Merry Christmas (2013)!

A Merry Merry Christmas to all!

"My Son is Mentally Ill", So Listen Up

I will like to share this article on a mother's struggle with her son's mental illness. Click here.

Today, many sufferers with psychiatric conditions continue to suffer in silence due to the misconceptions and stigma surrounding mental illnesses. Seeking early treatment will help to better the prognosis and outcomes of psychological conditions. Remember, mental illnesses are just like any other medical conditions.

How Common is Depression?

http://www.washingtonpost.com/blogs/worldviews/wp/2013/11/07/a-stunning-map-of-depression-rates-around-the-world/

This picture shows the rates of depression worldwide. The redder the colour, the higher the rates of depression in that country.

This picture is based on a study published recently in the journal PLOS Medicine. In this study, they found depression to be the second leading cause of disability globally, with slightly more than 4 percent of the world diagnosed with it.

However, due to stigmatisation and taboo, many with depression still do not step forward for treatment and suffer silently. If you or your family suffer from symptoms of depression, seek treatment now. Remember, early intervention brings about the best outcome.

Happy Deepavali

The staff at Dr BL Lim Centre For Psychological Wellness will like to wish all a Happy Deepavali!

Diwali Ki Light
Karay Sab Ko Delight
Pakro Masti Ki Flight Aur
Dhoom Machao All Night
Happy Deepavali 2013!!! 

Side Effects of Antidepressants

Antidepressants do have side effects and if you are prescribed these medications, make sure your doctor discuss them with you. I will discuss the side effects of some of the usual classes of antidepressants used. It is also interesting to note that even sugar pills can cause side effects, read more about it here.

1. Selective Serotonin Reuptake Inhibitors (SSRI)

These include Escitalopram, Setraline and Fluoxetine.

SSRIs are probably the most commonly prescribed class of antidepressants. SSRIs are safe and used in various age groups from children to elderlies. They are not only given in clinical depression (description of clinical depression click here) but also in other disorders such as anxiety disorders and even in anger management.

Common side effects of SSRIs include:

- Tummy discomfort
- Nausea
- Headaches
- Drowsiness
- Anxiety

These side effects are usually transient and are worst in the first 4-5 days. In the long term, some people may experience gaining weight or sexual dysfunction with SSRIs. However these are reversible once the medication is stopped.

2. Selective Serotonin Norepinephrine Reuptake Inhibitor (SNRI)

These include Duloxetine and Venlafaxine.

SNRIs are newer antidepressants. They have the advantage of also working on the norepinephric neurotransmitters in the brain as well. Their side effects profile are similar to SSRIs but they are more likely to cause nausea, dry mouth and excessive perspiration. Venlafaxine may increase blood pressure and your blood pressure should be monitored if you are given this medication by your doctor.

3. Tricyclics Antidepressants (TCAs)

This is an older class of medication and include Amitriptylline and Clomipramine.

They are more likely to cause side effects like:

- somnolence
- drowsiness
- dry mouth
- constipation
- difficulty passing urine
- blurred vision
-weight gain

TCAs can be dangerous in overdose as they can cause heart irregularities. For this reason, they are seldom used these days.

REMEMBER: In any medical treatment, your doctor will consider and discuss with you the benefits and risks of the treatment as well as any alternatives available. Whilst antidepressants can cause side effects, they have been shown irrevocably to save lives and prevent suicide. During the initial phase of treatment, your doctor will monitor you closely for any side effects and to make any necessary adjustments to the dosage or to change the medication altogether.

Studies have also shown that only 40% of patients with side effects will tell their doctors. So if you have side effects with medication bothering you, do let your doctor know so that he can better tailor his treatment for you!

Happy Hari Raya Haji

To all my Muslim friends and colleagues, a very happy Hair Raya Haji!

Eating Disorders In Singapore

1. What are the types of Eating Disorder?

Eating Disorders are a group of psychological conditions where sufferers have severe difficulties in their eating habits and behaviour. They include Anorexia Nervosa, Bulimia Nervosa, Binge-eating disorder and other types of eating disorder. About 1 in 15 females may be at risk of a ED but only a small proportion of these sufferers sought help with a psychiatric clinic in Singapore. Some patients seek help for other problems like depression but have ED as a coexisting problem which was picked up during our assessment.

2. Who suffers from certain EDs more? What is the demographic like and why?

In Singapore, young teenage school-going females are most likely to suffer from EDs like Anorexia. ED especially Anorexia can be perceived as a cultural phenomenon. In the past, we do not value thinness as much in our society. In fact, obesity was seen as a sign of wealth. However, as we become rapidly westernised and bombarded by the influence of western media, thinness and the emaciated look in females became idealised. Young girls are particularly vulnerable to these influences and they face more peer pressure from their friends in school and their social circles where everyone is trying to achieve the thin look. 

3. Is the demographic changing? Any reasons for this change?

Although there are no recent local data to support this, from my clinical experience, more males are starting to suffer from ED. This is due to the fixation on masculinity in males these days, again influenced by western media. In male ED, the fixation is often on muscle definition and exercising instead of the obsession on thinness.

There are also an increase in the cases of orthorexia nervosa, a less common type of eating disorder where the individual is obsessed about eating "healthy" food and about exercising. This is again in contrast to Anorexia where the individual is pursuing thinness. Orthorexia can nevertheless lead to the same consequences as Anorexia if the individual eliminates too many types of food from his or her diet and ends up not eating and emaciated.

4. What are the main causes of ED in Singapore and do the causes differ across gender, cultural or racial lines?

The exact causes of ED is unknown and is likely to be multifactorial. There is likely to be a genetic link as it can run in the family. Neurotransmitters (brain chemicals) like serotonin have been implicated. Many ED patients also have psychological problems such as low self esteem, impulsive or perfectionistic personalities and troubled relationship. Social issues such as media influences and peer pressure to look thin also play a part in tipping a person over into ED.

5. What do you think of the rise in ED cases? How representative do you think the numbers of treated patients are of the actual group?

I believe many cases are not still not identified and treated. We are also not catching them early enough and they surface only when the youth is in a serious stage. In fact, even for anorexia which is the most well recognised ED, patients are often already in a very bad physical state when they first see a doctor. Patients with other ED like binge eating disorder may not even seek help at all as their family and friends may often just see their behaviour as gluttony. There is also a stigma to seeking treatment for psychiatric conditions which prevents people from seek help.

6. What are the most obvious signs that someone needs help - and how can loved ones intervene?

Early signs of ED are often hard to pick up for parents. If a parent noticed that their teenager is always preoccupied with being fat when they are not, are secretly vomiting their food out or having menstrual irregularities they should raise the red flag. Other symptoms that may be obvious are overexercising and using laxatives to control weight. As ED particularly Anorexia has high mortality (death) rate, if parents are concerned, it is best that they seek a consultation with a psychiatrist to check so that treatments can be started early.

7. How should one seek help?

Help is readily available. One can just call up our psychiatric clinics 64796456 to make an appointment for an assessment. 

Those wishing to seek help from our restructured hospital, can call the SGH Eating Disorder Unit at 6326 6697.

ADHD in Children: FAQ Part 2

- How is it diagnosed in children?

The diagnosis of ADHD is made with careful clinical assessment by a trained specialist, usually a psychiatrist. A detailed history from the parents and teachers is taken to assess for ADHD symptoms and during the interviews, the child is observed for ADHD behaviour. Clinical scales may be used to determine the severity of ADHD and to assess improvement in subsequent follow-ups after treatment.

- In your opinion, do you think ADHD is over- or under-diagnosed in Singapore ? Why?

ADHD continues to be under-diagnosed in Singapore. Even though, parents and teachers are more likely to pick up the symptoms of ADHD and know that their kids have difficulties, many continue not to to bring their children to psychiatrists for formal diagnosis and  treatment. Parents are fearful that their children will be stigmatised and they have misconceptions about the illness and medication. They are unaware that without treatment, the consequences of ADHD is debilitating and affects the child negatively in the long term.  

- Why is it easy for ADHD (especially the milder cases) to go unnoticed? How common is it for parents/ teachers to think that the child is simply "naughty"? How to tell when the child's "naughtiness" could be ADHD?

Parents and teachers often think that children with milder forms of ADHD as being naughty and lazy. This is especially so when the symptoms are predominantly in the attention deficit domain. As these children do not display hyperactive behaviour and are often well behaved in school, adults may not realised that they are having problems concentrating in class and are not fulfilling their potential academically.

It is very common for ADHD symptoms to be misconstrued as "bad" or "naughty" behaviour by parents and teachers alike. Even after diagnosis, parents and teachers often require plenty of education and convincing before realising that the symptoms are not wilful or deliberate in nature. It is normal for kids to have naughty behaviour here and there. However, ADHD symptoms are pervasive, meaning that the child is constantly inattentive, hyperactive and impulsive in most situations. Unlike in naughty behaviour, these symptoms lead to long term difficulties academically in school and in other aspects of the child's life.

- How is ADHD treated? How safe is it for children to take medication for ADHD long-term?

ADHD can be treated with medications. Currently, two main types of medications are available, stimulants and norepinephrine uptake inhibitors. They help ADHD by  increasing the level of neurotransmitters (chemical messengers) in the brain called dopamine and norepinephrine. Behavioural modifications and therapy are also useful treatments and are always given alongside medications.

Latest studies showed that medications are safe and effective for long term ADHD treatment when taken under the supervision of a psychiatrist and earlier fear of untoward heart problems are unfounded. However when under treatment, the psychiatrist will continue to monitor for any possible side effects that may occur and will make the necessary adjustments when needed.

- How can parents of ADHD children cope and what can they do to help their child?

First and foremost, parents will need to be educated about that ADHD  is not unlike any other medical problems and ADHD children are not lazy, naughty or being wilful. As such, what parents need to do is not be punitive but to approach the symptoms with patience and compassion and to assist the child with managing his or her symptoms. Parents should consult their child's psychiatrist in learning about the specific approaches they can adopt. These will usually include setting up firm and consistent boundaries and routines for the child, rewarding and encouraging positive behaviour and meting out the appropriate consequences for bad behaviour. Adjustment to communication styles are important. Parents need to catch their child's attention before speaking to them rather than just yelling at them. Use as little words as possible as the ADHD child has poor attentional span and will not be able to follow long instructions.

ADHD in Children: FAQ Part 1

These are some questions about ADHD readers posted to me. Hope they are of help to both parents and children with ADHD.

- Typically at what age does ADHD surfaces?

Parents will notice ADHD symptoms in their children before the age of 7. Typically, the symptoms become more pronounced once the children go to preschool where they are required to sit through lessons especially when compared to other kids.

- In Singapore, what age is ADHD diagnosed?

In Singapore, ADHD is only diagnosed when the children are at least 6 years of age. Typically most children with ADHD are picked up in lower primary school from  7 years old to 9 years old.

- How do ADHD children behave and what is it about this disorder that causes them to behave in this way?

ADHD children have two main types of symptoms and behaviour, i.e. the inattentive and hyperactive-impulsive types. Most have both types of symptoms.

When kids have Inattentive type symptoms, they have difficulty in paying attention, they make careless mistakes in school,  have inability to stay in or to complete tasks and activities,  appear not listening to and not follow instructions, they are disorganised and lose things like toys and stationaries easily and are distractible and forgetful. 

Hyperactive-impulsive type symptoms include being fidgety, restless and have difficulty staying seated, excessive running and climbing, being always on the "go" and inability to play quietly, talking excessively and blurting out answers before hearing full questions and tendency to disrupt or interrupt activities like classes and will cut queues.

It is however pertinent to note that ADHD children can concentrate if they find something interesting but their symptoms are particularly pronounced when they are bored.

The causes of ADHD are not fully understood. We know that ADHD is hereditary and environmental toxins have also been implicated. In children with ADHD, executive functions which are the processes involving planning, working planning, memory and inhibition and initiation and monitoring of actions are affected.

- When a child has ADHD, what aspects of the child and his/her parents' life is affected ?

ADHD has far reaching consequences for the children and their parents. It impacts not only the child, but also parents and siblings, causing disturbances to family and marital functioning of the parents.

When untreated, ADHD children are found to perform much worse than their peers in school academically. They are seen as different by their classmates and have difficulties making friends and are not invited to social events like parties. Parents are stressed up coping with their behaviour and this often leads to tension between parents. As much more attention is needed for the ADHD child, their siblings are neglected. As a result, family relationships may be severely strained, and in some cases break down, bringing additional social and financial difficulties.

Postpartum Depression

In a study published in March this year in  JAMA Psychiatry,  1,396 of 10,000 mothers screened positively for postpartum depression on the Edinburgh Postnatal Depression Scale (EPDS). This study sponsored by the publicly funded National Institute of Mental Health in the US shows that depression after childbirth is a significant problem. Unfortunately, postpartum depression remains underidentified and undertreated. Some of the following are common myths about Postpartum Depression.

Postpartum Depression (PPD) is the same as baby blues.

Unlike baby blues that goes away after a few days, postpartum depression lasts for weeks to months. The symptoms of PPD is the same as for a Major Depressive Episode. 

PDD is normal and ok to be sad after having a baby.

Whilst changes in mood may be normal after birth, if they are prolonged or are affecting your ability to care for your child, you should seek medical attention. If left treated, PDD can lead to:

1) Inconsistent and poor childcare
2) Avoidant or venting type of coping strategies with child
3) Insecure attachment between mother and child (may result in anxiety and depression of the child in later life)
4) Risk and danger if mother becomes agitated or suicidal with depression

PDD occurs right after birth.

It can occur right after birth or even up to a year later. Most of the time it occurs within three months.

Treatment for PDD will prevent me from breastfeeding and harm my baby.

Effective treatment is available for PDD. Antidepressants safe for pregnancy can be used to treat PDD after the risks and benefits have been discussed. Psychological therapy with techniques such as CBT is also useful.

It is unfortunate that PDD often goes unrecognised leading to tragedies such as these. Seek help today as PDD  can be treated!

The Myths About Antidepressants

Antidepressants are the mainstay of treatment for clinical depression and anxiety disorders.  These medications are effective and safe for the general population. However, many remain skeptical about antidepressant treatment and many myths remains.

1. I will become reliant on antidepressants and be addicted.

This is one of the main concern that my patients have when they have to be started on an antidepressant medication. It is important to realise that unlike sleeping pills, it is not possible to be addicted to antidepressants. Antidepressants do not cause tolerance or cravings like street drugs do. The fact that there are no street values with antidepressants attest to the fact that they are not addictive. However, if a patient is on high doses of antidepressants for a long time, it is best for him or her to seek the advice of the psychiatrist and not stop medication abruptly as this can cause "discontinuation syndrome". Discontinuation syndrome can lead to physical discomfort and can be completely avoided by weaning off the medication slowly in a few weeks.

2. My condition will become worse that when it started if I stop the medications.

Your condition will not worsen or rebound simply because you stop your medication. Antidepressants treats your depression or anxiety and also protects you from future episodes. If you stop the medication, it is like you taking off your armour. You will be vulnerable to depression or anxiety again.

3. Antidepressants have terrible side effects.

Newer classes of antidepressants like SSRIs are currently the mainstay of treatment. Unlike older antidepressants, these newer medications are well tolerated. At times, side effects can still occur to the minority of people. Known side effects include weight gain, sedation and rarely sexual dysfunction. These side effects are reversible and if any these side effects arises, you must inform your doctor who will switch you to another medication.

4. My brain will be affected by the medications!

Sometimes patients worry that they will be "changed" by the medications and their brain will become different. Antidepressants normalises the neurotransmitters in your brain  and this in turn makes your mood normal again. Antidepressants are not "happy"pills. They help by making you cope better so that you can solve the problems you have in life and it is up to you to find new meaning and happiness.

5. I'll have to take medications forever!

Many patients are afraid that once they are on medications, they cannot come off it. Majority of patients will become better once they have been treated and will come off medications. Some patients who have multiple episodes of mood or anxiety problems and may decide to stay on the medications long term. Your doctor will discuss with you the pros and cons of taking medications and how long you will require them. Ultimately, you have the choice of whether to take medications and the choice to stop them.

ADHD Increases Risk of Mental Illness in Adulthood

A 20 year long study conducted by Mayo Clinic published recently showed that not only did symptoms of ADHD persist into adulthood, children with ADHD were also much more likely to be diagnosed with other psychiatric illnesses as adults.

In this study, the researchers followed a cohort of 5718 children born between 1976 and 1982. Within the cohort, 367 were diagnosed with ADHD and 75% received treatment for ADHD as children. 29.3% of the children with ADHD were later found to still have the disorder in adulthood and within this group of children, 81% had at least one other psychiatric condition. The concomitant conditions they had included major depression, generalized anxiety, hypomanic episodes, substance abuse and antisocial personality disorder. Also 57% of all children with ADHD had another psychiatric disorder as adults compared to 35% in the control group. The study also showed that suicide rate amongst ADHD children was five times higher than those without the disorder.

These data are no doubt disturbing and brings to the table stronger evidence to what doctors and psychiatrists have long suspected and observed anecdotally about ADHD. The evidences indicate that ADHD is an illness with serious consequences, morbidity and mortality. Starting treatment young will help the children cope with the hyperactive, inattentive and impulsive symptoms, preventing the eventual pathways leading to other serious mental illnesses, personality disorders and suicide. Treatment into adulthood is often necessary and doctors must be vigilant in assessing and picking up co-morbid psychiatric illnesses.

ADHD is by far the most common neuro-developmental condition in children. It should not be trivialised and ignored as it progresses into long term difficulties for the individual. Seek help today!

The Top Five Regrets of the Dying

Bronnie Ware is a palliative nurse who has been seeing dying patients. From her experience, she observed five common themes that often resurfaced with regards to the regrets of people who were dying.

1. I wish I'd had the courage to live a life true to myself, not the life others expected of me.
2. I wish I didn't work so hard.
3. I wish I'd had the courage to express my feelings.
4. I wish I had stayed in touch with my friends.
5. I wish that I had let myself be happier.

In essence, the dying often wished that they have lead a more meaningful and fulfilling life. That they have been more true to themselves and in touch of their feelings. They wished they had spent more time with family, friends and with the things they like to do instead of just their work. Such reflections are not new. Kubler Ross in her work about the grief of dying had often alluded to these.

Sadly, our society continues to overemphasize academic and occupational achievements. Family and other social aspects of life are often neglected.

If your time is ending, will you have any regrets?

How to Prevent a Relapse of Bipolar Disorder

Read my article on how to prevent a Bipolar Disorder relapse. Click here.

You can read about symptoms of Bipolar Disorder by following this link.

Can Changes in Diet Improve ADHD Symptoms?

Parents often ask me if certain food may make the ADHD symptoms of their children worse. One of the purported culprit is sugar and the "sugar rush" phenomenon is well known. Despite a lack of studies to support these claims, anecdotal reports are aplenty. In this news article a mother reports success with diet changes such as adding vitamins and omega 3's, avoiding addatives- red dyes in particular and skipping the simple processed sugars.

Read about symptoms of ADHD here.

Most adolescent suicidal behavior preceded by mental health treatment

A recent research(1) showed that the lifetime prevalence of suicide ideation among adolescents was 12.1%, suicide plans 4%, and suicide attempts 4.1%. One-third of adolescents with suicidal ideation went on to develop a suicide plan and 33.9% made an attempt. Most adolescents (88.4%) who transitioned from planning suicide to attempting suicide did so within a year.

Most adolescents who had suicidal ideation (89.3%) and attempted suicide (96.1%) met lifetime criteria for at least one DSM-IV mental disorder, which included major depressive disorder, specific phobia, oppositional defiant disorder, substance abuse, intermittent explosive disorder and conduct disorder. Most disorders significantly predicted suicidal behaviors, and the prevalence of mental disorders generally increased with the increasing severity of suicidal behaviors.

From this study, we can see that it is important to identify and provide early treatment for these troubled youths. Unlike physical illnesses, parents tend to ignore mental health issues and to believe that such problems will go away by themselves. Otherwise, they may feel that seeking help from a mental health professional is too stigmatising and may do more harm to their children.

Such ignorance, often lead to delay in seeking treatment and may result in the youths and parents defaulting follow-ups. Today, suicidal behaviors are among the leading causes of death in Singapore and worldwide, especially among adolescents and young adults. Seek help early and contact a psychiatric clinic in Singapore.

(1) Prevalence, Correlates, and Treatment of Lifetime Suicidal Behavior Among Adolescents Results From the National Comorbidity Survey Replication Adolescent Supplement  
Matthew K. Nock, PhD; Jennifer Greif Green, PhD; Irving Hwang, MA; Katie A. McLaughlin, PhD; Nancy A. Sampson, BA; Alan M. Zaslavsky, PhD; Ronald C. Kessler, PhD
JAMA Psychiatry. 2013;():1-11. doi:10.1001/2013.jamapsychiatry.55

3 Ways to Prevent Depression

A Squidoo lens by Dr Lim Boon Leng.

Should We Be Leaving Infants to Cry Themselves Back to Sleep?

A new study from Temple psychology professor Marsha Weinraub gives parents some scientific facts to help with that decision. The study, published in Developmental Psychology, supports the idea that a majority of infants are best left to self-soothe and fall back to sleep on their own. Read here.