Doped Up On Too Many Medications???

 I put the following comments in back to back for a reason.  Read on . . .

K writes in to say . . . I find being on so many medications made everything worse- not all- but most. The side effects where at times unbearable. But when I was on so many…it made me so doped up to the point of almost being high. When my doctor took me off of them I felt much more normal and more relaxed. But while being on so many, it almost gave me a sense of unreal, and I grew use to that. Now off the meds I feel like drugs are the way to bring back the “unreal subdued” feeling which I was feeling 24/7…now that everything else is under control– but me…

and . . .  

S writes in to say . . . I went through that. As a teenager, I had some issues with depression. Between the ages of fifteen and 21, I was on 37 different psychiatric medications – with a record high of six at once. As it turns out, I am one of those people who has a paradoxical reaction to the reuptake inhibitors as a class. But 15 years ago, people hadn’t recognized that as a problem – so the response to worsening depression and suicidal thoughts was hospitalization and more drugs. When I was 21, I stopped the meds cold turkey – not intending for that to be permanent, only for a couple of weeks so I could drink at a party. My life changed that night – three days later, I woke up and realized my world had color in it for the first time in six years. It was stunning. 9 years later, I am starting to have some recurrences of depression – but I will never take an SSRI again. The drug-train isn’t worth it, for me.

This is like a before and after.  Before and after growing up.  Before and after medicine.  K is a teenager, currently struggling with the issues that the second author appears to have lived through and mastered (to some degree).  As adolescents navigate the turbulent waters between the simple black-and-white world of pre-adolescence and adulthood, there is a natural tendency to be overwhelmed.  For some kids, the experience of wide ranging emotions, increasing responsibility, increasing freedom can be too much.  For some kids, getting control can be as simple as working hard to master a task, or talking through problems with friends/family.  For others, getting control seems an impossible task that requires extreme measures.  Getting high, cutting, purging, defiance.  It’s all about getting control of the ship in waters that are too turbulant to navigate. If you show up on the doorstep of the psych hospital or the psychiatrist’s office, they will be more than happy to oblige you and give you medicine that will control you.  Numb you up.  Dull you out.  For some, it feels ok . . . for a while.  Even if part of the experience is acceptable, there is always a component of it that is uncomfortable and bothersome.  What S came to see is how the experience of life can be so much more full when the veil is taken away.  It does require, however, more work and more self discipline.

It does come down to choice.  “How am I going to manage these feelings?”  “How am I going to do what I know is good for me?”  My guess, K, is that you know the answers to those questions.  If you don’t know the answers, you at least know who to go to for help.  AND, you know who to stay away from. You know who will drag you down and reinforce negative behaviors and habits.  I would agree with S that the answer may not be more and more psych medicine (although some may be helpful).  But is drug use, self-injury, purging, defiance, etc. really the way that will work for you in the long run?

Doesn’t seem any better than being doped up on psych meds to me.

Another life lesson by the deli-Lama

I was in the local supermarket on Saturday. There was this older lady who was taking care of me at the deli counter.  This supermarket is my usual haunt.  It is not unusual for me to be in there several times a week.  I have seen her before in there taking care of me and others.  She appears to be a bit older than me, perhaps in her 50’s.  Small in stature and thin. She appears serious in her manner both with her coworkers and with the customers.  I have tried to joke with her to no avail.  She does not crack a smile.  Today was no different . . . no,  I take that back.  She seemed more serious.  Her movements were more deliberate and more tense.  She moved more quickly and made less eye contact and her body language was more angry.  This lady clearly did not like her job.  When she asked for my order, I felt uncomfortable giving it to her.  She so clearly did not want to be there doing that job that I almost wanted to not order anything.  I wanted to go away.  I wanted to complain. I wanted to let her supervisor know that this lady was unpleasant and that I didn’t want to shop at their store if she continued to be there. As she cut my roast beef, I had various scenarios running through my head about her disciplinary meeting with her boss.

And then . . . the deli-Lama . . . I mean the Dalai Lama spoke . . . well, not really spoke, but his words came back to me as I stood there by the deli counter watching this woman cut my order. I had been judging her in so many ways, and, finding her not conforming to my perspective of what a “happy deli-counter worker” should be.   I was thinking harsh thoughts and could even have gotten irritated enough to “turn her in” to her boss for reprimand.  I am bothered that these thoughts came so easily to me, a learned shrink who is generally a nice guy.

In The Art of Happiness–a Handbook for Living (Riverhead books, 1998),  Howard C. Cutler, MD summarizes his conversations with the Dalai Lama.  I have not quite finished the book but already (obviously) have found it useful in moderating how I think and feel about events in my life.  In bringing to my deli situation more compassion and forcing myself to view the events from other perspectives (. . . you mean I am not the center of the universe?), I found that my irritation over the deli counter worker’s manner lessened considerably.  In the Dalai’s own words “the tendency to see someone as completely negative is due to your own perception based on your own mental projection, rather than the true nature of that individual”.  In talking about compassion, he states “it is a mental attitude based on the wish for others to be free of their suffering and is associated with a sense of commitment, responsibility, and respect towards the other”. 

With respect to my encounter at the deli counter, I know nothing about this lady. Except that she does an excellent job cutting my order to my specifications.  How difficult is it for her to be working at that job that is typically populated by people much younger or much older then her.  She has in her eyes the sparkle of intelligence, like she could be running the show, not cutting roast beef and cheese.  What has the thread of her life’s path been.  What has she seen.  What tragedies has she weathered? What ecstasies has she savored. Where in the world did she wish she was that Saturday morning if not at the deli counter helping me.  As I put myself aside and consider her as a person, I find myself no longer irritated, but filled with warm feelings of friendly compassion toward her.  I will see her again.  I will greet her with a smile and I will be nice.  However unhappy she is with her job or other aspects of her life, I will not contribute to her unhappiness or suffering.  I will strive, instead, to be respectful and thankful for her contribution to my life.

–Dan Hartman, MD

Vyvanse–new way to deliver an old drug (this one is ok!!!)

I know I recently gave a rant and a rave about the inventive ways that pharmaceutical companies make an old drug “new” by making it sustained release or orally dissolvable, but I wanted to call a new medicine to your attention.  Vyvanse is a recently approved medicine for ADHD.  It is good old dexedrine (dextroamphetamine), one of the active ingredients in Adderall, my overall favorite stimulant for ADHD.  The neat thing about this medicine is that it is a prodrug–a medicine that is inactive on its own and becomes active after being metabolized by the body.  In the case of Vyvanse (lisdexamfetamine dimesylate), once it is absorbed by the body, an amino acid (l-lysine) is cleaved off the molecule in the liver, leaving dextroamphetamine, the active ingredient.  The maximum concentration in the blood (Tmax) is reached in about 3.5 hours.  If it is taken with a high fat meal, the Tmax is reached in about 4.5 hours.  Food does not effect the overall availability of the medicine (measured as ‘area under the curve’).  Its duration of action is similar to Adderall XR showing clinically significant effects at 10 hours out.  The standard starting dose is 30 mg  and it comes in 30, 50, and 70 mg capsules.  It is completely dissolvable in water and can be taken that way without it effecting how it is absorbed or metabolized.  Since it is a less complicated compound than Adderall (which is a combination of a variety of dexedrine and amphetamine salts), it can be considered an option for someone who did not do well on, or tolerate Adderall.

The scuttlebutt on the street is that it has less abuse potential than Adderall or regular dexedrine because of it’s prodrug status.  In looking over the literature that the company provided for me, I don’t see that that is necessarily true.  I will have to see how my experience is with it in my patients over time.  Since it is new, I have yet to find an opportunity to prescribe it. 

Any comments from the audience???

–Dan Hartman, MD

To Be There (part II)

I have heard through the grapevine that some of my patients have been worried that I am unhappy with my job because my writing has become sparse and . . . well . . . sarcastic.  More sarcastic than usual.  Nothing could be farther from the truth.  I am, actually, quite happy with how my professional life has progressed.  Adding the responsibility of writing this blog has, at times, made the days and weeks more hectic, but, when I do write, it is always a pleasure.  My wit tends toward the dark, so I cannot help but allow that in.  It is part of who I am.  I don’t think it is your best interest or mine to filter my human-ness and present a more bland clinical personna.  That somewhat sterotypical approach toward psychiatry and patient care is readily available elsewhere.  I have been told that my patients like that fact that I am . . well . . . human.  I do not forget that I was a human long before I was a doctor.  My family helps keep me honest with that daily.

Speeking of family, there is a reason that I have been a bit distracted lately (other than the usual September, end of summer, vacation is over sort of busy-ness).  I wrote about my father-in-law on his birthday, April 30.  On that entry (one of my first), I talked about how important it was for me To Be There for him.  I have, unfortunately, had another opportunity to do so.  Pop is getting older and the years are starting to wear on him a bit.  Some medical issues forced a short-proceedure unit visit to one of Philadelphia’s esteemed centers of medical amazingness.  Due to an unfortunate confluence of bad luck, age, over-zealous medical interns, and nursing and surgical snafus, a one day visit turned into a week long debacle that required significant intervention by my wife and me (assisted by some very excellent and caring hospital staff).  The good news is that we got him out of the hospital before they killed him . . . but it was close.  He is now at home with us recuperating. 

Once again, I find my self reminded about how important it is to take care of each other.  And I am reminded about how often people forget this, not only in their professional lives, but in their personal ones as well.  One must read between the lines to get the full meaning of day to day living.  It is not just that he needs someone to fix him his coffee.  That he needs help bathing.  That he needs to be reminded that he WILL get better and feel stronger soon.  It is the opportunity to share space and breathe the same air.  It is about allowing yourself to feel the love that you feel for someone and to be open to the opportunity to show it.  About allowing yourself to be vulnerable and open.  And about making it safe for someone else to feel vulnerable and open.  The last week has been a struggle.  I have had no time, little sleep and have been angry (at our health system), sad and frightened.  Yet, it has been one of the best weeks of my life.  I have lived life over the last week.  I have made a difference.  I have Been There for Pop and my family. 

I love being human.

–Dan Hartman, MD

Seroquel . . .XR . . . SR . . .CR . . .whatever . . .

All right, here I am, first day back from vacation . . . and one of the first messages handed to me by my secretary is . . . “a drug rep wants to set up a lunch to discuss Fizzilrexcrap XR . . . a new version of Fizzilrexcrap”.  . . OK, OK it wasn’t about Fizzilrexcrap, but it might as well have been.  It was about Seroquel . . . actually, the new IMPROVED Seroquel.  “Improved in what way????” you might ask.  Believe it or not, the Eisensteins at AstraZeneca pharmaceuticals actually reformulated Seroquel (most often given as a once a day medicine) so that you only need to take it . . . well . . . once a day!  WWWOOOOOWWW.  Now, ordinarily, I might get excited about this news, but, being a bit underexcited about returning to work, I was underwhelmed . . . and declined the lunch.

While there are certainly extended release products that do make sense, there has been a pattern over the last 10 years by the pharmaceutical industry to create new products from old ones by modifying the delivery vehicle by which the medicine gets to you.  By that, I mean the pill structure.  By slowing or controlling the way the pill dissolves, you turn an immediate release medicine into an sustained release (SR), controlled release (CR), controlled delivery (CD) or extended release (XR) formula.  Another trick is to take a pill and turn it into a dissolvable tablet that can be taken without water (like there is someone in the developed world who doesn’t carry a water bottle or have access to a water fountain)  The patent gets extended and profits continue. Pharmaceutical companies are happy . . . your 401k is happy . . . your stock broker is happy . . . everyone is happy . . . right?  RIGHT???

No.

While certain sustained release medications make sense and are truely beneficial for the patient (most notably the sustained release preparations of stimulant medication and some antidepressant medications), others are thinly disguised veils for making profits.  At the risk of angering the pharmaceutical industry, I will describe . . .

Seroquel XL . . . like I said, when it is used for it’s antipsychotic properties, it is mostly given as a once, maybe a twice a day product.  When it is given during the day, it is mostly used for it’s sedative properties. To identify the “new” product as an inovation is a stretch, to say the least.

Zyprexa Zydis . . . dissolvable tabs.  Get a drink.  Take the pill.  Skip the Zydis.

Paxil CR . . . an oldie but goodie.  I didn’t understand this from the get-go.  The SSRI’s as a group are a once a day medicine.  To take Paxil and turn it into a CR product was, at the time, genius from a business standpoint . . . but of minimal clinical value.

Wellbutrin XL . . . OK, some value . . . for those who can’t remember twice a day dosing (I certainly could not), but I also understand the hesitancy of the insurance companies to fund it . . . oooooppppppssss! went generic! (at least the 300 mg tab, which is the important one anyway).

Effexor XR . . . in general, a good product.  The rate of people having trouble with plain old Effexor is high enough to justify the extended release version. 

Ambien CR . . . how can you possibly improve the best sleeping aid . . . they tried to do it.  While it is a good idea for a small goup of patients who are not able to get through the night with regular ambien, it hardly means that we have to prescribe it for everyone who needs a sleeping aid . . . especially now that regular ambien has gone generic.

Klonopin Wafers . . . dissolvable . . . waste of time.  Get a drink of water.

 Xanax XR . . . nice try . . . already went generic.

Ok, now that I have irritated the largest industry outside of the military, let me explain.

First and foremost, the duty of the doctor is to treat the patient with whatever is the most relevant medication for the presenting illness.  While this means that some of these extended release products are clinically important and helpful, it does not mean that they should be used just because they exist.  They do have a role in a very small section of the mental health population who, for whatever unusual reason, cannot or will not take the standard pill form.  In an era where the cost of care is escalating, and the outrage of the public is rising against under/un-insured people and insurance execs with million dollar salaries, I do feel that it is my duty . . . AND THE PATIENT’S DUTY . . . to try to minimize their health care expenditures.  Not at the expense of clinical care.  That is the first priority.  But do I really need to use the new improved once a day medicine with the old once a day version worked quite well???  

What do you think?

–Dan Hartman, MD

Seasonal Depression . . . “tis the season . . . “

Can anyone else feel the earth moving?  I don’t know if it is just getting back to work after time off or getting up earlier to get my kid to school, but I am dragging this week.  You don’t have to suffer from seasonal depression to appreciate how dark it is in the morning and how the quality of light is different.  Autumn is clearly almost upon us.

When September rolls around, I begin to discuss seasonal patterns of mood shifts with my patients.  Now is the time to consider use of a SAD-light (seasonal affective disorder light) if you typically get more melancholy and depressed over the fall and winter months.  While there are many products out there, many do not have the light output necessary to provide for clinical improvement in symptoms.  The florescent bulbs you get at the local do-it-yourself store are useless–they are not bright enough and they are too far away.  You need a very bright light of a specific wavelength that is close to you (18-24 inches).  Otherwise, you are wasting your money.

The product I direct my patients to is from a company out of Canada called Northern Light Technologies (you can reach them on the web at www.northernlighttechnologies.com).  The product of theirs that I steer people to is the SATelite, a somewhat unattractive desk lamp that is just excellent for treating seasonal mood disorders.  It is not too big but is bright and convenient.  I direct people to sit under it for 15-20 minutes per day (usually in the morning–you can have your coffee and scan the paper while you sit there).

Sometimes, this, by itself, is enough to provide for mood support for the winter season.  More often, it is used as an adjunct support for more traditional medications.  It can, in my experience, improve the response to medicine, and sometimes allow me to use a lower dose.  Now is the time to consider getting it because it comes with a 60 day money back guarantee that will allow you to return it if it doesn’t work for you (lets see the pharmaceutical companies match THAT!!!).  By the way, I have no financial stake in this company–I just think the product is good.

–Dan Hartman, MD