Exam Season - A parent's concern

1. Can you illustrate on how badly stress at school can affect children if left untreated?

A secondary 4 student in an elite school came to see me for low mood. He has been feeling that he cannot cope with his schoolwork and constantly feel pressurized as his classmates appear to cope better than him. He feels lousy about himself and that he is useless. He also started having suicidal thoughts. Despite having worked hard, he was very anxious prior to his school examinations as he was worried he would not do well and his results would be poor. He was also very fearful and catastrophized about the 'O' levels exams. 

2. What could happen to a child if they become too overwhelmed by anxieties? Some cases state self-mutilation and even suicide?

When a child becomes too stressed and anxious, they can develop aberrant behaviors. These can include tantrums and complaints of physical discomfort like stomachache in younger children. Teenagers may have deliberate self harm. They may become depressed and have suicidal behaviors. 

3. What are some of the ways I can help my children cope with academic pressure and exams today?

Focus on the process and not results. 

The most important factor in helping children cope with academic pressure is in shifting the focus and attention away from results to the process of working hard. This does not only emphasize the right value of hard work and perseverance but will also lessen anxiety as the child knows that as long as he worked hard, he has done well, rather than having to get good results in the examinations which can sometimes be dependent on factors such as luck. 

Stress management. 

Help the child learn about stress management. This can be achieve through proper rest and sleep, regular exercise, and having hobbies and time to play. A happy and stress free child will be more effective and passionate about learning. 

Sharing your experience. 

Children learn by modeling after their parents and mentors. Share anecdotes and stories about yourself and your experiences of how you dealt with your stress and academic hurdles. These stories will help the child know that he is not alone in facing these pressures and that he can overcome them. 

Maintaining long term goals and outlook. 

Explore with your child what his goals in life are and set long term targets. Understand that there are many ways to achieve these goals and many paths will lead them to where they will like to be in the future. When he realizes these, failing an exam or getting not so good grades will not be as daunting given the larger long term picture. 

Bipolar Disorder FAQs Part 3

8. What new treatments/ medications are currently available for this group of patients, and how do the medications work to help patients alleviate symptoms? I read a new study which say that antidepressants may in fact, worsen episodes of mania in this group of patients. See link. What is your take on this?

The main stay of treatment for Bipolar Disorder are mood stabilisers which include medications such as Lithium, Sodium Valproate and Lamotrigine. Antipsychotic medications have been shown to have mood stabilising properties as well and are often used in Bipolar Treatment. Antidepressants can be used in the depressive phase of the Bipolar illness but must be used with caution as they may trigger a manic episode. Many a times, multiple medications may be needed to stabilise the high and low episodes that a Bipolar patient encounters. After the mood has been stabilised and the patient is well, he and his loved ones should be educated about the illness process and prevention strategies. Therapy such as social rhythm therapy, a type of behavioral therapy used to treat the disruption in circadian rhythms that is related to bipolar disorder, is beneficial.

9. What are the chances of a remission with treatment? Possible for patients to lead a normal and fulfilling life?

Although we still do not have a cure, Bipolar Disorder is a very treatable illness. Chances of remission is remarkably high at 80% with treatment and most patients return to where they are in their lives before the mood episodes. Most patients with Bipolar Disorder will require long term treatment and it is important for them to remain on treatment when the illness goes into remission as those who are compliant to their treatment are much less likely to experience a relapse.

10.  Can someone having  manic episodes manifest aggressive or unusual behaviours that may warrant hospital admission?

Patients can become aggressive and even physically violent during episodes of mania. They may pick fights over small day to day issues with their family members and this can escalate to physical altercations needing police intervention and admission to a hospital to keep the patient safe. Some patients develop grandiose delusions thinking they are important people and may become paranoid that others want to harm them. They can become aggressive and violent towards the perceived perpetrators. There have been instances where patients think they have special power,

Bipolar Disorder FAQs Part 2

 4. Some women experience mood swings, for instance, during certain times of their menstrual cycle. When are "mood swings" not considered normal, and may warrant medical attention?

 Many women may notice that they have dysphoric or irritable mood before and during their period, These mood changes are often described as mood swings. These mood swings are generally unrelated to Bipolar Disorder as there is no swing into a manic state. However, if the individual experiences irritability, tension or low mood severe enough to interfere with work, social relationships and activities, they may be suffering from Premenstrual Dysphoric Disorder (PMDD).

 5. A local 2010 Singapore Mental Health Study found that the average time taken for bipolar disorder sufferers to seek help was 9 years. - Why do you think they take so long to seek professional help?

When the symptoms of Bipolar disorder is mild, it can be hard to detect. Most of the time, the afflicted individual may not have insight into their symptoms. In fact, many enjoy their "new found" confidence and inflated self esteem. Family members may think that the individual is just stressed out or being difficult instead of recognising the symptoms as due to Bipolar Disorder. The strong stigma that remains associated with psychological conditions also prevents individuals and there loved ones from seeking help with professionals until the condition becomes severe.

6. Based on your experience working with these patients, what usually prompts patients to seek medical attention for their symptoms?

Many seek help during their depressive phase, when they feel lousy about themselves. and through careful history taking with the patient and their loved ones, a history of previous manic episodes can be obtained. Many patients may be admitted by their loved ones to the hospital when they display unusual behaviours or become aggressive during their manic episodes.

7. How common is it for bipolar disorder to go undetected, or dismissed as something not serious? Why is that so?

 Although there are no available data, Bipolar Disorder is one of the most likely diagnosis to go undetected. Unlike many medical condition where lab tests or objective testing is available in making a diagnosis, the diagnosis of Bipolar Disorder can only be based on the history provided by the patient and his loved ones and observations made by the psychiatrist during the consult. In milder case of Bipolar Disorder where the individuals present with issues such as irritability, restlessness, insomnia, and excessive alcohol consumption. For someone who does not know the individual intimately, the mood changes may be assumed to be normal. Even loved ones may sometimes find it hard to decide if the individual's mood is unusually high or he is an exuberant person to begin with. They may see the change as a change in his personality rather than him having a mental illness.

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!

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!

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

Depression: Should I See A Doctor?

In life, it is not uncommon to be down and out especially if you have experienced an upsetting event. Clinical depression however, is a separate entity whereby the mood is low for more than two weeks accompanied by various other symptoms (see here). Clinical depression is a medical condition that requires treatment.

Why see a Doctor for Depression?

Many a times, people feel that they are strong enough to will themselves out of depression. Despite wanting to get away from everything, those with depression often soldier on with work and social commitments. In front of friends and family, they put up a strong front as if nothing is wrong. Sometimes in milder cases, the individual may recover shortly but in many cases, without help, the depression and ability to cope will worsen. This results in a vicious cycle.

Physical Assessment

In the assessment of depression, the doctor or psychiatrist will also perform a physical examination and sometimes blood tests to make sure that the low mood is not caused by medical problems such as hypothyroidism.

Suicide Assessment
The psychiatrist is also the most qualified person to perform a suicide assessment. If your friend of love one has depression, there is a risk that he or she may harbour suicide thoughts and may act on them in the future. A suicide risk assessment will help identify individuals at high risk of completing suicide so that immediate help and treatment can be performed.

Brain Changes in Depression
One cannot simply will away depression. It is not due to moral deficits or weakness in personality. It has a biological basis. In depression, actual structural changes of the brain occurs. Depression is associated with changes in metabolism and blood flow in the brain. Medication can protect the brain from these damages and potentially reverse these changes.

Treatment of Depression
Depression is very treatable. 70-85% of sufferers respond to medications. There really is no need to suffer the sleepless nights, endless guilt feelings and hopelessness. In addition to medication and psychological treatment, psychiatrist will advise their patients about practical steps to take to improve their mood. Watch this space for more advice about depression.

Hobbies: Do you have one?

As a psychiatrist, I often ask my patients about the things that they like to do, such as their hobbies. This can help us identify any changes in their interests towards things and gives us an indication about their mood.

The only problem about hobbies is that many Singaporeans don't have one! Patients would often tell me that Singapore is so stressful and "how to afford" a hobby in their busy schedule.

Some may think, "Is that possible, someone without an interest??!!"

When I first started out with my practice, I too often thought that patients who told me that they do not have hobbies were just having me on. Later, I found out that there were indeed a group of Singaporeans with no hobbies. They work from Monday to Saturday, rest at home on Sunday and go back to work again on Monday. They may sit in front of the television, but may not watching the shows at all. At best, they will sit on their usual seats in the corner of their HDB flats reading Wan Bao.

These are people from the babyboomers generation. Hard working and responsible, what life means to them is simply work and to provide for the family. These are great virtues in an Asian society. A man's worth is measured by his work and contribution to society.

But the problem arises when one day, the individual has to retire and many baby boomers have reached or are reaching this age. Suddenly, he is without a job. Suddenly, he is no longer useful. The day after retiring from his job, he is not only without a job but without any aim or meaning in his life.

It is no wonder that many of these people would become depressed. Sometimes, they may not recognise or refuse to admit their difficulties in their emotions and these may manifest as physical symptoms such as headaches, body weakness, chronic pain and giddiness. Severe cases become suicidal. Not having a job is an important risk factor for suicide.

All these because of (the lack of) a hobby?

Perhaps preparing for one's retirement is the more pertinent issue. You may be the most successful Head of Department but that does not equip you with the skills to live life upon retirement; unless you become an avid golfer. Retirement needs to be planned. One needs to slowly prepare and change his mindset and find new meaning of life beyond the present work.

And hobbies are a great way to do so.

Doing fun things and things you find interesting helps you to relax and relieve you of the stress of work. Upon retirement, you have something to look forward to; something you can put your focus and energy on. Hobbies need not be frivolous fun, they can be journeys of learning and can sometimes become a second career!

So it not about how you can afford to have a hobby. It is about how you cannot afford to live without one.