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Rapid Response of Major Depressive Disorder and Comorbid Eating Disorder NOS to a Novel Meditation Intervention
Letters to the Editor Davin Quinn, M.D. Department of Psychiatry, University of New Mexico School of Medicine Elizabeth Kuchler, R.N., M.S.N., F.N.P New Mexico Department of Health, Las Cruces Paulina Deming, Pharm.D. University of New Mexico Health Sciences Center, College of Pharmacy, Project ECHO Sanjeev Arora, M.D. University of New Mexico Health Sciences Center, Project ECHO
Disclosure statement: The authors report no financial and personal relationships with other people or organizations that could potentially and inappropriately influence (bias) their work and conclusions.
References
1. Dieperink E, Willenbring M, Ho SB: Neuropsychiatric symptoms associated with hepatitis C and interferon-␣. Am J Psychiatry 2000; 157(6):867– 876 2. Adams F, Quesada JR, Gutterman JU: Neuropsychiatric manifestations of human leukocyte interferon therapy in patients with cancer. JAMA 1984; 252(7):938 –941 3. Brok J, Gluud LL, Gluud C: Ribavirin plus interferon versus interferon for chronic hepatitis C. Cochrane Database Syst Rev 2005; 20(3):CD005445 4. Adams F, Fernandez F, Mavligit G. Interferon-induced organic mental disorders associated with unsuspected preexisting neurologic abnormalities. J Neuro Onc 1988; 6(4):355–359 5. “PegIntron” [Package insert]. Whitehouse Station, NJ: Merck and Co, Inc; 2011
Rapid Response of Major Depressive Disorder and Comorbid Eating Disorder NOS to a Novel Meditation Intervention TO THE EDITOR: Recently, there has been increasing interest in applying mind-body techniques, such as meditaPsychosomatics 53:4, July-August 2012
tion, to the treatment and prevention of mood disorders.1–3 Below, we present the first case of rapid response of chronic major depressive disorder (MDD) and remission of comorbid eating disorder NOS (ED-NOS) with an adjunctive, novel meditation intervention. Case Report Ms. G, a 63-year-old, divorced Lebanese female, on SSDI for depression, had a history of chronic, recurrent MDD (DSM-IV criteria) with three episodes since 2002, each lasting several months to years, and ED-NOS (consisting of recurrent binge eating.) Her most recent episode began in 2008, when, in the setting of relationship difficulties, she not only suffered depressed mood, insomnia, low interest and energy, difficulty concentrating, and increased anxiety, but also began to binge on food when extremely upset or anxious. Her binges led to the point that she felt bloated and had abdominal pain and cramping. These symptoms resulted in her obtaining both upper and lower endoscopies as well as an abdominal CT scan, which were unremarkable and thought to be consistent with “functional disease.” Binges occurred at least two or three times weekly, and resulted in a weight gain of approximately 11 pounds, from 140 to 151 (height 5=5==). There was no purging. Past psychotherapy trials included cognitive-behavior therapy for 3 months in 2008 with no response. Medication trials included fluoxetine and escitalopram, both with partial response. When meditation training began, she had been on a stable regimen of citalopram 30 mg per day, and trazodone 100 mg at night as needed for insomnia, for two years, with partial response in mood but no improvement in eating disorder symptoms. Ms. G continued to take the same medications throughout meditation training. At the initiation of therapy, her
Clinical Global Impression–Severity4 (CGI-S) score was 4 and Patient Health Questionnaire 95 (PHQ-9) score was 9. In once-weekly psychotherapy, Ms. G was first taught a standard mindfulness meditation breathing practice, in which she was directed to attend to her breath with moment to moment non-judgmental awareness, and to allow any passing thoughts to rise and fall. Although this practice “relaxed” her, she did not do it at home, nor did her symptoms improve. She was then taught a novel meditation exercise (developed by F.A.J.) consisting of creating a miniature mental image of herself in real-time, including her thoughts and feelings, placing that image in the center of her axial body, and attending to it with total acceptance. She was advised to regard this image compassionately. The metaphor of a Russian matryoshka nesting doll was utilized to help her understand the concept. This meditation exercise was performed for 15 minutes, and she described an immediate positive response of “self-love” to it. She was provided with a CD record of the meditation for homework practice. Three weeks later, she reported that she did this exercise 5 to 6 days a week for at least 15 minutes, and it had made her feel “strong” and “grounded.” Her self-rated feelings of depression and neurovegetative symptoms improved by 75%. Binge eating behaviors remitted. At the 3-month follow-up, CGI-S declined to 2, and PHQ-9 to 4, with predominant residual feeling of loneliness. She continued with the meditation about five times a week. This case suggests rapid efficacy of a novel meditation intervention for depressive symptoms and eating disorder behaviors. Possible mechanisms of action include increased self-compassion, behavioral activation, enhancement of function of the observing ego (ego psychology perspective), or relatwww.psychosomaticsjournal.org
401
Letters to the Editor ing to the self as a whole object instead of through split part objects (objectrelationships perspective). However, multiple possible nonspecific effects, including placebo or transference, limit the generalizability of the results. Systematic study of the utility of meditation techniques such as this for mood and eating disorders appears warranted. Felipe A. Jain, M.D. Michael Gitlin, M.D. Helen Lavretsky, M.D. Department of Psychiatry UCLA Semel Institute for Neuroscience and Human Behavior Resnick Neuropsychiatric Hospital Los Angeles, CA, USA
References
1. Freeman MP, Fava M, Lake J, Trivedi MH, Wisner KL, Mischoulon D: Complementary and alternative medicine in major depressive disorder: the American Psychiatric Association Task Force report. J Clin Psychiatry 2010; 71(6):669 – 681 2. Barnhofer T, Crane C, Hargus E, Amarasinghe M, Winder R, Williams JM: Mindfulness-based cognitive therapy as a treatment for chronic depression: a preliminary study. Behav Res Ther 2009; 47(5):366 –373 3. Eisendrath SJ, Delucchi K, Bitner R, Fenimore P, Smit M, McLane M: Mindfulnessbased cognitive therapy for treatment-resistant depression: a pilot study. Psychother Psychosom 2008; 77(5):319 –320 4. Clinical Global Impressions. In: Guy W, Ed. ECDEU Assessment Manual for Psychopharmacology, revised. Rockville MD: National Institute of Mental Health; 1976. pp. 218 –222 5. Kroenke K, Spitzer RL, Williams JB: The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001; 16(9):606 – 613
Deciphering the Branding of Legal Highs: Naphyrone Sold as Glass or Jewelry Cleaner Patients presenting under the influence of various psychoactive sub402
www.psychosomaticsjournal.org
stances referred to as “legal highs” has become commonplace in emergency departments over the past 18 months. The leading edge of this phenomenon was the availability of synthetic cannabinoid agonists sold under exotic brand names such as Spice or K2. Psychoactive bath salts containing cathinone derivatives (including mephedrone, 3,4-methylenedioxypyrovalerone [MDPV], and methylone) followed next. Possession of these substances has since been made illegal under the emergency scheduling authority of the Drug Enforcement Administration. Now, another legal high, this time marketed as “glass cleaner” or “jewelry cleaner,” has emerged to fill the vacuum. As with prior legal highs, information in the professional literature is lagging far behind that available in the popular media. When bath salts first surfaced in the United States, clinicians had little available guidance. Once the active agents were identified, a plethora of data from the United Kingdom (where they had instead been marketed as plant food) could be applied to the management of patients. The lag inherent in professional publication dramatically delayed the dissemination of important clinical information (i.e, that bath salts are, in fact, cathinone derivatives). The first popular media reference connecting the term bath salts to cathinone derivatives occurred in June 2009.1 The website of the National Institute on Drug Abuse only published this information in February 2011.2 The first article searchable on PubMed that linked bath salts and cathinone derivatives did not appear until May 2011,3 with more articles subsequently published, with most appearing only after the substances were already banned.
The popular media is now reporting on the emergence of “glass cleaner” or “jewelry cleaner” as the newest available designer drug. One enterprising local news station took a sample of the drug to their county medical examiner for analysis, discovering naphthylpyrovalerone (naphyrone) as the primary agent.4 Naphyrone is a very lipophilic -ketoamphetamine that blocks monoamine transport with a potency 10 times that of cocaine.5 Again, the experience of the United Kingdom (where the substance was sold as “pond cleaner” or “NRG-1” before being banned in 2010)5 is likely to be helpful to clinicians elsewhere in the world, but only if the information connecting the street and chemical names can be rapidly disseminated. Unfortunately, extrapolating from our experiences with bath salts, this might not occur broadly until July of 2013. Jason P. Caplan, M.D. Chair of Psychiatry Creighton University School of Medicine at St. Joseph’s Hospital and Medical Center Phoenix, AZ
Disclosure: The authors disclosed no proprietary or commercial interest in any product mentioned or concept discussed in this article.
References
1. Jackson P: High, above the law. BBC News Magazine, 2009, June 24. Retrieved from http://news.bbc.co.uk/2/hi/uk_news/ magazine/8098157.stm. Accessed from December 9, 2011 2. Volkow ND: Message from the Director on “Bath Salts”– emerging and dangerous products. National Institute on Drug Abuse. Retrieved from http://www. drugabuse.gov/about/welcome/Message BathSalts211.html. Accessed from December 9, 2011
Psychosomatics 53:4, July-August 2012
Disclosure statement: The authors report no financial and personal relationships with other people or organizations that could potentially and inappropriately influence (bias) their work and conclusions.
References
1. Dieperink E, Willenbring M, Ho SB: Neuropsychiatric symptoms associated with hepatitis C and interferon-␣. Am J Psychiatry 2000; 157(6):867– 876 2. Adams F, Quesada JR, Gutterman JU: Neuropsychiatric manifestations of human leukocyte interferon therapy in patients with cancer. JAMA 1984; 252(7):938 –941 3. Brok J, Gluud LL, Gluud C: Ribavirin plus interferon versus interferon for chronic hepatitis C. Cochrane Database Syst Rev 2005; 20(3):CD005445 4. Adams F, Fernandez F, Mavligit G. Interferon-induced organic mental disorders associated with unsuspected preexisting neurologic abnormalities. J Neuro Onc 1988; 6(4):355–359 5. “PegIntron” [Package insert]. Whitehouse Station, NJ: Merck and Co, Inc; 2011
Rapid Response of Major Depressive Disorder and Comorbid Eating Disorder NOS to a Novel Meditation Intervention TO THE EDITOR: Recently, there has been increasing interest in applying mind-body techniques, such as meditaPsychosomatics 53:4, July-August 2012
tion, to the treatment and prevention of mood disorders.1–3 Below, we present the first case of rapid response of chronic major depressive disorder (MDD) and remission of comorbid eating disorder NOS (ED-NOS) with an adjunctive, novel meditation intervention. Case Report Ms. G, a 63-year-old, divorced Lebanese female, on SSDI for depression, had a history of chronic, recurrent MDD (DSM-IV criteria) with three episodes since 2002, each lasting several months to years, and ED-NOS (consisting of recurrent binge eating.) Her most recent episode began in 2008, when, in the setting of relationship difficulties, she not only suffered depressed mood, insomnia, low interest and energy, difficulty concentrating, and increased anxiety, but also began to binge on food when extremely upset or anxious. Her binges led to the point that she felt bloated and had abdominal pain and cramping. These symptoms resulted in her obtaining both upper and lower endoscopies as well as an abdominal CT scan, which were unremarkable and thought to be consistent with “functional disease.” Binges occurred at least two or three times weekly, and resulted in a weight gain of approximately 11 pounds, from 140 to 151 (height 5=5==). There was no purging. Past psychotherapy trials included cognitive-behavior therapy for 3 months in 2008 with no response. Medication trials included fluoxetine and escitalopram, both with partial response. When meditation training began, she had been on a stable regimen of citalopram 30 mg per day, and trazodone 100 mg at night as needed for insomnia, for two years, with partial response in mood but no improvement in eating disorder symptoms. Ms. G continued to take the same medications throughout meditation training. At the initiation of therapy, her
Clinical Global Impression–Severity4 (CGI-S) score was 4 and Patient Health Questionnaire 95 (PHQ-9) score was 9. In once-weekly psychotherapy, Ms. G was first taught a standard mindfulness meditation breathing practice, in which she was directed to attend to her breath with moment to moment non-judgmental awareness, and to allow any passing thoughts to rise and fall. Although this practice “relaxed” her, she did not do it at home, nor did her symptoms improve. She was then taught a novel meditation exercise (developed by F.A.J.) consisting of creating a miniature mental image of herself in real-time, including her thoughts and feelings, placing that image in the center of her axial body, and attending to it with total acceptance. She was advised to regard this image compassionately. The metaphor of a Russian matryoshka nesting doll was utilized to help her understand the concept. This meditation exercise was performed for 15 minutes, and she described an immediate positive response of “self-love” to it. She was provided with a CD record of the meditation for homework practice. Three weeks later, she reported that she did this exercise 5 to 6 days a week for at least 15 minutes, and it had made her feel “strong” and “grounded.” Her self-rated feelings of depression and neurovegetative symptoms improved by 75%. Binge eating behaviors remitted. At the 3-month follow-up, CGI-S declined to 2, and PHQ-9 to 4, with predominant residual feeling of loneliness. She continued with the meditation about five times a week. This case suggests rapid efficacy of a novel meditation intervention for depressive symptoms and eating disorder behaviors. Possible mechanisms of action include increased self-compassion, behavioral activation, enhancement of function of the observing ego (ego psychology perspective), or relatwww.psychosomaticsjournal.org
401
Letters to the Editor ing to the self as a whole object instead of through split part objects (objectrelationships perspective). However, multiple possible nonspecific effects, including placebo or transference, limit the generalizability of the results. Systematic study of the utility of meditation techniques such as this for mood and eating disorders appears warranted. Felipe A. Jain, M.D. Michael Gitlin, M.D. Helen Lavretsky, M.D. Department of Psychiatry UCLA Semel Institute for Neuroscience and Human Behavior Resnick Neuropsychiatric Hospital Los Angeles, CA, USA
References
1. Freeman MP, Fava M, Lake J, Trivedi MH, Wisner KL, Mischoulon D: Complementary and alternative medicine in major depressive disorder: the American Psychiatric Association Task Force report. J Clin Psychiatry 2010; 71(6):669 – 681 2. Barnhofer T, Crane C, Hargus E, Amarasinghe M, Winder R, Williams JM: Mindfulness-based cognitive therapy as a treatment for chronic depression: a preliminary study. Behav Res Ther 2009; 47(5):366 –373 3. Eisendrath SJ, Delucchi K, Bitner R, Fenimore P, Smit M, McLane M: Mindfulnessbased cognitive therapy for treatment-resistant depression: a pilot study. Psychother Psychosom 2008; 77(5):319 –320 4. Clinical Global Impressions. In: Guy W, Ed. ECDEU Assessment Manual for Psychopharmacology, revised. Rockville MD: National Institute of Mental Health; 1976. pp. 218 –222 5. Kroenke K, Spitzer RL, Williams JB: The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001; 16(9):606 – 613
Deciphering the Branding of Legal Highs: Naphyrone Sold as Glass or Jewelry Cleaner Patients presenting under the influence of various psychoactive sub402
www.psychosomaticsjournal.org
stances referred to as “legal highs” has become commonplace in emergency departments over the past 18 months. The leading edge of this phenomenon was the availability of synthetic cannabinoid agonists sold under exotic brand names such as Spice or K2. Psychoactive bath salts containing cathinone derivatives (including mephedrone, 3,4-methylenedioxypyrovalerone [MDPV], and methylone) followed next. Possession of these substances has since been made illegal under the emergency scheduling authority of the Drug Enforcement Administration. Now, another legal high, this time marketed as “glass cleaner” or “jewelry cleaner,” has emerged to fill the vacuum. As with prior legal highs, information in the professional literature is lagging far behind that available in the popular media. When bath salts first surfaced in the United States, clinicians had little available guidance. Once the active agents were identified, a plethora of data from the United Kingdom (where they had instead been marketed as plant food) could be applied to the management of patients. The lag inherent in professional publication dramatically delayed the dissemination of important clinical information (i.e, that bath salts are, in fact, cathinone derivatives). The first popular media reference connecting the term bath salts to cathinone derivatives occurred in June 2009.1 The website of the National Institute on Drug Abuse only published this information in February 2011.2 The first article searchable on PubMed that linked bath salts and cathinone derivatives did not appear until May 2011,3 with more articles subsequently published, with most appearing only after the substances were already banned.
The popular media is now reporting on the emergence of “glass cleaner” or “jewelry cleaner” as the newest available designer drug. One enterprising local news station took a sample of the drug to their county medical examiner for analysis, discovering naphthylpyrovalerone (naphyrone) as the primary agent.4 Naphyrone is a very lipophilic -ketoamphetamine that blocks monoamine transport with a potency 10 times that of cocaine.5 Again, the experience of the United Kingdom (where the substance was sold as “pond cleaner” or “NRG-1” before being banned in 2010)5 is likely to be helpful to clinicians elsewhere in the world, but only if the information connecting the street and chemical names can be rapidly disseminated. Unfortunately, extrapolating from our experiences with bath salts, this might not occur broadly until July of 2013. Jason P. Caplan, M.D. Chair of Psychiatry Creighton University School of Medicine at St. Joseph’s Hospital and Medical Center Phoenix, AZ
Disclosure: The authors disclosed no proprietary or commercial interest in any product mentioned or concept discussed in this article.
References
1. Jackson P: High, above the law. BBC News Magazine, 2009, June 24. Retrieved from http://news.bbc.co.uk/2/hi/uk_news/ magazine/8098157.stm. Accessed from December 9, 2011 2. Volkow ND: Message from the Director on “Bath Salts”– emerging and dangerous products. National Institute on Drug Abuse. Retrieved from http://www. drugabuse.gov/about/welcome/Message BathSalts211.html. Accessed from December 9, 2011
Psychosomatics 53:4, July-August 2012