From medical at olympus.net Thu May 3 11:57:48 2007 From: medical at olympus.net (Douwe Rienstra) Date: Thu May 3 11:03:48 2007 Subject: [Medicine-for-people] Depression, Dementia, and Lithium Message-ID: ========================================== Medicine for People! May 2007 --------------------------------------- Contents Depression, Dementia, and Lithium - Lithium is an Essential Nutrient - Lithium and Bi-Polar Disorder - Lithium Increases Gray Matter in People with Bipolar Disorder - Lithium Protects the Brain from Dementia - Lithium and Depression - Lithium and Stroke - Adverse Effects of Lithium - Summary ========================================== --------------------------------------------------------- Depression, Dementia, and Lithium ---------------------------------------------------------- == Lithium == Some time ago one of the children in our practice, a child with a learning disorder, developed a new and disturbing symptom- trichotillomania. Trichotillomania is the fancy term for hair-pulling; George had bald areas on his scalp from playing with bits of hair on his head. What could we do? Searching the National Library of Medicine, I found a report that lithium had been effective in eight of ten children with trichotillomania. We started George on a low dose of lithium. Lithium, you ask? Isn't that for people with bi-polar (manic-depressive) disorder? == Lithium is an Essential Nutrient == Well, yes, dear Reader, but the beneficial effects of lithium on brain structure and individual mood are far too powerful to leave it in that pigeonhole. We, as individuals and as a society, need to recognize that lithium is an essential component of our diet and our physiology. Essential as in "required." In areas where lithium levels are low or absent in the drinking water, criminal behavior and drug abuse are higher than in areas with adequate lithium in the water. Lithium levels are lower in the hair of learning disabled students as well as violent criminals. When researchers gave low-dose supplements of lithium to those same groups, they discovered more stability of mood. So lithium has much more value to us as individuals and as a society than we're commonly aware of. But since we all know lithum as a treatment for bipolar disorder, let's start there. == Lithium and Bi-Polar Disorder == While doctors have written about bi-polar disorder since ancient times, only in 1949 was lithium first described as an effective mood-stabilizing agent for it, and only in 1970 was lithium approved by the FDA. I have many patients who happily take lithium to maintain a normal life despite bipolar disorder, and many who miss the "ups" when they take lithium and so avoid it and its alternative, valproic acid (Depakote). In these recent exciting decades our new technologic tools have allowed us to see into the living brain. Scans show that some areas of the brain shrink by 40 percent in volume in people with untreated bipolar disorder. Treat those people with lithium, however, and you can prevent this shrinkage. == Lithium Increases Gray Matter in People with Bipolar Disorder == Our brains contain neurons, which do the processing. Many of our neurons are in the outer layer, the cortex of the brain. When we look at the brain as a whole, this outer layer appears gray, hence the expression "gray matter." Deeper in the brain lies the white matter, composed mostly of axons, or connecting fibers. We do our computing in the gray matter and our data transmission in the white matter. One study of ten people with bipolar disorder measured gray-matter volume before treatment, then again after a month of lithium treatment. In eight of the ten patients, gray matter volume increased by about 3 percent, equivalent to about five teaspoons of functional brain. Further analysis showed that this was a true increase in neuronal tissue, not related to water retention or a lithium effect on the MRI image. Researchers found that the improvement in brain volume brought about by lithium occurred because lithium increased the production of proteins that protect brain cells from destruction. == Lithium Protects the Brain from Dementia == So far, lithium is the only substance we know of that enhances the function of these neuroprotective proteins. Let's look at the one called bcl-2. Bcl-2 protects the brain in two distinct ways. - Alzheimer's dementia involves the production in the brain of "gunk" called amyloid plaque and neurofibrillary tangles . Bcl-2 and another neuroprotective protein act to reduce the formation of amyloid plaque and neurofibrillary tangles. - We've written before (http://www.rienstraclinic.com/newsletter/2007/2007Jan.html#_edn1)that the stress hormone, cortisol, can have a damaging effect on the brain when present in excessive amounts. Bcl-2 protects the brain from this damage, as well as from damage due to free radicals and radiation. Researchers looked at 1400 people over the age of sixty and found that those who were given lithium for other reasons had significantly less cognitive loss than those who did not take lithium. While another study did not confirm this result, the great preponderance of the evidence indicates that lithium powerfully promotes brain health in many ways. Let's look at some of those ways. == Lithium and Depression == Not all depression will lift with an anti-depressant drug. In that case, psychiatrists will "augment" the anti-depressant drug with another drug. Lithium has been used for this purpose for over thirty years. This doesn't mean that we think that the depressed person has bipolar disorder. We just know, based on experience and research, that lithium can also help with depression. Lithium has a favorable effect on the serotonin system, the cortisol system, and, along with several anti-depressant drugs, it increases brain-derived neurotropic factor (BDNF). BDNF is important because even ordinary depression results in shrinkage of the brain. The healthy brain produces BDNF which promotes growth and regeneration of brain cells. Stress, depression, and aging all decrease the production of BDNF. == Lithium and Stroke == Lithium does not just promote growth of gray matter. It has been shown in animals to promote regeneration of the axon, the long fiber that carries a nerve signal from one place to another. In one experiment, researchers treated a group of rats with lithium for two weeks and compared them to group not so treated. In both groups, a major brain artery was blocked to cause a stroke. They measured the amount of brain tissue destruction in both groups, and discovered that the lithium treated group lost less than half as many brain cells as the untreated group. They walked better and suffered fewer coordination problems as a result. == Adverse Effects of Excessive Lithium == So, with all these benefits, why doesn't lithium enjoy a better reputation? The trouble is that lithium is best known as a treatment for bipolar disorder, and many people with that disorder require doses of lithium that are close to toxic levels. Such individuals need to be carefully monitored for toxic effects, which can include thyroid and kidney disorders, stomach upset, tremors, confusion, diarrhea, or lethargy . But lower doses, the doses normally found in our water and food, can cause no more trouble than the sodium, vitamin D, and vitamin A found in our food. (Each of which, by the way, is toxic in excess, just as lithium is.) Lithium is a metal, as is iron. Except for hydrogen and helium, it has the simplest structure of all the elements. Our bodies have required it for millions of years, and our cells contain special structures to pump it through the membranes. The question is not "lithium, good or bad?" but "lithium, how much?" There is no generally recognized RDA for lithium, but authorities believe it to be in the range of one milligram per day. This contrasts with the 80 to 160 milligrams of elemental lithium (up to 1800 milligrams of lithium carbonate ) for people with bipolar disorder. Many of the preventive effects for neurodegenerative disease occur at doses much lower than the dose used in bipolar disorder. == Summary == Our daily lithium usually arrives in our grains and vegetables, the amount varying from place to place due to differing levels of groundwater lithium. While lithium has long been known as "the medicine for those crazy manic-depressive folks," it has important benefits for the brain in general. It is life-saving for many people with bipolar disorder and ordinary depression. Under a physician's supervision, it can also help with other neurologic and psychiatric conditions as well. And George? Within a month, he stopped the hair-pulling. While he continued to be a challenge to his parents, their careful attention to his diet and to thoughtful limit-setting helped George to become a much happier and productive young man than most children faced with his initial challenges. ========================================== Note: A footnoted version of this newsletter appears on our website at http://www.rienstraclinic.com/newsletter/2007/2007May.html . ===================== === Recent issues of Medicine for People! === April, 2007 Beware the Lowest Bidder - Choosing Supplements for Health http://www.rienstraclinic.com/newsletter/April2007.html March, 2007 Brain Health as We Age Part 12 - The Final Chapter http://www.rienstraclinic.com/newsletter/2007/2007Mar.html February, 2007 Brain Health as We Age Part 11 - Reason for Hope: Nutrients to Preserve Memory and Sharp Thinking http://www.rienstraclinic.com/newsletter/2007/2007Feb.html Janaury, 2007 Brain Health As We Age Part 10 - The Hippocampus, Seat of Memory http://rienstraclinic.com/newsletter/2007/2007Jan.html December, 2006 The Shingles Vaccine: is it Right for You? http://www.rienstraclinic.com/newsletter/2006/2006Dec.html November, 2006 Brain Health As We Age Part 9 - Dementia - Know Thy Enemy http://www.rienstraclinic.com/newsletter/2006/2006Nov.html October, 2006 Brain Health As We Age Part 8 - Phosphatidylserine Preserves Brain Function thru Membrane Support; Not-For-Profit Nutritional Dispensary http://www.rienstraclinic.com/newsletter/2006/2006Oct.html Septermber 2006 Brain Health as We Age Part 7 - Homocysteine, Folic Acid and Vitamin B-12 http://www.rienstraclinic.com/newsletter/2006/2006Sep.html August, 2006 Health Care Finance Reform: Small Changes; Big Results http://www.rienstraclinic.com/newsletter/2006/2006Aug.html ========================================== === Reader Alert === We publish this newsletter monthly. If you do not receive every issue, your spam filter may be intercepting it. Please add us to your email "accept list." ========================================== Medicine for People! is written by Douwe Rienstra MD, edited by Carolyn Latteier, and published at Port Townsend, Washington. Copyright May, 2007. Click here: http://lists.olympus.net/mailman/listinfo/medicine-for-people to subscribe. Click here: http://www.rienstraclinic.com/newsletter/archive.html for previous issues. Write Dr Rienstra here: MedicineForPeople@RienstraClinic.com. More information about the clinic: http://www.rienstraclinic.com/ From medical at olympus.net Thu May 24 07:49:27 2007 From: medical at olympus.net (Douwe Rienstra) Date: Thu Jun 7 07:19:58 2007 Subject: [Medicine-for-people] The Long and Winding Road Message-ID: ========================================== Medicine for People! June 2007 --------------------------------------- Contents The Long and Winding Road ========================================== --------------------------------------------------------- The Long and Winding Road ---------------------------------------------------------- Sometimes people ask me if I am going to retire soon. I always say no. I tried it once, and it didn't work out. That would be back in the early 1970s. I had finished internship and one year of a pediatric residency and realized that I really didn't want to be a pediatrician. My teachers impressed me with their competence and sense of service, but I wasn't sure pediatrics was what I wanted to do. Plus I was feeling burnt out. I'd earned my undergraduate degree in three years, working nights in a research laboratory most of that time to help pay my college bills. Medical school, same thing; I worked in labs again every moment I could spare. With all that work and generous scholarships from Duke, I graduated with essentially no debt but with memories of too many 55 year old men, lying in the medical school wards surprised by some debilitating illness, wishing they had taken more time to enjoy their lives. Further, my dream had been of the old-fashioned Dr Welby type of doc, and while I had many fine teachers, Doctor Welby was nowhere among them. Our professors spoke of "managing patients" and "managing diseases." Young and full of drama, I cried, "They didn't teach me how to heal?" So I worked in an emergency department in Burien, saved up some money and decided to leave medicine behind. Young, rebellious and impressionable, I acquired some bell-bottom trousers, grew my hair long, and tried to imitate the (apparently) carefree hippies I saw around me. The trouble was, I wasn't that great at it. When I tried to hitchhike into Canada, the border guard took one look at my get-up and slyly asked, "Ever tried marijuana?" "Sure," I naively replied. He threw me out. When I stopped into a free clinic one idle afternoon in Berkeley and offered to volunteer, they said, "Look, if you want to work here, you can't just walk in. You need to apply and wait for approval." My most exciting dream had been to cruise to faraway places on a sailboat, so I bought a thirty foot trimaran sailboat. Over a two year period I explored Puget Sound, sailed around Vancouver Island, and then down to California. I saw many beautiful places and sea creatures. The sandy shore of Cape Scott at the north end of Vancouver Island will live in my memory forever, as will the Golden Gate Bridge in a silent September dawn and the sudden presence of an Orca appearing beside my boat in the still inland sea. I remember too all the work involved in maintaining a boat, and a bunch of time contemplating my navel, staring at a candle, and hoping to become enlightened. Didn't happen. I ended up in Morro Bay, out of money. The only work to be had there was in the biologic research station, which was advertising for a janitor. That seemed appropriate for someone dropping out of society, so I applied. However, I lacked certain basic job-landing skills. Where the employment form asked for schooling, I continued right down the page and listed my undergraduate degree and medical school. On the address line I wrote, "Yacht Triphoon, Pier 3". For some reason, they never even invited me for an interview. Really desperate now, I called the county medical society. They were glad to hear from me. A doctor in Pacific Grove had developed liver cancer and needed someone to cover his practice while he tried to sell it. I took that job for a month, but his practice was already minimal, and the few who were left did not regard bearded me as a satisfactory replacement for my dignified predecessor. At the end of the month he paid me $500 and closed the office doors. Happily, there was other work for an itinerate doctor. A general practitioner named Percy Jonat in Watsonville had broken his leg skiing. He needed a replacement, so I covered his practice 'til he could hobble enough to get back to work. His associates needed time off as well, so I worked in that clinic for most of a year. I was actually fired by them, twice, but that's another story. One day after about a month's work in Watsonville, I paused on the lawn of my house overlooking Pinto Lake. In that quiet evening, the realization came that I was happy in a way I had not been on the boat. Though the work was demanding and my time never my own as it had been, I felt useful. The work challenged me as sailing the boat had not. As I rested content by the lake, I thought of Raskolnikov in Dostoevsky's "Crime and Punishment." Raskolnikov had been full of discontent until the end of the novel, when, exiled to Siberia, he rests by the riverbank and comes to accept his place in the world, no longer to judge and to struggle to prove his superiority. True it then seemed to me, that privilege and rest are without value when not nestled closely with productive work. Shortly after that I shaved my beard, put on my coat and tie, accepted the medical profession as it was, and undertook to make my contribution. Now I understand Marge Piercy, who wrote The people I love the best Jump into work head first Without dallying in the shallows And swim off with sure strokes almost out of sight. They seem to become natives of that element, The black sleek heads of seals Bouncing like half-submerged balls. I love people who harness themselves, an ox to a heavy cart, Who pull like water buffalo, with massive patience, Who strain in the mud and the muck to move things forward, Who do what has to be done, again and again. I want to be with people who submerge In the task, who go into the fields to harvest And work in a row and pass the bags along, Who are not parlor generals and field deserters But move in a common rhythm When the food must come in or the fire be put out. The work of the world is common as mud. Botched, it smears the hands, crumbles to dust. But the thing worth doing well done Has a shape that satisfies, clean and evident. Greek amphoras for wine or oil, Hopi vases that held corn, are put in museums But you know they were made to be used. The pitcher cries for water to carry And a person for work that is real Now I realize what a blessing work can be. ========================================== === Recent issues of Medicine for People! === May, 2007 Depression, Dementia, and Lithium http://www.rienstraclinic.com/newsletter/2007/2007May.html April, 2007 Beware the Lowest Bidder - Choosing Supplements for Health http://www.rienstraclinic.com/newsletter/April2007.html March, 2007 Brain Health as We Age Part 12 - The Final Chapter http://www.rienstraclinic.com/newsletter/2007/2007Mar.html February, 2007 Brain Health as We Age Part 11 - Reason for Hope: Nutrients to Preserve Memory and Sharp Thinking http://www.rienstraclinic.com/newsletter/2007/2007Feb.html Janaury, 2007 Brain Health As We Age Part 10 - The Hippocampus, Seat of Memory http://rienstraclinic.com/newsletter/2007/2007Jan.html December, 2006 The Shingles Vaccine: is it Right for You? http://www.rienstraclinic.com/newsletter/2006/2006Dec.html ========================================== === Reader Alert === We publish this newsletter monthly. If you do not receive every issue, your spam filter may be intercepting it. Please add us to your email "accept list." ========================================== Medicine for People! is written by Douwe Rienstra MD, edited by Carolyn Latteier, and published at Port Townsend, Washington. Copyright June, 2007. Click here: http://lists.olympus.net/mailman/listinfo/medicine-for-people to subscribe. Click here: http://www.rienstraclinic.com/newsletter/archive.html for previous issues. Write Dr Rienstra here: MedicineForPeople@RienstraClinic.com. More information about the clinic: http://www.rienstraclinic.com/