It’s not just about the receptors . . . Sometimes it’s just about common sense
Dell writes in with an issue . . . but I think the real issue is deeper than the chemistry . . .
I’ve just been prescribed Vyvanse for refractory Clinical Depression. I was hospitalized twice decades ago then was started on a regimen of dexedrine which I never abused. It got me through graduate sschool. After about seven years I was taken off it. since then I have had several severe depressions as I am now. I have been prescribed every possible antidepressant; the SSRIs make me somnolent, only Wellbutrin improves my mood somewhat, but the inability to focus is making me even more despairing.
After such successful experience with dexedrine, I am very angry at shrinks/psychopharmacologists who have denied me the one drug that has kept me from diving off the Brooklyn Bridge. I hope Vyvanse works
In all the training we receive as psychiatrists . . . four years of college . . . four years of medical school . . . four years of post-graduate training . . . we never get a course in common sense. What a shame. In the theoretical world, you should not be prescribed a stimulant medication for depression. Whatever improvements you would experience would be considered a “drug-induced high” and not a recovery from depression. And while true for all stimulants, for some reason, dexedrine has been singled out as the “badder” of the two stimulants. For all practical purposes, there is nothing better or safer about Ritalin, but conventional wisdom is conventional wisdom. Once upon a time, the prescribing of dexedrine and dexedrine based products was frowned upon greatly. This is at least in part because it did become a big drug of abuse in the 60’s and 70’s. With modern psychopharmacology in its infancy, there was no advocacy to have dexedrine available.
The left-over from this is that most docs have the sneaking suspicion that people like you are just getting high and, therefore, prescribing it for you would be promoting your addiction. That is why you have a hard time getting it from a doc.
But, back to that missing course on common sense . . . If the typical stuff ain’t working . . . be innovative. And TAKE A HISTORY!!! If a patient has significant improvement on an unusual regimen of medicine, I guess that is the regimen that works. We can get lost in second-guessing ourselves about the clinical picture and the medications that we use. But, where the rubber hit the road, what works is what works. Its NEVER about fitting the patient into the text book.
I’m glad you finally found a doc who is willing to be practical with you. Communication with the doc is important and you must always always always be honest with him/her about your use of the medicine.
–Dan Hartman, MD
SHOCKING!!! The role of ECT in the treatment of mental illness
I just have a question for you: what are your views on ECT – mine are completely negative since I have had so many and they did absolutely NOTHING for me but cause long term memory loss.
There is absolutely NOTHING that will scare a patient more than when the doc starts bringing up ECT–electroconvulsive treatment . . . shock treatments, if you didn’t already know. It brings up all sorts of visions in your head from old pictures of crumbling and dirty state hospitals to Jack Nicholson in “One Flew Over The Cuckoo’s Nest”. It is frightening from the standpoint of what the experience might be like, but also because of what it means . . . “that I am really, really sick”. ECT is not a topic I have covered here before so I thought I would wright a brief entry about it. From a purely historical perspective, shock treatment is not one of psychiatry’s finest moments. In it’s earliest and crudest form, the patient would receive an infusion of insulin. That would drive the patient’s blood sugar down to the point where there was a disruption of brain function and the patient would have a seizure. (Wouldn’t you love to meet the guy that first thought of THAT!). In an effort to improve on this (HA HA), the world of psychiatry thought that it would be fun to put a jolt of electricity to the temple of a patient strapped to a gurney. That is the pretty picture immortalized by Jack. Aside from the behavior modification that this would bring about (after one or two of those, I would NEVER complain again about being depressed), people would have all sorts of complications such as broken teeth and bones, bruises, lacerated tongues, etc, etc.
It is nothing like that now.
ECT is done now done in highly controlled and medically sound conditions. During my training days, it was done in the surgical recovery room before the day’s surgeries began, but it can be done in less intense environments now as well. It is done to patients who are psychiatrically hospitalized, but also to patients on an outpatient basis. Obviously, there is a degree of medical clearance that must take place so that the patient getting it is in reasonable medical shape. It is done in the presence of a supervising psychiatrist who is trained in the application of ECT. Also present is an anesthesiologist, and at least one nurse. A patient who is getting the treatment done will lay down on a gurney and have an IV started. Sedation is given to essentially knock you out so that you have no memory of the event. A blood pressure cuff is blown up slightly over the systolic number to limit blood flow to one arm. The patient is then given a very short acting neuromuscular blocking agent (similarly given during some surgeries) that prevents you from moving during the ECT treatment. A bite block is put into place and, because you are paralyzed and unable to breathe on your own, the nurse hooks up a bag to the bite block and breathes for you. An measured burst of electric current is then applied to your temple and your brain has a seizure that lasts for about one minute. Because you have been given a neuromuscular blocking agent, you don’t move . . . except for your arm with the blood pressure cuff on it. Because the cuff restricted the flow of the neuromuscular blocking agent to your arm, there is some slight movement of the forearm and hand. This is carefully managed by a nurse or aide. When the seizure is over, the cuff is taken down. The nurse “bags” your breathing until the neuromuscular agent wears off (only a few minutes). The sedation wears off over the course of 10-30 minutes and you are able to get up and go home. It is neither scary to watch or experience.
ECT is used as a “last resort” intervention. It is a big deal. Nobody likes it. Nobody likes to recommend it. But, for many people, it is the difference between life and death. Or life being reasonably happy and life being a depressed hell. It can be a useful intervention in refractory depression, Bipolar Disorder and psychosis. It is most commonly used to treat refractory depression. The typical scenario for recommending ECT is when someone has essentially failed multiple trials of medications, combinations of medications, and various augmenting strategies. It should never be recommended as a first line, second line, or third line intervention. It is used when nothing else has worked. It is highly effective in taking people who are very, very depressed and helping them to be to less depressed and, sometimes, happy. It is used in conjunction with antidepressants and the idea is for the antidepressants to “take over” and maintain the patient’s mood improvement after the ECT jump-starts their recovery. Because it is a big deal, it is not a process that is easy to initiate. Where I practice, it requires an evaluation by a doc that specializes in ECT. It must then be approved through the insurance company (because they know better than anybody about how to keep you healthy . . . more on that another time). You are then set up for a series of treatments. Usually this consists of six to twelve treatments that occur at a rate of two or three per week. So you are talking about multiple weeks of treatments. Improvement often occurs after just a few treatments, but it might take ten or twelve before you get better. It is important that the treatments continue even after improvements occur as a way of solidifying the improvements. This is FAR from an exact science. The conventional wisdom we always used back in the day was do it till they are better . . . then do two more! It is clear that if you don’t continue after a certain degree of improvement occurs, there is a higher chance of relapse. It does not work for everyone, but most have a degree of improvement if not a resolution of their symptoms.
It’s the potential side effects that scare most people. It it’s worst, it can cause long term memory issues that you don’t recover from. In the short run, most people experience a degree of amnesia for the events of the time before and after the shock treatments. This can be a few hours or be a few days of amnesia. It can result in a period of incontinence following the events. You can be a walking zombie with little personality and little motivation for a while after the treatments. Most of the side effects gradually taper off over time. But for some, there is a residual memory deficit that manifests mostly as short term memory loss. It can be permanent.
That is why it is not a first line agent . . . or a second . . . or a third . . .
There are some that feel that it should be banned and never used. I think this would be throwing the baby out with the bath water. It is a life-saver for some people. I have seen it take people who appear to be doomed to life-long depression and return them to normalcy. I have told my wife that if I ever get seriously and intractably depressed that I want to be given ECT. But like all medical procedures, it is not without risks and negative outcomes. Those risks must be carefully considered by the patient and family of the patient who will receive the treatment. As with all medical procedures, you MUST be willing to accept the risk of the negative outcome before giving your consent for the procedure.
Medicine . . . and psychiatry in particular . . . is a messy business with a great many potential pitfalls. Approaching any treatment option needs to be done carefully, systematically and thoughtfully by all involved.
I know this subject brings up strong feelings . . . send me your comments. I will pass them along.
–Dan Hartman, MD
Antidepressants make your anxious kid go BONKERS??? . . . a fine time for a mood stabilizer!!
My seven yr old son was diagnoised with Generalized Anxiety Disorder 1 1/2 yrs ago when it appeared he had a panic attack in school which led to two months of severe anxiety to the point where he could not leave the house. He was put on zoloft and went manic on that. We had never seen manic behavior in him before. He was then switched to 5mg of lexapro and 1 mg abilify. He pulled out of that spiral and went on for the next year with very few anxiety attacks. If we did encounter anxiety, it would go away the same day. This past summer we saw more incidents of the anxiety that cropped up at camp. Since we were seeing more anxiety this summer, his dr. bumped him to 10mg lexapro. Within two weeks I noticed more manic behavior. Manic behavior for my son is similiar to how an adhd child may act. Not super severe but not how he normally acts.
We backed him back down to the 5mg of lexapro. Two weeks ago he started school and it has been a disaster. There was discussion of a fire drill and now he is severely anxious about it. He cries and shakes for a few hours a day during school(wonderful teacher who has implemented some great strategies for him) and he worries about it at home.
Dr. felt we should up the abilify to 2 mg and either take him off the lexapro or up to 10mg once the abilify is upped for a few weeks. He feels our son could have Bipolar III due to his sensitivity to the anti depressants.
I agree with your doc. The pattern of behavior that your child seems to be experiencing is that of a Bipolar III. For those of you not familiar with that designation, it is a relatively new name for an old concept. It has been known for many years that there is a small subset of patients who respond to antidepressants with significant manic or hypomanic symptoms. Off these medications, there is no sign of mania . . . just depression. Hence, the dilemma. How do you treat these patients successfully and safely. Well, you do just what your doc is doing. You place the patient on a mood stabilizer (like Abilify) and titrate the antidepressant very carefully. It could potentially indicate an underlying tendency toward Bipolar Disorder but the research on this is unclear, especially in a young child. In any case, it would be important to consider him as having a Bipolar variant. This would allow you to approach any medication issue in a way that would maximize his safety.
Another way of treating depression in a patient with Bipolar III is with Lamictal. But the issue here is not depression, but anxiety. Plus, using Lamictal in patients below the age of 12 can be a bit tricky and must be done very, very carefully.
So, I am in complete agreement with your doc. I would increase the dose of the Abilify to 2 mg and then titrate the Lexapro up. Remember, you can also titrate up a bit slower by using the 5 mg tab and going up by 2.5 mg. If hypomanic symptoms again present themselves, you can titrate the Abilify up further.
–Dan Hartman, MD
A duty to listen . . . you don’t violate confidentiality if you keep your mouth shut
My daughter’s father has recently (within the last week)begun taking an antidepressant for depression. He and I had been getting along well with no fights or hostility depsite some disagreements during this time. We are divorced but are friends and are able to attend family functions and cooperate as to our child 95% of the time or more. Since he began taking this medication he has become very moody. One moment he is iritable, suspicious, aggressive, angry, blaming and paranoid the next he is fine the next he is yelling the next he is paranoid. The two months leading up to this he was on a roll at work, socially and was very interested in sex. Then he said he just became lost (within the span of two weeks). A close friend of mine had a depression diagnosis change after she went on an antidepressant and tried to commit suicide so I consulted with a psychiatrist here who says he has been misdiagnosed and is likely bipolar.
I informed his GP who prescribed the meds as well as his psychologist. His GP’s position is that she can’t follow up on my information because of confidentiality. I don’t understand this. I didn’t ask for any information. I do understand that I am his ex-wife but I’m not asking them to tell me anything about him. I just want to make sure he gets follow up, if needed. (I am wary of armchair diagnoses even from docs I know and trust.)
What is a doctor’s duty to act on information about a patient’s reaction to a medication from a third party in this situation?
This is a difficult situation . . . but not uncommon. Peripherally involved family members often have a better eye on the situation than either the patient or me. Dealing with the patient one-on-one in a vacuum has severe limitations. Especially when I get such a small slice of a person’s time (I’m sure the GP has only minutes to reassess how your ex is doing on any particular follow up. For this reason, I LOVE when family is involved. These situations often occur, however, when a family member reaches out to me to give me information when they are not part of the treatment (so far), but are fearful of something bad happening. This is often a parent of a twenty-something who is still involved with the child’s life but in a very peripheral way. They, like you, are fearful that the patient may react to their attempts to help by getting angry or upset and pulling away, thus damaging the relationship and limiting the chance of giving help. Your situation is unique in that it is not typical for divorced people to have a “95% getting along” thing. It points to your mutual maturity and dedication as parents. It is vitally important that that attitude be maintained. So . . . what do we do here.
A couple points stand out from your letter. 1) you are “friends”, 2) you attend mutual family functions, and by extension, I assume that you remain friends with some of his blood relatives, 3) the pattern of symptoms you describe, and, 4) you know who his GP and his psychologist are.
First, lets start with what I think is going on here. If we don’t have a diagnosis . . . we can’t treat. While we are not going to have a diagnosis here, there are some very clear pointers that will also give us some direction with what to do. I agree with the armchair shrink who thinks your ex might be bipolar. It has all the right features. You describe him being “on a roll” at work with an increase in social ability, improvement at work and a heightened sex drive. These are clear indicators of a hypomanic episode. Nobody EVER goes to the doc to complain about that. It feels G-R-E-A-T . . . which is part of the problem. An intervention at those times is difficult. You get a response such as . . . “what, you don’t want me to be happy???” . . . or . . . “you are just jealous” . . . but rarely do you get insight. The unfortunate truth of a hypomanic episode is that, like all good things, it must come to an end. And when it does, it is not pretty. Typically, the mood state that follows hypomania or full blown mania is depression. And, as if being depressed is not bad enough, the difference in feeling between being hypomanic and being depressed is so great that it is doubly extra painful for the person. Once you taste hypomania, your “set-point” for “normal” is different. Being “just OK” can feel a little depressed. Going from the heights of hypomania to the depths of depression feels just terrible. And THAT is when people go to their doc for treatment. The GP, having limited time and limited experience with complicated psychiatric issues, will see someone who was doing well but now has several weeks of classic symptoms of depression and will prescribe an antidepressant. The response of a patient with Bipolar Disorder is classically what you describe above. Moody, irritable, unpredictable, hostile, and potentially aggressive. It can be persistent, or, as you describe above, can be co-mingled with times where he is his usual self. Or, even worse, it can co-mingle with the return of hypomanic symptoms where the patient feels really, really, really gooooooood again. And can think . . . “aaaaahhhhh . . . this medicine is really working!!!!” The irritable moody episodes are often externally blamed by the patient. For example, “I’m angry because I’m sick and tired of you acting like this . . . it’s not me . . . it’s you who has the problem . . . ” Which is why dealing with this by yourself will be very difficult.
So, here is what I suggest . . .
First, you need an ally. My guess is that you are not the only family member who has seen this. Or, If you are, there must be someone who will be willing to step up to the plate and help this guy out. Doing it alone risks you being identified by him as the bitchy meddlesome ex-wife, a position you have avoided so far. If no one will help, do it alone, but there is safety in numbers. Once you have your ally, you can decide how you will approach this. There is no one right or wrong way. It depends on the patient in question, and the nature of the relationships between him and those who are intervening. It is imperative that it be done in a concerned and non-threatening manner. The point is to get him help, not to harass him. Somehow, this message must be conferred. If it is the consensus of those who are willing to intervene that it should NOT be done face to face, then, we must use alternate means . . .
THE LETTER . . .
I get these all the time. The letter from the concerned family member, letting me know what is going on. They invariable have a totally unhelpful ending such as . . . “don’t tell him I told you!” What, you afraid of being a tattle-tail???? Docs HATE these because it puts them in the position of having information that should be acted on but “not” being able to say where the information came from. Does it violate HIPAA (more on that in another blarticle). NO. HIPAA prohibits the release of protected health information without the patient’s consent. It says NOTHING about receiving information from family members. If someone calls me or writes me a letter, they know I am involved with the patient’s health care. They write or call me by name. Its not like they started in the yellow-pages under “A” and finally got to “H”. When I accept phone calls by family members, I will tell them that I am answering the phone call as a courtesy to the caller and I am neither confirming or denying that the person in question is or was under my care. HIPAA does not allow me to talk. It does allow me to listen. I will then suggest that, if they think the patient is under my care, they can write me a letter or they can come in to the next session with their family member and we can deal with this as adults. If they write me a letter, I will, most likely, be sharing it with the patient. But . . . I don’t always need to.
For the above example, the doc could simply say to your ex that it is not uncommon for patients who start antidepressants to feel irritable and be more easily angered . . . ” . . . anything like that happening with you?” If he admits it . . . BINGO!!! Problem solved. GP refers your ex to a psychiatrist because the situation is too complicated and potentially dangerous for the patient. The same can be done with the psychologist. He or she can query your ex more thoroughly about changes in mood and, if elicited, get him in with a psychiatrist. Whenever possible, I do bring up the letter or the verbal communication from the family. It keeps everything honest and above board. If, I need to bring the communication up to get the patient to address what I feel are clinically important issues that he is ignoring, I do. If I feel that the patient has enough insight into the situation and bringing up the letter or communication would be detrimental, I don’t bring it up. Every case is different and must be handled in a clinically appropriate fashion. But, from a doc’s perspective, having knowledge and not acting on it could potentially be a liability issue.
You seem to be a caring and concerned friend to your ex. He is lucky. What you describe are very serious and concerning mental health symptoms consistent with a Bipolar Disorder. If it is, his health, his career, his relationships, and maybe even his life is at risk. Do what you need to do to get him help. Even if it is initially upsetting for him, it would be my hope that, someday, he will look back on this and see what a good friend you are.
–Dan Hartman, MD
Treat or wait? The annual ADHD question
With the start of September, all thoughts turn to . . . medicating our kids??? Well, as bad as that can sound to some, it IS time for the annual debate. A question for which there is no clear answer. Let’s examine several scenarios and I’ll give some suggestions . . .
We’ll start with an easy one . . . the very hyperactive and disruptive kid with focusing difficulties. This is kind of a no brainer. Despite what some detractors might say, these kids really, REALLY benefit from the use of medicine. There are always ways the school environment can get tweaked to help them, but, for most, they will have significant difficulties no matter what you do. It is important, in my book, to treat these kids aggressively with medication so that they can begin the year on a good footing. If they can get into patterns of good relationships with both peers and teachers, and get into a good pattern of classroom behavior and homework achievement, it sets the pace for the rest of the year. It creates a buffer to absorb difficulties that may crop up later in the year. It gives them some sense of self confidence that keeps the bar high for later expectations. As you parents out there know, the personality match between the teacher and the kid can have a huge impact on the quality of the year. If the teacher must act the strong-man to manage behavior early in the school year, the likelihood of the kid liking the teacher and feeling comfortable with him goes way down. That can sink the whole year.
How about those inattentive kids without behavior problems? This is one of those grey areas that requires clinical finesse. A lot goes into the decision about using medicine here. How difficult is it for the kid to stay integrated into the classroom experience? How much impact does the focusing issue have on knowledge acquisition and academic success? How important is the school year (eg, 11th grade is way more important than 7th grade). Is the medication well tolerated or does it cause significant side effects? I could go on and on . . . (as I said, this is a big grey area!). In thinking about what to do, I consider as many of these factors as possible. Most kids want/deserve a trial off medicine at some point in their academic experience. Taking all these factors into account is very important as is the timing of the trial off. For these kids without behavior problems, the start of the school year can be a good time, as long as their progress in school is carefully monitored and there is good communication between home and school. What you don’t want is for half the year to go by, the kid to feel completely lost, and THEN have the teacher give a call to let you know about your summer plans . . . summer school. As I mentioned above, a potential danger in this strategy is that a bad start can effect a whole year, even if caught early and with efforts put into recovery. The alternative strategy is to medicate early so that the child gets a good footing for the school year, and then stop the medicine. This, too, must be done carefully and communication between school and home needs to be good. Sometimes, we do these trials off without the teacher’s knowledge. It allows the teacher to be ‘blind’ to the condition and to give more unbiased reporting of events. It then falls on the parent to touch base with the teacher about academic and social progress. Since most kids with ADHD take stimulants medication that wears off at the end of each day, a change in ability to concentrate can be readily apparent to the teacher (and the parent during homework time).
A strategy I will use for these mid-year trials off medicine is to gradually reduce the dose that is given to a child (eg, Adderall 20 mg for a month, then 15 mg for a month, etc,). While more difficult to ‘catch’ the onset of difficulties, it does allow us to re-check the lower threshold for medication. This can be especially powerful in kids who are motivated, maturing, and learning better ways to manage their own time and their own tendency toward being distracted. It is always best to have a discussion about what the end-points will be that will trigger an increase in medicine. If these end-points are written down, it will allow for a smooth and non-traumatic transition back to medicine. The truth is that, for most kids, if they had trouble focusing and concentrating last year, they will have trouble this year. The question will be how much trouble, and how will they deal with it. Planning ahead for these contingencies will increase the chances for a positive outcome, whether or not it includes continued use of medicine.
If it is determined that medicine is still needed, it is also important to frame the re-start in a way that is not defeating for the child’s esteem. It is not that someone “failed” the trial off medicine. It is just that we need to keep the medicine in place for a while longer. Reassure both the parents and the child that another trial off the medicine should occur in the future. That the most important think is that the child does as well as he or she can in school, and that their experience of school be positive. Just like “every day is a new day” with the stimulant medicine . . . every year is a new year at school and it presents another opportunity to consider a trial off the medicine.
–Dan Hartman, MD
Rash from Lamictal . . . do you have to stop it?
This letter brings up an important question about Lamictal . . .
I’m a 45 y/o female properly diagnosed and treated as bipolar for 1 & 1/2 years. Prior to this diagnosis, I was treated soley for depression for 10 years (the last 5 as refractory.) I am presently doing GREAT on Lamictal 200mg daily and Effexor 300mg daily. The problem? I’ve had a rash on my leg for 2 weeks and only today made the connection to Lamictal’s potential for a life-threatening rash. I can rule out contact dermatitis. I’m not experiencing SJS symptomes. I will contact my ANP on Tuesday for evaluation and probably drug discontinuation. My question? What titration schedule do you use to discontinue Lamictal? What titration schedule do you use to concurrently add another AED such as Topamax? I really appreciate your time and dedication to this topic! Have you had particular success with another AED? I can’t begin to tell you how well I have been doing since the addition of Lamictal. It changed my life. I hate to give it up.
It can be very discouraging to FINALLY find the medicine that works well, only to have that medicine turn on you. As you know, this is more likely to occur with Lamictal than it is with other medicines. The quick answer to the title question is . . . “yes, of course”. But lets look at the issues involved in this medicine and the rash. As is true with much of psychiatry, there is grey area that must be explored and considered.
You can read the information in the dreaded “Black Box” yourself, the risk of serious rash in patients taking Lamictal for Bipolar Disorder is approximately 8 in 10,000 (0.08%). The conventional wisdom is that there are certain factors that may increase your risk. These include concomitant use of Depakote, exceeding the initial dose recommendations, and titrating up too quickly. If there is any concern about a Stevens-Johnson reaction, the medicine must be stopped and immediate medical attention sought. The more you read about this condition, the scarier it becomes. Just to scare the crap out of you completely . . . here is a link:
http://www.emedicine.com/med/topic727.htm
Read at your own risk.
That said, what do we do with the young lady above?
Most of the cases of rash and, especially, the serious varieties of the rash, occur in the first weeks and months of treatment with Lamictal. The rash that is especially concerning is that which is associated with mucus membrane. Here, we have a rash that is occurring 18 months into treatment (unusual), and only on the leg (also unusual). Given how this medicine has turned your life around, I would not be so quick to stop it. The area of rash should be seen by someone who is experienced in rashes (often NOT the psychiatrist). This may be a case for one of those rare emergency appointments with a dermatologist. At the very least, I would get in to see your family doctor. Rashes are kind of like headaches. There are so many reasons for them, it is often hard to pin down the exact reason with any clarity. It would be a shame (to say the least) to move away from what has been a life altering treatment for your Bipolar Disorder and not be certain that it is required. If the pattern of the rash is static (not worsening) it may be reasonable to wait and watch. It may be caused by something you were not aware of (it may be a contact dermatitis after all). So, I’ll talk about the taper below, but, please, get in to see someone (not on the phone) and have the rash evaluated. Make sure that the doc doing the evaluation clearly understands that taking you off the Lamictal may cause a return of serious depression. It is a decision that cannot be made lightly.
Tapering the Lamictal can be done quickly or slowly without significant physical symptoms for most people. As a general precaution, it is recommended that a taper be done over the course of two weeks or so (there were a couple of people in the initial Bipolar trials who had seizures on discontinuation but there were confounding factors that made it unclear if the removal of Lamictal was to blame). When I am not in a hurry, I can sometimes take a couple of months. I know you are looking for specifics, so I could guestimate that I might take off 50 mg every 5 days or so if I was in a hurry. Now, what to do next . . .
Tough call. Plus, I have no other information about you except what is above. Generally speaking, if Lamictal does not work, we use standard antidepressants along with mood stabilizers to help decrease the risk of hypomanic or manic episodes. You are already on an antidepressant (Effexor). You could add in an AED (anti-epilepsy drug) such as Depakote, but more and more I am adding in Abilify. It is a great mood stabilizer, has a low risk of causing weight gain, and has been shown to augment the benefits of antidepressants. There are some difficulties with it that I have outlined in other blarticles, but, overall, it is a great medicine for most people. You can also add Wellbutrin in to the Effexor, but I would not do that unless you are on a mood stabilizer.
Remember, you must be well monitored by your doc during this transition period, whether it is monitoring this rash or transitioning to other medicines.
Let me know how things go.
–Dan Hartman, MD
