EKG monitoring for patients on antipsychotics
One of the controversies in pharmacologic management has been the need to monitor EKGs in patients who are on antipsychotic medication. This was not much of an issue until Geodon was approved for treatment of schizophrenia a number of years ago. During the initial studies, it was noticed that there was an increased risk of a certain type of EKG change. With its expansion into use in Bipolar Disorders, the number of prescriptions written for it has skyrocketed and, more than ever, we must contend with this issue. So . . . what, really, is the issue???
Turns out that some medicines (Geodon being only one of them) can change the intervals in the lumps and bumps on an EKG. These lumps and bumps each correspond to the flow of electricity through the heart and, in turn, the contraction and relaxation of different parts of the heart. Each of the squiggles on an EKG has been given a letter name and the safe and pathologic intervals between these are well established. When a cardiologist reads your EKG, he or she is measuring these intervals and looking for specific patterns in the various electrical views of the heart taken in a standard EKG. During the approval process for Geodon, it was noticed that there was an increased risk of “prolonged QTc”. What is that and what does it mean? If you think of an EKG in your mind, the most defining feature is the tall spike in the middle of the other squiggles. That is called the QRS complex. “R” being the point at the top of the wave, and “Q” and “S” being the bottom of the wave (left and right side respectively). The QRS complex corresponds to the contraction of the ventricles of the heart–the big chambers that send blood to the lungs and to the rest of your body. Right after the QRS complex is the “T” wave. This is more gentle and sloping. This represents the relaxation of the ventricles. The distance between the “Q” and the end of the “T” can vary with heart rate. If your rate is very high, then the QT is shorter. To deal with that, cardiologists have come up with the “QTc” or the corrected QT-interval . . . corrected for the changes in the value caused by an increase in heart rate. If the QTc is prolonged, it increases the risk of a lethal cardiac arrhythmia. Anytime a medicine is used that can increase QTc, it is a reasonable precaution to check the EKG to make sure that QTc is not prolonged. The assumption has always been that if you have an OK EKG on the medicine, you are good to go. Or are you . . . ?
An article in the June, 2005 edition of the Journal of Clinical Psychopharmacology found that patterns of QTc prolongation are not necessarily consistent in patients receiving antipsychotic medicines. When EKGs were administered over time to patients taking various doses of various antipsychotic medications, those who were positive for QTc prolongation were not consistently positive for QTc prolongation. While the study was small and did not include rigorous measurement of blood levels of the medicine, it did call into question the value of a single EKG for clearance for patients taking a medicine that can prolonge QT intervals. It was recommended that an additional EKG be taken to increase the chances of finding an abnormal value (if one exists). This may be even more important in patients with other factors that can lead to QTc prolongation and arrhythmias (bradycardia–heart rates < 60, pre-existing heart disease, and some electrolyte abnormalities).
So, should you be worried if you are on Geodon???
No.
Should you have an EKG???
Yes . . . and probably a second . . . just to increase the margin of safety.
–Dan Hartman, MD
Post-partum Depression–on being prepared
Since I see a fair number of patients who are of the age where they expect and want to have babies, the issue of managing depression during and after the pregnancy often arises. Today I thought I would focus on a small segment of this large issue–that of the spector of postpartum depression. This issues splashes across the front pages of newspapers periodically when some tortured soul ends up harming her own kids while in the midst of a serious postpartum depression. While bringing the issue out onto the table (good), it also can provide more stigma to the condition. Some people start to think that postpartum depression is synonymous with “gonna murder my kids”. This is obviously not the case. All the same, it MUST be looked for and, once diagnosed, carefully managed, so that the risk of tragic outcome is minimized.
To that end, I wanted to summarize the results of an article I ran across in the American Journal of Psychiatry (September, 2006). The article entitled “Familiality of Postpartum Depression in Unipolar Disorder: Results of a Family Study” took a look at how we might predict the risk for a woman developing postpartum depression after delivery of a first baby. Our diagnostic criteria (DSM-IV) uses a fairly broad time frame for the diagnosis of this syndrome–Major Depression criteria must be met within the first six months after delivery. What the study found was that when you use more restrictive criteria for the family history you get greater predictive value of the family history. Specifically, women with a family history of developing depression within 6 months of delivery (the standard DSM criteria), had a 15 % risk of developing postpartum depression themselves. In comparison, women with a family history of developing Major Depression within 2 months of delivery (more restrictive time criteria than DSM currenly uses), had a 42 % risk of developing postpartum depression. This increased predictive value is certainly important, but we must remember how difficult it can be to get this sort of information from our relatives. It is going to be difficult for many families to get this information accurately. People will likely remember being “blue” or “sad” following delivery, but will be hard pressed to remember how soon after delivery the symptoms worsened. The clear message from this study is the need to ask the questions and to have my patients ask their family the questions. Your risk is never zero, even without a family history. Knowing that there is a strong family history of early onset postpartum depression provides us with time to develop a plan of monitoring and quick action should a new mom start to experience symptoms of depression.
–Dan Hartman, MD
A warning . . .
Joanne writes in with a warning . . .
From The FDA Enforcement Report
1/30/08
PRODUCT
Lithium Carbonate Extended Release Tablets, USP, 450 mg, 90 and100 count bottles, Rx only, NDC 0143-1277-01, Recall # D-085-2008
CODE
100 count bottle; Lot number 62395C, Exp. Date 3/2008,
90 count bottle; Lot number 62395B, Exp. Date 3/2008
RECALLING FIRM/MANUFACTURER
West-Ward Pharmaceutical Corp, Eatontown, NJ, by letter on December 26, 2007. Firm initiated recall is ongoing.
REASON
Failed USP Dissolution Specification; 18 month stability.
VOLUME OF PRODUCT IN COMMERCE
156 bottles of 100 count.
DISTRIBUTION
Nationwide and PR
Thanks Joanne!
Another turning point, a fork stuck in the road . . .
I want to pass along a thank-you to all who have written in recently on the use of nutrition and life-style changes to address psychiatric issues (esp depression/anxiety/anger). I find myself a bit overwhelmed with the volume of information that is available out there. My intent is to critically look at as much of this information as I can and to seriously consider how I can incorporate these ideas into my practice and into my writings on line. This will obviously take some time. The worst thing I could do would be to . . . say . . . read an article on vitamin B6 and then prescribe it for e v e r y b o d y . . . While I’m sure that the potential for mis-steps is less than the potential for mis-steps when prescribing our standard pharmaceutical poisons, I will be approaching this with an open mind and a critical eye. It is not enough that a prescribed treatment does no harm. When people are suffering and lives are interrupted (and at risk of ending), it is important that the interventions make a difference. While I do not have blind faith in the use of standard pharmaceuticals, I have seen their potential and have seen their benefits. People do get better on them. Not everyone, and not without some having significant side effects. But standard pharmaceuticals will continue to have a roll to play. My hope is that I will learn enough quickly enough to begin to reduce the roll that they play in my patient management. But I do plan on giving the same critical eye to the nutritional industry. After all, look at the sites that propose major adjustments to diet and the use of nutritional products . . . the all have books and vitamins for sale and a “save to cart” button. I do believe that the authors of these sites are in this line of work to help . . . but financial incentives can jaundice someone selling vitamins as easily as it can jaundice a pharmaceutical industry executive. Which is why I have no advertising on this site and don’t want any.
I will keep you informed of my progress.
I will continue to write this column as a sounding board for people who are “stuck” in the middle of the current psychiatric system with their psychiatric issues. Nutritional interventions will not take the place of medications and there are many people with many questions. I will continue to be here to help.
Thank you for your help.
–Dan Hartman, MD
