Individual therapy, or sometimes called psychotherapy, is a process through which clients work one-on-one with a trained therapist in a safe, caring, and confidential environment. This is done in order to explore the client’s feelings, beliefs, or behaviors; work through challenging or influential memories, identify aspects of their lives that they would like to change, better understand themselves and others, and set personal goals, and work toward desired change.
The types of individual psychotherapy commonly practiced include cognitive behavioral therapy, supportive psychotherapy, interpersonal therapy, and psychodynamic psychotherapy. Furthermore, there is growing evidence that different types of psychotherapy can be conducted successfully via telepsychiatry; however, certain procedures should be followed to facilitate successful outcomes and a pleasant experience.
Scheduling and visit times and treatment modality should mimic an office visit. In line with this, patients are encouraged to use a large screen monitor while setting a reasonable distance from the monitor and using a microphone or linking their monitor to their phone rather than keep their laptop on their lap. At the same time, the patients are encouraged to have high-speed internet, good lighting and an encrypted platform which mimics Skype rather than split screen monitor.
Cognitive Behavioral Therapy
Cognitive behavioral therapy (CBT) is a comparatively new therapy that can help the patients manage their problems by changing the way they think and behave. In contrast to other forms of psychotherapy, CBT is more focused on the present, more problem-solving oriented, more structured, interactive and cost effective. Patients often report improvement in symptoms and destructive behaviors within a few sessions, and develop skills which will help them manage symptoms in the future or prevent recurrence of symptoms.
CBT can be used to treat many conditions including anxiety, depression, PTSD, OCD, phobias, bulimia, obesity, smoking cessation, schizophrenia and many more. Unlike psychodynamic psychotherapy, CBT is useful for acute exacerbation of symptoms such as those related to anxiety and depression.
Multiple studies have demonstrated the effectiveness of CBT, either as a solo therapy or in conjunction with psychiatric medicine. PET scan and researches showed CBT as well as supportive therapy demonstrated similar changes to the brain of those taking anti-depressant medication. It is accepted that for many conditions, CBT combined with psychiatric medication, works better than medication alone, and the use of CBT can help individuals discontinue their medication.
One important aspect of CBT is to help patients change their distorted and behavior in order to have an improvement in their mood and functioning. This involves the following process: (a) identifying the trigger, (b) identifying the automatic thoughts, (c) identifying the consequences of negative behavior and mood, and (d) replacing the automatic thoughts with more reasonable ones.
At each therapy session, the patients are guided in developing an “action plan” or “homework”, implementing solutions to the identified triggers or to making changes in their thinking and behavior. This process gets the patients actively involved in their own treatment wherein they begin to recognize that the way to get better is to change the way they think and what they do on a daily basis.
Marriage or relationship counseling, also called couples or marital therapy, is a type of psychotherapy that helps couples of all types recognize and resolve conflicts and improve their relationships. Through marriage counseling, the patients can make thoughtful decisions about rebuilding their relationship or going separate ways.
Relationship therapy is most effective when both parties are screened for symptoms of mental illness including depression, anxiety, chronic irritability, insomnia, and PTSD (post-traumatic stress disorder). This is because people who are depressed tend to displace anger, blame others, feel suspicious or paranoid, experience inappropriate guilt, and use more immature defense mechanisms. Treating psychiatric symptoms enables couples to engage in the therapy and achieve more productive results.
The principle of relationship therapy is that a couple, who was once happy together, should be able to able to regain their happiness together. Common causes of therapy failure include the following: one or both parties have already decided they want to be out of the relationship, and or untreated mental illness in one or both parties. Sometimes a useful therapy outcome would be people grow apart and de-guilting, de-blaming and ensuring a respectful partition with minimal damage to any children.
The endocrine system consists of glands which secrete hormones that act like messengers carrying chemicals signals and communicating almost all functions in the body. However, their role in regulating the body’s mental health is generally neglected in the field of psychiatry even though it has long been understood that they are one of the most important regulators of mood, anxiety, energy, sleep, attention, concentration.
Many hormones, regulated by the hypothalamus and secreted by the pituitary gland, can affect mood and behavior. The most common example is thyroid dysfunction because patients with mild deviations in thyroid function can exhibit changes in mood, energy, and behavior. Even people with normal thyroid function wherein levels are not so abnormal enough to cause psychosis, cardiac dysfunction or death, may still have deviated enough to cause mood disturbance.
The sex hormones such as estrogen, progesterone, and testosterone can contribute to psychiatric disturbance, especially if they are imbalanced. For example, the contraceptive pill, that has an increased level of the hormone, is noted to cause anxiety and depression. Patients with polycystic ovarian syndrome and endometriosis who usually have hormonal imbalances often exhibit symptoms of depression and anxiety. Low testosterone levels and growth hormone levels in older men have been associated with higher suicide rates.
Therefore, the purpose of the endocrine evaluation is to test for endocrine causes of psychiatric symptoms, prior to prescribing medication in patients with other clinical signs or history of endocrine disturbance, severe symptoms, and previous treatment failure.
Family Therapy is a type of psychological counseling or psychotherapy that helps family members improve communication and resolve conflicts. Most families can benefit from this therapy when they are faced with psychological challenges proven to be unhealthy for their relationship. The aim of the therapy is to have better communication among and between its family members; thereby hoping that there will be improvement in their functioning. The understanding and support among members will be enhanced so that the family, as a unit, will be able to develop creative and appropriate problem-solving strategies and strengthen their coping skills.
Usually, Family Therapy combines techniques from supportive, interpersonal, and behavioral therapy. Behavior therapy and interpersonal therapy are similar to individual therapy but this will rely heavily on the problems that the patients will present. The combination of techniques aims to help each family member understand what the other member is experiencing, causes for behavior, accountability, consequences of behaviors, and effect of behavior on others and on interpersonal relationships. At the same time, Family therapy involves addressing communication skills and destructive communication techniques, and behaviors such as domestic violence, demeaning, depriving, name calling, stonewalling, control games and manipulation behaviors.
Family therapy via telepsychiatry is also an option that a patient can take. Research showed high satisfaction level among patients, psychiatrists and other professionals cared for via telepsychiatry. This process can improve the family’s access to a therapy since barriers to seeking help will be reduced. Telepsychiatry can also enhance feelings of safety, security, and privacy for the patients and their family members. This approach is especially useful when one or more family member travel frequently, when there is difficulty scheduling all together in the office, or when adult children live in different locations.
Medication management therapy (MTM) is a treatment system used by doctors and pharmacists to ensure that patients are receiving optimal therapeutic outcomes for prescribing medications that they may be taking.
Marijuana, cocaine, heroin, nicotine or tobacco are all natural substances, while beta blockers, aspirin, statins, synthetic insulin (all of which prolong lives) are all pharmaceuticals. This highlights the fact that everything natural is not always good and everything pharmacological is not always bad.
Effective medication management involves thorough evaluation of symptoms, causality, reasons for past treatment failure, evidence-based medicine combined with individual evaluation, monitoring for drug-drug or drug-food interactions, and genetic testing if indicated..
Effective pharmacological management of psychiatric symptoms involves optimizing symptom reduction. At the same time, this management minimizing side effects through careful monitoring, selecting the correct medication and utilizing poly-pharmacy, if indicated.
Genetics is one of the most important factors regarding how well patients respond to medication and whether they will have side effects. Before prescribing an antidepressant or an antipsychotic, psychiatrists are trained to ask whether any of their family members take medications in the same class, and which medications are responsive to them. If for instance, they have good response to Zoloft and became more anxious with Lexapro, it is more likely that the patients will respond to Zoloft and feel anxious with Lexapro.
Genetic Testing or Pharmacogenomics is the process at studying the patients’ DNA and based on their DNA sequences, predicting which medications will more likely have a good response or which one will produce side effects to them. The algorithms are created by going through the DNA sequences of other patients with similar DNA sequences and receptor structure, analyzing the data regarding their response to particular medications, and which of them will elicit side effects too. This information is used to predict which medications they will respond well and which medications they will be at risk of having an adverse reactions.
It is important to note that response to medication is multifactorial, and genetic testing is useful in giving more information although it is not 100% accurate. There is still a need to rely on clinical presentation, history, and response to past treatments as the most important factors in decision making. Indications for genetic testing include patients’ failed trials from previous medication, patients indecisiveness on what medication they wish to start, or if they simply just want the information.
Psychodynamic or Psychoanalytic Psychotherapy are based on analytical psychology and psychoanalysis theories and practices. This therapy helps the patients understand and change complex, lifelong and often unconscious emotional and relationship problems thereby reducing symptoms and alleviating distress. Unlike other therapies, it is directed towards developing the emotions and having a deep-seated change in personality.
The technique is to identify through transference, countertransference, talk therapy, exploration, confrontation and interpretation unconscious thoughts and desires. It is believed that unconscious thoughts, desires, fears, beliefs, especially repressed emotions such as anger, guilt and mistrust can lead to ineffective use of defenses causing thoughts and behaviors which can be destructive sometimes and can sabotage personal well-being and interpersonal relationships. Identifying the origin of these thoughts and behaviors in a supportive space can help alleviate distress and change the thoughts and behavior.
Patients who experience a loss of meaning in their lives or who are seeking a greater sense of fulfilment may be helped by psychoanalytic or psychodynamic psychotherapy even if they do not have what would normally be regarded as serious mental health problems. Sometimes patients seek help for specific reasons such as eating disorders, psychosomatic conditions, obsessional behavior, or phobic anxieties. At other times, help is sought because of more general underlying feelings of depression or anxiety, difficulties in concentrating, dissatisfaction in work or inability to form satisfactory relationships. It may benefit adults, children, and adolescents. For children, this can help those who have emotional and behavioral difficulties which are evident at home or school such personality problems, depression, learning difficulties, school phobias, eating or sleeping disorders.
Psychoanalytic or psychodynamic psychotherapy provides an effective treatment for a range of psychological disorders, both as a treatment in its own right and as an adjunct to other forms of treatment. It can contribute significantly to patients’ mental and physical health, to their sense of well-being and to their ability to manage their lives more effectively.
Medical Casualty Screening
The brain is an organ just like the heart, lungs, liver, and kidneys. All the organs in the body are interconnected by blood, nervous system, hormones, and other connective systems. Damage to the brain, caused by medical illness, can lead to impairment in brain functioning. Therefore, it is important to identify the underlying cause of psychiatric symptoms and initiate treatment when prescribing psychiatric treatment.
Common Medical Causes of Psychiatric Symptoms include:
- Cardiac: About 50% of patients experience depression after myocardial infraction or heart attack. The cause is unknown but possibly linked to beta blocker therapy or sympathetic dysregulation.
- Endocrine: The most common examples include thyroid dysfunction and pituitary dysfunction, polycystic ovaries and sex hormone dysregulation.
- Hematological: Anemia can cause psychiatric symptoms.
- Infectious: HIV can penetrate the blood-brain barrier and can cause psychiatric disturbance if anti-retroviral therapy is not initiated.
- Medication-induced: Beta blockers can cause depression if not monitored. Estrogen-dominant contraceptive pills are another common cause of medication-induced mood disturbance.
- Nutritional: Multiple nutritional deficiencies can cause psychiatric disturbance (see the nutritional screening section).
- Obesity: This can cause secondary depression due to sleep apnea and overproduction of estrogen in fat cells, causing mood disturbance.
- Respiratory: Obstructive sleep apnea is a common cause of depression and anxiety, as well as cognitive disturbance. Sometimes symptoms resolve spontaneously with treatment of sleep apnea.
- Substance abuse treatment: Cocaine and amphetamine withdrawal can cause suicidal depression. Nicotine and marijuana usage has also been linked to depression and anxiety. A supportive approach is required to managing symptoms and helping individuals detox.
- Trauma: Head trauma can cause psychiatric and cognitive disturbance.
- Tumor: Brain tumors and other cancers can cause mood disturbance by many mechanisms. Direct brain metastases, other related illness and treatment can cause stress and anxiety as well. Many types of chemotherapy inhibit growth hormone which causes depression.
It is believed that collaboration with your primary care doctor is important because this can minimize underlying medical causes which could exacerbate psychiatric symptoms if possible.
Even the Neanderthals understood there was a causal relationship between nutritional deficiency and psychiatric disturbance yet this is a factor which is still very much neglected in modern day society. As people get older, they become more sensitive to nutritional deficiencies, as their bodies become less efficient at processing nutrients.
Mechanisms of nutritional deficiencies and neurotransmitters vary as vitamins and minerals are required for multiple purposes which includes the following: neurogenesis or production of nerve cells, protection of the myelin sheath which is the protective coating of nerve cells, production of neurotransmitters such as serotonin and dopamine, production of oligodendrocytes which are the immune cells in the brain, and hormone synthesis. At the same time, many neurotransmitters in the brain are made up of amino acids such as tyrosine and tryptophan and protein-energy malnutrition is linked to depression.
Children with chronic protein-energy or global malnutrition such as Kwashiorkor and marasmus appear depressed and present with a cognitive disorder and delayed milestones. These conditions are noted to have long-term adverse effects on the intellectual capacity of the child. Furthermore, Iron deficiency in children can lead to permanent brain damage. This gives an indication of how important nutrition is to our brain development and overall health. Although most Americans do not appear malnourished, their diet tends to be high in fat, simple carbohydrates and sugar but low in essential nutrients. Although most patients do not need more than a balanced diet with minimal supplementation, some do have undiagnosed deficiencies which can exacerbate their symptoms. Some psychiatric medications can induce p450 enzymes and compete for metabolism of certain vitamins and minerals.
Well-known examples of nutritional deficiency as a causality of the psychiatric and cognitive disorder include Iron deficiency anemia as well as deficiencies in zinc, calcium, iodine, magnesium, omega-3 fatty acids, vitamins B1, B12, C, and B6 (folate is required for the development of the neural tube and deficiency during pregnancy causes spina bifida):
- Iron deficiency anemia causes depression and anxiety.
- Zinc deficiency has been associated with anxiety and irritability.
- Deficiency of calcium and iodine can lead to mood disturbance.
- Magnesium deficiency has been associated with depression.
- Deficiency in omega 3,6,9 supplementation can help symptoms of depression.
- Vitamin B1 deficiency causes Korsakoffs dementia in alcoholics.
- Vitamin B6 deficiency in pregnancy causes fetal spina bifida.
- Vitamin B12 deficiency in pernicious anemia causes psychosis and depression.
- Vitamin C causes scurvy which can result in psychiatric disturbance.
The patients’ nutritional evaluation will involve as simple screen for obvious deficiencies, such as iron and calcium, however referral to a nutritionist is optional.
Heavy Metal Screening
Heavy Metals include iron, lead, mercury and many others. They are found in the air, soil, water and almost all products that the patients use. Heavy metals are essential for the patients’ survival but overexposure can lead to toxicity causing psychiatric, neurological and physical symptoms and even death.
Most patients can tolerate fair amount of heavy metal. Exposure to heavy metals can be eliminated in feces, urine, and sweat; however, excessive exposure from an unknown source or errors of metabolism can lead to psychiatric and cognitive disturbance.
Majority of these heavy metals like aluminum and mercury cross the blood-brain barrier and enter the brain tissues. Furthermore, these heavy metals also block certain nutrients by competing in the binding sites on enzymes and proteins.
Acute exposure may present with the classical symptoms of toxicity while in low level exposure, the presentation of symptoms is more of insidious in nature. It is worth screening individuals who have a history of possible exposure and who are exhibiting unexplained symptoms.
Common sources of exposure include:
- Lead: Hair dye, mascara, tobacco and pottery paint can cause amnesia, mood swings, irritability and depression, explosive anger and attention deficit disorder.
- Mercury: Seafood such as tuna fish, dental fillings and laxatives can cause mood swings, depression, cognitive problems and psychosis.
- Aluminum: This can be found in cookware, deodorants, artificial food coloring and many other sources and its toxicity can lead to neurocognitive disturbance and tics.
- Arsenic: Compounds containing this are found in insecticides, herbicides, and fungicides for fruits and vegetables can increase crop yield but its toxicity can cause headaches, confusion, convulsions and night blindness.
- Copper: This can be found in cookware, hard water, hot tubs, swimming pools, oysters, chocolate and copper IUD. Overexposure can cause fatigue, insomnia, detachment and depression.