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