Fredrich C Schramm Medical Alert System

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medical psychiatry series

An Integrative Approach to the Prevention and Treatment of Postpartum Depression (PPD) and Postpartum Anxiety Disorder (PPA)

Dean Raffelock, D.C., L. Ac, CCN, DACBN, DIBAK

Hyla Cass, M.D.

Postpartum depression (PPD) Postpartum Anxiety (PPA) have become a national epidemic in the United States, affecting 15%-20% of all new mothers, or about 600,000-800,000 women annually. (1) It is now estimated that over 30 million Americans are on antidepressant or anti-anxiety medications. (2) The majority of this 30 million are women who have one or more children. The chance of suffering from PPD increases with each successive child. (3)

The most common medical treatment for postpartum depression is SSRI (selective serotonin reuptake inhibitors) antidepressant drugs. Postpartum Anxiety Disorder is most commonly treated by the benzodiazepine family of drugs like Valium, Ativan, Xanax, and Klonopin. Combination reuptake inhibitors for both serotonin and norepinephrine (SNRIs) are also commonly used in postpartum depression. In the case of postpartum psychosis, antipsychotic drugs are used and are immediately necessary. Many women are now given samples of SSRIs as they are leaving the maternity ward. Most medical sources believe that PPD is caused by an imbalance of brain chemistry and that pharmaceutical intervention is the treatment of choice. While a certain percentage of women suffering from PPD do need pharmaceutical assistance, these are far fewer than are actually receiving them. Recent Meta-studies show this to be true.  While it is clear that some women with PPD do need and benefit from pharmaceutical intervention, it is our experience that an integrative approach yields the best results.

 

Postpartum Anxiety Disorder is mostly treated

The most common Postpartum Depression symptoms  include the following:

1. Persistent feelings of despair and/or anxiety;
2. Loss of energy and low levels of daily functioning;
3. Sleep and eating disturbances;
4. Inability to focus, concentrate or make decisions;
5. Feelings of worthlessness, shame and guilt;
6. Feelings of indifference and/or resentment towards the baby;
7. Intrusive negative thoughts and/or obsessive worries–in the most serious cases, this includes thoughts of harming oneself or the baby;
8. Reduced sex drive;
9. Loss of joy and appreciation for life;
10. Irritability or excessive anger.

The literature generally outlines several types of postpartum disorders that have special features beyond the typical symptoms of depression. These include:

1. Postpartum Anxiety Disorder (PPA). Here, the primary symptoms are excessive nervousness, hyper-vigilance, racing thoughts and in some cases outright panic. Panic attacks are especially frightening–sufferers often believe they are dying, as they experience shortness of breath, dizziness and a pounding chest.

2. Postpartum Obsessive-Compulsive Disorder. Most often, this takes the form of obsessive thoughts or worries about the baby and may be accompanied by compulsive behaviors such as constantly checking if the baby is breathing, constantly washing to protect the baby from germs, etc. The most disturbing type of obsessive thoughts are those in which the mother envisions harming her baby in some way. These thoughts are unwanted, intrusive and terrifying to the mother. It is important to emphasize that, except in extremely rare instance of psychosis (see below), these thoughts are not accompanied by any actions. Nonetheless, the mother may be so frightened by her own thoughts that she avoids the baby and consequently neglects her. It is terribly difficult for new mothers to acknowledge having such thoughts, and as a result, many suffer in isolation.

3. Post-traumatic Stress Disorder. PTSD can occur in response to a real or perceived traumatic childbirth or because of unresolved past trauma–sometimes sexual in nature–triggered during childbirth. A woman who experiences PTSD is likely to have recurring, memories, dreams or even flashbacks of the traumatic labor/birth. She will be hyper-vigilant and startle easily, and will likely suffer from sleeplessness, irritability, poor concentration and apathy. Women who have experienced a particularly traumatic childbirth often show symptoms of both PTSD and PPD.

4. Postpartum Psychosis. This is the most extreme and rarest of all postpartum disorders. When it occurs, the mother loses touch with reality and her symptoms may include extreme disorientation (e.g., not knowing who she is), delusional or paranoid thinking, and visual or auditory hallucinations. The few, tragic cases where mothers have harmed their children while in a psychotic state have received enormous media attention. As a result, many people inaccurately associate PPD with psychotic symptoms and dangerous behavior. This constitutes yet another reason why women fail to get help–they want to avoid being labeled with such a stigmatized disorder.

Article Premise: Fully Replenishing a New Mother's Postpartum Nutritional Reserves Has Been Largely Ignored and Should  be An Integral Part of Treating Postpartum Depression.

Foundations of A Nutritional Approach to PPD
The human body is entirely formed from nutrients. Every muscle, organ, gland, bone, cell, and fluid is composed entirely of nutrients (environmental toxins notwithstanding). All of the neurotransmitters, hormones, biochemical structures, and metabolic pathways are formed from nutrients.

No other normal physiological process uses up and drains more vital nutrients from a postnatal woman's body than the process of being pregnant, giving birth, and caring for a new infant which may include breastfeeding. The fact that a mother's body donates all the nutrients required to form her baby's body is too often overlooked when it comes to the medical treatment of PPD. Not only does the placenta literally rob the mother's body of all the key nutrients required to make a baby's body, but the placenta itself is formed from nutrients taken from the mother's body. This is the main reason that many postpartum women become nutritional drained and this nutrient depletion syndrome can lead to postpartum depression and anxiety disorder.

Other factors that may contribute to a drain of a new mother's nutrient reserves are loss of blood during the birth process, sleep deprivation, breastfeeding, returning to work too soon, and the immense extra energy required to take care of a new infant with intense needs. If a pregnant woman's or new mother's nutrient reserves are too low, she is much more vulnerable to experiencing PPD and PPA because all of the body's normal metabolic processes are entirely dependent upon nutrients. The preponderance of extremely poor quality pharmaceutical prenatal vitamins significantly adds to the tendency of nutrient depletion.

Rarely is there is any mention that the body's production of neurotransmitters is completely dependent upon their nutritional precursors. (4) Nor are the causes of these nutritional precursor deficiencies discussed. Additionally, the interdependent relationship between hormones and neurotransmitters is rarely taken into consideration by most physicians when considering treatment for PPD and PPA. The nutritional requirements of mitochondrial function, the importance of liver function from Western and Eastern perspectives, and some individual nutrients like Omega 3 fish oils, pharmaGABA, L-theanine, SAMe, inositol, magnesium, and the herb St. John's Wort can also be of great assistance in treating PPD and PPA. These will be briefly discussed.

An integrative approach to treating PPD may include nutritional therapies, bio-identical hormone replacement, moderate exercise, a nutrient dense diet, proper rest, psychological counseling/support, stress reduction techniques, elimination of caffeine, alcohol and other addictive drugs, and if needed, pharmaceutical intervention.

Neurotransmitter Nutritional Precursors

Serotonin and Tryptophan

The amino acid L-Tryptophan is required for the body to produce serotonin. Ninety-five percent of the serotonin in the human body is produced in the intestinal tract. Approximately five percent is produced in the brain. The serotonin produced in the intestinal tract is unavailable to the brain because serotonin cannot pass through the blood- brain barrier. L-Tryptophan also does not easily pass through the blood-brain barrier and requires a carrier protein to ferry it into the brain. The consumption of simple sugars changes brain neuron cell membrane amino acid selectivity, allowing tryptophan to enter the brain more easily. Hence, the craving of sweets is often a sign of serotonin deficiency.

Serotonin has been referred to as the brain's mood elevating and tranquilizing chemical. Inadequate serotonin levels are linked with depression, anxiety, insomnia, irritability, and weight gain. Serotonin mediated depression usually contains an element of anxiety. Serotonin is considered an inhibitory neurotransmitter. Its functions include:

- Inhibiting Glutamate excitability over diverse regions of the CNS
-Stimulating its own receptors on GABA neurons prompting GABA to perform its inhibitory function
- Inhibiting the release of the Catecholamines: Dopamine, Norepinephrine, and Epinephrine.

A comparison of the effects of optimal serotonin levels to low serotonin levels to reveals the following contrasts:

1) Hopeful/optimistic—————-Depressed
2) Calm—————————Anxious
3) Good-natured——————–Irritable
4) Patient————————–Impatient
5) Reflective/ thoughtful————–Impulsive/Reactive
6) Loving /Caring——————–Abusive
7) Able to concentrate—————-Short attention span
Creative/focused——————Blocked/scattered
9) Moderate carbohydrate intake——–Excessive carbohydrate intake
10) Good sleep and dream recall——–Insomnia and poor dream recall

Tryptophan is converted to its metabolite, 5- Hydroxy-Tryptophan (5-HTP) which is then converted to serotonin. Niacin, iron, and folic acid are required for L-Tryptophan to be converted into 5-HTP. The body also requires pyridoxal-5-phosphate along with 5-HTP in order to produce serotonin. Magnesium and riboflavin (B2) are required for the conversion of pyridoxine (B6) into pyridoxal-5-phosphate. Deficiencies in any of these nutrients can limit the production of serotonin. Numerous double-blind studies have shown 5-HTP to be as effective as antidepressant drugs with fewer and milder side effects and most times better tolerated. (5-11)

 

    

From Martin Hintz, M.D. –Neuro Research

 A number of significant factors contribute to low L-Tryptophan levels in many people, especially postpartum women whose bodies are providing the proteins needed to form another human body, these include excessive levels of cortisol, epinephrine, norepinephrine, and dopamine. The ratio of L-tryptophan to other amino acids available in most foods is quite low.

An overabundance of the adrenal gland hormone cortisol (a very common occurrence in stressful psychological and physiologic states) adversely affects serotonin production and sensitivity in four different ways:

1. Excess cortisol significantly decreases the number of serotonin (5-HT1A) receptor sites. (12)
2. Excess cortisol suppresses serotonin receptors. (13, 14)
3. Excess cortisol increases serotonin reuptake. (15)
4. Excess cortisol, causes tryptophan oxygenase (TO) to metabolize tryptophan into kynurenine, leaving less tryptophan to become serotonin. (15,16)

If cortisol levels are too low in the amygdala, serotonin no longer has an Inhibitory effect on Glutamatergic activity, suggesting that cortisol plays a key role in maintaining Serotonergic-mediated modulation. (16,17) This may be another factor involving insomnia in PPD.

Added to the reasons that serotonin deficiencies are growing more common and contributing to PPD is a stress-related overabundance of the catecholamines. Epinephrine, norepinephrine, and dopamine also deplete serotonin because the inhibitory monoamine neurotransmitter serotonin is supposed to balance these three excitatory monoamine neurotransmitters. The more stress a person experiences, the more the body increases the production of the catecholamines in an attempt to respond to this stress. This requires a postpartum body to produce even more serotonin – though deficiencies in nutrient precursors may interfere with its production.

The use of 5-HTP as a nutritional precursor to serotonin has significant advantages over tryptophan. 5-HTP easily passes directly through the blood-brain barrier without the need for a carrier protein, allowing for an easier conversion into serotonin in the brain. Sublingual forms of 5-HTP work more quickly. Dosage varies from 25 mg per day to 300 mg per day or more.

A deficiency of vitamin B6 (pyridoxine), which is required for serotonin synthesis, is often found in premenopausal female patients with depression. (18) Replacing B6 in cases of deficiency is an important aspect of PPD treatment that may enhance serotonin production in the brain. (19) The use of the vitamin B6 metabolite, pyridoxal-5-phosphate, instead of B6 is suggested especially when magnesium and/or riboflavin deficiencies are suspected or confirmed. There is some controversy whether it is best to supplement 5-HTP and pyridoxal-5-phosphate together or take them separately, adhering to a two-hour wait period. Our clinical experience indicates that it fine to supplement them together. Many products including a combination of 5-HTP and P-5-P are available.

Some controversy exists regarding the simultaneous use of SSRIs and serotonin nutritional precursors. The pharmaceutical companies seem adamant about avoiding this and often mention the possibility of Serotonin Syndrome, a dangerous condition generally brought about by combining serotonin enhancing medications, especially MAO inhibitors, with medications, herbs, or nutritional precursors that also enhance serotonin activity. Symptoms of serotonin syndrome may include nausea, headache, agitation, diaphoresis, hypertension, tachycardia, and hyperthermia that can go over 104 F. This appears a remote possibility at best when just using 5-HTP or using 5-HTP in combination with one SSRI medication. (20)

SSRIs appear to not only keep serotonin in the neuron synapses longer by inhibiting reuptake, but also by pulling the nutritional precursors for serotonin from the storage vesicles and reuptake ports. In fact, in our clinical experience, many women with PPD do better when taking 5-HTP and P-5-P along with their SSRIs than taking SSRIs alone. Serotonin precursor deficiencies may be the reason that SSRIs don't work for some, work and then stop working for others, and why it is not unusual for a woman with PPD to have been prescribed two or more different SSRIs over time. The SSRIs do not give a net increase of serotonin so they need enough available serotonin in order to have enough to re-uptake.

 

Dr. Dean Raffelock- catacholamine chart

The catecholamines are predominantly energizing and mood elevating when produced at appropriate levels. Synthesis of the catecholamines occurs in the CNS, adrenal medulla, and peripheral sympathetic neurons. Norepinephrine and dopamine act primarily as neurotransmitters in the CNS. Epinephrine acts primarily as an adrenal hormone to mobilize energy.

The catecholamines influence most organ systems. When levels are excessive they are catabolic and can lead to the body metabolizing its own nerve, muscle and bone tissue. Low levels can lead to depression, fatigue, and weight gain.

Dopamine: Dopamine is the catecholamine precursor for norepinephrine and is found both in the CNS and adrenal medulla. Its functions include motor function and posture, cognitive function (attention, focus, working memory and problem solving), and pleasure sensations. Dopamine can act either as an inhibitory or excitatory neurotransmitter in response to incoming afferent signals.

Norepinephrine (noradrenaline): CNS norepinephrine mediates mood regulation, drive, ambition, learning and memory, alertness, arousal and focus. Clinically, there is often an inverse relationship between norepinephrine (excitatory) and serotonin (inhibitory). When serotonin is low, norephinephrine may be over-upregulated, resulting in "fight or flight" responses leading to anxiety and/or panic attacks. Over-expression of CNS norepinephrine is clinically associated with anxiety, aggression, irritability, mania or bipolar disease, immune suppression, and hypertension; low norepinephrine is associated with atypical depression, with symptoms of fatigue, hypersomnia, hyperphagia, lethargy and apathy.
(21,22)

Epinephrine (adrenaline): Epinephrine synthesis is dependent upon norepinephrine being converted into epinephrine by methylation.
Hans Selye (1974) described the three phase s of the "General Adaptation Syndrome" to stress (23):

Phase I: Alarm reaction: high epinephrine/high cortisol

Phase II: Resistance: high cortisol/low DHEA, variable epinephrine

Phase III: Exhaustion: depletion of cortisol, epinephrine and DHEA
Adrenal exhaustion is a major factor in depression related to chronic or severe stress.

A woman suffering from PPD should be closely questioned about her symptoms; SSRIs are routinely given to women who have functional hypoadrenia involving the adrenal cortex and/or medulla, or low thyroid function (discussed below). Low glucocorticoid and/or catecholamine levels can cause the symptoms of fatigue, malaise, and depression. (24,25)

Many women with PPD require pharmaceuticals and/or nutriceuticals that address deficiencies in both serotonin and the catecholamines. Nutritional therapies for catecholamine balance include:

§ DL-phenylalanine and L-tyrosine, the amino acid precursors for epinephrine, norepinephrine, and dopamine. DL-phenylalanine also helps to increase endorphins, which are mood-elevating. Many PP women diagnosed with bipolar disorder will respond well to high dose DL-phenylalanine therapy (26), along with serotonin precursors and high-dose (6 grams per day) omega-3 fatty acids in the form of fish oils. (27)

§ L-cysteine, sulfur, iron, and folate, required for conversion of L-tyrosine into L-dopa.

§ Pyridoxal-5-phosphate, required for the conversion of L-dopa into dopamine. Copper and vitamin C are required to convert dopamine into norepinephrine. Pridoxal-5-phosphate, B12, and folic acid are required to convert norepinephrine into epinephrine.

Gamma-Aminobutyric Acid (GABA)

GABA is the most important and widespread inhibitory neurotransmitter in the brain. Low levels of GABA are particularly important to look for when anxiety and insomnia are included in the symptom display of PPD/PPA. GABA is essential for balancing excitatory neurotransmitters and hormones such as cortisol, epinephrine, norepinephrine, and glutamate. Too much excitation without adequate GABA inhibition can lead to: (28)

- Insomnia
- Restlessness
- Irritability
- Anxiety
- Panic Attacks
- Seizures

GABA's job clinically is to induce relaxation, calmness and aid sleep. Where there are glutamate receptors (powerful excitatory neurons), there will be GABA receptors nearby. GABA allows only the most important excitatory signals to pass by and dampens or quenches extraneous excitatory signals when GABA levels are adequate.

Benzodiazapines (Valium, Klonopin, Zanax, Ativan, etc.) and sleep pharmaceuticals like Ambien and Sonata work on GABA receptors, as does moderate alcohol consumption. L-theanine, lactium (milk peptides), L- glutamine, taurine, and bio-identical progesterone can act as nutraceutical/hormonal GABA agonists. The drug Gabatril is a GABA re-uptake inhibitor as is Valerian extract. A newer nutriceutical product called pharmaGABA seems to yield more effective results than synthetic GABA.

From a Chinese Medicine perspective, serotonin and GABA would be Yin (relaxing, harmonizing, cooling, nurturing, moisturizing, inhibitory) and the catecholamines would be Yang (energizing, mobilizing, warming, excitatory, drying). From both Eastern and Western perspectives, it is important to balance these opposing groups of brain chemicals to obtain balance. A woman with PPD who now has more energy but can't sleep is just as unhappy as a woman who now can sleep but who is even more lethargic than before treatment.

Balancing neurotransmitters is key. Balancing neurotransmitters and hormones is clinically even more effective.

Hormone-Neurotransmitter Interactions

The relationship between neurotransmitters and hormones in PPD is often overlooked. Neurotransmitters and neuropeptides are required in order to mediate hypothalamic production of releasing hormones, enabling the pituitary gland to properly conduct the hormonal orchestra. The hypothalamus is considered a key part of the mid-brain, the "emotional brain," so there is little wonder why imbalances in neurotransmitters and hormones can adversely affect emotional states.

Thyroid hormones. The catecholamines and thyroid hormones are closely related in many of their functions. L-tyrosine, along with iodine, is the precursor for thyroglobulin and thyroid hormones T-3 and T-4. A depression with no anxiety, with the predominant symptoms of exhaustion and difficulty stringing multiple positive thoughts together, is most often associated with low adrenal (29) and/or thyroid function (30-32) and generally doesn't respond well to SSRIs or serotonin nutritional precursor therapy.

It is well known that low thyroid function can cause physiologic depression and fatigue. Giving T3 induces a rise in serotonin, and in animals with hypothyroidism, serotonin synthesis is reduced. (33) T3 appears to desensitize presynaptic Serotonin autoreceptors. (34) Conversely, the diurnal peak of TSH, observed during the physiological circadian rhythm, is serotoninergic dependent. (35)

Thyroid function and serotonin function are interdependent both clinically and bio-chemically. Optimal thyroid function is dependent on optimal serotonin levels. Optimal serotonin balance is dependent on optimal thyroid function. TSH increase is dependent on adequate serotonin stimulation of hypothalamic TRH, allowing TSH to rise. (36) Suppressed TSH currently may more appropriately represent low serotonin states than any real assessment of true thyroid function. The thyroid hormone triiodothyronine (T3) augments and accelerates the effects of antidepressant drugs. Fluoxetine + T3 are better at desensitizing 5-HT hypothalamic autoreceptors than either alone. (37-39)

Estrogen: A growing body of evidence points to estrogen's importance in serotonergic function. (40) Estrogen inhibits serotonin reuptake. (41,42) Estrogen treatment is shown to selectively enhance serotonin (5-HT1A-mediated) responses in the hippocampus (43,44) Estrogen increased the firing activity of 5-HT (serotonin) neurons in both male and female rats. (45,46) In short, estrogen appears to be nature's SSRI.

Presently, there is a great deal of controversy regarding estrogen HRT. The HERS study and WHI studies have stirred the controversy without making the important distinction between bio-identical and pharmaceutically altered estrogens; neither is any distinction made between progesterone and progestins. The clinician is encouraged to become very well versed in this area regarding risks versus benefits of HRT. Many women with PPD can benefit from low-dose bio-identical estrogen HRT if indicated and potential benefits outweigh risks.

Progesterone: Bio-identical progesterone has a known anti-depressant/anti-anxiety effect. Throughout pregnancy, the placenta produces copious amounts of progesterone, increasing blood levels to many times pre-pregnancy levels. Post-partum, this supply is suddenly gone, along with its soothing effects on the mother's nervous system.
Allopregnanolone is synthesized by the reduction of progesterone via the enzymes 5-reductase and 3-hydroxysteroid dehydrogenase (3-HSD). Allopregnanolone is one of the most potent known modulators of GABA receptors. (47,48) Allopregnanolone has behavioral and biochemical characteristics similar to ethanol, barbiturates, and benzodiazepines. (49,50)

Bio-identical progesterone can be very helpful for women with PPD with anxiety and insomnia. Using the  PharmaGABA and bio-identical progesterone simultaneously is often very helpful to relieve anxiety and sleep issues.

DHEA: DHEA increases the firing activity of serotonin neurons. (51) DHEA also increases dopamine and norepinephrine synthesis via mRNA for tyrosine hydroxylase. (52) Because of this, DHEA can be helpful in some forms of PPD. DHEA also inhibits GABA and is therefore a GABA antagonist. (53) Clinically, if the use of DHEA causes insomnia and irritability, most likely the patient is GABA deficient and this should be addressed before continuing to supplement DHEA.

Testosterone: increases serotonergic neuron firing in the raphe area, increasing mood. (54)

Mitochondrial Function

      

 

from Metametrix Lab- Ion Panel Booklet

 

Inefficient mitochondrial function can limit ATP production, lower energy and contribute to or cause physiological depression. More than 90% of all cellular oxygen consumption is used to fuel mitochondrial metabolism. Mitochondria must transfer huge numbers of electrons to produce energy. Mitochondrial dysfunction can affect all organ systems, including neurons and glands.

Dietary fats, carbohydrates , and proteins all need to be converted into acetyl-coenzyme A (acetyl CoA) before entering the Krebs cycle and electron transport chain. The nutritional precursors required for fatty acids, glycerol, and cholesterol to enter the Krebs cycle and generate ATP are riboflavin (B2), L-carnitine, niacin, and biotin. Thiamin (B1), riboflavin (B2), niacin (B3), pantothenic acid (B5), biotin, and alpha-lipoic acid are required for carbohydrates and proteins to enter the Krebs cycle in the mitochondria.

Within the Krebs cycle, cysteine and iron are needed to convert cis-aconitate to isocitrate. Niacin, magnesium, and manganese are required to convert isocitrate into alpha-ketoglutarate. The amino acids glutamine, histidine, arginine, proline and glycine are needed to form alpha-ketoglutarate. Thiamin, riboflavin, niacin, pantothenic acid, and alpha lipoic acid, are needed to convert alpha-ketoglutarate into succinyl-CoA. The amino acids isoleucine, valine, and methionine are needed to form succinyl-CoA. Magnesium is required to convert succinyl-CoA into succinate. Riboflavin is required to convert succinate into fumarate. The amino acids tyrosine and phenylalanine are needed to form fumarate. Niacin is required to convert malate into oxaloacetate.

All these nutrients are required to produce 36 units of ATP per molecule of acetyl CoA in the Krebs cycle. A significant deficiency of any of these key nutrients can cause mitochondrial dysfunction and contribute to fatigue and depression.

Niacin and coenzyme Q10 are required for oxidative phosphorylation (electron transport chain, or ETC). Normally, the ETC produces another 3 units of ATP in the mitochondria in addition to the Krebs cycle's 36. A significant deficiency in either of these can also reduce ATP production and contribute to a physiologic depression.

Mitochondrial dysfunction is often overlooked in the treatment of PPD. A study done with postpartum women showed that a comprehensive postnatal nutrient program, including many of the Krebs cycle/oxidative phosphorylation nutrients, relieved many postpartum symptoms including mild to moderate PPD.

Liver Detoxification

 

NUTRITION: A FUNCTIONAL APPROACH-Jeffrey Bland, Ph.D

For many centuries, Chinese medicine has correlated liver meridian dysfunction with anger, irritability, and depression. From this perspective, suppressed anger often leads to depression. Concepts such as rising liver heat and stagnant liver Qi are used to depict how faulty liver meridian function could dramatically affect emotional states. When the flow of electrons within a meridian is up or down-regulated, the organ dependant upon that meridian will become dis-eased. Many practitioners of Chinese medicine are taught to consider the liver the "seat of the emotional body" because of this strong correlation of liver dysfunction with negative emotions.

In the Orient the term "hot liver" is used to depict someone who has anger issues. The English use the "liverish" to describe one who is irritable. From a Western medicine point of view, most clinicians are aware how an alcoholic's liver cirrhosis can first cause irritability and eventually depression.

In the past two decades much more information has come to light regarding phase one and phase two liver detoxification pathways. These pathways greatly contribute to the body's ability to excrete exogenous and endogenous toxic chemicals. Environmental toxin levels (xenobiotics) are ever on the rise and require that the liver play a very important role in their excretion.

Added to this burden of detoxification are the internal production of increased stress hormones and other body chemicals that require excretion. All of these chemicals require that the liver have adequate nutrients to facilitate their excretion.

Phase one liver detoxification consists of oxidation, reduction, or hydrolysis. The cytochrome P450 system mixed function oxidases perform the most important beginning function of detoxifying these exogenous and endogenous toxins. Phase I liver detoxification requires an adequate supply of nutrients, enzymes, and antioxidants. This list includes riboflavin, niacin, pyridoxine, folic acid, cobalamin, glutathione, phospholipids, carotenes, vitamin C, bioflavonoids, flavonoids, vitamin E, selenium, copper, zinc, manganese, CoQ10, and nutrients contained in thiols, pycnogenol, and silymarin.

Phase II liver detoxification consists of conjugation pathways in the hepatocytes. Amino acid conjugation (binding) of toxins requires glycine, taurine, glutamine, ornithine, and arginine. Sulfation requires sulfur-bearing amino acids or elemental sulfur. Sulfation is required to break down and package estrogens, DHEA, thyroxine, cortisol, catecholamines, melatonin, ethyl alcohol, bile acids, tyramine, cholecystekinin, cerebrosides and others. Glucuronidation requires magnesium and B6 to break down estrogens, other steroids, melatonin, and many xenobiotics.

Methylation requires B12, B6, and folic acid to break down and eliminate catecholamines, histamine, and many drugs and xenobiotics. Glutathione conjugation helps to detoxify heavy metals and numerous xenobiotics. Glutathione requires glutamate, glycine, and cysteine or N-acetyl-cysteine plus selenium and vitamin C for its formation. Acetylation, another detoxification pathway, requires B2, B5, molybdenum, and vitamin C in order to do its function.Sulfoxidation transforms toxic sulfite molecules into usable sulfates.

Mothers in the U.S have a high toxic burden that is evidenced by the levels of toxins in mother's milk. (55) If the liver is too burdened and unable to perform its many tasks of detoxification, this may contribute to PPD.

Omega-3 Fatty Acid Deficiencies and PPD

A deficiency of omega-3 fatty acids has been linked with depression. (56-59) Numerous studies have demonstrated the efficacy of fish oil supplementation in depression. (60,61)

The human brain is 60% fat. The quality of fats that compose neurons significantly influence brain function including moods. A relative deficiency of flexible omega-3 fatty acids compared to the more rigid omega-6, saturated, and cis-trans fatty acids impairs the function of cell membranes and their ability to selectively allow passage of molecules in and out of neurons. The brain is composed of and uses more fatty acids than any other body structure. DHA – referred to by Allport as the "queen of fats" (62) – is responsible for the fastest cellular movements. As the primary structural and cognitive fat of the brain, DHA also affects moods.

A developing fetus' brain, nerves, eyes, skin, and cellular membranes all require omega-3 oils, especially DHA. The placenta selectively removes omega-3 oils from the mother's blood stream via the placenta often leaving the mother significantly deficient in these essential oils. (63,64). The recommended dose for omega-3 fish oils when treating PPD is 6-12 grams per day.

Hypericum perforatum (St. John's Wort):

Over twenty-five double-blind studies have shown the herb St. John's Wort to produce as good or better results compared to SSRI drugs with significantly fewer side effects. (65-71) In Germany, where hypericum is a prescription drug and covered by insurance, over 20,000,000 take this herb for depression. One of the benefits of taking St. John's Wort is an increase of serotonin. (72)

SAMe (S-adenosylmethione):

SAMe is a methyl donor in the production of monamines, neurotransmitters, and phospholipids such as phosphatidylserine and phosphatidylcholine. SAMe serves as a precursor for glutathione, coenzyme A, cysteine, taurine, and other essential compounds. SAMe is involved in converting methionine into sulfur and is important in homocysteine metabolism.

When compared with other antidepressants, SAMe tend to work faster and more effectively with virtually no negative side effects. In fact, SAMe has beneficial side effects including improved cognition, slowing of the aging process, improved joint function and less pain, and liver protection. (73)

Normally the brain synthesizes adequate SAMe from the amino acid methionine. Supplementing SAMe in depressed patients increases serotonin and dopamine levels, improves membrane fluidity, and improves the binding of neurotransmitters to receptor sites (74,75). Numerous double-blind studies demonstrate the efficacy of SAMe for depression. (76-78) The suggested dose of SAMe to treat depression ranges from 400-1600 mg a day.

Inositol

Depressed patients have lower brain levels of inositol. (79) Inositol is useful in maintaining healthy serotonin metabolism, and by doing so helps treat many conditions like depression, agoraphobia, panic disorder (80-82), and obsessive compulsive disorder (83).
Research shows that taking 6-12 grams of inositol per day for 4 weeks significantly improves mood and reduces the severity of depression. (84-86) Inositol can be safely used with antidepressant medications. (87)

L-Theanine

L-theanine is known to increase levels of GABA and has an anti-anxiety effect as well as improving cognitive function. (88) L-theanine may also normalize dopamine levels which are often depleted by various stresses. (89) L-theanine significantly reverses glutamate-induced toxicity. (90)

 

Integrating High Quality, High Potency Prenatal and Postnatal Nutrient Systems into Preventing and Treating Postpartum Depression and Anxiety 

 

Clinically it is imperative that higher quality, higher potency, more comprehensive prenatal an postnatal nutrient systems be utilized in the treatment and prevention of postpartum depression. It is common knowledge in many 3rd world countries that the postpartum recovery period is 24 months because this is the amount of time women are told to wait between pregnancies to replenish their bodies and avoid many postnatal health problems. These women have more community and extended family support too which significantly reduces the incidence of PPD.

Most prenatal vitamin supplements are inadequate to fully supply developing baby and mother with the potency and quality of nutrients required to fuel pregnancy and the postpartum periods. These are highly nutrient dependent process.
A randomized, double-blind, placebo-controlled clinical trial done on a comprehensive postnatal nutrient program called After Baby Boost showed excellent results, improving 14 common postpartum symptoms including postpartum depression, anxiety, insomnia and mood swings. Parameters measured were breast tenderness, concentration, cramping, depression, dizziness, fatigue, headaches, insomnia, irritability, joint inflammation and pain, mood swings, nervousness, palpitations, sweating, temperature changes (hot or cold), vaginal dryness, and water retention.

After Baby Boost contains high-potency vitamins and minerals including CoQ10, alpha lipoic acid, 2 grams of fish oils with 3 antioxidants to prevent rancidity, and nighttime minerals (calcium and magnesium citrate). The placebo used was a leading prenatal vitamin.

After Baby Boost significantly outperformed the prenatal vitamin in all 14 symptom categories, indicating that most postpartum women require more comprehensive, higher potency nutrient replenishment than prenatal vitamins provide. (91)

Obstetricians rarely stress the importance of a high-quality, nutrient dense diet. Nor do they prescribe high quality prenatal vitamins.  Women are often told, "you are eating for two now, so eat whatever you want." In actuality, only 300 extra calories are needed per day during pregnancy. It is important that these be nutrient-dense calories. Unrestricted eating of carbohydrates contributes to obesity and can contribute to metabolic diseases including physiologic depression and even, diabetes of pregnancy.

Integrative PPD Treatment

It is hoped that the reader becomes more aware of this simple concept: A baby's body is entirely composed of the nutrients donated by its mother's body. Because all physiologic processes and chemicals (neurotransmitters, hormones, metabolic pathways, etc.) are nutrient dependent, nutritional deficiencies can often be the fundamental cause of PPD. While antidepressant drugs are necessary for some, the longer-term solution often requires a well-thought-out integrative approach that includes (1) replenishing nutritional reserves through dietary supplements,(2) psychotherapy and/or  childbirth/PTSD therapies such as EMDR, (3)adequate sleep (often very difficult with a new infant), (4) moderate exercise, (5) deep belly breathing/meditation, (6) community support, (6) a nutrient dense diet, and (7) drug therapy when necessary

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About the Author

Dr. Dean Raffelock D.C., L. Ac., CCN, DACBN, DIBAK has been a clinical nutritionist since 1977. He is Vice President of Research and Development for www.soundformulas.com , a nutritional company dedicated to helping pregnant and postpartum women receive optimal nutrition before, during, and after giving birth. He is the formulator of After Baby Boost™ the world's first and only clinically tested comprehensive, postnatal 3 bottle nutrient designed to help new mothers fully replenish the nutrients donated to form their baby's body. He is also the formulator of Before Baby Boost™, the world's first truly comprehensive 3 bottle prenatal vitamin system. He is the lead author of the book A Natural Guide to Pregnancy and Postpartum Health (Avery, 2003). He is President of Sound Formulations, LLC-a consulting company that formulates and manufactures nutritional products for numerous nutriceutical companies. Dr. Raffelock has a multi-disciplinary practice in Boulder, Colorado and may be reached at DrDeanR@soundformulas.com , Soundformulations@gmail.com. 

 

Hyla Cass, M.D. is a board-certified psychiatrist, former Assistant Clinical Professor of Psychiatry at UCLA School of Medicine, and author of several books, including Natural Highs, 8 Weeks to Vibrant Health, and Supplement Your Prescription. A member of the Medical Advisory Board of the Health Sciences Institute and Taste for Life Magazine, she is also Associate Editor of Total Health and served on the board of California Citizens for Health. Dr. Cass has also served as president of Vitamin Relief USA (www.vrusa.org). She has a clinical practice of integrative medicine and psychiatry in Pacific Palisades, CA. For more information, see her website: www.drcass.com.

Psychiatry $46.23 Part of the National Medical Series (NMS), this book provides a quick review of clinical Psychiatry with USMLE-style (vignette) questions for self-study and assessment. Features include 500 USMLE-style questions in vignette format, a comprehensive exam, and a convenient outline format. This updated edition will include the latest medications, treatment protocols, evidence-based practice guidelines, and revised diagnostic criteria using DSM-IV-TR. New to this edition will be an expanded focus on geriatric psychiatry and emergency psychiatry, as well as traumatic brain injury.

The Medical Basis of Psychiatry $229 The Medical Basis of Psychiatry

100 Cases in Psychiatry $38.71 The 100 Cases series books are a popular learning and revision tool that work by guiding the reader through each clinical case in a highly structured manner. Each scenario provides details of the patient's medical history and the key findings of a clinical examination, together with initial investigation results data for evaluation. Key questions then prompt the reader to evaluate the patient, and reach a decision regarding their condition and the possible treatment plan; while the answer pages reveal the processes a clinician goes through in such situations. The volumes are designed with the student in mind, and include features to aid self-directed learning, clinical reasoning and problem-solving. The format is suitable for general self-assessment as part of exam revision, for swotting up before psychiatry OSCEs, and for junior doctors about to start a rotation in the psychiatry ward. 100 Cases are particularly relevant for students on problem-based learning courses. 100 Cases in Psychiatry covers a wide range of topics such as phobias, bereavement, and paranoia, across the following subject areas: Adult Psychiatry, Older People, Forensic Psychiatry, Child and Adolescent Psychiatry and Learning Disability Psychiatry.

Philosophy, Psychology and Psychiatry $81.25 Philosophy of mind as traditionally understood has rarely engaged directly with psychology and psychiatry. This collection establishes the importance of this interdisciplinary approach and explores new directions in the philosophy of psychiatry and psychology. The essays are by a distinguished group of contributors whose interests and expertise embrace the cognitive, biological and medical sciences as well as the social sciences and humanities. They address questions such as what establishes personality or personal identity? how should insanity, or sanity, be defined? and what is consent? Author: Griffiths, A. Phillips Series Title: Royal Institute of Philosophy Supplements Series Number: 37 Binding Type: Paperback Number of Pages: 252 Publication Date: 1995/03/30 Language: English Dimensions: 8.98 x 6.34 x 0.60 inches

History of Psychiatry and Medical Psychology $286 As a discipline, psychiatry has always walked a fine if not easily defined line between social and biological science. This title traces this evolution in its social, political, and philosophical contexts, charting the rise of psychology as a legitimate field of scientific pursuit, and of psychiatry as a medical specialty.

Psychiatry (2nd Edition) $79.57 Updated, revised, and reorganized, the new Second Editions of the Clinical Sciences Series reflect the format of the USMLE Step 2. Each volume systematically presents the core information of a single segment of the medical curriculum, from Family Medicine to Psychiatry. You will also learn timehonored tricks of the trade, as well as the latest advances in clinical medicine: new diagnostic tools, new therapeutic interventions, and new pharmacologic options. Author: Shaffer, L. Blaine/ Shaffer, Blaine/ Oklahoma Notes Series Title: Oklahoma Notes Binding Type: Paperback Number of Pages: 260 Publication Date: 1996/05/29 Language: English Dimensions: 10.95 x 8.49 x 0.61 inches

Psychiatry: PreTest Self-Assessment and Review $36.7 The student tested-and-reviewed way to prep for the psychiatry shelf exam and the USMLE Step 2 CK "I found the book very thorough and an overall good resource for a psychiatry rotation and USMLE Step 2 presentation. I already have recommended this book to my classmates and friends." -- Joshua Lynch, Medical Student, Lake Erie College of Osteopathic Medicine " I think this text stands up to the expectations of medical students who depend on PreTest as a study aid during preparation for exams." -- Edward Gould, Medical Student, SUNY Upstate Medical University "Praise for the last edition: " "The Pretest Series is widely used in preparing medical students for the clerkship shelf exams and the USMLE, and this psychiatry edition is, overall, quite good. The content is thorough, the questions concise, and the answers explained well. For those students who prefer to study using question-and answer type review books, this should fulfill their needs. It is nice to see an updated edition of this ever popular review book. 4 Stars "--"Doody's Review Service" "Psychiatry: PreTest Self-Assessment & Review" is the perfect way to assess your knowledge of psychiatry for the USMLE Step 2 CK and shelf exams. You'll find 500 USMLE-style questions and answers that address the clerkship's core competencies along with detailed explanations of both correct and incorrect answers. All questions have been reviewed by students who recently passed the boards and completed their clerkship to ensure they match the style and difficulty level of the exam. 500 USMLE-style questions and answers Detailed explanations for right and wrong answers Targets what you really need to know for exam success Student tested and reviewed "Psychiatry: PreTest Self-Assessment & Review" is the closest you can get to seeing the test before you take it. Great for clerkship and the USMLE Step 2 CK "Psychiatry: PreTest" asks the right questions so you'll know the right answers. Open it and start learning what's on the test.

Humanizing Psychiatrists: Toward a Humane Psychiatry $27.91 The long-awaited final installment of the Biocognitive Model Series "Humanizing Psychiatists" is the third of a series directed at developing the Biocognitive Model of Psychiatry as the replacement for the three nineteenth century models of mental disorder, psychoanalysis, behaviorism and biological psychiatry. In this volume, the author continues to explore the logical status of theories used in psychiatry. He shows that Dennett's functionalism and Searle's biological naturalism cannot be used as the basis for a theory for biological psychiatry. He argues that phenomenology is a valuable technique but can never form a genuine theory. in addition, he shows how orthodox psychiatry uses its publishing industry to suppress criticism of itself, which is a gross breach of scientific ethics. He then shows how his Biocognitive Model of Mind can be applied to clinical practice with dramatic results. Praise for Niall McLaren's Biocognitive Model of Mind "This book is a tour de force. It demonstrates a tremendous amount of erudition, intelligence and application in the writer. It advances an interesting and plausible mechanism for many forms of human distress. It is an important work that deserves to take its place among the classics in books about psychiatry." --Robert Rich, PhD, AnxietyAndDepression-Help.com "Dr. McLaren brilliantly wields the sword of philosophy to refute the modern theories of psychiatry with an analysis that is sharp and deadly. His own proposed novel theory could be the dawn of a new revolution in the medicine of mental illness." --Andrew R. Kaufman, MD Chief Resident of Emergency Psychiatry Duke University Medical Center About the Author Niall McLaren, M.D. is a psychiatrist practicing in Darwin, in the far north of Australia. He has long had an interest in the philosophical and logical status of theories used in psychiatry.His work is radical in the extreme but he sees no option if psychiatry is to move beyond its present status as an ideology and finally into the realm of the sciences. For more information please visit www.NiallMcLaren.com

Psychiatry in Medical Practice $40.04 This fully updated third edition of Psychiatry in Medical Practice takes into account major changes in medical education since 1994. New sections provide information on problem-based learning and observed structured clinical examinations. Divided into four sections, this book covers: clinical approaches to the patient syndromes of disorder disorders related to stages of the life cycle services, ethics and the law. As well as retaining the key features of the previous editions, this book includes two brand new chapters on risk assessment and the Mental Health Service. A handy portable reference card is also included; this has been updated to incorporate a scale for assessing cerebral impairment in the elderly, and a new assessment of suicidal risk scale. This highly practical book is an essential guide for all medical students and doctors in training who are involved with psychiatry. It is also a useful reference tool for those who are more experienced in the field.

Core Clinical Cases in Psychiatry (Paperback) $43.34 You`ve read your textbook and your course notes. Now you need to apply your knowledge to real life clinical situations. The problem-solving approach of Core Clinical Cases guides you to think of the patient as a whole, rather than as a sequence of unconnected symptoms. With its emphasis on everyday practice strongly linked to underlying theory, the series integrates your knowledge with the realities of managing clinical problems, and provides a basis for developing sound analytical and confident decision-making skills. The core areas of undergraduate study are covered in a logical sequence of learning activities: the same questions are asked of each clinical case, followed by detailed explanatory answers. Related OSCE counselling cases, with related questions and answers, also feature in each section. Key concepts and important information are highlighted, and the reader-friendly layout reflects exactly the type of question you will encounter, making these volumes the perfect revision aid for all types of case-based examination. The Psychiatry volume, fully revised and updated in this third edition, focuses on the following topics: * Psychosis * Mood disorders * Anxiety disorders * Chronic disorders * Older people * Young people * Psychiatry in general medical settings * Substance misuse * Psychiatry and aggression Volumes in the Core Clinical Cases series remain absolutely invaluable in the run up to clinical, written or OSCE examinations, and ideal course companions for all undergraduate medical students at various stages in their clinical training.

The Neurology and Psychiatry Work-Up $28.94 This new series of pocket-sized books provides practical, how-to guidance for medical students approaching patients for the first time in a new clinical rotation. Each book identifies pertinent positives and negatives in histories and physicals; provides guidance on working up a patient, including appropriate diagnostic studies and procedures; explains the rationale behind clinical decision making; and provides diagnosis-based, evidence-based, high-yield, peer-reviewed journal references. Each book in this series focuses on the important stages or timelines within a specific clinical discipline.

Biological Treatments in Psychiatry (2nd Edition) $165.19 This clear and authoritative textbook describes biological and physical therapies in psychiatry, relating them closely to patient management. A critical evaluation of the literature is provided and the authors considerable experience in clinical practice and research will give the reader a unique insight. All the major biological and pharmacological treatments are covered, including antidepressants and antipsychotics. Both neuropharmacology and problems of diagnosis and response to treatment are fully discussed. Important features are: An uptodate and practical account, ideal for clinicians Electronconvulsive therapy (ECT) and psychosurgery are covered Chapters dealing specifically with drug treatment in children and in the elderly Provides a clear discussion of the scientific background needed for professional examinations in psychiatry (such as MRCPsych) This will be invaluable to psychiatrists in training and its practical approach will be of use to clinicians, consultant psychiatrists who want to ensure that they are aware of recent developments and treatment practices, and clinical psychiatrists. Author: Lader, Herrington/ Lader, Malcolm H./ Herrington, Reginald Series Title: Oxford Medical Publications Binding Type: Hardcover Number of Pages: 464 Publication Date: 1996/01/01 Language: English Dimensions: 9.44 x 6.04 x 1.17 inches

History of Psychiatry and Medical Psychology: With an Epilogue on Psychiatry and the Mind-Body Relation $130.78 This book chronicles the conceptual and methodological facets of psychiatry and medical psychology throughout history. There are no recent books covering so wide a time span. Many of the facets covered are pertinent to issues in general medicine, psychiatry, psychoanalysis, and the social sciences today. The divergent emphases and interpretations among some of the contributors point to the necessity for further exploration and analysis.

Psychology and Psychiatry: Integrating Medical Practice $377.33 In the traditional medical setting, clinical psychology and psychiatry have operated independently, but clinicians now recognise that psychologists and psychiatrists working together can maximise the effectiveness of treatment and improve quality of life for individuals and families. Up to 25 of medical patients present with significant psychological problems and unless practice is integrated, these problems often remain untreated. An integrated practice and training allows clinicians to recognise and treat psychological problems, thereby reducing the economic and social costs associated with such illness. In addition, the input of psychology and psychiatry is now understood to have a role in disease progress and medical management as well as in prevention and health promotion. Compares the disciplines of clinical psychology and psychiatry, and their practice in medical environments Provides a how to and what to expect for clinicians who use the services of psychologists and psychiatrists Forecasts the development and growth of this approach in medical, social and policy contexts Offers professional development guidance to psychologists and psychiatrists working outside the medical arena Author: Milgrom, Jeannette/ Milgrom, Jeanette/ Milgrom Binding Type: Hardcover Number of Pages: 380 Publication Date: 2001/05/16 Language: English Dimensions: 9.12 x 6.00 x 1.07 inches

Rapid Psychiatry $36.95 This pocket guide is a must for all clinical medical students and junior doctors and provides an excellent revision tool in the run-up to exams. It is also perfect for when working on the psychiatric attachment, as it covers many of the conditions encountered on the wards, in clinics, and in general practice. Now thoroughly updated, it includes new sections on Neuropsychiatry, the Psychiatry of Learning Disability, Forensic Psychiatry, and Psychotherapy, as well as common disorders, their assessment and their treatment. Featuring the key points of the Mental Health Act, along with a glossary of terms, Rapid Psychiatry is the ideal refresher, covering just the basic relevant facts.

Forensic Psychiatry $115 Examines the idea of evil in a medical context and a mental health setting. This book attempts to challenge the belief that the concept of evil plays no role in scientific psychiatry and is not helpful to our understanding of aberrant human thinking and behavior. It provides research methods for psychological exploration of the notion of evil.

Psychiatry by Ten Teachers $45 Everything the medical student needs to know about psychiatry, written by ten experts from across the UK.

Psychiatry Finals $39.95 This revision guide contains Extended Matching Questions (EMQs) and Observed Structured Clinical Examinations (OSCEs) that comprehensively cover the major topics in Psychiatry likely to be tested at medical school. It will also be an invaluable resource to those taking other exams such as the PLAB and postgraduate Psychiatry examinations. Part 1 comprises 58 EMQs, divided into 8 chapters, covering questions on mental state examinations, general adult psychiatry, developmental and organic disorders, treatments, and management issues. Most EMQs focus on a particular presentation or issue and are based on clinical vignettes that describe a clinical scenario. Each EMQ is organized as five stems with 10 possible choices and answers to each EMQ are given at the end of each chapter with additional notes clarifying specific options not covered in the questions. Part 2 covers OSCEs, which are based on common clinical scenarios and stations frequently encountered in exams. The 23 questions cover history-taking, communication, and practical stations. Ideal for medical students and junior doctors, this book is intended to complement rather than replace other psychiatry books, and will help students develop a better understanding of the clinical aspects of psychiatry.

Changing American Psychiatry $71 As Medical Director of the American Psychiatric Association from 1974 to 1997, Melvin Sabshin, M.D., brings a unique perspective on the history of post–World War II psychiatry to Changing American Psychiatry: A Personal Perspective.

A Historical Dictionary of Psychiatry $52.95 A historical dictionary of psychiatry. It covers the subject from autism to Vienna, and includes the key concepts, individuals, places, and institutions that have shaped the evolution of psychiatry and the neurosciences, from their origin. It is suitable for students of medical history.

Oxford Handbook of Psychiatry [With Emergencies in Psychiatry] $104.22 The Oxford Handbook of Psychiatry and Emergencies in Psychiatry pack represents excellent value. The combination of practical advice and background information with an easily accessible guide in emergencies presents a unique package essential to every doctor with an interest in psychiatry. The Oxford Handbook of Psychiatry provides comprehensive coverage of all major psychiatric conditions and sub-specialties. It is aimed at psychiatric trainees and medical students studying psychiatry, trainees entering individual psychiatric sub-specialties, consultant psychiatrists, general practitioners, and other healthcare professionals who come into contact with psychiatric patients. It provides detailed and practical advice on the management of psychiatric disorders, in-depth coverage of psychiatric assessment, psychopathology, evidence-based practice, mental health and capacity legislation in the British Isles, difficult and urgent situations, transcultural psychiatry, and therapeutic issues. The new edition features a completely updated legal section with coverage of the new English mental health act, updated coverage of the Scottish mental health act, and new coverage of incapacity legislation in England, Wales, and Scotland, a completely updated section on schizophrenia, and the addition of new drugs and new clinical guidances from recognized institutions such as NICE. It also includes specialist chapters on learning disabilities, psychotherapy, and child psychiatry reviewed and revised by specialist registrars currently working in the fields. This book is internally cross-referenced and has both key references to important papers and to further information resources. As well as being indexed alphabetically, it is also indexed by ICD-10/DSM-IV coes, and there is a quick index for acute presentations. This handbook is practical and directive in style, designed to provide portable reassurance to doctors beginning psychiatry. There is helpful advice for the management of difficult and urgent situations, and the text is peppered with clinical observations on the practice of clinical psychiatry and guidance based upon the experience of the authors. Emergencies in Psychiatry provides a practical and problem-oriented accessible guide for those who have to deal with psychiatric emergencies. This book contains guidance on how to assess and manage these emergencies and how to maneuver successfully through the practical difficulties that may arise, while also avoiding medical, psychiatric, and legal pitfalls. A variety of specific emergencies and emergencies in different settings are covered, such as aggression and violence, victims of abuse, emergencies related to drug addiction, people with learning disabilities, and emergencies in old age age psychiatry and primary care.

Liaison Psychiatry $57 Liaison psychiatry services have the potential to improve pateint care and streamline medical services but are underdeveloped in many European health systems. This book follows on from the 1994 publication 'Liaison psychiatry: defining needs and planning services' and is planned as a practical guide to the development of services for a range of specialist settings. These include service in obstetrics, A&E, intensive care, pain clinics and trauma services. In addition there is guidance on the general principles of developing a case of need for services, and working with purchasers or commissioners of health care. The book will be of particular value to clinicians seeking to develop services in these areas, and those seeking evidence on the value of such services. Features: practical guide to estimating needs and planning services for aspects of general hospital psychiatry; comprehensive assessment of evidence from the existing literature; and how best to make a case of needs to purchasers/commissioners of health care.

Correctional Psychiatry $269.24 Author: Rosner, R./ Harmon, R. B./ Rosner, Richard Series Title: Critical Issues in American Psychiatry and the Law Series Number: 6 Binding Type: Hardcover Number of Pages: 324 Publication Date: 1989/03/31 Language: English Dimensions: 9.08 x 6.92 x 0.94 inches

Teaching Psychiatry $86.99 In psychiatry, as in all of medicine, clinicians are frequently involved in training students and residents yet few have themselves been trained in pedagogy. Improving the quality of psychiatric education should both improve the quality of psychiatric care and make the profession more attractive to medical students. Written by a team of international experts with many years of experience, this comprehensive text takes a globally relevant perspective on providing practical instruction and advice on all aspects of teaching psychiatry. It covers learning from undergraduate and postgraduate level to primary medical and community settings, enabling readers to find solutions to the problems they are facing and become aware of potential issues which they can anticipate and be prepared to address. The book discusses curriculum development using examples from around the world, in order to provide trainees with the basic attitudes, knowledge and skills they require to practise psychiatry. Features: Instruction on developing a curriculum for Residency training, teaching interviewing skills, teaching psychotherapy and using new technology Innovative ways of engaging medical students in psychiatry and developing their interest in the specialty, including experience with new types of elective and research options and development of roles for students in patient care Focuses throughout on how to teach rather than what to teach Includes descriptions of workplace-based assessments Discussions of both theoretical and practical perspectives and examples of particular innovations in the field using case studies Presented in a thoroughly readable and accessible manner, this book is a primary resource for all clinicians involved in teaching psychiatry to medical students and trainees.

Adult Psychiatry $131 Blackwell's Neurology and Psychiatry Access Series has been designed to teach the art of diagnosis and treatment of neurologic and mental disease using a rational approach. In this way the trainee specialist can apply both deductive and inductive reasoning to arrive at a diagnosis and formulate a plan for treatment.The Access Series consists of four books:. Child & Adolescent Psychiatry. Adult Psychiatry. Child & Adolescent Neurology. Adult Neurology. It is the goal of this text in the Blackwell Neurology/Psychiatry Access Series to convey not only essential knowledge but also the collected wisdom of its many highly regarded contributors. To achieve the goal of conveying not only knowledge but wisdom, each volume is divided into three sections:. Tools for Diagnosis. Diseases and Disorders. Common Problems. Also included to facilitate a physician's use of this book are:. Nosologic Diagnosis tables. ''Pearls and Perils'' boxes. ''Consider Consultation When''. Selected annotated bibliographies. A complete bibliography. Key Clinical Questions and What They Unlock. The Nosologic Diagnosis tables are based on a discriminator model to promote clearer understanding and are superior to a criterion-based model and others that lack similar specificity. This strong emphasis on differential diagnosis and on providing a structure for the understanding of the disease process means that they are true ''how to do it'' books.

Manual of Psychiatry $27.92 MANUAL OF PSYCHIATRY EDITED BY AARON J. JROSANOFF, M. D. Clinical Director, Kings Park State Hospital, N. Y. Lieutenant Colonel. Officers 9 Section, Medical Reserve Corps, U. S. Army FIFTH EDITION. REVISED AND ENLARGED NEW YORK JOHN WILEY SONS, INC. LONDON CHAPMAN HALL, LIMITED 1920, 19O5, 19O8, 1911, 1916, 192O, BY A. J. ROSANOFF RAUNWORTH CO. OOK MANUrACTURKRfl BROOKLYN. N. V. LIST OF CONTRIBUTORS J. ROGUES DE FURSAC, M. D., formerly Chief of Clinic at the Medical Faculty of Paris, Physician in Chief of the Public Insane Asylums of the Seine Department. Chapters or sections dealing with symptomatology, general therapeutic indications, epilepsy, dementia prsecox, paranoia, manic-depressive psychoses, involutional melancholia, acute and chronic alcoholism, drug addictions, genera 1 paralysis, deliria of infectious origin, psychoses of exhaustion, uraemic delirium, myxoedema and cretinism, and senile dementia. AARON J. ROSANOFF, M. D., Clinical Director, Kings Park State Hospital, N. Y., Lieutenant Colonel, Medical Section, Office Reserve Corps, U. S. Army. General editorial responsibility also chapters, sections, or appendices dealing with etiology, history taking, methods of examination, special diagnostic procedures, psychotherapy, psy choanalysis, prognosis, prevalence of mental disorders, pro phylaxis, medico-legal questions, extramural psychiatry, arrests of development, constitutional psychopathic states, psychoneu roses, Huntingtons chorea, cerebro-spinal syphilis, cerebral arteriosclerosis, traumatic psychoses, hyperthyroidism, organic cerebral affections, Wassermann reaction, association test. H. L. HOLLINGWORTH, Ph. D., Associate Professor of Psychology, Columbia University.Chapters or appendices dealing with applications of psychology in psychiatry, normal course of mental development, and standard psychological group tests. Miss MART C. JARRETT, Associate Director, Smith College School for Social Work formerly Chief of Social Service, Boston Psychopathic Hospital. Chapter dealing with applications of sociology in psychiatry. CLARENCE A. NEYMANN, M. D., Superintendent, Cook County Psychopathic Hospital, Chicago. Appendix dealing with lumbar puncture, cell count, and chemical tests of cerebro-spinal fluid. iii PREFACE TO THE FIFTH EDITION IN the course of the World War unprecedented oppor tunities enabled psychiatry to make great strides. The movement for mental hygiene is developing direction, organization, and force. Psychiatrists no longer confine their activities within the walls of institutions for the insane, but are constantly organizing connections with general hospitals, schools, charitable organizations, courts of law, penal institutions, etc. In the endeavor to keep this MANUAL abreast of progress and to maintain its usefulness to the student of psychiatry numerous changes and additions have been made in pre paring the present edition. New chapters, sections, or appendices, dealing with the following subjects, have been added

Blueprints Psychiatry $23.42 Part of the highly regarded Blueprints series, Blueprints Psychiatry provides students with a concise review of what they need to know in their psychiatry rotations or the Boards. Each chapter is brief and includes pedagogical features such as bolded key words, tables, figures, and key points. A question and answer section at the end of the book includes 100 board-format questions with complete rationales. This edition includes new images, more USMLE study questions, and a Neural Basis section for each major diagnostic category. A companion Website includes a question bank and fully searchable text.

Massachusetts General Hospital Handbook of General Hospital Psychiatry: Year Book Handbooks Series $3.94 Recognized as the "gold standard" in consultation psychiatry, the newest edition of this handbook is an authoritative, compact, and affordable resource for psychiatrists, residents, and non-psychiatric medical staff. Written by members of the prestigious MGH Department of Psychiatry, it contains practical advice and strategies for diagnosing and treating the most common psychiatric problems seen in the general hospital setting. For the psychiatrist, it remains a practical guide to cognitive, behavioral, and psychopharmacological tools needed to diagnose patients and to advise non-psychiatrists. For the primary care provider, it provides basic psychiatric information to assist in care of medical patients under psychiatric care or who have a psychiatric dimension to their illness.

Psychiatry (Paperback) $102.87 "This book is very different from any medical textbook you`ve ever read… its greatest merit is to have single-handedly transformed the perception of psychiatry from that of Cinderella speciality to that of hottest speciality on offer." Following in the footsteps of the groundbreaking first edition, this second edition of Psychiatry is a comprehensive textbook of mental health that brings its subject alive with numerous case studies, images and photographs, and short references from the arts, history, and philosophy. These not only facilitate learning and memorisation, but also highlight the subjective experience of mental illness, and stimulate thought into the nature of the human experience. Based on extensive feedback from students and lecturers, this second edition places greater emphasis on psychological treatments, clinical skills, and exam success, and integrates more than 350 self-assessment questions. Other important features include: A clear and attractive layout with colour coding and colour images and photographs Learning objectives, boxed summaries, and self-assessment questions in every chapter Step-by-step coverage of the psychiatric history, mental state examination, and formulation, with an integrated account of the signs and symptoms of mental disorders and a model case history Clinical skills/OSCE boxes on competencies such as enquiring about delusions and hallucinations, assessing suicidal risk, and assessing capacity Greater coverage of psychiatric subspecialties An expanded chapter on the history of psychiatry with introductions to Freud and Jung Psychiatry is the perfect textbook for medical students, junior doctors, GPs, and all healthcare professionals needing a thorough account of mental disorders.

PUSHBUTTON PSYCHIATRY $34.95 This volume uncovers the roots of electroshock in America, an outgrowth of western patriarchal medicine with primarily female patients. The authors trace the history of electroshock in the United States in three historic stages: from an enthusiastic reception in 1940, to a period of crisis in the 1960s, to its resurgence after 1980. Early American experiments with electrical medicine are also examined, while the development of electroshock in America is considered through the lens of social, political, and economic factors. The revival of electroshock in recent decades is found to be a product of growing materialism in American psychiatry and the political and economic realities of managed medical care. The new material in the Updated Paperback Edition describes the resurgence of electroshock in the private psychiatric sector as a treatment of choice for depression.

Psychiatry in Prisons $49.95 Psychiatry in Prisons provides a comprehensive overview of the history, problems and development of psychiatric health care in prisons, focusing particularly on the UK. The contributors tackle a broad range of issues, from familiar mental health issues such as substance misuse, self-injury and health screening to complex legal, moral and philosophical dilemmas. It also draws comparisons with the US correctional mental health system and the delivery of mental health services in New Zealand prisons. This comprehensive guide is an indispensible resource for psychiatrists, psychiatric nurses, prison medical officers, probation officers, prison discipline staff and any other professionals concerned with mental health care in custodial settings.

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