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Worrying about Covid 19 is normal! If worry leads us to problem-solving that will help us stay safe and minimize our chances of becoming sick. That’s great news. The trick is letting go of worry and start problem-solving.

Yes, Shelly, duh, HOW!!??

Remember Cognitive Behavioral Techniques and use them. The basics can help too so eat right, get enough sleep, and exercise. Then call a friend, go for a walk, watch a favorite TV show, do15 sit-ups, clean a junk drawer, and take a few slow deep breaths. When you do worry, forgive yourself, re-set, and use a few of your favorite calming techniques, and problem solve if needed.

Anger is one of the first emotions we experience.  It can be useful when it spurs us on to make changes.  It can help decrease anxiety because it focuses attention, although there are better ways to manage anxiety. Anger can get in the way of relationships and even destroy them.  Loosing one’s cool can harm us at work, school, and socially. After an outburst people can feel guilt and shame. Anger can even be a symptom of depression.  However, it is often very hard to control anger, and sometimes it feels impossible to do. Some easy remedies are counting to 10, taking a few deep breaths, removing ourselves from the situation, thinking of something we have found humorous in the past, and/or repeating the mantra “I choose to stay calm”.

Research has shown that exercise can help control anger, and can help with mild to moderate depression, even a single session can have a prophylactic effect  tempering angry feelings.

Have you made any New Year’s Resolutions this year?Did you last year? Did they work out for you?

Try making small resolutions and only for a limited time period, such as I will walk 10 minutes on MWF for one week. Remember the more specific you can be, the more likely you’ll be able to follow through. Building on the walking idea, you could add the time you will do it; 8 AM. Want to make it stronger, find a partner to walk with you, now since the commitment is beyond just you; it’s stronger.
Studies have shown that exercise is an effective remedy for mild to moderate depression. It lifts mood!  In turn we feel better about ourselves, and when a tiny bit of that blossoms, and seeds, life gets  better. We are working on changing, change one thing and our minds open to changing other things as well.

Making the decision to take an antidepressant is often difficult.  The side effects can be uncomfortable as your body adjusts to the new medication, and waiting for the medication to take effect can be frustrating.  The following article from Wall Street Journal discusses that taking over the counter pain killers can decrease the efficacy of SSRI’s.

APRIL 26, 2011
Aspirin and Prozac Can Mix Badly, Study Says

By SHIRLEY S. WANG

Antidepressants and aspirin don’t mix, a new study suggests.

Researchers found that painkillers such as aspirin and ibuprofen appear to decrease the effectiveness of a popular class of antidepressants that includes Prozac and Celexa.

The finding, published Monday, may help explain why even the most effective antidepressants don’t work for everyone. At best only about two-thirds of patients respond effectively to Celexa and other selective serotonin reuptake inhibitors, or SSRIs.

Non-steroidal anti-inflammatory drugs, or NSAIDs, are a widely used class of pain medicines and include aspirin and ibuprofen but not acetominephen.

“It appears there’s a very strong antagonistic relationship between NSAIDs and SSRIs,” said Jennifer Warner-Schmidt, first author of the study and a researcher at Rockefeller University in New York. “This may be one reason why the response rate [in patients of SSRIs] is so low.”

The finding, which need to be confirmed in further studies, was published in the journal Proceedings of the National Academy of Sciences.

By the Numbers

253 million prescriptions for antidepressants in the U.S. in 2010
It isn’t clear from the study whether taking ibuprofen for an occasional headache is enough to blunt the effect of an antidepressant or whether it takes long-term use for a condition such as arthritis for there to be an inhibitory effect.

Major depression is estimated to affect 16.5% of U.S. adults over their lifetime, according to the National Institute of Mental Health.

Antidepressants, the bulk of which are SSRIs, were the second most popular drug class prescribed in the U.S. last year, netting $11.6 billion in sales, according to IMS Health, which tracks pharmaceutical sales.

There were 253 million prescriptions for antidepressants in the U.S. in 2010.

The Rockefeller researchers initially looked at changes of a biochemical marker of depression in mice when the animals were consistently given an SSRI, an anti-inflammatory or both medicines.

They figured if there was any effect from combining the two, it would have been to improve depressive symptoms since inflammation, an immune system response to infection, it thought to worsen or even cause depression in some people, Dr. Warner-Schmidt said.

Instead, they found that mice given a combination regimen had a dampened response—and sometimes no response—to the antidepressant compared to the group that got the SSRI alone. Mice who received just the anti-inflammatory didn’t show any change in the protein marker, called p11.

The researchers then looked to see if there was any evidence of this effect in humans. By examining data from an already-completed 4,000-patient large clinical trial of depressed patients known as STAR*D, they found that there was indeed a significant difference. Depressive symptoms—such as feeling down, crying more frequently than usual or having decreased appetite—in patients who took Celexa went away 55% of the time, but that rate dropped to 45% in individuals who reported they also had taken an anti-inflammatory.

The results, though preliminary and in need of replication, suggest that there could be clinical implications for patients who take both types of medications, experts said.

“If it’s substantiated in further studies, it would certainly imply we would have to use a different treatment for patients who are chronically taking NSAIDs,” like those with arthritis, said Steve Wengel, a depression researcher and chair of the University of Nebraska Medical Center psychiatry department who wasn’t involved with the current study.

But Dr. Wengel said that physical pain can make depression worse so patients taking both types of medicines may have harder-to-treat depressions.

The Rockefeller researchers plan to carry out a study that follows human SSRI users over time—some taking NSAIDS and some not—to better investigate the issue.

Madhukar Trivedi, who co-led the STAR*D trial and wasn’t involved in the new study, called the mouse data “clearly compelling” and the STAR*D analysis “very fascinating” but in need of follow-up.

Dr. Trivedi, a psychiatry professor at the University of Texas Southwestern Medical Center, Dallas, said he wouldn’t routinely urge depressed patients to stop taking an NSAID based on the findings, but if they weren’t responding well to the SSRI, he would evaluate whether they needed the painkiller.

Patients who are taking these medicines shouldn’t stop them on their own, experts said, and should talk to their doctor if they have concerns.

It isn’t clear why NSAIDs suppress the effect of SSRIs, but it could be simply an interaction between the drugs where NSAIDs prevent SSRIs from reaching the brain, the researchers said.

“Physicians should consider the advantages and disadvantages of giving an anti-inflammatory with the antidepressant depending on how severe the pain is and how depressed they are,” said Paul Greengard, senior author on the paper and head of the molecular and cellular neuroscience lab at Rockefeller.

Write to Shirley S. Wang at shirley.wang@wsj.com

Copyright 2011 Dow Jones & Company, Inc. All Rights Reserved

For those of you who have worked with me for awhile the information from this article from the WSJ by Melinda Beck will seem familiar. The premsise being don’t beat yourself up for being anxious, accept it and work with yourself.

Conquering Fear To help patients, therapists often counsel either changing behavior to address their fears or denying fears as irrational. Now, a third approach argues that accepting fears can loosen their grip.  The boss loves your work. Your spouse thinks you’re sexy. The kids—and even the cat—shower you with affection. But then there’s the Voice, the nagging presence in your head that tells you you’re a homely, heartless slacker.

Worry About Getting Fired

Change: Resolve to work harder and be indispensable.

Deny: Remember your recent raise and glowing review.

Accept: Understand that everyone feels this way and ask yourself if worrying is worth it.
Even people who appear supremely fit, highly successful and hyper-organized are sometimes riddled with debilitating doubts, fears and self-criticisms.

“Most people are struggling with difficult thoughts and feelings. But the show we put on for others says ‘I’ve got it handled,'” says Steven C. Hayes, a professor of psychology at University of Nevada-Reno. In reality, however, “there’s a big difference between what’s on the outside and what’s on the inside.”

Cognitive-behavioral therapy aims to help patients conquer their self doubts in two ways: Either by changing the behaviors that go along with it (I’m so fat—I need to get to the gym!) or by challenging the underlying thoughts, which are often distorted. (I’m 45-years old and I’m comparing myself to anorexic models. Get serious!)

Now, a third-wave of cognitive-behavioral therapy is catching on in psychology and self-help circles. It holds that simply observing your critical thoughts without judging them is a more effective way to tame them than pressuring yourself to change or denying their validity.

‘Tame’ is an interesting word,” says Dr. Hayes, who pioneered one approach, called Acceptance and Commitment Therapy. “How would you go about taming a wild horse? You wouldn’t whip it back into a corner. You’d pat it on the nose and give it some carrots and eventually try to ride it.”

For More Information on Mindfulness-Based Therapies:

This new psychology movement centers on mindfulness—the increasing popular emphasis on paying attention to the present moment. One of its key tenets is that urging people to stop thinking negative thoughts only tightens their grip—”like struggling with quicksand,” Dr. Hayes says. But simply observing them like passing clouds can diffuse their emotional power, proponents say, and open up more options. (“Here’s that old fat feeling again. You know, this happens every time I look at fashion magazines. I am sure judging myself harshly. Do I want to go to the gym? Or I could go to a movie. Or I could stop reading magazines.”)

“Part of what mindfulness does is get to you to recognize that these critical thoughts are really stories you have created about yourself. They are not necessarily true, but they can have self-fulfilling consequences,” says Zindel V. Segal, a professor of psychiatry at the University of Toronto who devised Mindfulness-Based Cognitive Therapy to help depressed patients. “If you can get some distance from them, you can see that there are choices about how to respond.”

Mindfulness also involves paying attention to your breathing and other physical sensations while observing your thoughts so you have a tapestry of information to consider, says Dr. Segal. In fact, neuro-imaging studies have shown that when people consider problems mindfully, they use additional brain circuits beyond those that simply involve problem-solving.

A Fear of Flying

Change: Force yourself to fly as much as possible until the fear subsides.

Deny: Remind yourself that flying is much safer than driving.

Accept: Expect and acknowledge the fear; breathe deeply and focus on the moment.
Although some critics initially dismissed mindfulness-based therapies as vacuous and New Age-y, dozens of randomized-controlled trials in the past decade have shown that they can be effective in managing depression, panic disorders, social phobias, sleep problems and even borderline personality disorder.

A study of 160 patients with major depression, led by Dr. Segal and published in the Archives of General Psychiatry last month, found that mindfulness-based cognitive therapy was just as good at as antidepressants at warding off relapses of depression.

The National Institutes of Health is funding more than 50 research studies involving mindfulness treatments for psychological problems.

A growing number of therapists are also using mindfulness-based acceptance in their practices. Katherine Muller, associate director of the Center for Integrative Psychotherapy in Allentown, Pa., says she sometimes brings out a little plastic gnome to represent a patient’s negative feelings. “The idea is, ‘These feelings are going to come. What are you going to do about them?’ ” she says. “You don’t have to react to them at all. Just allowing them to exist takes away their power.”

She also finds that practicing mindfulness is more effective at easing her own fear of flying than being reminded about the safety statistics.

On one flight, she says, “all my cognitive skills were going right out the window.” Then another psychologist suggested focusing on the tray table rather than fighting her fears. “It helped me center my head and get a grip,” she says. “It gave me a chance to watch the movie and talk to the person next to me, rather than focus on how the plane might go down in a fiery ball.”

Psychologist Dennis Tirch, director of the New York Center for Mindfulness, Acceptance and Compassion-Focused Therapies, uses this formula to help even people with profound developmental disabilities take control of their emotions: “Feel your soles of your feet. Feel yourself breathe. Label your emotions and make space for your thoughts.”

Feeling Fat and Ugly After Reading Fashion Magazines
Change: Resolve to eat less, exercise more and improve what you can.

Deny: Remember nobody looks that good; even the models are air-brushed.

Accept: Realize that magazines always make you feel fat; assess how much you really care.
Extending some compassion for yourself is also an important part of the new mindfulness therapies, Dr. Tirch says. “I can’t tell you how many clients I have who are just beating themselves up about things” says Dr. Tirch. “Give yourself a break—not so you can curl up in bed and stay home, but so you can interact better with the world.”

Kindness and accepting your thoughts nonjudgmentally doesn’t mean having to settle for the status quo, proponents say. Rather than be paralyzed by negative thoughts, you can opt to change your situation—get to the gym or work harder—but with a clearer set of options based on what really matters.

Some critics note that such advice doesn’t sound so different from standard cognitive-behavioral therapy or being kind to the “inner child” of earlier psychotherapy approaches. And some experts say that still more scientific data are needed to evaluate its effectiveness, particularly now that it’s being applied to such a wide array of disorders.

It’s also not clear yet who might benefit most from mindfully accepting their thoughts rather than reasoning with them. For example, Dr. Tirch thinks that it’s still important to convince someone with severe agoraphobia that a piano won’t fall on their head if they leave the house.

Yet Marsha Linehan, a professor of psychology at the University of Washington, found that the acceptance therapy she developed in the 1990s enabled suicidal patients and those with borderline personality disorder to accept their feelings and get help while trying to challenge them would only have created more bad feelings.

“It’s the nonjudgmental part that trips most people up,” says Dr. Linehan. “Most of us think that if we are judgmental enough, things will change. But judgment makes it harder to change.” She adds: “What happens in mindfulness over the long haul is that you finally accept that you’ve seen this soap opera before and you can turn off the TV.”

Write to Melinda Beck at HealthJournal@wsj.com

Web sites:

Acceptance and Commitment Therapy research, referrals, chapters and conferences
Mindfulness-Based Cognitive Therapy resources, classes and therapists in the U.S., Australia and Europe
The Center for Mindfulness in Medicine, Health Care and Society at University of Massachusetts, founded by Jon Kabat-Zinn
Association of Behavioral and Cognitive Therapies
Books:

“Get Out of Your Mind and Into Your Life,” 2005 by Steven C. Hayes
“The Mindful Way Through Depression,” 2007 by Mark Williams, John Teasdale, Zindel Segal and Jon Kabat-Zinn.
“Dialectical Behavior in Clinical Practice: Applications Across Disorders and Setting,” 2007 by Linda A. Dimeff, Kelly Koerner and Marsha M. Linehan

Depression is often why people seek out therapy.  When depression is mild to severe, exercise can alleviate many symptoms.  However, if symptoms are severe, medication can be beneficial.  Below is an excerpt from a Medscape article addressing this issue.

In patients with mild-to-moderate major depression (operationally defined as HAMD17 scores of 12-25), aerobic exercise that expends at least 17.5 kcal/kg/week at least 3 days/week has been shown to reduce depression severity by nearly 50%, an effect described as comparable to that seen with antidepressants.^[48] However, a Cochrane database analysis of exercise for major depression found only a moderate effect size — comparable to that of cognitive therapy — but no statistically significant difference from placebo or no treatment.^[49] In patients who have major depression with incomplete remission with antidepressants, an adjunctive individualized exercise program showed significant reductions in residual depressive symptoms.^[50] In more severe forms of major depression, aerobic exercise has not been demonstrated to exert a comparable effect to antidepressants.

Patty’s assertion that antidepressants “do not work for depression anyway” may have been a misreading of a recent meta-analysis comparing antidepressants with placebo for mild-to-moderate forms of depression, which indeed found no clear advantage of antidepressants in the absence of greater severity.^[51] That meta-analysis, however, was confined to only 6 studies of 2 antidepressants — paroxetine and imipramine — and was limited in its generalizability by a number of methodologic shortcomings. There is little dispute that antidepressants are efficacious in more severe forms of major depression, and the premature cessation of antidepressants after an initial response carries a high likelihood for relapse.

High levels of expressed emotion in the spouses or significant others of depressed patients (such as perceived criticism, hostility, and emotional overinvolvement) were originally described as predictors of relapse in schizophrenia, although contemporary studies have also identified links between high expressed emotion and residual depressive symptoms after initial response^[52] as well as subsequent relapse rates.^[53] However well-intended Patty’s intentions may be with respect to Dennis’ depression and its treatment, appropriate family psychoeducation at this point would involve a discussion of the disease model of depression; that is, the recognition of Dennis’ depression symptoms as manifestations of an illness that arise within a vulnerability-stress model. One would review the signs and symptoms of major depression, the concept of a biologic predisposition to depression and the importance of treatment irrespective of possible etiologies, and the role of family members (Patty) with respect to relapse prevention. The latter includes ways to recognize signs of impending relapse and seek treatment, as well as efforts to encourage Dennis’ adherence to treatment recommendations. Should it appear that Patty’s attitudes, beliefs, and attributions about Dennis’s illness may be interfering with Dennis’ treatment, it may then be appropriate to undertake a more focused intervention that addresses communication enhancement training, which involves teaching skills for active listening, delivering positive and negative feedback, and requesting changes in behavior.

There are a number of basic tenets worth addressing when educating a family member about major depression in a loved one, including the following points:

• Depression attains clinical importance when it involves a collection of signs and symptoms affecting not only mood but also the sleep-wake cycle, energy, appetite, thinking, motivation, capacity to feel pleasure, behavior, and outlook or perspective about life and one’s future.
• Genetics may sometimes contribute to an individual’s inherent vulnerability for depression but hereditary factors alone do not fully explain the lifetime risk for depression.
• Life stresses (such as losses, separations, or difficulty adapting to change) may or may not catalyze or precede the onset of a depression. However, because the exact causes of depression remain unknown, efforts to differentiate “situational” from “biologic” causes of depression may not be informative. Depression will not develop in all individuals who endure the same life stresses, and it is thought that predisposing genetic or other biologic susceptibilities may be necessary prerequisites for the occurrence of a major depression in the context of environmental interactions.

Patty also raises the issue of treatments for depression other than traditional antidepressant medicines. There has long been interest among patients as well as practitioners about the validity and utility of complementary and alternative medicine treatments for depression. Research rigor has not fully kept pace with clinical interest in this area, as evident from the plethora of small, underpowered proof-of-concept studies that limit the ability to draw broad conclusions. Recently, however, the Canadian Network for Mood and Anxiety Treatments published a consensus-based guideline on complementary and alternative medicine approaches to major depression, ranked by perceived levels of research support.^[54] In the absence of a seasonal pattern of depression (where light therapy is accorded the highest level of evidence and a first-line recommendation), the identified interventions of sleep deprivation, exercise, and yoga are viewed as second- or third-line recommendations, all with evidence supported by at least 1 randomized trial with adequate sample size and/or meta-analysis with wide confidence intervals. The evidence base for acupuncture was viewed as lacking sufficient information from which to form any recommendations. Two nutraceutical remedies, omega-3 fatty acids and s-adenosylmethionine, were viewed as second-line recommendations as monotherapy supported by at least 2 adequately-powered randomized trials, while other remedies (notably, the steroid dehydroepiandrosterone and folic acid as monotherapy and adjunctive therapy, respectively) were identified as third-line treatments supported by at least 1 randomized trial. In addition, St. John’s Wort was identified by the study group as a first-line monotherapy treatment for mild-to-moderate depression (supported by 2 or more adequately-powered randomized trials) and a second-line treatment for more severe forms of depression with less extensive support from randomized trial data.

When should a structured psychotherapy be considered as an appropriate augmentation strategy to pharmacotherapy for depression — particularly if an initial medication response is poor? In STAR*D, 71% of depressed patients who did not respond to an initial SSRI trial declined the option of cognitive therapy for depression in favor of alternative medication strategies,^[55] even though response and remission rates were comparable between augmentation of cognitive therapy and changing to an alternative antidepressant.^[56]Cognitive therapy was a more acceptable treatment option among patients with higher education levels and a family history of a mood disorder.^[55]