Alcohol and Klonopin . . . decision time

I have been putting this off for a while.  I have a nice lady who lives in difficult circumstance.  She has struggled with addictions most of her life, whether it is food, drugs, and now, alcohol.  Both her circumstance and her biology lead her to be tremendously anxious, depressed and to have mood swings that are sufficient to warrant an atypical bipolar disorder.  Getting these factors under control has been impossible, because her life circumstance has been so difficult . . . really heart-wrenchingly difficult.  Typical antidepressants have not worked.  Benzos have helped tremendously . . . but she is drinking.  Sometimes to great excess . . . while she is taking Klonopin.  But today . . . is decision day.  For both her and for me.  Today she must decide if she is going to choose health, or a continued pattern of behavior that is unhealthy and dangerous.   The danger in situations like this is that the patient will be consumed with hopelessness when faced with the decision.  Instead of choosing one path or another, they can choose to die.  Great care is needed.  And support.  I can be careful . . . but she has minimal support.  But the current situation must change.

The biology under my concern is how benzos like Klonopin interact with alcohol.  There is an ion channel in the brain called a chloride channel.  It decides when and how much chloride ion goes into a nerve cell.  The chloride ion is very negative (negatively charged, I mean . . . not pessimistic).  When it is concentrated inside the cell, the inside of the cell is very negatively charged and very stable.  When a nerve cell “fires”, the inside becomes positive for a very brief period of time before the chloride channel can once again restore the nerve cell to the negative state.  This channel has numerous receptors on it that interact with a variety of hormones, medicines, chemicals, etc.  This includes benzodiazepines like Klonopin, Valium, Xanax, barbiturates, and . . . alcohol.  When these substances are ingested, the chloride channel opens up and the cells become hyperpolarized . . . really negative compared to the outside.  This makes them more stable and less likely to reach threshold to “fire”.  While this may sound like a good thing . . . and in some situations (eg seizure disorders) it is.  But when they are too, too hyperpolarized . . . you stop breathing.  Not a good thing. 

So when my nice, but overwhelmed patient uses too much alcohol in addition to her Klonopin . . . she is at risk.

So today is decision time.

It’s either me and my benzos . . . or the alcohol. 

Both she and I know that the alcohol must go.  

But will she have the courage?

Think some kind thoughts for her today.

–Dan Hartman, MD

When is Lamictal Good for Regular Old Depression?

In our striving to provide our patients with the latest, the greatest and the newest treatments for one condition or another, many psychiatrists go out on a limb to try new things.  Some of us go wwwwaaaaaayyyyy out on a limb.  There are two sides to this, of course.  You don’t want a shrink who is so “by the book” that there is no innovation and flexibility.  At the same time, there needs to be some logical, scientific and intellectually palatable explanation for what is being done.  Sometimes the docs are straight forward and forthcoming about their reasoning.  Some patients, however, come to me not having a clue as to why they were placed on one medicine or another.  

When a new treatment comes up, I am always a bit hesitant to jump on the bandwagon and start prescribing.  That is the way it was when Lamictal started to be used a number of years ago (quite a few years ago now that I think about it).  My early experiences were not positive and the risk of rash seemed so high that I rarely used it.  Over the years, as the conventional wisdom grew regarding the usefulness of Lamictal, I used it more and more as an alternative for patients who had Bipolar Disorder with significant symptoms of depression.  As my use increased, I became less concerned about the “rash” issue, even tho some of my patients developed a rash.  I even had two patients who developed Stevens-Johnson Syndrome and required a brief course of steroids to recover (which both did without any dermatologic disfigurement).  It’s usefulness clearly out-weighed the potential liabilities.  I now recommend it as a first line agent for all of my patients with significant symptoms of Bipolar Depression.

But here is where we go out on that limb . . . if it is good for Bipolar Depression, is it equally good for Unipolar Depression?  And if it is, when should it be used instead of a standard antidepressant?  There are three distinct opportunities for a medicines to be used.  It can be used as initial therapy, as a “last resort” when some one has failed multiple other trials, or as an “add on” to other therapies that have had limited or no benefit. Typically, when a new medicine is tried (or an old medicine is tried anew), it is used when other medications have failed.  Seems to me that that is a huge handicap.  Clearly, people who have failed standard treatment have more difficult pathology than those who have responded nicely to their first whiff of Prozac.  Yet, people do respond to these treatments, and that then sets the stage for trials as a first line agent or as adjunctive treatment.

So, where does Lamictal fit in at this point?  Out here in the trenches, we need to go on conventional wisdom and our own clinical experience.  The data for Lamictal is often contradictory and difficult to interpret.  There was not enough solid data for the medicine to be pushed through the FDA approval process and, since it is now generic, it never will be.  There is some data showing that it can be helpful as a first line agent, especially in patients who have more mild forms of depression.  It is rarely used for this, however, unless the patient’s history gives hints of a possible underlying Bipolar Disorder, or if there is a strong family history of Bipolar Disorder (remember, almost all Bipolar patients experience depression first and then have a later manic episode).  When reviewing the potential side effects (especially the risk of rash and Stevens-Johnson Syndrome), it is a rare patient who would pick Lamictal over a standard SSRI.  From a medical-legal perspective, can you imagine the fun a prosecuting attorney would have with a shrink who pushed use of an “off-label” medicine with a potentially deadly side effect over the standard FDA-approved medicine with no risk of deadly side effects?  I shudder to think!  If the doc is pushing for use of Lamictal in this situation, he or she better be able to explain why very clearly to you.  

The second situation would be using it as an adjunctive treatment for other agents.  My own algorithm for treating resistant unipolar depression does include using Lamictal, but only after I have tried combinations such as SSRI and Wellbutrin, or Cymbalta and Wellbutrin.  The exception here would be someone who is getting some improvement with a standard antidepressant, but has some moodiness that might lend itself to improvement with a little mood stabilization.  Even then, I often turn to Lithium to boost the effectiveness of the antidepressant.  At low doses, there is minimal side effects for most people and there is limited risk.  Blood work does not need to be done as rigorously when low doses are used.

As always, the patient must be warned about the risk of significant skin rashes and the medicine must be titrated very slowly.  Compliance is key because a period of significant non-compliance (and I count anything longer than two or three days significant) would necessitate starting back at the beginning and titrating back up again

–Dan Hartman, MD

Chronic suicidal thoughts . . . to be or not to be . . .

The presence of chronic suicidal thoughts is one of the more difficult issues to deal with in psychiatry.  It is one of the issues that separates psychiatry from all other branches of medicine.  When patients see my colleagues, they want to get better.  Sometimes, when patients see me . . . they just want to die.  This freaks people out.  Me too, sometimes.  But it is part of the business so, I guess, I have learned to deal with it.  Part of the difficulty with it is the sense of being out of control of it.  Surgeons like to cut and sew.  If something is broken, the way to fix it surgically is pretty clear (tho’ obviously requires great skill).  Maybe it will work, maybe it won’t . . . but what to do is usually clear.  And the doctor runs under the assumption that the patient will do everything in their power to cooperate with the healing process.  Patients who present with chronic suicidal thoughts are not so simple.  This is especially true if the patient does not have clear stressors that are producing this sense of despair.  Someone who has experienced significant loss, be it job or a relative, often has difficulty re-defining himself.  That sense of loss-of-self that comes with that situation gives us a clear direction to proceed.  Most of us have had such a loss, and most of us have entertained killing ourselves.  Thoughts like that are really quite normal . . . as long as you don’t follow through on them . . . And addressing the issues is relatively straight forward.  Redefine yourself while grieving the loss. (I didn’t say it was easy . . . just straight forward).

But what about the person who has relatively little life stress?  Or the stressors are not the sort that would seem to be at the root of such a strong desire to eliminate one’s self.  This intangible state is what is most difficult for the patient, for their family, and for the health care providers that are involved.  For some patients, the presence of chronic suicidal thoughts can be the manifestation of past abuse.  It can be an indication of significant personality disorder.  But for many, it seems to be an independent entity that occurs with limited cause.  

Very scary.

Very, very scary.

But, not without a possible solution.  

More than with any other patient group, a patient with suicidal thoughts must be connected with a therapist that they trust and respect.  They must be actively working with that therapist on life skills management that includes social networking without fostering dependence, developing a pattern of activity for oneself that supports physical and emotional health, and strengthening spiritual connectedness with other people and whatever you conceive as “God”.  And, most importantly, an emotional distance between who you are and what you think.  After all, we don’t have to follow through on EVERYTHING we think about doing.  Imagine the chaos if we did!!  Even though the thought to kill one’s self can seem as irresistible as the urge to take the next breath, it is necessary to purposefully distance yourself from that thought.  Acknowledge the thought . . . but distance yourself from it.  ”OK, I have the thought to hurt myself . . . I think I’ll go for a walk instead . . . ”  I encourage those patients who I see with these thoughts to develop a very clear list of things that they will do before hurting themselves.  I don’t tell them they cannot hurt themselves.  I decided a long time ago that it was foolish for me to think that my admonishment to not hurt yourself would carry more weight than someone who is close to the person.  But I do expect that they will follow through on our plan (key here is OUR plan) to keep them safe.  And one of the items on that list of to-do’s is that they MUST talk to me or their therapist.  Not TRY to reach me . . . but actually talk to me or their therapist.  The idea here is to create a system of diversions that waste time.  The more time that goes by, the more likely it is that the patient will move from the “have to hurt myself” stage to the chronic nagging stage of self-injurious thoughts that are much easier to ignore.

While this sounds a bit simplistic . . . it can work.  If the patient “works it”.  As with all of medicine, the active participation of the patient in the healing process makes a profound difference.

From a pharmacologic standpoint, what is done with chronic suicidal thoughts?  Obviously, the underlying depression or anxiety is treated.  But, in addition to that, Lithium can be used.  Of all the medicines that we have, Lithium is the only one that has been shown to decrease frequency and severity of suicidal thoughts.  Sometimes, the effect is very dramatic.  I have had patients who have had suicidal thoughts for years find resolution for these symptoms after just a few days on Lithium.  It is magic when it happens!  Both for me and for them.  

As difficult as suicidal thoughts are for the patient and for those around them, I can say that it is exceedingly rare for someone to not get better if they hang in there and work hard at it.  But it is the sort of psychiatric problem that requires openness with your mental health care provider, trust that things will get better, and resolve to do what it takes to make things better.  Most importantly, I try to instill the understanding in the patient that they are not alone.  That their life, however much they do not value it, is valuable to other people.  That the effects of suicide are much more than they can understand when they are overwhelmed by their thoughts.  The move It’s a Wonderful Life is a bit cliche and sweet . . . but every patient who has survived a period of suicidal thoughts or actions reaches a point where they say . . . “I’m so glad I’m alive”.

–Dan Hartman, MD

A mid-year assessment . . . a new start

So here we are folks . . . half way through the year!  Here in the northern hemisphere, the sun is high in the sky and hot hot hot. The roads are clearer on the morning’s ride to work with people taking off and schools closed.  I’ve taken a little time off and hope to take a little time off later in the summer to recharge the batteries . . . 

It is a good time to take a look back and think about how successful I have been in implementing my plans for the year . . . YIKES . . . NOT VERY!

I had hoped that I would be a bit more careful about how I handled this year.  Relax more, play more, spend more time with the family, be less stressed, have more fun . . . Instead, as perhaps with many of you . . . the busy-ness of life has intruded on me.  It has been difficult for me to compartmentalize the “want to dos” from the “have to dos”.  Unfortunately, the “have to dos” are winning.  In some weeks, it is a blow-out! WTT 0: HTT 27 . . . ninth inning . . . two outs!!!  What’s a shrink to do?  What is anyone of us to do???

 

Well, the eternal optimist in me is still alive.  It is never too late.  The good thing about a quiet and sunny saturday morning in July is that there is still lots of time to decide what you will to for the year.  As I opened one of my many books of quotes looking for something inspirational for the “Quote of the Day”, I came to the following anonymous quote . . . “We mold out habits at first, but our habits mold us in the end”.

H m m m m m m . . . read that a few times.

My habits have once again leaned toward overdoing for others.  Doing instead of delegating.  Ignoring my needs and taking care of others (what a doctor type I am!), etc.  My worry is that in the long run, I gyp myself out of good times and gyp others out of the best part of me.  Once again, I remind myself of the need to slow down.  My list of things that I want to do/”have” to do is long and will always be long.  My psyche does not tolerate the hint of a vacuum and will fill all available minutes with perceived need.  The challenge is to include in that intrusive list of things to do the act of doing nothing.  Of just being.  Of sitting and watching.  Letting the thoughts of yesterday and today come and go and not rest to long in the moment lest they cloud my awareness of what is that moment.  

The morning started cool and sunny with nothing to distract me as I immerse myself in the universe of my back yard.  No other human present, and me being quiet and slow, the life that flows through my little slice of nature flowed as a tide flows . . . in . . . and out . . . the wrens and sparrows flowing in and around the feeders, swirling as they fight and play with each other.  Calling and calling from one tree to another around and around using the space between me and the trees and the grass and the cloudless sky to speak to me of an unfettered freedom and joy that I wish I could share in more often.  The cicadas with their far off metallic hum and the squirrels with their chattering.  The morning doves hoo hoo as they take the fallen leftovers from the grass beneath the feeders.  And above all, the wind, reminding that there is something greater and more powerful and more untamed that moves us about . . . the tops of the great trees move in their choreographed dance . . . wooosh . . . wooooooosh . . . wooooooooooooooosh . . . and then . . . quiet . . . and the sound of the birds . . . and the cicadas . . . and a far off jay . . . and the sound of the wind . . .

When is it time to go off the meds?

Joelle writes in with a common question:

I am on 600 mg of Lamictal and was prescribed this medication a year ago. My doctor increased my dose from 50mg slowly taking me to 600mg over a period of 4 months. It took this much to feel less suicidal and even balanced in my mind. Recently I have felt concerned about this amount even though I feel completely normal and funtioning. How in the world do I begin to come down? I am not certain why I feel it necessary to begin taking significantly less, perhaps because there was a major power outage in my area and realized how the pharmacies were closed and I ran out. I hallucinated when trying to fall asleep and the paranoia I was suffering from frightened me. I know I should speak with my doctor and have him guide me. But he is of the strong impression I should remain on this dose. I am only trying to seek a second opinion. Thank you for your time.

Forget the power outage . . . when to go off the medicine is ALWAYS question number one for most people.  It can be very frightening to want to be on the medicine and not to be able to get it.  This can happen for reasons such as yours or just not having the money to pay for the medicine.  It often leads to a heightened desire to limit or eliminate the medicine.  There are several issues here, tho’, so lets separate them out . . .

First, lets think clinically.  Now that we are firmly entrenched in the 21st century, we can think of psychiatric illness as biologically based and not a personality flaw or an impairment in our upbringing.  Under certain circumstances, medication is clearly indicated to assist in the management of the illnesses.  From your description, the medication has made an important difference.  To be able to achieve a period of stability after feeling un-balanced and suicidal is nothing short of a life-saving miracle.  Now, I do not know much about your history, but use of this medication in such a high dose is unusual and would suggest that other medications have failed.  It would also indicate to me that this is part of a long standing illness and not just a single event in a younger person (sorry if my assumptions are wrong).  So from a clinical standpoint . . . is it time to come off the medicine.  I would guess not.  It sounds like you have had this discussion with your doc and he/she is also of the opinion that you should hold tight.  If you trust this doc, I suggest you listen to him/her.  You don’t hire a doc to tell you what you want to hear, you hire a doc to tell you what you need to hear.  If it is the doc’s clinical opinion that you should continue with this medicine, stick with it.  It is ALWAYS acceptable to have the “get off the meds” conversation with your doc.  Lowering the dose or getting off should be re-considered every three to six months for most people.  The decision to change the dose or the medicine should be clinically based whenever possible and not based on life circumstance (whenever possible).  Issues such as duration of illness, pattern of re-occurrence, response to the medicine, side effects of the medicine should take precedence when possible in the decision making process.

Now . . . lets think “real world” . . . 

I will be the first to admit that, far too often, us shrink-types don’t recognize or act in a way that is sensitive to a patient’s life circumstance.  Issues such as paying for the medicine, family pressures to get off the medicine, a person’s embarrassment about being on medicine, and, such as in your case, fear of catastrophic inability to get the medicine, can all lead to a feeling that you must get off medicine.  I don’t discount these factors as important, but consider them issues that must be dealt with.  Sometimes they DO lead to a decision to get off the medicine.  When these issues outweigh the clinical recommendation to stay on the medicine, however, the patient is at higher risk of relapse when the medicine is stopped.  Relapse of symptoms can have a devastating impact on work, relationships and self-esteem so the risk of relapse should . . . must . . . be carefully managed.  In my work with patients, I try to approach these issues in a thoughtful and methodical manner.  If it is a financial issue . . . I try to find patient assistance programs or use samples to offset overall cost.  If it is a family member that is pushing for a change . . . get the family member in to discuss the issue with me.  Usually it is just a matter of increasing their understanding of the issues at hand.  If it is an access issue (such as a repeat of a power failure), I would get a 7 day supply of the medicine as a buffer in case access is restricted (you can pay out of pocket or use samples to get the medicine).  Keep the week’s supply on the side but remember to rotate it with new medicine every few months when you get your usual prescription.  That way, your rescue stash is not expired when you need it sometime next year.

In any case, remember to use your doc as a sounding board and a consultant.  If you have a doc you trust, use them to work through these medication related issues.  If you don’t trust your doc . . . you need a new doc.  Non-clinically related medication issues can usually be resolved with a little extra communication or some ingenuity and problem-solving.

–Dan Hartman, MD