December 12, 2017

Psychopharmacology in Pregnant & Lactating Women

There is a gap between what experts recommend/current evidence suggests and what we as providers sometimes intuitively practice when it comes to psychotropics in pregnant and lactating women. It is crucial to understand that the primary goal of treatment in pregnancy is to minimize the number of exposures a fetus experiences. We should limit exposure to medication but also illness. Exposure to chemically imbalanced environment of illness has negative impacts on fetus as well. When we discontinue/reduce/ switch an antidepressant or mood stabilizer just before or during pregnancy, we are dramatically increasing a woman’s chances of relapse (60-70% MDD: 80-100% bipolar disorder) and thereby increase the number of times a fetus is exposed to medication and/or illness.

Overall, antidepressant use in pregnancy and lactation appears to be relatively safe for mother and fetus/newborn. Most studies demonstrate low or undetectable blood levels of antidepressant in infant during breastfeeding. Generally we don’t need to discontinue or decrease antidepressants use in women who are attempting to conceive or pregnant as evidence has shown high rates of relapse due to discontinuation and antidepressants have been shown to be relatively safe for use during pregnancy and breastfeeding.

With regards to mood stabilizers, it is recommended not to use valproic acid and carbamazepine during pregnancy, though they are considered safe for breastfeeding. If pregnant women are prescribed these medications, they should be supplemented with high-dose folate. If a pregnant woman is prescribed Lamotrigine, she should keep taking it as prescribed and serum drug levels should be monitored. Pregnant women who have severe Bipolar Disorder and are prescribed Lithium should strongly consider continuing to take it as discontinuation is associated with high risk of relapse. However, for women with significant euthymia and few past mood episodes, the prescriber could consider slowly tapering Lithium and reintroducing after the first trimester. Any pregnant woman kept on Lithium should have her levels closely monitored during pregnancy, though, to avoid perinatal toxicity.

Antipsychotics can be safe to use in pregnancy as long as it is monitored. Patients should be considered to continue on antipsychotics, particularly those with severe mental illness. For pregnant patients on atypicals, monitor glucose and obtain U/S of fetal size in late pregnancy. The one antipsychotic that should be avoided during pregnancy and breastfeeding is Clozapine.
When treating anxiety for pregnant women, benzodiazepines may be prescribed for those with overwhelming anxiety or sleep disturbances as benefits outweigh the risks. It is important to avoid prescribing benzodiazepines before delivery, however. Some alternatives that may be considered are gabapentin and pregabalin.

Reference Articles:
Cohen LS. (2017) Evolving practice in perinatal psychopharmacology: Lessons learned. Clinical Psychiatry News. .

Payne JL., (2017). Psychopharmacology in Pregnancy and Breastfeeding. Psychiatr Clin North Am, 40(2):217-238. doi: 10.1016/j.psc.2017.01.001.

Lingford-Hughes A., Welch S., Peters L., & Nutt D. (2012). BAP updated guidelines: Evidence-based guidelines for the pharmacological management of substance abuse, harmful use, addiction and comorbidity: Recommendations from BAP. Journal of Psychopharmacology, 26(7), 899–952. pmid:22628390.

Dose Related Psychiatric Adverse Effect of Lamotrigine in Management of Bipolar Disorder

Lamotrigine is increasingly being used as an effective maintenance treatment in bipolar disorders to control mood swings. This medication is generally well tolerated with most of its adverse reactions being well documented. However there are some reports of certain psychiatric symptoms associated with the use of Lamotrigine for treatment of mental disorders, but there is a paucity of data to support such findings. Here we discuss the case of a Caucasian female who presented to us with a history of bipolar disorder which was well controlled with Lithium. However the patient was advised to taper the use of Li due to long term Li induced damage to kidneys. She was started on Lamotrigine as an add-on, on a cross taper model. Initially she tolerated Lamotrigine well with mild-moderate physical side effects of nausea, warm flashes and constipation. After the dose was titrated to 100 mg/day of Lamotrigine, the patient demonstrated some psychiatric side effects such as vivid dreams and nightmares, which was resolved on reducing the dose of Lamotrigine to 50 mg/daily. However over the long term, she had a relapse of bipolar symptoms as Lamotrigine seemed not to be tolerated at high enough dose to prevent such a relapse. This case is consistent with some previous reports of occurrence of dose related psychiatric adverse side effect of Lamotrigine.

Read the full article at the following link:

Would Therapy Help Me?

What to Expect with Therapy

  • How does therapy work?     Therapy helps identify the underlying causes of your problems, and gives you effective ways of addressing them. It gives you the opportunity to understand why you feels the way you do, and how to make changes that will assist you in both feeling better and being more functional.
  • What does therapy address?     Therapy addresses all other issues related to your issue, such as causes, emotions, behaviors, impact of relationships (past and current), and your personality style.
  • How long will I attend therapy?     Some patients respond after only a few sessions, others need a little longer. Your therapist will be able to discuss with you the number of visits needed


Confidence in my Therapist

  • Do I have to tell my therapist everything?     You do not need to tell your therapist everything, you only need to talk about what you are comfortable talking about.
  • What if I feel uncomfortable talking about my problems with a stranger?     The therapist understands your discomfort, and will help you feel at ease.
  • Are the things I talk about held in confidence?     Absolutely, therapists are required to maintain confidentiality based on HIPPA regulations.
  • What if I don’t like my therapist?     It’s okay to be honest, and request a different therapist. Your physician, or the practice manager can help make that change confidentially.


Frequently Asked Questions about Therapy

  • Why aren’t medications enough?     Medications only address biochemical issues of your problem, and provide symptomatic relief. Therapy will help you understand the causes of your issue, and help you develop coping skills that aide in recurrence prevention.
  • How will I feel better, faster?     The combination of medication and therapy will help you feel better, faster. Research studies indicate that the fastest, and best patient outcomes are achieved through the combination of medication and therapy.
  • What outcomes should I expect from therapy?     You should expect to be able to successfully manage your symptoms, improve your ability to function, improve your relationships, and have an improved sense of well being.
  • Does my insurance cover therapy?     All major insurance companies offer mental health benefits.


Types of Therapy

  • What is CBT?     CBT stands for Cognitive Behavioral Therapy. It is a form of psychotherapy in which the therapist and the client work together as a team to identify and solve various exaggerations or distortions in thinking caused by a mood state.
  • What is DBT?     DBT stands for Dialectical Behavioral Therapy. It is a combination of individual therapy, and DBT skills training. It combines standard cognitive-behavioral techniques for emotional regulations. It also addresses reality testing with concepts of distress tolerance, acceptance, and mindful awareness. It is largely derived from Buddhist meditative practices, and the Eastern philosophy of mindfulness. It is designed to help emotion regulation difficulties.
  • What is EMDR?     EMDR stands for Eye Movement Desensitization and Reprocessing. It is a therapy used to reduce the effects of traumas. EMDR uses a therapeutic approach that helps you to be less sensitive to trauma triggers and it successfully lowers your response to memories or flashbacks related to traumas
  • What are life groups?     We offer a weekly DBT group that teaches specific life skills, and it also provides an opportunity to talk to others, who are experiencing a similar problem. It offers support and encouragement.


Still Have Questions?

  • Our therapists are available to speak with you if you have any more questions. Simply call the office, and there will be a prompt offering their extensions where you reach their voicemail, and they will return your call.


Knowledge for the Brain…Recommended Reading Material

This is a book list that is helpful for many issues including; anxiety, depression, relationships, anger, and more. Numerous of these books have been recommended by professionals who have suggested them to their clients. They are both fiction and non-fiction depending on your preference.

Spontaneous Happiness – Everyone wants to be happy. But what does that really mean? Increasingly, scientific evidence shows us that true satisfaction and well-being come only from within.

–Andrew Weil, MD


Go Ask Alice – This groundbreaking classic is more compelling than ever for today’s readers. A sensation when it was first published and a perennial best-seller ever since, this real-life diary charts an anonymous teenage girl’s struggle with the seductive — and often fatal — world of drugs.


The Dance of Anger – Dr. Lerner teaches women to identify the true sources of our anger and to use anger as a powerful vehicle for creating meaningful and lasting change. The Dance of Anger has sold more than 2 million copies and been translated into more than 30 foreign editions.

–Harriet Lerner, PhD

Aromatherapy for healing the spirit – Restoring emotional and mental balance with essential oils.

–Gabriel Mojay

Acupressure for emotional healing – Learn emotional healing acupressure points and affirmations for depression, grief, PTSD, anxiety and worry.

–Michael Reed Gach, PhD, Beth Ann Henning, DIPL., A. B. T.

Love Is A Choice – Breaking the Cycle of Addictive Relationships and letting go.

–Robert Hemfelt, Frank Minirth, and Paul Meier

Finding Your Way Home – “Home” to a place of deep awareness, everyday acceptance, and sustained care of our hearts and souls, in this empowering book that makes a companionable guide for anyone on the path to healthier living.

–Melody Beattie

Codependent No More – How to stop controlling others and start caring for ourselves.

–Melody Beattie

Feel the Fear And Do It Anyway – Dynamic and inspirational, FEEL THE FEAR AND DO IT ANYWAY is filled with concrete techniques to turn passivity into assertiveness. Dr. Susan Jeffers, teaches you how to stop negative thinking patterns and reeducate your mind to think more positively. You will learn: the vital 10-Step Positive Thinking Process; how to risk a little every day; how to turn every decision into a “No-Lose” situation, and much more.

–Susan J. Jeffers, PhD

Addiction to Perfection: The Still Unrevised Bride – Marion Woodman’s “Addicted to Perfection” is the best of her many works. She describes how we are all addicted to perfection and to being what our parents wanted us to be. This is expressed in active addicts through the abuse of alcohol, food, and sex according to our compulsive needs for father, mother and union (in corresponding order).

–Marion Woodman

Brain Rules: 12 Principles for Surviving and Thriving at Work, Home, and School – An owner’s manual for my brain! John Medina did a wonderful job of making me feel NORMAL (what is this?) or rather reiterating what I know creates peace…’of mind’.

–John Medina

Joy For Beginners – On a rare gloriously sunny day in Seattle, six women gather to celebrate their friend Kate’s recovery from cancer. Wine glass in hand, Kate strikes a bargain with them: to celebrate her new lease on life, she will do the one thing that’s always terrified her — white water rafting. But if she goes, each of them will also do one thing they always swore they’d never do — and Kate is going to choose their adventure, from getting a tattoo to learning to bake bread to reconciling with a former friend. ”

–Erica Bauermeister

The School of Essential Ingredients – Beautifully written novel that brought up questions about the important and meaningful aspects of life all emerging through cooking as related to social interactions.””

–Erica Bauermeister

The Nature Principle: Human Restoration and the End of Nature-Deficit Disorder – The immediacy of Richard Louv’Ź”s message in Last Child in the Woods: Saving Our Children from Nature-Deficit Disorder galvanized an international movement to reconnect children with nature. Now, in The Nature Principle, Louv reaches even further with a powerful call to action for the rest of us. Our society, says Louv, has developed such an outsized faith in technology that we have yet to fully realize or even adequately study how human capacities are enhanced through the power of nature. Supported by groundbreaking research, anecdotal evidence, and compelling personal stories, Louv shows us how tapping into the restorative powers of the natural world can…

 –Richard Louv in Books

Last child in the woods: saving our children from nature-deficit disorder – Richard Louv was the first to identify a phenomenon we all knew existed but couldn’t quite articulate: nature-deficit disorder. His book Last Child in the Woods created a national conversation about the disconnection between children and nature, and his message has galvanized an international movement. Now, three years after its initial publication, we have reached a tipping point, with Leave No Child Inside initiatives adopted in at least 30 regions within 21 states, and in Canada, Holland, Australia, and Great Britain. This new edition reflects the enormous changes that have taken place since the book—and this grassroots movement—

–Richard Louv in Books

History of a Suicide: My Sister’s Unfinished Life – Moments of exquisite pain and surprising joy fill this memoir by a poet who sets out to understand the shocking death of her sibling.

–Jill Bialosky

Suicide: The Forever Decision – For those thinking about suicide, and for those who know, love, or counsel them, this book discusses the social aspects of suicide, the right to die, anger, loneliness, depression, stress, hopelessness, drug and alcohol abuse, the consequences of a suicide attempt, and how to get help.

 –Paul G. Quinnett

Secret Life of Bees – “If you need something from somebody always give that person a way to hand it to you.”

–Sue Monk Kidd

Dance of the Dissident daughter – A woman’s journey from Christian tradition to the sacred feminine. With exceptional storytelling skills, Sue Monk Kidd writes personally and passionately about her own unexpected journey into feminine spirituality, identifying the unseen path that women navigate in order to reclaim the wholeness lost within patriarchal faith traditions.

–Sue Monk Kidd

The Four Agreements -In The Four Agreements shamanic teacher and healer Don Miguel Ruiz exposes self-limiting beliefs and presents a simple yet effective code of personal conduct learned from his Toltec ancestors. Full of grace and simple truth, this handsomely designed book makes a lovely gift for anyone making an elementary change in life, and it reads in a voice that you would expect from an indigenous shaman.

–Don Miguel Ruiz

Succulent Wild Women – This delightful book, handwritten and painted by the inimitable SARK–creator of her own line of inspirational posters, greeting cards, and gift items–exults in the pleasure of living life to its fullest. Exploring everything from sexuality, love, and romance to fat, fears, and recovery, SARK offers women the keys to expressing themselves in every dimension of their lives. of color art.


Man’s Search for Meaning – Psychiatrist Viktor Frankl’s memoir has riveted generations of readers with its descriptions of life in Nazi death camps and its lessons for spiritual survival. Between 1942 and 1945 Frankl labored in four different camps, including Auschwitz, while his parents, brother, and pregnant wife perished. Based on his own experience and the experiences of those he treated in his practice, Frankl argues that we cannot avoid suffering but we can choose how to cope with it, find meaning in it, and move forward with renewed purpose. Frankl’s theory—known as logotherapy, from the Greek word logos (“meaning”)—holds that our primary drive in life is not pleasure, as Freud maintained, but the discovery and pursuit of what we personally find meaningful.

–Viktor Frankl

The Anti-Anxiety Food Solution: How the Foods You Eat Can Help You Calm Your Anxious Mind, Improve Your Mood, & End Cravings

–Jack Challem

I Used to Be So Organized: Help For Reclaiming Order and Peace – Glynnis’ newest book, I Used to Be So Organized addresses the frustrations many women feel when they can’t handle their lives. They know, deep in their hearts, they should be able to manage things. After all, they used to be organized…ten or twenty years ago. By now, life seems to hand them on distraction and challenge after another. Combining spiritual encouragement and practical application I Used to Be So Organized presents a balanced approach to finding order and peace for today’s overwhelmed woman. This book contains 23 chapters, each short enough for a busy woman to read during a lunch break. Every aspect of life come together in this one easy-to-read guide.

–Glynnis Whitwer

Psychotropic Medications and Dry Mouth

Xerostomia, commonly known as “dry mouth”, is a reported side effect of >1,800 drugrs from >80 classes. This condition often goes unrecognized and untreated, but it can significantly affect patients’ quality of life and cause oral and medical health problems. Although psychotropic medications are not the only offenders, they comprise a large portion of the agents that can cause dry mouth. Antidepressants, anticonvulsants, anxiolytics, antipsychotics, anticholinergics, and alpha agonists can cause xerostomia. The risk of salivary hypofunction increases with polypharmacy and may be especially likely when 3 or more drugs are takenper day.

Among all reported side effects of antidepressants and antipsychotics, dry mouth often is the most prevalent. For example, in a study of 5 antidepressants 35% – 46% of patients reported dry mouth. Rates are similar in users of various antipsychotics. Patients with severe, persistent mental illness often cite side effects as the primary reason for psychotropic noncompliance. Patients may not taste food properly, experience cracked lips, or have trouble eating, oral pain, or dentures that no longer fit well. Additionally, oral diseases such as dental decay and periodontal disease, inflamed soft tissue, and candidiasis also may occur.

There are several ways for patients to manage their dry mouth symptoms. Patients should be dilligent in their oral hygiene practices, including brushing and flossing. They should use a toothpaste containing fluoride – preferrably one free of sodium lauryl sulfate – and schedule regular dental visits, where they can receive high fluoride applications or be prescribed high fluoride prescription toothpastes. Patient should avoid foods high in sucrose content, rinse their mouth with water soon after eating, and drink fluoridated water regularly. Patients may be able to stimulate saliva flow with sugarless gum, candies, and foods such as celery and carrots. Patients should also avoid cigarettes, caffeinated beverages, and mouth rinses that contain alcohol. Some patients may benefit from sleeping in a room with a cool air humidifier. Patients can also try over-the-counter salivary substitues, which are dispensed in spray bottles, rinses, swish bottles, or oral swab sticks. In addition, products such as dry mouth toothpaste and moisturizing gels also may help relieve their symptoms.

**Information obtained from Current Psychiatry, Vol. 10, No. 12


Eye movement Desensitization and Reprocessing, EMDR, is a powerful new psychotherapy technique which has been very successful in helping people who suffer from trauma, anxiety, panic, disturbing memories, post traumatic stress and many other emotional problems. Until recently, these conditions were difficult and time-consuming to treat. EMDR is considered a breakthrough therapy because of its simplicity and the fact that it can bring quick and lasting relief for most types of emotional stress. EMDR is the most effective and rapid method for healing PTSD (Post Traumatic Stress Disorder) as shown by extensive scientific research studies.

The studies to date show a high degree of effectiveness with the following conditions: loss of a loved one, injury of a loved one, car accident, fire, work accidents, assault, robbery, rape, natural disaster, injury, illness, witness to violence, childhood abuse, victims of violent crimes, performance and test, anxiety, trauma, depression, anxiety or panic, phobias, fears, childhood trauma, physical or sexual abuse, PTSD, bad temper, low self-esteem, relationship problems, worrying, trouble sleeping, and more. The EMDR technique is the most effective when used in conjunction of other traditional methods of therapy in treating these and many other emotional disorders. EMDR therapy can help clients release their anxiety and fear with positive images, emotions and thoughts.

What are the symptoms that can be helped by EMDR? EMDR can help symptoms such as high anxiety and lack of motivation, depression, memories of a traumatic experience, fear of being alone, unrealistic feelings of guilt and shame, difficulty in trusting others, and relationship problems.

Since the initial medical study in 1989 positive therapeutic results with EMDR have been reported with the following populations: people who have witnessed or been a victim to a disaster (rape, accidents, earthquakes, fires, murder, gang related violence; clients suffering PTSD; suffers panic disorders and anxiety attacks, suffers of phobia, chemically dependent clients; persons exposed to excess loss (loss by death, violence, divorce, loss of a house by fire); crime victims and police officers who were once overcome with violent memories; accident or burn victims. Although a fairly new therapeutic technique, EMDR is meeting with success all across the country. EMDR is a natural process. The client and become partners on a journey to help move traumatic and blocked energy. Together they work to transcend and free up the energy, so the client can return to their natural grounded state of being. The goal of this work is to help the client heal, so they can return to their life in peace.

There are a number of factors to consider when evaluating the appropriateness of EMDR therapy for a clients particular situation and history. During your initial consultation with a trained therapist, all the relevant factors will be discussed in full to help you both come to a decision to move forward with EMDR.

For more information about EMDR or to schedule an appointment, please call Cary Behavioral Health and speak to Mary Emerson at (919) 466 – 7540

Adult ADHD Skills Training Program

The Adult ADHD Skills Training Program is a six week program designed to foster skill development. The main purpose of the program is to help clients gain a better understanding of the effects of ADHD in their lives and develop personal strengths and coping strategies in order to better deal with it. The program will encourage you to identify negative beliefs and behaviors that are causing problems in your life. Since many individuals with ADHD are demoralized from years of struggle and unmet expectations, one of the main goals of the treatment is to transform this negative outlook into a more hopeful, realistic view. The Adult ADHD Skills Training Program also focuses on the practical issues that often come with ADHD, such as disorganization, work performance problems, and poor time management. Each session is usually just a copay, however you should contact your insurance company to determine your mental health benefits. Please address any further inquiries to Dr. Jeff Randall.

Introducing Mindfulness Based Cognitive Therapy

Dr. Murthy is now offering Mindfulness Based Cognitive therapy and Constructive Living therapy, based on a holistic approach addressing all four of the human dimensions including: Physical, Mental, Emotional (Social), and Spiritual. It is a structured educational approach guiding one to take better care of oneself, to live a healthier, more adaptive life rather than seeking temporary symptomatic relief. Mindfulness training allows us to remain balanced and clear-sighted, as if we were a mountain and our experiences were clouds. The mountain remains still as it observes the thunderstorms, rainbows, and sunshine.

Eating Disorder Therapy Group

The Eating Disorder Therapy Group is an ongoing program designed to address eating related issues in a group setting for people living with pre/post gastric bypass surgery, pre/post lap band, compulsive eating, binging, purging, and other food and eating related issues.  The main purpose of the group is to understand and address cognitive, emotional, and behavioral issues related to eating problems.

For more information, click here to download a full brochure.

New Website for CBH!

Cary Behavioral Health has renovated its website to provide new advantages for clients, including easier access to self-help resources and a convenient and secure client portal for electronic access to health records.