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.