Who holds the pills???

I still have a few connections at one of the local psych hospitals in my area, so I hear from time to time complaints and concerns from “the inside”.  One of the big questions that comes up is why kids have access to their medicine and, oftentimes, are given complete control of their medicine.  This is not just an issue for the inpatient world where they manage the kids who overdose on medicine they have control of,.  It is also an issue for my outpatient world.  In my area of treatment, the most common problem is not that they take too much of their medicine, but often not enough.  A frequent occurrence is the decompensating kid who, lo and behold, has not been taking their medicine.  The parents will come in and say that they knew the child was off their medicine because they were acting up. This begs the question . . . “who should hold the pills”.

Without a doubt, parents tend to manage their child’s mental health issues with a different level of intensity.  The level of supervision and oversight of a child’s medicine for asthma, seizures, or diabetes is far greater and taken more seriously.  It is far too common for parents to expect a minor child to “take responsibility” for their mental health issues and take their antidepressant or stimulant medicine on their own in a responsible fashion.  But isn’t the child with mental health issues by definition suspect in their judgement over major life issues?  The issues involved with depression are as potentially severe as those with the above medical issues, yet kids are often expected to take their pills as prescribed, and to let the parents know when they are running short so more can be ordered.  That sort of inattention with antidepressants can lead to increased risk of self harm either from worsening of depression when pills are not taken or an increase in antidepressant-mediated suicidal ideation which is worse in the period when the medicine is initiated (non-compliant kids who restart medicine essentially re-titrate the medicine over and over again).  Stimulant medicine can be used in a inconsistent fashion and still be beneficial, but non-compliance with the medicine will result in academic and behavior issues in some children who are not consistently taking them for school.  The other issue of huge concern is the potential for abuse with the stimulant medicine.  Stimulants that are not properly monitored can be taken inappropriately, or even sold to peers (yes, that does happen).

So . . . who should hold the pills?

It is my belief that the parents of any child under the age of 18 should be holding the pills and monitoring the administration of those pills in almost every case.  Once a level of trust is built up and there is a clear pattern of compliance and cooperation from the child, I can see moving to a system of using one of those Sunday-Saturday weekly pill dispenser/reminder things that the child can access and the parent can monitor DAILY to make sure that the proper medicine is taken.  But even that should be in a common area and not just handed over to the kid to take.  Any deviation from a pattern of compliance should result in the parents being more involved in the taking of the medicine.  The other issue that comes up is access to medicine for kids with suicidal ideation.  Since suicidal ideation can run the gamut from vague and fleeting to intense and persistent, this can be very tricky.  When in doubt, however, buy a lock box and put all of the family medicine (including over the counter medicines) in it for safe keeping.  Remember, one of the deadliest medicines out there is good old Tylenol–too much will destroy your liver.

As always, monitoring and good communication with your child is the best predictor of a good outcome when they are faced with any illness, be it medical or psychiatric.  Parents must be willing to step up to the plate and take control of the medicine–it is not about trust . . . it’s about being a good parent.  There are many areas in your child’s life where you can foster a sense of responsibility.  It does not . . . and should not . . . include their medical or psychiatric care.

–Dan Hartman, MD

Keeping your eye on the ball

It is so easy to get distracted. 

I have so many goals for myself.  This blog is certainly one of them, but it is only the tip of the iceberg that you see. And this goal started to be a goal several years ago.  I have had some of my goals for years and have done little to pursue them . . . life is soooo short and way tooooo busy. 

You folks that come in to see me suffer from the same distractible difficulties that I do, but this has more profound complications for you since you are in the process of healing.  What are your goals?  When you think of yourself as “better” what do you see yourself doing.  How will you be different than you are today?  How will your interactions with others be different.  What, specifically needs to change for you to start to achieve your goals?  This feeds right into the whole holiday period where we are forced to reassess who we are and what we do and what are our plans for the coming year.  Those irritating “resolutions” that end up being part of your own guilt cycle that brings you down when you think about it.  But really, if those goals were really . . . I mean REALLY . . . what you wanted to do . . . would it be so hard to do them?  Seems to me that the times I am happiest are when I strip away from my busy self all the nonsense that I have gathered around me and do the stuff that is at the core of who I am.  Then, I get a glimpse of contentment.  This can be hard for those with layers and layers of habits and expectations placed on them over the years.  But when you get yourself into a quiet spot where you are not going to be disturbed . . . and think back . . . to what it was like to be 10 . . . or 8 . . . or 12 . . . or 20 . . . or whatever age you were when you can pull on that thread of contented/happy/freedom to where you feel like your natural self.  What characterizes that time of life for you?  What did you do then that you could get back to and feel some of that same good feeling.

I’ll use myself as an example.  Music has always been a core feature of my growing up years.  Playing music, writing music/poetry/essays, listening to music etc was a part of everyday life for me and my family growing up.  Somehow, in the crush of life, I forgot that.  The 80’s and 90’s are a musical wasteland for me–I was in medical school and residency training and starting my doctor career and had no time for music (correction . . . I didn’t MAKE time for music).  I didn’t pick up my guitar for YEARS at a stretch (tho it sat in the living room gathering dust). And then my kids turned me on to . . . the iPod and Amazon.  And with it, I re-discovered music that I hadn’t listened to in years.  And found it easy to discover new music that just seemed to bring a part of myself back alive.  Although I continue to get distracted by the demands of work and family, I have found it easier to bring that sense of happy/content/excited back into my life through my old music hobby made new with the advent of technology and my own growth. I was listening to less NPR on the way to work and more music so that when I got to work, I wasn’t preoccupied with the worries of the world, but had a song in my heart and in my head that could sustain and feed me through the day.  

On a good day, I even pick up my guitar and play.  And I have more and more good days anymore.  I’m thinking about adding in another positive I used to do.  I used to stretch and sit quietly once or twice a day to calm my inner mind.  My life is a whirlwind of other’s expectations for me and it seems I am often running to fast to slow down.  But that is not good for me and it is not good for you either.  So my next step for myself is to find that quiet space between my ears and visit it on a regular basis.  You have a quiet space, too,  if you take the time to look.

So, for you . . . what would make a bad day a good day . . . or a good day even better.  What did you used to do that fed your soul?  Is it prayer or meditation.  Is it music.  Is it a good book.  Is it a walk outside.  Is it knitting or sewing.  Is it cooking.  What is it that you used to do that made you feel proud to be you . . . happy to be you . . . glad to be alive? It sounds ridiculously simplistic but, fortunately, not all of life is complicated.  One of the keys to happiness is to find those things that make you really happy and to do them over and over again. Basic cognitive therapy stuff.  Distract yourself from the bad stuff by doing good stuff.  Take time to do good and fun stuff every day.  Don’t get distracted by the whirlwind of crap in your life . . . keep your eye on the ball . . . keep your eye on your own happiness and what it will take to get you there.

–Dan Hartman, MD 

A Thanksgiving Message

I want to take this opportunity to wish each of you a happy and healthy Thanksgiving holiday.  I know that my own life is overly busy, overly stressful and ripe with opportunities to feel overwhelmed and cheated by life.  Truth be told, I’ve been known to give in and feel pretty crappy at times.  Today, I will step back and try to be glad for what I have.  I will look for the opportunity to give thanks . . . to friends, to family and, to my “Higher Power”.  I will thank them for what they do for me (emotionally/spiritually/etc . . . I’m not talking about material things here!).  I will ignore what they don’t do . . . we are all,  after all, overwhelmed and over stressed and we all have our emotional limitations!  I will take each moment as it comes and try not to worry about tomorrow and what it might bring.

Thank you for your patronage of my site.  Even when I don’t write, I check it every day and see how many people visited.  Thank you for your comments and your questions (it makes my job of writing easier).  My sincere best wishes go out to each of you for good health, emotional healing, fellowship with good and healthy people (sometimes even family) and a chance to rest and relax today (once the dishes are done).

–Dan Hartman, MD 

Holiday Blues (Part I)–a Thanksgiving message for us all

And so . . . the holiday season is upon us.  The Christmas decorations have been in the stores for weeks, the music is on the radio . . . and what if you just . . . don’t . . . feel it.   A visitor to the blog writes in . . .

 I never understood how anyone could be depressed during the holidays. There’s so much going on. But alas I now understand. All of a sudden I am very alone. The silence in this house is deafening. There’s only me and my adult disabled daughter. She’s autistic /aspergers so she stays to herself. Next February, I will be a widow for 3 yrs after watching him die over a 5 yr period in long term care following a auto accident. I just had to put my mother in long term care this past February. she doesn’t know me. She doesn’t even recall my name when I tell her. My oldest girl is going through a divorce. She’s trying to find a new emotional happiness after a horrible betrayal in what she and everyone else thought was a storybook marriage. She and the kids are spending Thanksgiving with a new friend. I took off Thanksgiving thinking we’d all be together but now I realize I’m actually caught up in empty nest syndrome. I am so tearful and I don’t know what to do.
The job I have now is not all it’s cracked up to be. I love being a nurse but the facility is not me and I’m too old to start over yet again. It was tough enough having to start over last April when my old hospital closed. I just can’t keep up with the young nurses that are out there now. My brain is filled to capacity. I was taking classes to complete my BSN but I just can’t focus. I get good grades but I don’t feel like I’ve learned anything.
I’m 55 yrs old. I’m not feeling this 50 is the new 30 business. My body hurts. I feel I must go on so I can take care of my two girls and the kids, especially the autistic one. I’m not suicidal. I would never do that to my girls and besides I am a christian and I’d like to be with my family again in the afterlife.
The more I think about the holidays the sadder I get. I’m tearful just writing this. But at the same time I feel like my purpose has been served. I need a support group. Can you help me?

At first glance, this writer’s story seems so very sad, and her situation seems so . . . empty.  But what it seems like as I read it over and over and over trying to come up with some words of wisdom is NOT that your life is too empty, but that your life is too full . . . too full of people who you take care of and seemingly devoid of people who take care of YOU.  You have spent the last decades of you life taking care of others . . . you are so good at it they PAY you for it at work, right.  You are a nurse.  You take care of people for a living.  When your husband was alive, you took care of him.  When he was injured in the accident, you took care of him and supervised his care in the nursing home.  You are supervising the care of your mother who is a mental invalid.  You have to take care of your autistic daughter.  You have to take care of your emotionally injured daughter.  WHO IS TAKING CARE OF YOU?!?!?!?!?  Taking classes for your BSN is a good distraction from the crap in your life but it is about as cozy and nurturing as a dental visit . . . no a dental visit is better–at least at a dental visit, you get the feeling that someone is caring for you.

I’m going to be blunt because the holiday season is upon us. 

DO THIS:  Get out a piece of paper and write down a list of everyone you know that you have talked to over the last month or two.  Include folks from church, from work, old acquaintances, neighbors . . . everyone you can remember.  Review the list and identify the people that you would like to spend time with.  Then (and here is the hard part that requires putting your pride on the back shelf for a minute) pick up the phone and start going down your list and CALL A FELLOW HUMAN AND ASK TO SPEND THANKSGIVING DINNER WITH THEM.  Tell them what is going on.  You took the day off to be with family but your daughter can’t make it.  You feel very alone because your husband is dead and your mother is in a nursing home.  Ask them for your help.  I’m sure that your you will find that a few of them might be going away.  It is inevitable that some will not be able to accommodate you.  BUT, it is equally inevitable that you WILL find someone to break bread with.  There are many many people who would jump at the opportunity to be filled with the warm feelings that come with helping others (that is why you became a nurse in the first place so you know the feeling).

Once that is taken care of, you need to start setting yourself up to be cared for by people.  I would certainly recommend that you get yourself in with a therapist that will work with you on this in a systematic fashion.  A group would be helpful.  Connecting with groups at church or the community would be helpful.  You have been so strong for so many people for so long . . . I think you may have forgotten what it is like to let your guard down.  To let others really in.  To let others take care of you for a change.  Your aching body is telling you that you are too tense too often.  A symbol (so to speak) of your guard being up all the time. 

I want to hear back from you.  I want to hear what happened when you made your calls.  I’m sure that others would be interested as well.  Because your situation is not that unique.  So many people spend so much of this holiday season feeling disconnected from others when we feel like we “should” be feeling connected.  But being connected is a very active process and requires work on your part–get to work and let me know how it goes.

–Dan Hartman, MD

ADHD–a good excuse or a reason to take responsibility?

ADHD presents special challenges to both the kid that has it and to his or her parents.  Being the parent of a typical kid these days is challenging enough.  When you throw in the distractibility, impulsivity and academic struggles that come with ADHD, it can magnify other issues that are hard all by themselves (like sex, drugs and rock n’ roll).  One of the frequent questions that I get from parents is how to modify the expectations they have for their kid.  Can they expect as much from them as they did from themselves or from an older sibling. 

This is a challenge whenever you have a kid.  How much do you push?  How much do you back off?  How angry do you get?  How understanding should you be?  With each kid being different . . . how is a parent to know?  Again, putting the overlay of a psychiatric issue on top does complicate it somewhat . . . or does it?  Let’s think for a moment what expectations you should have for any child.  Should every child be expected to get straight A’s in school all the time?  Should every child be expected to get every assignment done on time without ever forgetting or losing something?  Should every child be expected to NEVER fail a test?  I suggest that the answers to the above questions is “no”.  What is school if not a learning experience.  And what better learning experience (for many of us) but failing or doing poorly when we know we could have done better . . .

. . . when we know we should have done better . . .

. . . aaaaahhhhhh . . . I think I have stumbled onto an answer.  Perhaps it is not so much about succeeding as it is about doing your best.  When I think back to when I felt really good about an academic achievement, it is not always the “A” that I got.  As a matter of fact, the grade that I am most proud of in my life is the C+ I got in Biochemistry in college.  The fact that I could say that I tried as hard as I could made that “C+” feel like an “A”.  SOOOOOooooooo, perhaps the issue that we need to cultivate in our kids is a need to do your best.  Perhaps what we need to teach them is how to know when you try your best.  What does it look like.  What does it feel like.  And what do you do when you try your best and fail.  People in general (and kids in particular) are always good at making excuses for themselves.  If you do poorly at something and don’t find an external excuse for it, then it must mean that there is something wrong with you. ”I’m stupid” . . . “I’m lazy” . . . “I’m a f*** up” are the internal tapes that tend to run in your head, and these are hard to hear and don’t make you feel so good.  It is way easier to think . . . “that teacher is stupid” . . . “that teacher doesn’t know how to teach” . . . “this school is f***ed up” . . .because that takes you off the hook.

The approach that I use with my kids with ADHD is to clearly talk to them about how all kids need to try their best.  All kids need to deal with differences in themselves that can make getting good grades more difficult.  All kids need to deal with differences in their family or social circumstance that make getting good grades difficult.  In life, we are all faced with challenges.  It is how we respond to those challenges that . . . determines . . . or is a reflection of . . . who we are as a person.  There is, without exception, a way to overcome most difficulties that are presented to you in life.  There are ways to maximize your abilities in the face of adversity.  If you have trouble paying attention, you may have to sit in the front of the class instead of in the back with your friends.  If you have trouble keeping track of your stuff, you have to work with a tutor on organizational skills.  If you tend to get angry, you may have to learn better anger management skills.  If you get dealt a bad hand in poker, you don’t get mad at the dealer.  You might win a few hands by bluffing, but the other players in the game will quickly learn that you don’t have a full house every time you bet high.  Ultimately, you must take responsibility for the cards in your hand and do what you need to do to better them.     

What is the parents role in this?  It is to keep the kid focused on doing their best.  Yelling at them rarely works.  They just get resentful of you and figure out how to get what they want behind your back.  Keep the conversation focused on how to do your best.  How to learn what needs to be learned to make school easier and more successful for you.  There are certainly times where restrictions must come into place but it is the presentation of those restrictions that is the most important.  It is not “you failed and you are bad so no Nintendo for you!!!”  You just look like a jerk to your kids, and they feel bad about themselves.  What you are really saying to them is that they cannot manage the distractions well enough so you must take some away.  It would ultimately work better if you are actively involved with them on their homework and encourage good communication and active participation and reward their efforts with what your kid feels good about afterward. Perhaps, even, play the video game WITH your kid (imagine that!!).  Parenting is nothing if it is not a creative adventure with a host of challenges.  If you try to view yourself as a “teacher” of skills rather than “the disciplinarian”, you may be able to turn an episode of difficulty into a positive learning experience rather than a conflict.

–Dan Hartman, MD

The window of opportunity is not locked

I have noticed in my increasingly longer life, that the window of opportunity only stays open so long.  There seems to be chances in life to grab the brass ring, but then the time passes and you are left in the dust . . . or are you?  Sometimes the answer is yes.  But often times, the answer is no. 

As we move forward in life, there are opportunities that present themselves and then pass.  It can be quite discouraging when life seems to move forward without you and you feel very stuck in your current situation.  Whether it is in your professional life or your personal life, is is one of life’s common experiences.  This has occurred in the life of one of my most loyal customers . . . er . . . patients.  She has had a certain situation occur over and over in her life and she cannot seem to get herself and her family off of a certain track of behavior and reoriented to a new way of living with each other.  The family system is continually undermined by certain segments of the household, resulting in a repetition of events.  In my work with her, I have talked about opportunities coming and going . . . and coming and going . . . and the need to make changes at times when those opportunities present themselves.

It has been hard for her and her family.

This past month, yet again, the opportunity for change came and went.  She is understandably discouraged and saddened.  And not sure how to make things change.  At times she feels alone and unaided by her family in her quest to make her home a home, and not just a house with warring parties.  We spoke of the opportunity for change.  We spoke of the need to strike when the iron is hot . . . of grabbing the brass ring . . . of a window of opportunity . . .

But decisions were made, made in good faith by good hearted people, and the window of opportunity closed.  And the song remains the same.  The system has re-equilibrated right back to where they were before.  And the sense of defeat and hopelessness and sadness is palpable. 

The good news here, is that, like before, the window will open.  Systems tend to operate like they have been operating.  People change, but they don’t change that much unless they work at it or find God.  Just like the times before where the window opened, it will open again.  The opportunity will present itself yet again.  You can use the knowledge that you have gained from this closing to use the next opening for what YOU want YOUR life to be. Life is NOT like a window.  It is a carousel ride that goes around and around.  And here is your chance . . . hold on . . . stretch . . . reach . . . here it comes . . . grab the brass ring!

–Dan Hartman, MD  

The Plague comes to visit . . . MRSA hysteria and the need to get back to work

All of a sudden, people have started showing up in the office with MRSA.  It is freaking people out . . . completely.  There have been calls for specialized cleaning services to come to the office and disinfect and decontaminate.  Therapists are voicing hesitancy about seeing certain patients.  There was even a recommendation by someone (a doctor-type, no less) to CLOSE the office!  So, how much of this is reality based fear and how much is hysteria?

I hate to chuckle about a “deadly disease” but I can’t help it (remember, my sense of humor runs to the dark and sarcastic).  I first learned about MRSA in medical school . . . 1984 . . . when I did my surgical rotation at the VA hospital in Philadelphia.  I distinctly remember one poor GI who was in isolation for who knows how long because his diabetic wounds were contaminated with MRSA and were not healing well.  Guys like this would languish in isolation for months . . . often only getting out when they were “discharged to heaven”.  I made it my personal mission to get that guy out of isolation before my rotation ended.  Every day I was there (which was like every day) I would go into his room and scrub his wounds, his armpits and his crotch with an abrasive antibiotic scrubber.  I would put topical antibiotics up his nose and anywhere else I could reach.  Boy, was HE glad to see me coming! (Actually, he was.  Guys in isolation didn’t get many casual visitors).  After repeated positives on the cultures, I finally got a two sets of negative cultures on him the last week I was there and he was ’sprung’ to a regular ward.  I felt good.  But was he clear of MRSA.  Probably not.  And neither was I.  We doctor types would joke amongst ourselves that when we are sick in the hospital, they better not culture US for MRSA or we’ll end up positive in isolation as well (I guess that is one way to get a private room!).

My point here is that MRSA is by no means new.  It has been recognized for DECADES.  The reaction of people is a bit over the top, much like the reaction to any new infectious threat is (all think back to AIDs hysteria, please).  The news paper this week ran an article about a whole variety of infectious agents that are developing significant antibiotic resistance.  It will be, unfortunately, a more common scenario as we go into the coming decades.  So, what do you do about this MRSA thing???

Wash your hands and don’t pick your nose.

Simple, but effective.

Oh, and, by the way, relax . . . and get back to work.

–Dan Hartman, MD 

Zoloft . . .by any other name would . . .

My apologies to Shakespeare.

Whenever one of the antidepressants goes generic, there is a small percentage of people that have a return of symptoms of anxiety or depression that had previously been in good control.  When the medicine gets switched back to the brand name only, the symptoms become under control again.  This, of course, feeds into the whole idea that part of the response to antidepressants is a placebo response.  But I am equally sure that it comes down to an issue of quality as well.  Brand name medicines are made under very strict quality controls and standards of quality.  Generics, on the other hand, enjoy some latitude as to the potency of the medicine that is produced.  {NOTE:   the following statement might be incorrect . . . please write in if you know differently}.  My understanding {please see previous sentence}, is that generics can be anywhere from 85% to 125 % of the potency of the brand name product.  If I was a manufacturer, I just might aim for that 85 %.  After all, it does boost profitability of the tablet by 15 %.  I know that sounds very cynical, but business is business.  If it was just that, I could boost the dose of a generic up and I would get the same amount of medicine to the receptors and all would be well . . . but it is typically not that easy.  For some, increasing the dose does not do it.  Switching back to the brand name does.  Does this mean that the active ingredient in the generic product not the same as the active ingredient in the brand name?  Does it come down to bioavailability based on an effect of the inert ingredients in the generic product. I don’t know.  But I do believe that what my patients report to me is real.

But anyway, back to Zoloft.  I heard an interesting tidbit from the Pfizer rep who was in the office the other day.  As part of their financial planning as Zoloft went generic earlier this year, they purchased a “generic” company so that they could continue to manufacture sertraline and make some money off the Zoloft wave.  So, if you go to your pharmacy and ask for the “Greenstone” generic, you will be getting brand name Zoloft at generic prices!  Pretty neat, huh!?!