"Depression & Lupus" Chat Transcript for Dr. Al Herzog
December 11, 2008Moderator
Good afternoon. The Lupus Foundation of America is pleased to welcome Dr. Al Herzog.
Dr. Herzog is the Medical Director, Professional Programs at the Institute of Living / Hartford Hospital in Hartford, Connecticut. He is a psychiatrist and is a past speaker of the American Psychiatric Association. Dr. Herzog has been active in organized medicine in several other areas. He was President of the Connecticut State Medical Society (2001-02) and is a Delegate to the American Medical Association's House of Delegates from Connecticut. He also practices adolescent and adult psychiatry in Hartford, Connecticut.
Dr. Herzog is a Professor of Clinical Psychiatry at the University Of Connecticut School Of Medicine. He has written on a wide variety of medical topics ranging from psychiatry to organized medicine. He received his medical training at the University of Pennsylvania, was a resident in Internal Medicine at Hartford Hospital and received his psychiatry training at Yale. He is Board Certified in Psychiatry and is a Distinguished Fellow in the APA as well as the Society for Clinical and Experimental Hypnosis.
We welcome Dr. Herzog, and thank him for joining us this afternoon. Without further delay, let's begin. The first question comes to us from Wisconsin.
Moderator
Everyone feels depressed at some point in his/her life. How do you know when lupus is causing the depression? How do you know you're experiencing depression? How do you distinguish between depression and just simply feeling sad? What effect does Plaquenil have on depression symptoms? -- Johnson Creek, WI
Dr. Herzog
Depression involves sadness -- but goes beyond it. It also usually involves changes in one’s appetite, sleep habits, libido, energy and worthlessness. Generally speaking, Plaquenil should not affect depression.
Moderator
It is believed that depression brings flares. Does depression play an important role in triggering lupus? What is the best way to avoid it? -- Mumbai, India
Dr. Herzog
A good question. I am not sure we know enough about what causes lupus flares. Certainly life stresses can. Depression as a separate entity – it is quite possible also. How to avoid it? Try your best to keep a positive outlook.
Prayingmama
I would like to know if there are foods that we as “Lupies” can eat to minimize depression symptoms or aid in boosting our moods.
Dr. Herzog
Re: foods -- some research suggests that omega 3 fatty acids can be very helpful in mood stabilization. I am not aware of other foods. As you know, some research has shown St John’s Wort to be an antidepressant, although recent research on this is not conclusive.
glo
I'm sorry I don't know what Plaquenil is.
Dr. Herzog
Plaquenil is a medicine that is still used to treat malaria, but has been found to be helpful in treating certain autoimmune disorders like rheumatoid arthritis and lupus.
Moderator
What are the proper steps one should take if he or she is a lupus patient, and thinks he/she is afflicted with depression? -- Denton, TX
Dr. Herzog
It is possible the doctor treating your lupus can be your first step. Usually with depression, it makes sense at some point to also consult with a psychiatrist. Using the appropriate antidepressant, given the other meds you may be on, can be tricky.
Koka
Can daily exercise increase serotonin and combat depression?
Dr. Herzog
Depression and exercise -- I advise almost all my depressed patients to exercise. I am not sure about raising serotonin, but it does raise endorphins. Think of endorphins as the body’s natural tranquilizers and mood elevators. Many of us wish we could give them to people -- not possible yet. Of course, for many lupus patients, exercising readily is not possible.
Celestial
Do you recommend light therapy for seasonal depression for someone during a flare? If so, what type?
Dr. Herzog
Generally I advise light therapy and give out info as to how to obtain the proper light – it needs to be 10,000 lumen strong, and white light is best. However, I would be very cautious in using this therapy with lupus patients for fear of causing a flare. Otherwise, for seasonal affective depression, light is a great treatment.
Moderator
My sister has severe lupus. How can I help her through the depression? It is robbing her of her strength to keep dealing with all of the health issues. -- Houston, TX
Dr. Herzog
Your daily support, whether in person or by phone, is very helpful even though it may not seen that way to you at times. Another way … sometimes point out to her how life still has meaning or can have meaning to her. Ultimately, help her get some help for her depression. Again, your support with this is crucial. Your caring is the most important part you can play. Don't forget to use lupus support groups whenever possible.
Jose Aviles
Is there a specific medication to treat depression for people with lupus, or is depression medication the same for everyone?
Dr. Herzog
Depression in lupus pretty much responds to the same medications as all other depressions. I generally like Wellbutrin because it does not cause weight gain and is activating. I need to add that I am aware of one published report where Wellbutrin was thought to be the cause of a cutaneous lupus eruption.
Moderator
How should I explain depression & lupus for a psychological evaluation for Social Security Disability? -- College Park, MD
Dr. Herzog
It will be important to point out how lupus negatively affects your functioning -- both physically (no energy, pain, etc.) and psychologically (poor concentration, mental fatigue, etc .). Coordinate with your physician.
Moderator
What is your opinion about the newly publicized magnetic treatment for depression? -- Reston, VA
Dr. Herzog
This new treatment is a simple treatment for many who are depressed -- I look forward to having it available as a treatment option. However, it does not always help. It may take up to 20+ treatments, and now we need to get insurance coverage for it. The apparatus has just been approved in the US.
mwisdom
What is your opinion of Cymbalta?
Dr. Herzog
I have used Cymbalta fairly frequently in lupus patients because it has the additional advantage of also helping with some pain relief. The down side is that it is expensive and often you have to fight with insurance companies to make it available.
Moderator
Does lupus cause chemical changes in the body that can cause or contribute to depression? -- Lexington, KY
Dr. Herzog
Probably in those instances where lupus affects the brain directly -- estimates range anywhere from 5% to 80%. I favor the former. This could be the case because lupus can then directly affect the limbic lobe -- that part of the brain very directly involved in emotions.
Moderator
What causes lupus fog? How do I deal with it? -- Castle Rock, CO
Dr. Herzog
Lupus fog probably is most often a side effect of the medications we use to treat it. Although in theory, it could at times be caused directly if the brain is involved by lupus.
Moderator
I'm only sixteen years old. Is it really possible for me to be suffering from depression, and is there any non medicine way that I can help it? -- Yukon, OK
Dr. Herzog
Unfortunately, being 16 is old enough to suffer depression. Aside from meds, other things that help: CBT therapy, talk therapy, and exercise.
Moderator
What are your feelings about antidepressants and chronic diseases? -- Riverview, WI
Dr. Herzog
If I get the drift of the question, many chronic diseases often end up with a depressive component – why? The time factor, demoralization from impairments, etc. Antidepressants can be helpful but also important is how one goes about perceiving that condition – ie., is my glass half full or half empty?
Moderator
Please explain CBT therapy.
Dr. Herzog
What do we mean by CBT therapy? It stands for cognitive behavior therapy and is based on the notion that if we can affect the way we think about ourselves, we can then feel differently (better) about the way we feel. It sounds simple but turns out to be a very effective therapy in depression.
mwisdom
What can one expect from an antidepressant, in terms of feeling better?
Dr. Herzog
The most recent study -- a large one not paid for by drug money -- showed that up to 80% of patients (maybe even 90%) will have improvement in their depression, but it often takes 3-4 trials of different medications if the first one does not work. The key is not to give up after the first one provides no effect in 1-3 weeks.
Moderator
Do you recommend a spinal tap to confirm that someone has brain involvement from SLE if the MRI is negative for active lesions/inflammation? Also, why is depression sometimes difficult to treat in SLE? -- Perry Hall, MD
Dr. Herzog
I am probably not the best person to talk about diagnosing brain lupus; I will leave that to the neurologists/rheumatologists. Depression is tough to treat because the first medication we prescribe may not be helpful. It sometimes takes a second or even third one to find the right one. Also many factors play a role in lupus depression, from family circumstance to individual variations.
Moderator
Is psychosis a symptom of the disease? -- Springfield, IL
Dr. Herzog
Psychosis can be a symptom of lupus, but rarely. It might happen in those instances when the brain is involved with lupus. My experience is that this does happen at times but in the range of 5-10% -- although some folks have cited higher percentages.
Moderator
How can you tell what is clinical depression or what might be hormonal related depression? Also, how does job-related stress play into a lupus patient's mental well-being? -- Ocala, FL
Dr. Herzog
Job stress is, of course, a common element of lupus flares. Clinical depression is usually involved with many body systems, and includes appetite changes, energy/sex drive/sleep changes. I am not sure what exactly you mean by hormonal depression -- if you mean menopausal depression, the answer is unclear. If you mean thyroid-related depression, then fixing that endocrine imbalance is key to getting over the depression.
Kimberly
What would be the added risks for pregnancy and possible post-partum depression?
Dr. Herzog
Don’t forget that during pregnancy, the mother`s cortisone levels are quite high -- so that helps lupus. On the other hand, all these hormone levels drop off precipitously right after delivery, making post-partum depression always a possibility. However, I am not aware of that being more so with lupus. Overall, post-partum depression is higher than we used to think.
sheena
I was diagnosed with Systemic Lupus in 2005. I'm 37 years old and sometimes I feel like my family just don't understand me. I'm doing the best that I can but at times I get depressed. Is this normal with lupus?
Dr. Herzog
I would contend that feeling depressed at times with SLE is a “normal” response -- I see it as a grieving response. I would educate your family members about this, but also have them come with you to some lupus support groups to get a chance to talk to others with lupus so they become more supportive.
Moderator
Do we know which comes first ... tendency towards depression or lupus symptoms? I have heard from people in the Psych business that often women with trauma end up with lupus due to the mind body connection of trying to protect oneself on a mental and physical level. -- Milwaukee, WI
Dr. Herzog
I know of no credible study that is that specific re: causation of lupus. Certainly, folks you describe have a high underlying stress level … but don't forget, with say 10% of the population having some depression, no wonder sometimes these conditions overlap – i.e. are co-morbid.
Moderator
The final question for today's chat comes to us from Wadsworth, OH. My mom had lupus and seemed to have what I would call manic episodes -- she would get very worked up. I would have to do what I called "peel mom off the ceiling." Is this a normal response from 35 years of living with lupus?
Dr. Herzog
If your Mom is on steroids/cortisone, I have seen an occasional manic bout from that. If not, she may have co-morbid bipolar illness. Either way I suggest a psychiatry consult to tease out the different factors, and before initiating treatment.
Moderator
That is all the time we have for today’s chat. Thank you to Dr. Al Herzog for joining us.
Please join us Wednesday, January 14, 2009 at 3 p.m. EDT for our returning guest Dr. Don Thomas. Dr. Thomas will discuss Newly Diagnosed / Living with Lupus.
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