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

Rapid-cycling Bipolar II–what to do . . . what to do

Jeff writes in with a common problem . . . feeling kind of crappy on the medicine:

Hey doctordan, I was in counseling for 11 months. Blah.  The same questions over and over. Point being, I dont need to talk . Honestly. I’m a smart cookie. Now, ONTO the LAMICTAL I have been diagnosed with Bipolar II disorder with rapid cycling and panic disorder and anxiety. I am off in lala land now, What is that ? Is it the Citalopram, or lamictal .  I have no energy and I just feel blah.   Its kind of like I went back in time. To a point before I was ever treated. The question is this, do you think decreasing the dosage will have any great impact or will cause it to be worse, the citalopram makes me sleepy but not enough to sleep. BTW 150 mg lamictal and 40 mg citalopram. This whole illness hit in nov 2005 and is realy consuming my life and its pissing me off. Any help would be appreciated. This is affecting my ability to work, communicate with others. Its just crap. I need that special pill that grows a new brain… If you have any extra send them my way. PLEASE.

OOOOooooooohhhhhhhhhHHHHHH . . . you want the SPECIAL pill!   I’ve been holding on to that for JUST such an occasion!!!  Don’t I wish . . . (not as much as you, I know).

A couple of things come to mind here.  Let’s talk about diagnosis.  If you truely have a rapid cycling Bipolar II disorder, then I wonder about the medication approach that is being used.  Conventional wisdom is that rapid cycling is best treated with Lithium.  Studies have shown that to be the most effective intervention for smoothing out the cycling pattern.  Not treating the depression, but just smoothing out the peaks and valleys.  Sometimes when we use Lithium, we end up with less of the ups and more of the downs in the mood cycle . . . leaving one to feel blah.  Sounds like you are already there.  Lamictal certainly has some mood stabilizing properties, but mostly for depressive symptoms and not for the hypomanic symptoms that are part of the definition of Bipolar II.  Can it work . . . sure.  But from your description, it doesn’t sound like it is.  Actually, your mood seems overly dampened down, like we can occasionally see with anti-manic mood stabilizers like Lithium.  Another area of concern is the high dose of the citalopram.  Again, conventional wisdom says antidepressants can promote mood instability.  In your vignette, all I hear is BLAH . . . depressed and flat.

Not knowing what you have been on in the past (clearly important information) I can only suggest generalities.  My guess is that the BLAH you have is from the Lamictal.  If I was your shrink, I would consider what my mood stabilizer options are and substitute.  Lithium, as mentioned above, is a good option if you have not been on it before.  Another option is Abilify . . . the overly expensive and highly advertized new-ish mood stabilizer.  Despite the hype . . . it actually is one of my favorites recently.  I have seen significant success in a good number of patients.  There is data showing it can enhance mood when given in combination with antidepressants (Prozac in the studies done) and will provide mood stability as well.  The process of switching you over to a new regimen should be slow . . . but not too slow if you are feeling crappy.  Perhaps adding the new mood stabilizer and lowering the Lamictal at the same time.  You will need to be re-assessed after a month or two to see how you are. 

Another point is the therapy.  No matter how smart you are, therapy can be helpful.  Must be with the right person and the right approach must be used.  The trick is finding that right combination.  Don’t discount therapy altogether . . . that would be like giving up on marriage after a string of bad dates!  I always recommend asking friends or family that may have had contact with the mental health system in your area.  Another excellent resource is your family doc (they know who is good).

 

–Dan Hartman, MD