are some considerations for treatment and management.

• Sexual health should be addressed in psychiatric appointments since dysfunction can be a symptom mental illness.  It often improves as part of healing and is benefitted by treatment including pharmacotherapy.
• The reason why SSRI’s cause dysfunction is still uncertain but does appear to be dose dependent.
• Most common sexual side effect is delayed ejaculation, but other side effects can include anorgasmia, decreased lubrication, decreased libido and impotence.
• At times, Zoloft is prescribed to target premature ejaculation.
• Paroxetine appears to cause the greatest sexual side effects
• Zoloft appears to cause greater side effects than Prozac and Lexapro which appear to be equivalent
• Over 40 percent of patients experiencing sexual dysfunction will consider stopping SSRI medication

 
Treatment options:

• Wait- Often side effects decrease over time.  A few months can make a significant difference
• Reduce the dose- Dose reductions can improve these side effects
• Change dose time- At time the side effect may only occur for a few hours after the dose. Consider moving to a time when it would decrease effect on sexual activity
• Wellbutrin: If a patient is demonstrating response to an SSRI, consider Bupropion to target sexual dysfunction
  • Studies with daily dosing at 150-300 mg of XL demonstrated improvement in 66% of patients
  • As needed dosing of 75 mg appeared to provide benefit to 38% of patients
• PDE5 inhibitors: Sildenafil and tadalafil provide benefit to men with erectile dysfunction. Benefits in women remain unclear
• Saffron- Potential effects of nitric oxide levels in the body appears to benefit sexual interest
  • Studies in men and women demonstrated benefit at 4 weeks with 15 mg twice a day
  • Male erection quality improved
  • Female lubrication and sexual interest improved
  • Limited benefit to orgasm
  • Overall safe with adverse events/side effects similar to placebo

 
PSSD: Post SSRI Sexual Dysfunction can be a concern. While most regain normal sexual health after discontinuation of medication, there is evidence that certain people may have lasting sexual consequences from these meds. The exact number is unknown.  Usually there is gradual improvement, though for some this appears to be permanent consequence. This is noted in case reports in literature.
 
Conclusion: Sex is an important and enjoyable part of life. Depression can impact interest significantly. Frustratingly the medications that treat this condition can also affect sexual functioning at times. This dilemma stresses the need that sexual health should be discussed as a standard part of a mental health appointment.  If not, medication compliance may wane, symptoms may worsen and functioning decline.  Additionally, all patients should be aware of the risk of sexual dysfunction related to these medications and have access to potential viable treatments.

• Corliss, Julie: https://www.health.harvard.edu/womens-health/when-an-ssri-medication-impacts-your-sex-life

• Csoka AB, Bahrick A, Mehtonen OP. Persistent sexual dysfunction after discontinuation of selective serotonin reuptake inhibitors. J Sex Med. 2008 Jan;5(1):227-33. doi: 10.1111/j.1743-6109.2007.00630.x. Erratum in: J Sex Med. 2008 Dec;5(12):2977.. Csoka, A [corrected to Csoka, AB]. PMID: 18173768.

• Jing E, Straw-Wilson K. Sexual dysfunction in selective serotonin reuptake inhibitors (SSRIs) and potential solutions: A narrative literature review. Ment Health Clin. 2016;6(4):191-196. Published 2016 Jun 29. doi:10.9740/mhc.2016.07.191

​-written by Joshua Stein, MD

-written by Joshua Stein, MD
 
The initial steps in managing a variety of anxiety disorders in teenagers is initiation of an SSRI.  Commonly this class of medications can result in symptomatic improvement with initial notable benefits occurring at 6-8 weeks with additional improvement over time.  At times, the medications do not appear to work or are not tolerable.  The following considerations would be appropriate if SSRI’s do not appear to be the correct option.

1. Is the dose high enough? At times, SSRI trials for anxiety do not reach the appropriate dose, out of concern to keep doses minimal. Please consider, if tolerable, reaching the following doses before giving up on a trial.
   1. Zoloft 100 mg
   2. Lexapro 10 mg
   3. Prozac 20 mg
   4. Celexa 40 mg
   5. (Paxil is not indicated in teens/children)
2. If there is a partial, but not full response at the above doses, consider going higher.
3. If higher dosing is not tolerable, consider augmentation.
   1. Buspar 10 BID at times can benefit anxiety.
   2. Wellbutrin XL 150 to 450 mg can be beneficial.
   3. Low dose second generation atypical augmentation can be beneficial especially in OCD
4. Change classes. Consider a cross titration to Cymbalta/Duloxetine.    It carries an FDA indication for GAD in children 12 and up.  A common starting dose is 30mg.  The introduction of an SNRI offers a novel treatment that often provides substantial benefit when SSRI trials fail.
5. Consider symptomatic relief.  At times, as needed or scheduled hydroxyzine, propranolol, gabapentin or rarely a benzodiazepine can offer immediate relief from panic or catalyze long term treatment.
6. Do not ignore the need for therapy. Anxiety of all kinds is often built upon a foundation of automatic negatives, catastrophic ideations and other problematic misconceptions.   Therapy requires effort, but also leads to long term success that can be generalized. GAD, OCD and social anxiety disorder require therapy, commonly CBT.
7. Call PAL.  We love hearing from, and brainstorming, with other physicians and providers.  

Q: Have you experienced very much hypertension with Pristiq?

• A: All SNRIs can cause hypertension. According to this meta-analysis, “It was established that SSRIs did not affect blood pressure, while SNRIs led to a modest increase in SBP and DBP with statistical significance compared with SSRIs.” In my clinical experience the risk increases with dosing, especially Venlafaxine, which does not start having noradrenergic effects until 150mg. Blood pressure should be monitored routinely when utilizing SNRIs.

Q: Do you recommend Wellbutrin as monotherapy ever? I have only used it in combination, but have several parents who are on it in monotherapy and inquire about it.

• A: Yes, Wellbutrin is a reasonable monotherapy for major depression. However, as this is not an FDA-approved medication for pediatric population, it is typically not a first line therapy, and its use is off-label. It is a reasonable choice after failure of two SSRIs and an SNRI. I have found Wellbutrin to be a good option for those with neurovegetative depression, with anergia, low motivation, and psychomotor slowing. Oftentimes 150mg of Wellbutrin XL will be a therapeutic dose, though I often advance to 300mg if no improvement after four weeks. I often reserve the 450mg dose for those who experience improvement at 300mg, but stops working after a time.
• For augmentation of SSRI or SNRI, I typically start Wellbutrin XL 150mg daily. If you happen to know your patient is a slow metabolizer of Wellbutrin, starting at a lower dose is indicated. I would continue to advance the dose to 300mg daily for augmentation if not benefit after four weeks.

Q: Is dose of Wellbutrin to restore sexual dysfunction the same as normal augmenting dose?

• A: From brief literature review, it appears the benefit of Wellbutrin with SSRI induced sexual dysfunction typically comes fairly quickly (within 2 weeks) at starting doses (100mg of SR or 150mg of XL).

Q: Are there any long term effects for using hydroxyzine long term?

• A: It appears long term use of Benadryl is correlated to development of dementia, so I would assume the same applies to hydroxyzine. The study involved patients >65. Regardless, in child psychiatry we typically use hydroxyzine for a PRN, and use SSRIs and SRNIs as the primary medication for anxiety.

Q: Which benzo do you use for flight anxiety?

• A: Typically Ativan. I always recommend taking a “test dose” before the flight in case of adverse reaction (disinhibition), which is better to see at home than at 30,000 feet. 

 - Dr. Adam Klapperich

While the answer to the riddle “What lies in a bed but never sleeps” is actually “A River,” many parents may assume it is their eight-year-old or teenager. Despite it being a necessary and standard part of existence, getting a good night’s sleep is increasingly evasive. In fact, the 2020 sleep aid global market reached 78.7 billion dollars and is expected to reach 162.5 billion dollars by 2030, according to ResearchandMarkets newswire. There are numerous assumed potential causes, including increased screen time, sleep apnea, and shift work, but overall, sleep concerns are becoming more pertinent and a regular patient concern. Notably, sleep changes are ubiquitous across the DSM-5. 
The goal of this post is to review pharmacologic strategies in children, both on and off label, and some common issues each may have.

Sleep hygiene seems to be mentioned often, but rarely enforced by parents. This practice includes the implementation of standard bedtimes, absence of caffeine, a relaxed bedroom and primarily the removal of screens. While this article does not go in depth into these practices, it is important for any primary care provider to familiarize themselves with screening and education on sleep hygiene. Additionally, screening for sleep apnea in any child with attentional issues is important as well.

The ever present melatonin has become so commonplace that it now occupies an entire section in most pharmacies. In children, it is FDA approved and there is clear evidence it improves sleep initiation, duration and quality; however the risks remain unknown. As melatonin is a hormone, long term use appears to disrupt endogenous production, especially when used at high doses. There appears to be evidence that 0.5mg is appropriate, while higher doses are used most often when chasing waning benefit. It is recommended to only be used short term or as needed. Most parents report loss of effectiveness in their children after regular use. At times, subsequent insomnia may occur as well. It can be helpful both to initiate sleep and to promote a healthier circadian rhythm. For patient centered information consider the mayo clinic website: https://www.mayoclinic.org/healthy-lifestyle/adult-health/expert-answers/melatonin-side-effects/faq-20057874

Clonidine is also commonly used in children for sleep initiation. Often 0.1-0.2 mg given at bedtime promotes rapid sleep initiation. This can often help benefit sleep when rebound hyperactivity occurs as a stimulant wears off. While it does not carry FDA approval, it does meet community standard for care and is generally quite safe. One drawback is that it wears off after 4-6 hours, potentially not benefiting those with middle insomnia or early waking. However, given the short half-life, a second dose can be used. Please note that overdoses can be lethal due to respiratory depression. This medication must be locked away from small children.

Trazodone is so sedating that it often cannot be prescribed when needed as an anti-depressant. On the other hand, it is inexpensive and benefits middle waking due to long duration of action. Given this, it has found a place as a commonly used sleep aid. Community standard initial dosing is commonly 25 mg, though at times patients may find up to 150 mg beneficial. Notably, in patients under 25yo, a reminder that it is an anti-depressant and carries the black box warning regarding increased suicidal ideation is important. It is certainly a serotonergic agent. A reminder to discuss serotonin syndrome in patients on additional serotonergic meds including but not limited to SSRI’s, SNRI’s and Triptans. Additionally, in males there is a rare but present risk of priapism. It is necessary to discuss with the patient and their parents before prescribing. Finally, trazodone can cause vivid dreams. In patients with nightmares this can be unpleasant if not unbearable. If prescribing trazodone is commonplace in your practice, consider reviewing this short Healthline article to review its side effects:  https://www.healthline.com/health/sleep/trazodone-for-sleep#risks

In certain depressed patients, initiation of Remeron, especially at low doses, may complement their primary treatment. Its boost of appetite and benefit to sleep initiation and maintenance is strikingly beneficial. The rapid onset of these side effects are due to histamine 1 antagonism. Often its long term use is not tolerated due to weight gain, but in the short term, can jump start treatment. Common starting dose of 7.5 mg to 15 mg is appropriate. A reminder that, similar to trazodone, this medication carries the black box warning related to increased suicidal ideation in persons younger than 25 years old.

Benadryl, Atarax, Hydroxyzine, Doxylamine Succinate are off label anti-histamines often used in children to promote sleep. Commonly these are used as needed rather than on a regular basis. While sleep latency greatly improves, there is question if the sleep is in fact restorative, with numerous studies noting a decrease in REM time when used. Often there is AM grogginess related to this class that may undermine daytime learning, especially in the morning. Given this concern there is a greater consideration to use only as needed rather than on a regular basis.  Doses 25 mg or less often avoid frustrating side effects related to anti-histamine use. Approximately ten percent of the childhood population has a paradoxical energizing. It would be best to test dose prior to any long distance overnight flights.

In adults, the use of benzodiazepines and its sibling medications Zolpidem, lunesta etc have found a place in daily dosing and as needed. Currently, there is not an FDA indication in children under age 18. There are often only rare cases where these medications are considered. Notably, there is street value with these medications and if prescribed, please review DEA considerations with the patient.

Finally, Seroquel and other atypical anti-psychotics clearly can be sedating, and at times are prescribed as standalone sleep aids. This practice should be avoided due to risks of weight gain, odd/abnormal movements, pre-diabetes and lipid derangement. However, if a child requires an atypical antipsychotic due to a primary mental health condition, such as ASD agitation, it may be appropriate to consider Seroquel due to its sedating nature if insomnia is present. As always, the lowest effective dose should be considered.

This list is clearly not exhaustive but hopefully offers some guidance regarding initial steps in the treatment of insomnia in children and teens. A second stanza of the previously mentioned River Riddle is “what runs but never walks?” Perhaps use this as a reminder that if a child is running bedtime and refusing to turn off screens, the most potent, safe and necessary treatment is family therapy rather than any of the meds listed above.

Joshua Stein MD

For further information: https://link.springer.com/article/10.1007/s40675-016-0036-1#Sec3

​“You might’ve noticed I’ve got a slight weight problem.  I went to this doctor.  Well, he told me I swallowed a lot of aggression…along with a lot of pizzas.”
 
You might recognize this quote from the 1981 movie Stripes. I sometimes think of Dewey Oxberger, played by John Candy, when prescribing psychotropic medications that can cause weight gain. We all know the second generation antipsychotics can lead to our patients swallowing a lot of pizzas. However, things are less clear regarding antidepressant medications. We know that risk of weight gain can be a major factor in a teen’s decision to start an antidepressant medication, and weight gain can lead to noncompliance. The aim of this article is to review the risk of weight gain with antidepressants commonly prescribed in the primary care setting.

Data points to a definite risk of mild weight gain with “long term” treatment with SSRI medication (meaning six months or more). This is less likely in treatment of six months or less. When weight gain does occur with short term SSRI treatment, the rates are comparable with placebo. This does not apply to Paroxetine (Paxil), which is more likely to cause weight gain than the other SSRIs in short or long term treatment.
In a 6-month placebo controlled trial (N=284) paroxetine showed significant weight gain (increase 7% or greater body weight) in 25.5% of patients. Sertraline (Zoloft) showed 4.2% significant weight gain and fluoxetine (Prozac), which showed 6.8%. Fluoxetine may show a transient weight loss in the initial phase of treatment.

There is limited data indicating citalopram (Celexa) and escitalopram (Lexapro) may cause higher rate of weight gain than sertraline and fluoxetine, though this is likely not significant.
Mirtazapine is well known to cause weight gain in the short and long term. Often this is prescribed to stimulate appetite. Weight gain is related to its histamine H1 and serotonin 2C receptor activity. Weight gain is often seen in the first four weeks of treatment.

As far as SNRI medication, Venlafaxine (Effexor) has been shown less likely than SSRI to cause weight gain. In a 52-week open-label study, duloxetine (Cymbalta) treated patients had a mean weight gain of 1.1 kg at endpoint. Duloxetine-treated patients experienced weight loss after short-term treatment, followed by modest weight gain on longer-term treatment.
​
Overall, antidepressants, aside from paroxetine and mirtazapine, and tricyclics, appear to have minimal large scale effects on body weight. Fluoxetine appears to be the SSRI least likely to cause weight gain.