When is Lamictal Good for Regular Old Depression?

In our striving to provide our patients with the latest, the greatest and the newest treatments for one condition or another, many psychiatrists go out on a limb to try new things.  Some of us go wwwwaaaaaayyyyy out on a limb.  There are two sides to this, of course.  You don’t want a shrink who is so “by the book” that there is no innovation and flexibility.  At the same time, there needs to be some logical, scientific and intellectually palatable explanation for what is being done.  Sometimes the docs are straight forward and forthcoming about their reasoning.  Some patients, however, come to me not having a clue as to why they were placed on one medicine or another.  

When a new treatment comes up, I am always a bit hesitant to jump on the bandwagon and start prescribing.  That is the way it was when Lamictal started to be used a number of years ago (quite a few years ago now that I think about it).  My early experiences were not positive and the risk of rash seemed so high that I rarely used it.  Over the years, as the conventional wisdom grew regarding the usefulness of Lamictal, I used it more and more as an alternative for patients who had Bipolar Disorder with significant symptoms of depression.  As my use increased, I became less concerned about the “rash” issue, even tho some of my patients developed a rash.  I even had two patients who developed Stevens-Johnson Syndrome and required a brief course of steroids to recover (which both did without any dermatologic disfigurement).  It’s usefulness clearly out-weighed the potential liabilities.  I now recommend it as a first line agent for all of my patients with significant symptoms of Bipolar Depression.

But here is where we go out on that limb . . . if it is good for Bipolar Depression, is it equally good for Unipolar Depression?  And if it is, when should it be used instead of a standard antidepressant?  There are three distinct opportunities for a medicines to be used.  It can be used as initial therapy, as a “last resort” when some one has failed multiple other trials, or as an “add on” to other therapies that have had limited or no benefit. Typically, when a new medicine is tried (or an old medicine is tried anew), it is used when other medications have failed.  Seems to me that that is a huge handicap.  Clearly, people who have failed standard treatment have more difficult pathology than those who have responded nicely to their first whiff of Prozac.  Yet, people do respond to these treatments, and that then sets the stage for trials as a first line agent or as adjunctive treatment.

So, where does Lamictal fit in at this point?  Out here in the trenches, we need to go on conventional wisdom and our own clinical experience.  The data for Lamictal is often contradictory and difficult to interpret.  There was not enough solid data for the medicine to be pushed through the FDA approval process and, since it is now generic, it never will be.  There is some data showing that it can be helpful as a first line agent, especially in patients who have more mild forms of depression.  It is rarely used for this, however, unless the patient’s history gives hints of a possible underlying Bipolar Disorder, or if there is a strong family history of Bipolar Disorder (remember, almost all Bipolar patients experience depression first and then have a later manic episode).  When reviewing the potential side effects (especially the risk of rash and Stevens-Johnson Syndrome), it is a rare patient who would pick Lamictal over a standard SSRI.  From a medical-legal perspective, can you imagine the fun a prosecuting attorney would have with a shrink who pushed use of an “off-label” medicine with a potentially deadly side effect over the standard FDA-approved medicine with no risk of deadly side effects?  I shudder to think!  If the doc is pushing for use of Lamictal in this situation, he or she better be able to explain why very clearly to you.  

The second situation would be using it as an adjunctive treatment for other agents.  My own algorithm for treating resistant unipolar depression does include using Lamictal, but only after I have tried combinations such as SSRI and Wellbutrin, or Cymbalta and Wellbutrin.  The exception here would be someone who is getting some improvement with a standard antidepressant, but has some moodiness that might lend itself to improvement with a little mood stabilization.  Even then, I often turn to Lithium to boost the effectiveness of the antidepressant.  At low doses, there is minimal side effects for most people and there is limited risk.  Blood work does not need to be done as rigorously when low doses are used.

As always, the patient must be warned about the risk of significant skin rashes and the medicine must be titrated very slowly.  Compliance is key because a period of significant non-compliance (and I count anything longer than two or three days significant) would necessitate starting back at the beginning and titrating back up again

–Dan Hartman, MD

Chronic suicidal thoughts . . . to be or not to be . . .

The presence of chronic suicidal thoughts is one of the more difficult issues to deal with in psychiatry.  It is one of the issues that separates psychiatry from all other branches of medicine.  When patients see my colleagues, they want to get better.  Sometimes, when patients see me . . . they just want to die.  This freaks people out.  Me too, sometimes.  But it is part of the business so, I guess, I have learned to deal with it.  Part of the difficulty with it is the sense of being out of control of it.  Surgeons like to cut and sew.  If something is broken, the way to fix it surgically is pretty clear (tho’ obviously requires great skill).  Maybe it will work, maybe it won’t . . . but what to do is usually clear.  And the doctor runs under the assumption that the patient will do everything in their power to cooperate with the healing process.  Patients who present with chronic suicidal thoughts are not so simple.  This is especially true if the patient does not have clear stressors that are producing this sense of despair.  Someone who has experienced significant loss, be it job or a relative, often has difficulty re-defining himself.  That sense of loss-of-self that comes with that situation gives us a clear direction to proceed.  Most of us have had such a loss, and most of us have entertained killing ourselves.  Thoughts like that are really quite normal . . . as long as you don’t follow through on them . . . And addressing the issues is relatively straight forward.  Redefine yourself while grieving the loss. (I didn’t say it was easy . . . just straight forward).

But what about the person who has relatively little life stress?  Or the stressors are not the sort that would seem to be at the root of such a strong desire to eliminate one’s self.  This intangible state is what is most difficult for the patient, for their family, and for the health care providers that are involved.  For some patients, the presence of chronic suicidal thoughts can be the manifestation of past abuse.  It can be an indication of significant personality disorder.  But for many, it seems to be an independent entity that occurs with limited cause.  

Very scary.

Very, very scary.

But, not without a possible solution.  

More than with any other patient group, a patient with suicidal thoughts must be connected with a therapist that they trust and respect.  They must be actively working with that therapist on life skills management that includes social networking without fostering dependence, developing a pattern of activity for oneself that supports physical and emotional health, and strengthening spiritual connectedness with other people and whatever you conceive as “God”.  And, most importantly, an emotional distance between who you are and what you think.  After all, we don’t have to follow through on EVERYTHING we think about doing.  Imagine the chaos if we did!!  Even though the thought to kill one’s self can seem as irresistible as the urge to take the next breath, it is necessary to purposefully distance yourself from that thought.  Acknowledge the thought . . . but distance yourself from it.  ”OK, I have the thought to hurt myself . . . I think I’ll go for a walk instead . . . ”  I encourage those patients who I see with these thoughts to develop a very clear list of things that they will do before hurting themselves.  I don’t tell them they cannot hurt themselves.  I decided a long time ago that it was foolish for me to think that my admonishment to not hurt yourself would carry more weight than someone who is close to the person.  But I do expect that they will follow through on our plan (key here is OUR plan) to keep them safe.  And one of the items on that list of to-do’s is that they MUST talk to me or their therapist.  Not TRY to reach me . . . but actually talk to me or their therapist.  The idea here is to create a system of diversions that waste time.  The more time that goes by, the more likely it is that the patient will move from the “have to hurt myself” stage to the chronic nagging stage of self-injurious thoughts that are much easier to ignore.

While this sounds a bit simplistic . . . it can work.  If the patient “works it”.  As with all of medicine, the active participation of the patient in the healing process makes a profound difference.

From a pharmacologic standpoint, what is done with chronic suicidal thoughts?  Obviously, the underlying depression or anxiety is treated.  But, in addition to that, Lithium can be used.  Of all the medicines that we have, Lithium is the only one that has been shown to decrease frequency and severity of suicidal thoughts.  Sometimes, the effect is very dramatic.  I have had patients who have had suicidal thoughts for years find resolution for these symptoms after just a few days on Lithium.  It is magic when it happens!  Both for me and for them.  

As difficult as suicidal thoughts are for the patient and for those around them, I can say that it is exceedingly rare for someone to not get better if they hang in there and work hard at it.  But it is the sort of psychiatric problem that requires openness with your mental health care provider, trust that things will get better, and resolve to do what it takes to make things better.  Most importantly, I try to instill the understanding in the patient that they are not alone.  That their life, however much they do not value it, is valuable to other people.  That the effects of suicide are much more than they can understand when they are overwhelmed by their thoughts.  The move It’s a Wonderful Life is a bit cliche and sweet . . . but every patient who has survived a period of suicidal thoughts or actions reaches a point where they say . . . “I’m so glad I’m alive”.

–Dan Hartman, MD

A mid-year assessment . . . a new start

So here we are folks . . . half way through the year!  Here in the northern hemisphere, the sun is high in the sky and hot hot hot. The roads are clearer on the morning’s ride to work with people taking off and schools closed.  I’ve taken a little time off and hope to take a little time off later in the summer to recharge the batteries . . . 

It is a good time to take a look back and think about how successful I have been in implementing my plans for the year . . . YIKES . . . NOT VERY!

I had hoped that I would be a bit more careful about how I handled this year.  Relax more, play more, spend more time with the family, be less stressed, have more fun . . . Instead, as perhaps with many of you . . . the busy-ness of life has intruded on me.  It has been difficult for me to compartmentalize the “want to dos” from the “have to dos”.  Unfortunately, the “have to dos” are winning.  In some weeks, it is a blow-out! WTT 0: HTT 27 . . . ninth inning . . . two outs!!!  What’s a shrink to do?  What is anyone of us to do???

 

Well, the eternal optimist in me is still alive.  It is never too late.  The good thing about a quiet and sunny saturday morning in July is that there is still lots of time to decide what you will to for the year.  As I opened one of my many books of quotes looking for something inspirational for the “Quote of the Day”, I came to the following anonymous quote . . . “We mold out habits at first, but our habits mold us in the end”.

H m m m m m m . . . read that a few times.

My habits have once again leaned toward overdoing for others.  Doing instead of delegating.  Ignoring my needs and taking care of others (what a doctor type I am!), etc.  My worry is that in the long run, I gyp myself out of good times and gyp others out of the best part of me.  Once again, I remind myself of the need to slow down.  My list of things that I want to do/”have” to do is long and will always be long.  My psyche does not tolerate the hint of a vacuum and will fill all available minutes with perceived need.  The challenge is to include in that intrusive list of things to do the act of doing nothing.  Of just being.  Of sitting and watching.  Letting the thoughts of yesterday and today come and go and not rest to long in the moment lest they cloud my awareness of what is that moment.  

The morning started cool and sunny with nothing to distract me as I immerse myself in the universe of my back yard.  No other human present, and me being quiet and slow, the life that flows through my little slice of nature flowed as a tide flows . . . in . . . and out . . . the wrens and sparrows flowing in and around the feeders, swirling as they fight and play with each other.  Calling and calling from one tree to another around and around using the space between me and the trees and the grass and the cloudless sky to speak to me of an unfettered freedom and joy that I wish I could share in more often.  The cicadas with their far off metallic hum and the squirrels with their chattering.  The morning doves hoo hoo as they take the fallen leftovers from the grass beneath the feeders.  And above all, the wind, reminding that there is something greater and more powerful and more untamed that moves us about . . . the tops of the great trees move in their choreographed dance . . . wooosh . . . wooooooosh . . . wooooooooooooooosh . . . and then . . . quiet . . . and the sound of the birds . . . and the cicadas . . . and a far off jay . . . and the sound of the wind . . .

When is it time to go off the meds?

Joelle writes in with a common question:

I am on 600 mg of Lamictal and was prescribed this medication a year ago. My doctor increased my dose from 50mg slowly taking me to 600mg over a period of 4 months. It took this much to feel less suicidal and even balanced in my mind. Recently I have felt concerned about this amount even though I feel completely normal and funtioning. How in the world do I begin to come down? I am not certain why I feel it necessary to begin taking significantly less, perhaps because there was a major power outage in my area and realized how the pharmacies were closed and I ran out. I hallucinated when trying to fall asleep and the paranoia I was suffering from frightened me. I know I should speak with my doctor and have him guide me. But he is of the strong impression I should remain on this dose. I am only trying to seek a second opinion. Thank you for your time.

Forget the power outage . . . when to go off the medicine is ALWAYS question number one for most people.  It can be very frightening to want to be on the medicine and not to be able to get it.  This can happen for reasons such as yours or just not having the money to pay for the medicine.  It often leads to a heightened desire to limit or eliminate the medicine.  There are several issues here, tho’, so lets separate them out . . .

First, lets think clinically.  Now that we are firmly entrenched in the 21st century, we can think of psychiatric illness as biologically based and not a personality flaw or an impairment in our upbringing.  Under certain circumstances, medication is clearly indicated to assist in the management of the illnesses.  From your description, the medication has made an important difference.  To be able to achieve a period of stability after feeling un-balanced and suicidal is nothing short of a life-saving miracle.  Now, I do not know much about your history, but use of this medication in such a high dose is unusual and would suggest that other medications have failed.  It would also indicate to me that this is part of a long standing illness and not just a single event in a younger person (sorry if my assumptions are wrong).  So from a clinical standpoint . . . is it time to come off the medicine.  I would guess not.  It sounds like you have had this discussion with your doc and he/she is also of the opinion that you should hold tight.  If you trust this doc, I suggest you listen to him/her.  You don’t hire a doc to tell you what you want to hear, you hire a doc to tell you what you need to hear.  If it is the doc’s clinical opinion that you should continue with this medicine, stick with it.  It is ALWAYS acceptable to have the “get off the meds” conversation with your doc.  Lowering the dose or getting off should be re-considered every three to six months for most people.  The decision to change the dose or the medicine should be clinically based whenever possible and not based on life circumstance (whenever possible).  Issues such as duration of illness, pattern of re-occurrence, response to the medicine, side effects of the medicine should take precedence when possible in the decision making process.

Now . . . lets think “real world” . . . 

I will be the first to admit that, far too often, us shrink-types don’t recognize or act in a way that is sensitive to a patient’s life circumstance.  Issues such as paying for the medicine, family pressures to get off the medicine, a person’s embarrassment about being on medicine, and, such as in your case, fear of catastrophic inability to get the medicine, can all lead to a feeling that you must get off medicine.  I don’t discount these factors as important, but consider them issues that must be dealt with.  Sometimes they DO lead to a decision to get off the medicine.  When these issues outweigh the clinical recommendation to stay on the medicine, however, the patient is at higher risk of relapse when the medicine is stopped.  Relapse of symptoms can have a devastating impact on work, relationships and self-esteem so the risk of relapse should . . . must . . . be carefully managed.  In my work with patients, I try to approach these issues in a thoughtful and methodical manner.  If it is a financial issue . . . I try to find patient assistance programs or use samples to offset overall cost.  If it is a family member that is pushing for a change . . . get the family member in to discuss the issue with me.  Usually it is just a matter of increasing their understanding of the issues at hand.  If it is an access issue (such as a repeat of a power failure), I would get a 7 day supply of the medicine as a buffer in case access is restricted (you can pay out of pocket or use samples to get the medicine).  Keep the week’s supply on the side but remember to rotate it with new medicine every few months when you get your usual prescription.  That way, your rescue stash is not expired when you need it sometime next year.

In any case, remember to use your doc as a sounding board and a consultant.  If you have a doc you trust, use them to work through these medication related issues.  If you don’t trust your doc . . . you need a new doc.  Non-clinically related medication issues can usually be resolved with a little extra communication or some ingenuity and problem-solving.

–Dan Hartman, MD

Ak-ak-ak-ak-akathesia . . .the trouble with Abilify

 Now . . . don’t get me wrong . . . I am a big fan of Abilify.  Even if their over the top marketing binge is so financially disgusting to me that I want to reflexively run screaming into the night.  I mean, really, how many prime time advertisements for this product do they need???  Then my patients come in talking about how expensive the medicine is . . . like $1000 for a month’s supply . . . ridiculous.  

But anyway . . . I digress . . .

As many of you know, Abilify is the newest addition to the genera of medication I affectionately refer to as “mood stabilizing antipsychotic tranquilizers”.  This usually gets a patient’s or a parent’s attention as I talk about all the horrible things that can go wrong when someone takes these medicines.  And make no mistake, you have to know that these medicines are not without their issues.  But, overall, they are GREAT medicines.  They are reliable in what they do and they work quickly.  OK, so they can contribute to weight gain . . . diabetes . . . hypercholesterolemia . . . affective flattening . . . irreversible movement disorders . . . I mean . . . no medicine is perfect . . . right? . . . RIGHT??? . . .

Where the rubber hits the road (that is where my office is) Abilify is a great medicine.  It covers mood instability, irritability, manic symptoms, and can boost the effectiveness of antidepressants.  It’s tendency to cause weight gain, and the other above mentioned bug-a-boos is less than most of the other members of this class.  People rarely get sedated and dopey on it.  But more frequently than with the other medicines, it seems to induce akathesia.

Akathesia is one of my favorite words.  The definition of akathesia is “the subjective feeling of wanting to jump out of your skin”.  ISN’T THAT A GREAT DEFINITION???  And that is exactly what someone will say if they develop akathesia.  They will call or come into the office and will be trying to describe this vague internal uncomfortableness that leaves them jumpy and restless and out of sorts and I will ask . . . “so . . . do you feel like you want to jump out of your skin?” and they will invariably respond “YES!!!” like I understand them better than anyone else in the universe.  Cool feeling for me.  Lousy feeling for them.

This is one of those states of being that is just horrible.  If you every have had the displeasure of watching old video shorts of patients in state mental hospitals that are rocking and rocking furiously in their seats . . . that is extreme akathesia.  It is caused by the action of the medicines at the dopamine receptors and is rarely treatable by anything but getting off the medicine.  Cogentin and benzos typically just don’t touch it.  The best solution is to get the patient off the medicine as quickly and safely as possible and to try something else.  Since moving to the second generation of neuroleptics, I have seen less and less akathesia in my patients.  The older second generation agents seemed to cause this less.  So patients on Risperdal, Zyprexa, and Seroquel only presented back with akathesia rarely.  Ever since I became an Abilify convert, however, I have seen a steady stream of patients complaining about this.  So much so that I routinely tell people that they might feel agitated on the medicine and that they need to call me if they do.  And I have gotten my fair share of calls.

So why am I still using Abilify?  Well, the frequency of the development of akathesia is not that high (no, I have not done the statistics).  And many people get great benefit from it.  If they do develop akatheisa, I lower the dose and, if that is not successful, take them off and try something else.  The potential benefits that the medicine brings far outweighs the low risk of a temporary level of discomfort. As long as they know that it can happen, and that they don’t have to live with it.  

That would be intolerable.

–Dan Hartman, MD 

 

Dealing with the unsupportive partner . . .

I have had a rash of patients (a gaggle of patients . . . ?) who have had great difficulties with their significant others . . . ok . . . ok . . . all the patients are female and they are referring to their generally bull headed and unsympathetic husbands. I will admit that my slice of time with these women is brief and infrequent (med checks in a managed care market), but the pathology that is described by the patients is clearly biologically psychiatric and the women are suffering. I will give two brief summaries . . .

Ariel is a young lady in her twenties who has a pattern of anxiety symptoms that is very obsessive with some compulsive behavior. She has been treated for Panic Disorder and Depression in the past but went off her meds because she felt well and “didn’t want to need the medicine”. She did well for about 5 months and then had the gradual reoccurance of the primary symptoms (OCD variant) that has created significant panic symptoms and mild depression. This very nice lady was seen by me as a quasi-emergency. The underlying OCD pattern was not picked up by her previous doc, but seems to be at the root of her issues. She is suffering . . . I mean . . . S..U..F..F..E..R..I..N..G . . . with her symptoms. She was in tears in my office describing the anquish she felt about her husband’s inability to understand what she was going through. He was going to be MAD that she came home on medicine. Yet, that medicine has helped greatly in the past and caused no side effects for her (not even sexual side effects . . . the usual reason husbands don’t like medicine).

Another example . . .

Belle has been seen by me for years. She CLEARLY meets criteria for Bipolar Disorder. From my first meeting with her she as been able to see the symptoms, discuss the symptoms, accept her diagnosis . . . but refuses to go on any mood stabilizer. Her severe depressive symptoms led to a trial of Zoloft which has been helpful for both the depression and the PMDD symptoms that she has experienced. Every time she comes in, we discuss mood stabilizers . . . and she refuses. But today was different. Things have gotten worse. She is jumpy . . . she is not sleeping . . . she is impulsive . . . and her level of irrititability is so much worse that she can no longer control herself. She is mean . . . I mean . . . REAL mean (her description). And she is finally able to talk about the options. Most of the options she refuses (standard items such as Depakote, Lithium). She is willing to consider Abilify or Trileptal . . . but her husband will be . . . MAD . . . because . . . SHE SHOULDN’T NEED SOMETHING LIKE THAT!!!

Here is where the “rant and rave” begins . . .

What the heck are these men thinking. These are nice women who are trying desperately to do the right thing . . . to take care of themselves and to treat their husbands and families well. They are trying to manage what are clearly biologically mediated processes and not just being . . . “weak” or “not strong enough” (which is how their husbands are making them feel). Because of this, they must deal not only with their internal pathology, but also their own sense of biological failure, a sense of letting their spouse down, and a growing feeling of inadequacy as a person/spouse/etc.

As a doctor, a psychiatrist, a man, a husband . . . I find this intolerable. I have encouraged both women mentioned above to invite their husbands to the next meeting with me. I encourage all of you out there (man or woman) who have a spouse or significant other who is not sympathetic or cooperative, to get your psychiatrist to invite them in to the session to teach them about what is really going on . . . that mental issues are not about personal inadequacy, but about biology . . . about how you are put together . . . your chemistry. If you are married, you married someone with a specific chemistry. And if that person has a problem, you promised to help them out. You are not allowed to be a miserable tyrant. If you don’t understand, don’t just complain and be negative. Follow through on your vows . . . for better or worse . . . get in there and help out . . . be active . . . be positive . . . be a man.

–Dan Hartman, MD

Physically sick from the meds . . . what to do . . . what to do

Leslie writes in with a question . . .

I have been taking Lamictal for a short period of time. My doctor added Abilify 10 days ago and I have had a low grade fever ever since. She says it’s flu but I now am certain it is the medication. The fever has also made me too nausious to function normally. I’ve also had a huge appitite and sweating. I think I should stick with lamictal and wellbutrin.
Any thoughts?

The sort of symptoms that you describe are unusual.  While you do not go into depth, I am assuming that in addition to the low grade fever, you have some muscle aches, upper respiratory symptoms and the “generally feeling crappy” feeling that goes along with the flu.  If you have all of those symptoms . . . maybe you have the flu . . . but the flu generally does not last for 10 days and generally is WORSE than what you describe.  I mean, really . . . anytime I have the flu, I feel like I’m gonna DIE.  I am afraid that this sounds a bit like medication side effect more than the flu (tho’ some of these side effects are really wierd).

So . . . what to do . . . what to do . . .

If you have the time and patience, I would (as always, in consultation with your shrink), taper off the Abilify, establish a new baseline, and then re-challenge with the Abilify.  If the same side effects occur, then it was because of the Abilify.  If not . . . guess you had the flu!  You don’t go into detail about your symptoms so I don’t know if the Abilify was for mood stabilization or to augment the benefits of the antidepressant.  That would, of course, determine the next step if the Abilify is not tolerated.

–Dan Hartman, MD

Lamictal and acne

Red writes in with a common complaint about Lamictal . . .

I’m a 29 y/o female. I started Lamictal July of 07 (150mgs) and since then I have developed horrible acne along my jawline that takes weeks to clear up and new pimples develop every other day. They are painful. I also have pimples on my chest. I’ve never had bad skin in my life. I also noticed that I have more peach fuzz on the sides of my face and the hair on my head seems to be thinning as well. This really sucks for me because the Lamictal is the first thing that has helped to get me out of depression. Im also taking Lexapro 10mgs. I want to get off the Lamictal to see if these nasty side effects subside, but Im also scared to be on an emotional roller coaster again. I stopped birth control (Yaz) about 7 months ago and thought that if I start back on it again, it may help with the acne? It is supposed to be FDA approved for bc, acne, and PMDD symptoms, so maybe my answer lies in that. Before making my decision to stop the lamictal, I’ll see my Pdoc and my dermatologist. Mental health issues are a big pain in the butt to deal with!!!!!!

With the huge increase in use of Lamictal comes the inevitable huge increase in complaints about Lamictal.  No . . . nothing can ever be easy!  For most folks who take it, Lamictalis wonderfully helpful and has minimal side effects.  Acne, as described above, is one of the more common complaints for those who do experience difficulties.  It then leaves you with the dilemma of choosing whether you feel good . . . or look good.  Most people choose to look good.  More on that in another blarticle.  From your description of your situation, there are a number of options available for you. 

1.  Birth Control Pills–As you mention, some of the newer birth control agents can be helpful for a variety of issues.  As with mental health medicines . . . it is always a bit of a guess . . . might help . . . might not . . . won’t know till you try.  If you were on it before and it was helpful, it is certainly worth a try.  Especially if your acne only emerged after you stopped the Yaz. 

2.  Don’t stop the Lamictal . . . just lower the dose–The dose of Lamictal you are taking (150 mg) is a good solid dose.  You might not need that much, especially since you are doing better.  It is common to need less of a medicine to sustain improvements after an acute episode of difficulty.  The decrease should occur slowly.  Skin takes a while to heal and adjust to medication changes.  I would recommend decreasing to 100 mg for a few months and then, if needed, more cautious tapering (eg by 25 mg every month or two).  You are really balancing how you feel with improvements in your skin condition.  One way of enhancing your mood as you lower the Lamictal is to maximize the Lexapro you are taking.  For example, you may only need 100 mg of Lamictal when you are on 20 of Lexapro and your skin might be better.   If, as you decrease the Lamictal dose, your acne remains bad and your mood begins to become more depressed . . . you have a difficult choice to make. 

3.  Other options–The fact that the addition of a mood stabilizer to an antidepressant has helped your mood opens the door to other mood stabilizer options, namely Abilify.  Recent work (and my clinical experience) shows that the addition of Abilify to an antidepressant can be helpful in improving mood.  Abilify comes with its own side effect difficulties, but at least it does no cause acne.

Remember, no medication changes should take place without a consultation with your psychiatrist. Make sure that you tell your doc about any over-the-counter agents you are taking as well as any herbal supplements.   I’m also glad to hear that you are seeing a dermatologist.  There are many new products for acne and choosing which one will help can be quite difficult.  Also, you should have hormonal studies done to make sure that there are not underlying reasons for your hair and skin difficulties.  As you so eloquently summed it up in your last sentence . . . mental health issues are a big pain in the butt!!! Make sure you are working actively with a psychiatrist and make your changes in a slow and methodical fashion.  It increases the chance that you will ultimately find the combination of medicines that work effectively for you.

–Dan Hartman, MD

Zombie children . . . what is the goal when stabilizing mood?

I can’t begin to tell you how often this issue has walked into my office.  A kid and family who have struggled with symptoms goes to her doctor to discuss the pro’s and con’s of the current regimen and nothing is changed.  Are her symptoms gone . . . no.  Are there concerning side effects . . . yes.  Are they told to get used to it . . . yes.  Is there a message of hope . . . no.  No wonder there is such negative connotations to being a shrink.  I’ll admit (and will readily defend psychiatric treatment as a whole), treating mood issues in teenagers is difficult and the medicines we use are often inadequate and problematic.  It is not uncommon to have difficulty pinning down the proper medicine and the proper dose for the medicine.  In my book, however, it is never . . . let me repeat . . . NEVER acceptable that a child is stuck with continued symptoms and significant side effects from the medicine that he or she takes.  If it ain’t working . . . it needs to be changed. 

The issue in questions was a nice young man who had developed a depression and had a difficult reaction to the antidepressants that were prescribed.  Instead of getting lots better, he got more agitated and suicidal.  Even self injured.  Despite the absence of other symptoms of the disorder, the kid got diagnosed with Bipolar disorder and was placed on Lamictal and Abilify, both of which I would agree are reasonable next steps in treatment.  The kid got better.  Not ALL better, as in back to normal.  Just better.  As in not agitated, not suicidal, not as angry.  But still . . . off.  Not back to baseline.  Not back to ‘normal for the situation’ happy.  He appeared distant, disengaged and flat.  He became less creative, less spontaneous, and very bland.  In his parent’s eyes, he just did not seem to be himself.  A bit zombied.  They were reassured that it was part of the Abilify’s effect and that it may be something to get used to.  But in the parent’s eye . . . their kid wasn’t right.  Something wasn’t right.  And they didn’t feel like they were getting listened to.

In my work with kids, I try to keep in mind that the goal is absence of symptoms and absence of side effects.  If I don’t get that with a medication combination, then something else must be tried.  There are certainly circumstances where you cannot or should not change the medicine (eg, right before finals, right before the class trip to florida, etc) when the risk of destabilization cannot be tolerated.  In those cases, however, I talk to the kid and the parents about the need to change, what the options are and when we should implement those changes . . . That is . . . I give them hope.

Hope . . .

The great worry sponge.

There is nothing worse than watching your child struggle with mental illness.  Nothing.  If your child struggles with seizures, diabetis, or (God forbid) cancer, people call you, ask how everything is, have benefits for you . . .

If you child struggles with mental illness, you are on your own.  And so are they.  Despite the great enlightenment that mental illness is physical illness of the brain, where the rubber hits the road, people still don’t treat you the same.  And you don’t feel the same.  And it is hard to find support.

But I digress . . .

So what would I recommend?  In the above patient, I am still very worried about the irritable reaction to the antidepressant trials.  I don’t think of the patient as Bipolar.  There are just no other symptoms.  But we must be cautious.  Another mood stailizer trial is in order.  One that is likely to provide some benefit and not cause side effects.  In my thoughts about this kid, I am going to try Trileptal.  Works well for most kids.  Causes few side effects for most kids (tiredness is the most common), and doesn’t cause affective flattening or weight gain.  Seroquel could be an option, but that is too sedating for many kids and, unless there is huge sleep issues, is not my first choice.

I’ll let you know how things work out.

–Dan Hartman, MD

Does every kid on stimulants need an EKG?

Oh boy, oh,  BOY!!! When my wife showed me this issue on the internet last night I gave a big sigh and an eye roll.  I knew the phone calls would start early and heavy.  For those of you who have not heard, the American Heart Association issued a recommendation that all children who are going to be placed on stimulants should receive “careful heart screenings that include electrocardiograms (EKG’s) to rule out heart abnormalities”.  These recommendations were based on the data that was used in the FDA’s review of stimulants last year.  That data (reported to the FDA) included 19 cases of sudden unexplained death and 26 additional cases where children suffered strokes, cardiac arrests or other cardiovascular events while on the medicine between 1999 and 2004.  In the statistical analysis of the data, however, there was no evidence that pointed to the stimulants as the causative factor in these tragic events.  The sad truth is that kids sometimes have cardiac events and the rate of those events is not statistically higher in kids that took stimulants.  Also of note here is that other professional organizations (such as the American Academy of Child and Adolescent Psychiatry) do not share these recommendations.  Following the FDA review, the warnings for use of stimulants were amended to include the risk of cardiovascular events.  Most of us who prescribe these meds have included a warning about the low risk of sudden unexplained death when we talk to parents about the medicine. 

So what do I think about the AHA warnings???

I think they add a new layer of confusion to the process and needlessly increase the costs of health care when we are all trying to be reasonably frugal.  Medical tests need to be tailored to the clinical situation and there is no evidence that giving an EKG to every child that is going to be placed on stimulants is going to save lives.  My position on this remains unchanged by these recommendations because they are not based on new data and the data that has already been presented and reviewed was inconclusive at best. BUT, now, thank you very much, I have to practice a more defensive brand of psychiatry and order an EKG on every child that I see.  That means when you bring your child to me and they are failing school because they can’t pay attention, you are going to have to wait an additional week or two . . . or three . . . to make the appointment to get the EKG, get the EKG done (probably during school hours), get the EKG read, and get the report back to me so that I can prescribe the medicine.  All that in addition to the one to two month wait to see me (unless you are lucky and squeeze in earlier).  Does it make sense? NO.  If I ran the world, here would be my recommendations:

1.  EKG and full cardiac work up is mandatoryfor any child who has a history of a heart murmur, chest pain, passing out, or if there is a family history of cardiac events at a young age.

2.  EKG and full cardiac work up should be done if the parents want it.

Pretty straight forward . . .

The unfortunate truth is that no matter what we do, we cannot keep our kids completely safe.  Not giving a kid medicine is not necessarily keeping them safe.  Untreated ADHD (and stimulants are the gold standard for medication treatment) is associated with academic decline, lower self esteem, depression and increased risk of substance abuse.  Avoiding use of medication that clearly helps most kids just because of the statistically insignificant risk of a cardiac event would make no sense.  More kids die every year driving with their family on summer vacation and no one is advocating staying home.  The risk of cardiac events should not keep you away from using these medications to help your kids.  But the bottom line is . . . if the work up would make you feel better, get it done. 

–Dan Hartman, MD