Transcranial Magnetic Stimulation–Part II

Sorry for the lack of writing folks, I been biiiiiiizzzzzzzzzyyyyyyy!

I am proud to announce that I am an official TMS provider!  My NeurostarTMS machine was delivered the first week of November and I spent the better part of last week being trained on how to use it in real-life situations.  From a professional standpoint it is awesome.  For the standard psychiatry part of my practice, the most technically challenging aspect of the day is clicking the top of my pen so I can write prescriptions.  Using TMS is a whole other world.  For those who have little understanding of what TMS is (which I would guess is most of you since this is brand new technology), it involves stereotactically mapping out the part of the brain that sends signals to your right hand, and then using those coordinates to estimate the location of the prefrontal cortex that would be most likely to cause mood improvement if subjected to a series of magnetic pulses.  The machine itself is amazingly awesome in how it is set up to make this doable.  That fact that it works to help people who are suffering feel better?  I cannot describe how that makes me feel.

The persistent suffering of my patients with non-responsive depressive symptoms is very difficult.  I am very skilled at not letting their sadness become my sadness, but I develop a very nice relationship with these people over time and it IS sad for me to see them suffer.  I have depression in my family, so I know first hand how frustrating it is for patients and their families to spend month after month not getting better.  I know how my decisions with the medicine can impact on lives and families and make or break them.  To have a new hope to give these people . . . brings tears to my eyes.  I have one patient already receiving active treatment and I have several more who are in the pipeline ready to start by the end of the month.  I will let you know how things go over time.

So, I’ll be back to writing soon.  I still have organizational issues to address to get TMS fully integrated into my practice.  If you want to learn more about TMS, go to the company website and see for yourself . . .www.neurostartms.com.

–Dan Hartman, MD

Transcranial Magnetic Stimulation . . . A New Hope For Treatment Resistant Depression

A former patient wrote this to check in with me . . .

As a former patient of your practice, what are your thoughts on treatment resistant depression?  Anything new or in the pipe line?   At present I am doing well with Pristiq ,lithium, and Depakote. I am also involved in a sleep study with a blind trial of rozerem with a Doctor at a local hospital. Best of luck to you. You should start writing a book by now.

First off, it always warms my heart to hear from former patients!  Thanks for taking the time to view my blog and to ask a very good question (great segue!!).

Managing treatment resistant depression (TRD) is one of the more challenging tasks for us in the mental health world.  But as challenging as it is for me . . . it is far more difficult for the patient who is living it . . . and their family.  It is near impossible to change how you feel when you feel as bad as you do with TRD.  The people around you feel so dis-empowered and, in many cases, progressively more angry, at your “lack of trying” or your “lack of caring”.  It is true that when you are at your worst, you feel like you don’t care and you may not try . . . but that is because of how impossible a task it seems.  When you are in the depths of your depression, you might as well be asked to pick up a truck.  Can’t do it.  Can’t smile . . . can’t laugh . . . can’t get out of bed.

Very scary for those around you who care about you.  They can feel hopeless and helpless.  Confused and angry.  And hurt.

So what is there to offer these days.

First off, how about just good basic treatment.  Even that can be in short supply at times!  It is vitally important that people get good basic treatment.  This would include solid trials with medicine (enough medicine for long enough) AT THE SAME TIME as you are getting good therapy.  Good basic treatment would also include combination treatments with complementary antidepressants, neuroleptics (Abilify is the most common agent here), lithium or thyroid hormone.  With everyone’s physiology being different, it is impossible to predict what is going to work for a particular person.  Sometimes things just click in and life is good again.  Sometimes, it is unsuccessful trial after unsuccessful trial.  Frustrating.  And potentially deadly.  Under treated depression is a potentially lethal disease that must not be minimized.  Any

In the past, repeated medication failures would indicate a need to consider ECT . . . Electro-convulsive Treatment . . . shock treatment.  The mention of this invariably scares the tar out of anyone who hears that it might be the only way out of severe depression.  Visions of Jack Nicholson getting shock treatment in One Flew Over The Cuckoo’s Nest are hard to get out of your head.  The stories of memory loss and cognitive impairment (a very real risk with ECT) has to make one consider if muddling along feeling like crap would be better than plugging in to ECT.  I have personally been an advocate of ECT for severe treatment resistant depression, and have told my wife that I wanted it if I was ever in a position of being severely depressed to the point of incompetence.  But now there is a new option.

Transcranial Magnetic Stimulation (TMS) has been in use in Europe, South America and Canada for years.  It has been shown, when done carefully, to improve about half of the patients who have failed previous medication trials and bring a third of the patients to remission.  REMISSION.  Wow.  That means ALL BETTER.  And, it has virtually no side effects.  No memory issues.  No cognitive issues.  Just better.

It doesn’t get better than that.

Not everyone benefits from it, but the treatment is specifically for patients who have failed all conventional trials.  It is expensive still, because insurances are slow to pay for new treatments.  The company who has gained approval of their machine (Neuronetics) has a great patient advocacy program that tries to get approval through the insurance company and, if that fails and the patient has the treatments, tries to get reimbursement.  They have been successful in a handful of cases.  That is a start.  There are also financing plans in place to help people get the treatment while they wait for the insurance companies to get on board.

So, as an FYI to my wife . . . if I ever get severely depressed and am not coming out of it . . . I’ll take TMS, please!

–Dan Hartman, MD

PS     I’m working on the book!

Balancing The Need For Benzos and Antidepressants To Cover Anxiety

I noticed another fellow talked about being on 3 mg on klonopin for 15 years. For me, it’s been about .5 to .75 mg per day for 14 months but I have still been unsuccessful coming off of it. Do you recommend using acupucture and meditation during a slow taper? I also take 60 mg. of celexa. Should I ask my psychiatrist to put me on an SSRI that is stronger or at least different to help with my k-pin weaning?

When I read your question . . . my head is filled with . . . why . . why . . . WHY????

Why did you go on the Celexa?  Why is the Celexa dose 50% higher than the typical maximum dose? Why go off the Klonopin?  Why have you been unsuccessful coming off?  Much of the answers to these questions centers on why you are on the medicine you are taking.  I must take some liberties and assume some facts here.  I will assume that you had a primary diagnosis of Major Depression that was accompanied by some anxiety.  I will assume that you got good resolution of your symptoms with the above medicines.  I will assume that you are tired of being on so much medicine and now want to wean off.  As I look at the regimen you take, my concern is not that you are on the Klonopin, but that the dose of the Celexa is so high.  Why is that?  There are certainly times where that aggressive approach is warranted, but not usually.  Too much of an antidepressant can, at times, precipitate MORE anxiety and feelings of edginess.  That could, perhaps, be at the root of your difficulty getting off the Klonopin.  If you are stable and doing well on the medicine, the first step might be to lower the Celexa down to a normal dose and then try to titrate off the Klonopin.  I will also remind you that some people just do better on Klonopin.   The doses you are using are modest, so unless you have a particular reason to come off (getting pregnant, wanting to drink alcohol, etc), there is no specific reason that you MUST come off.  I shy away from the view that Klonopin is a “bad” medicine that must be minimized at all costs.  It’s badness is really dependent on how the person taking it uses it.

Another factor that must be considered is what is your diagnosis.  If you had a strong history of anxiety before you had Depression (or developed it as part of the depressive complex), it could be that you will have persistent depression that could be addressed with medicine.  Sometimes the antidepressants work alone to do this, sometimes we NEED to use benzos.  While most antidepressants will work for most people, some do respond better to one than they do to another.  No way to predict this.  You mention a “stronger” antidepressant . . . ain’t no such thing.  It is not about one being stronger or weaker.  It is just about one working better for YOU.

Here is what I’d suggest.  First, have a planning session with your doctor about what you want to do and why.  Get him to outline steps to take and then you must stick to those steps without fail . . . or at least make no changes without re-consulting him or her.  It sounds like your primary desire is to get off the Klonopin.  Any taper should be exceedingly slow since you have been on the medicine for a long time.  I would go down by no more than .25 mg every month.  Your antidepressant dose should be no more than the maximum recommended dose (to avoid overstimulation).  If you cannot reduce the dose of Klonopin without getting anxious, put the dose back to the last comfortable dose.  You can then switch to a different antidepressant (the choices are many and you would have to work that out with your doc).  Once you are stabilized on the new antidepressant, try to wean down on the Klonopin again . . . very slowly.

Ultimately, if your experimentation leads you to conclude that the Klonopin is a must to keep you from feeling anxious, you must decide if you really need the antidepressant.  If the Klonopin is needed for anxiety, the only reason for the antidepressant is for depression OR to help keep the dose of Klonopin down.  You might, in the long run, do quite well with only a  low dose of Klonopin on board.  In any case, you will need to be patient.  You have been on the medicine for a long time and getting these adjustments made might take many months or even a year or more to figure out.  Work out with your doc your ultimate goal and stick to slow methodical steps toward this goal.

–Dan Hartman, MD

Treatment Resistant Depression–Under Recognized and Under Treated

As a psychiatrist . . . as an empathic person . . . it is very difficult to hear stories like the one listed below:

My heart is broke and i Feel I will never leave this deep black dark hole that I cant escape… Im tearing up heavily as I write this message… Ive been on 50 different types of medications it feels like the past 4 years and im only 25…. no one understands… and as much as they think they do.. they dont….. I am taking myself off all my medications by weaning myself off… there is no point in being on them and still experiencing all the symptoms that i would as if i was not on them.. I feel defeated,, my only hope is in jesus christ, some sayy well its a chemical imbalance and I know it is, but i cant take these meds anymore.. i have failed over and over, though Im not giving up it seems failure still follows right behind me. with poor commitments , poor job history, poor relationships.. Im seriously heartbroken…………

Treatment resistant depression is a crushing illness for those people unfortunate to experience it.  People with seriously debilitating medical illness can still take solace from friends, family, activities, etc.  Not so if you have severe unremitting depression.  You feel very, very alone, and you tend to push people away so, for many people with this illness, you really are alone.  I have yet to hear of a “Beef and Beer” being thrown to help encourage and support someone with psychiatric illness.

The numbers for depression are staggering.  In a study done in 2003, Kessler et al. found that 14 million adults in the us experience an episode of Major Depression.  Of those, only about half (7.2 million) received treatment.  Of that 7.2 million who received treatment, only 3.2 million received adequate treatment.  If you extrapolate data from the STAR*D study (that is the “Sequenced Treatment Alternatives to Relieve Depression” study–the nation’s largest depression treatment study) to this population, you get some scary numbers.   In the STAR*D study, only 67% of the patients reached clinical remission.  So, by those estimates, 67% of 3.2 million . . . or 2.1 million . . . got better.  Roughly 2.1 million out of the 14 million US adults who get depression receive adequate treatment and respond to that treatment.  That’s 15 %.  Pitiful.  Can you imagine the outcry if only 15 % of the 23 million adults with diabetes got adequate control of their symptoms.  Or if 15 % of the 1.5 million victims of heart attack reached remission of their symptoms.  It would not be tolerated.  With mental illness, however, the silence is deafening.  This lack of attention and lack of adequate treatment is why Major Depression is expected to be the second highest cause of human disease burden worldwide by 2020.

So, what are our options?

1.     Clearly we who experience or treatment mental health issues must stop being embarrassed by the illness and stand up for recognition and adequate treatment.  With the current battles going on in Washington, DC about health care, how many of you have contacted your Representative or Senator to urge them to make adequate mental health coverage mandatory?  If not, go to www.usa.gov and click on “contact elected officials” and let them know how you stand on this issue.

2.     Get yourself educated.  Or, if you cannot because of your illness, get a family member to be your advocate for you and attend some of your doctor’s appointments with you if at all possible.  The mental health system in this country is not good and you have to be savvy and on top of your treatment.  People bring family members to appointments regarding cardiac issues, diabetes, and irritable bowel disease all the time . . . because they need the support and the guidance.  Having an educated  someone go with you to the med check or evaluation can be equally vital to treatment.  If the doc is not willing to allow that . . . get a different doc.

3.     Make sure your med trials make sense.  Remember those numbers at the top of this blarticle????  Of the 7.2 million people who got treated, 4 million . . . more than half . . . received inadequate care.  It is vital that depression be aggressively treated.  One of the main causes of treatment failures is not getting enough medicine for long enough.  That can be from intolerable side effects or it can be from inadequate prescribing.  The end result is the same . . . persistent symptoms of depression.

4.     Use of adjunctive agents.  More and more, combination pharmacotherapy is able to help patients achieve improvement in their symptoms.  That can be innovative combinations of antidepressants or addition of augmenting agents such as lithium, thyroid hormone or second-generation neuroleptics.  Again, the more educated you can be, the better you will be to discuss these options with the doctor.

5.     Do all the right things . . . eat right . . . get enough sleep . . . exercise . . . pray or meditate . . . stimulate your mind . . .

6.     Get yourself a good therapist that is going to listen to you . . . work with you . . . and kick your butt when you need it kicked.  Too often we allow ourselves to fall into a pattern of negative behaviors that promotes our depression.  It takes a great deal of courage and a great deal of help to confront those patterns.  A good therapist is worth their weight in gold.

7.     Innovative approaches.  When all the right things are done . . . some people continue to have significant symptoms of depression.  For that population, we would, in the past, prescribe ECT.  That can work well for some, but can have very significant consequences for others with long term cognitive issues.  It is also a time-consuming and potentially hazardous invasive medical procedure.  But it was all we had until . . . Vagus Nerve Stimulators.  That was a bust, as far as I am concerned.  I tried to get several patients approved for it without success.  And the cost was prohibitively high (tens of thousands of dollars for the procedure) and the outcome was still questionable.   And it was very invasive (wrapping an electrode around your vagus nerve and implanting a pacemaker-like stimulator in your chest).  And NOW . . . . . . . . . . . we have TMS . . . Transcranial Magnetic Stimulation . . . which has been present in Canada and elsewhere for years, was approved by the FDA for a company called Neuronetics which developed a TMS system that proved effective for the treatment of Major Depression that did not respond to one adequate trial of an antidepressant.  More on that another time.

So, to the writer of the letter above, I do not know what the quality of your treatment has been . . . but my guess is that there continue to be other options available for you, but you must be open to these options . . . and you may need to get yourself some help in attaining these options.  My thoughts and best wishes go out to you.

–Dan Hartman, MD

What Makes Vyvanse So Special? Simple.

As time goes on, I become more fond of Vyvanse as a medication for my patients with ADHD.  As my loyal readers know, I am very hesitant to jump on the pharmaceutical bandwagon and I view all new products with great skepticism.  Especially when they are re-hashes of old medications as many of the “new” meds for ADHD are.  In recap, Vyvanse is just Dexedrine.  Dexedrine is one of the oldest products on the market for treating ADHD symptoms.  It fell into great disfavor (in certain circles) because of it’s abuse potential.  In the 1970’s and 80’s it was clearly the choice for too many people for weight loss, avoidance of needed sleep, and study-binges.  It’s use was frowned upon and it became unusual for psychiatrists to use it for their patients with focus and concentration issues. Which is a shame.  There is a segment of the population that only responds to and/or tolerates a dexedrine based product.  Those kids then received less than adequate treatment.   Over time, however, attitudes change and prescribing practices change and . . . most importantly . . . the pharmaceutical industry comes out with a new product.  Like Adderall.  

The wonder drug.  

(At least for Shire!)

With the advent of Adderall on the market, use of dexedrine based products shot up exponentially.  As you may remember, Adderall is a combination of four amphetamine salts (equal amounts of Dextro-amphetamine Saccharate, Dextro-amphetamine Sulfate USP, Amphetamine Aspartate Monohydrate and Amphetamine Sulfate USP).  It was followed quickly by the emergence of Adderall XR (imagine that) which is, to this day, my most commonly prescribed stimulant product.  Because it is good.  Works for most kids and adults (tho’ not all) and is very well tolerated (by most, but not by all).  In comparison, Vyvanse is a “simpler” medication.  It is a single agent (Dextro-amphetamine) attached to a lysine molecule (an amino acid) that is removed in the gut.  Once the lysine is removed, the Dexedrine can be absorbed.  Simple . . . simply ingenious . . . but simple.

In my arsenal of medication for ADHD, I use Vyvanse for those people who do well on Adderall but do not tolerate it due to mild to moderate side effects.  So those kids who’s appetite is too impaired, feel jittery and wired, feel “not themselves”, etc., often do quite well with a simplified product (which is what Vyvanse is).   The development of Adderall was, after all, a trick to get us to use dexedrine again.  It is nothing new.  Just a reformulation and a nifty delivery system.  The fact that it works comes as no surprise to me.  I guess I should be more surprised that more people don’t have difficulties with it.  It is bad enough when we give a single moiety to a patient, let alone a combination of four.  I think that it is the only product on the market that DOES come as a combination of four agents.  (There are lots of ‘double’ agents such as Symbyax, Vytorin, etc).  Seems to me it would increase the likelihood that a patient would not tolerate one of the agents.  By moving to Vyvanse, I am providing a significant simplification of the medication regimen to the patient.  The primary impediment to this is the insurance companies that want me to use something else that has been on  the market for a while before using Vyvanse (which is relatively new).  So I end up going to a Ritalin based product such as Concerta or Metadate.  Which is not the best for the patient . . . but something I do not control.  I certainly anticipate that, over time, there will be more use of Vyvanse as more docs become more comfortable with it as a product.  I know that my comfort level with it is quite high and I feel it is one of the better products out on the market at this time.

–Dan Hartman, MD

MANIFESTO DELLA FAMIGLIA–May Peace Reign Supreme In This House

In the hustle and bustle of family life, it is inevitable that conflicts and arguments will occur from time to time.  The more kids you have, the more this is likely just because of the sheer number of personalities involved (but small families are hardly immune!).  This can be particularly difficult to manage for “the sandwich generation” . . . that group of us who are stuck between grown kids and our own parents and siblings.  We can get treated as “kids” by our parents . . . treated as an idiot by our siblings and considered a moron by our children.  It’s a wonderful life!  Trying to please everyone all the time is an impossibility.  Trying to maintain a sense of peace within yourself is equally difficult.  We in our middle age have a distinct advantage over our kids, however, in that we can see how family dynamics play out over time.  We can see . . . because we have lived . . . how small arguments and conflicts can grow into huge rifts that, over time, alienate sections of a family from each other.  We have lived the pain of this.  We have seen how brother and sister end up not speaking and how that leads to cousins not speaking and how all involved (and those on the sidelines) end up experiencing a tainted version of day to day living.  

Is this how your family is?  Is this the way you want it to be?  I put this question to the middle age crowd out there because you are the ones who are mature enough and experienced enough to see the big picture.  Kids (and I count most of you who are below the age of 30) don’t have the distance to see the big picture.  It is also a rare kid who will put their own interests and intentions secondary to a siblings (they are still vying for the emotional power that attention from mom and dad affords).  That leaves it to you to set the tone.  Our elder parents are often not psychologically sophisticated enough, or energetic enough to step in and create sweeping changes to difficult family dynamics.  It is up to you.

What I would suggest is that you put an end to your collusion with the petty arguments that your kids are involved in.  In the big scheme of things, most of the arguments don’t mean dookie.  Will it matter 100 years from now who insulted who at some party.  Will it matter 100 years from now if a debt is not repaid.  Not really . . . unless someone’s fragile ego or someone’s sense of what is right and what is wrong is so injured that communication is stopped.  Then, as noted above, cousins won’t know cousins . . . and someone will be eating Christmas dinner alone.  Is it really worth it?  Would you refuse to go to the funeral of your sibling . . . or of your sibling’s child . . . if your sibling said something that made you mad . . . or did something that really bothered you?  If you could forgive then . . . why not now when there is still time reclaim your relationship?  As Ronald Reagan said . . . ” my 20% enemy is still my 80% friend”.  If you are going to be alienated by something that is said by someone who is important to you . . . you are going to end up being alone.  ’Cause EVERYONE will eventually piss you off.  That is just fact.  As humans, we tend to blunder through our relationships and make mistakes.  If we are not willing to apologize . . . and accept apologies . . . we are sunk.

Forgiveness is oil for the machinery of friendship.  

Without it relationships grind to a halt.

I would encourage you parents out there to insist that HOME is a safe place.  Sometimes the kids live at home.  Some are out in the world and only visit occasionally.  Regardless, the family home is neutral territory.   Conflicts and arguments that come up are discussed peacefully or put to the side during family events.  It is about spending time with each other and reminding each other how important we are too each other.  It is about maintaining those relationships despite our human blunders.  And, ultimately, it is about being humble enough to understand that we all make mistakes and we all need a double dose of forgiveness.  

MANIFESTO DELLA FAMIGLIA

In questa casa, la pace regnerà supremo

In this house, peace shall reign supreme.  All are welcome and no one shall be excluded.  Differences of opinion that will lead to argument are left at the door.  Disagreements are managed with words of kindness and support and we treat each other with respect.  Mistakes shall be forgiven, errors shall be overlooked . . . for we all make mistakes and errors in our daily lives.  All will be given what they need to the best of our abilities.  Score will not be kept.  Sides will not be taken.  Forgiveness will be served in abundance, as will love . . . laughter . . . kindness . . . and peace.

 

–Dan Hartman, MD

A Challenge . . .

I have long searched for new and different ways to settle my mind down and to remain centered and grounded.  In my work with people who are decidedly NOT grounded, it is imperative that I maintain my focus.  This is important not only for the welfare of my patients but also for my ongoing mental welfare as well.  But long before I was a shrink, I was a seeker of knowledge.  One who was always on the prowl for titbits of knowledge and wisdom.  Some I found through my practice of standard religion, but I have also been open to wisdom from other sources as well . . . the tao te ching . . . A Course In Miracles . . . Castaneda . . . Chopra . . . wherever I can find it.  Putting this knowledge into practice is another issue, tho’.  The many things I want to accomplish each day vie for my attention and, if I am not very careful, meditative time for myself is left to last . . . and then does not get done.  For me, meditative practice MUST occur before the start of the day.  If not . . . won’t happen.   I was recently sent an email from a site my wife turned me onto called the Urban Monk (www.urbanmonk.net).  It was another case of “right place/right time” and I have found it very helpful.  It, combined with some other recent influences, led me to this particular entry which has at it’s core a list of affirmations that I found very inspiring.   I have recently been encouraging my family members to slow down and to do some regular meditating.  I intend to give this particular entry to them and encourage them to follow through with this.  At the bottom of this entry, I have added relevant links to the Urban Monk and to a set of CDs put out by Jon Kabat-Zinn that I think are the best for teaching meditative practices.  I encourage all to slow down . . . and keep exploring and keep learning.

TRY THIS . . .

Sit in a comfortable position.  Either on a chair or on the floor.  There are no rules here, just be comfortable.  Sometimes a little bit of stretching beforehand can help you feel more at ease and relaxed.  Once you have found a position that is comfortable, do the following simple breathing exercise . . .

     1.     Close your eyes and begin to pay attention to your breathing.  

     2.     When you are ready, start counting your breaths.  With every breath in . . . one . . . out . . . two . . . out.  

     3.     With every count in, allow yourself to feel more relaxed and peaceful.

     4.     Count up to 50 breaths.  When you find you have wandered in your thoughts (and you will . . . expect it), start back at the number you can last remember.  It doesn’t matter if you are wrong.  There is no test and no right and wrong with this.

     5.     When you get up to 50 breaths, open your eyes and read the following affirmations either aloud or quietly to yourself.  Whichever is most comfortable for you.

 

AFFIRMATIONS:

I make the conscious choice to be free, and to hold my freedom as a priority, not to be compromised.

I take full responsibility for my happiness and know that it is never dependent on anyone or anything outside of myself.

I prefer my essential and intrinsic happiness to the temporary fulfillment of desires.

I value my inner peace more than I do winning, defending my identity, proving my point, or reactivly expressing momentary emotions.

I refuse to be reactive, and to let my emotions be controlled by others.

Anger does not guide my hand.  Fear does not inhibit my action.  Desires do not govern me.

Attachments do not bind me.

I do not engage in self defeating behavior.

I accept that which I cannot change.

I have no need to control or possess others.

I do not depend on others for validation or approval.

I allow others the freedom of being themselves, without judging them or attempting to change them.

I can forgive others because I understand that we all act according to our current level of consciousness and understanding.

I am complete in the present moment and therefore do not look to the future for fulfillment.

I am free to give love, without conditions or expectation.

I know that my identity is self defined and self imposed.

I see the impermanence of all things and so do not cling unnecessarily to them.

I realize that all perspectives are fragmentary and incomplete.

I allow others to be free by dropping all demands and expectations of them.

I learn from the past, but do not allow it to interfere with the present.

Though I cannot always control my thoughts, I can control which ones I pursue and give energy.

I understand the difference between what exists in thought and what exists in reality.

I see that if my thoughts have no correlative in physical reality that they are little different than imagination.

I know that all answers lie within and that they can only be obtained through experience.

I will help anyone that I can, knowing that ultmately the responsibility is theirs alone.

I realize that, when I become disturbed, that nothing is missing.  Instead, something has been added and is obscuring my inherent peace and stillness.  That my attention has deviated from the present moment.

I am a light unto myself.

 

BREATHE

     1.     When you have completed the affirmations, repeat the breathing exercise that you started with, counting again up to 50 breaths.

 

In completion . . .

I challenge all of you who read this (and myself as well) to do this every day for the next 30 days and see what difference it makes for you.   Write to me and let me know what you have witnessed in yourself.  As I mentioned above, I did not write the affirmations listed above and am just passing them along.  I encourage all of you to go to the source for this and read the entry on the Urban Monk entitled “A Light Unto Yourself/In Case Of Emergency”.  It was originally written by John J. Patton and is very good.  In addition, I have given a link to an excellent set of CDs by Jon Kabat-Zinn that teach meditation better than any book or CDs I have come across.  I am especially fond of the “series 2″ CDs and would encourage all to get those as well.

http://www.urbanmonk.net/777/a-light-unto-yourself/

http://www.mindfulnesstapes.com/

Have a peaceful and happy week.

–Dan Hartman, MD

Why Don’t I Get Better When All I Do Is Medicine?

I am not bipolar but am on 200 mg of Lamictal and 50 mg of Zoloft.  I have tried many meds and I never feel good.  I have read alot and done alot of research.  I have found that there is no proof of chemical imbalances or that these meds work better than a placebo.  Why don’t doctors try more natural solutions, and more talk therapy.  I would like to know your thoughts on this.  Thank you.

No . . . THANK YOU!!!  I don’t agree with all of what you say, but I agree with your underlying sentiments, that too often there is little done EXCEPT to throw medication at a problem.  As far as your initial assertion that there is no proof of “imbalances” in the brain, I disagree.  While direct measurement of neurotransmitters in brain tissue is not currently possible (I personally would NOT volunteer for that particular experiment), there is indirect evidence of neurotransmitter abnormalities.  Researchers do this by measuring the metabolites (the break-down products) of neurotransmitters in urine.  It is not an exact science and has not (and probably never will) reach the point of being a true test for depression.  But, if you gather a group of depressed patients and a group of non-depressed patients together and measure their urine metabolites, you can detect a statistical difference.  Not particularly helpful to me in the office, however.  PET-scans have been able to show a consistent reduction in the activity of parts of the brain, but this, too, has limited benefit.  Bottom line is, if you show up in my office with the clinical symptoms of depression . . . you are depressed.  Doesn’t take an Einstein to do this job.  

But what do you do next?

The standard of care is currently to go through an algorithm of medications.  An algorithm is a decision tree that helps you decide what you do next, given a set of circumstances.  You come in with depression and meet criteria, you get an antidepressant.  Usually an SSRI like Zoloft.  If that doesn’t work, then you get a trial of a different SSRI.  If that doesn’t work there is a next step . . . then a next step . . . then a next step . . . etc . . . etc.  Most people respond with the first antidepressant tried.  Some people, however, seem to not respond no matter what is tried.  Or, you get a partial response.  Some symptoms gone, others still in place.  It can be very frustrating for both patient and psychiatrist.  But the use of an algorithm is vitally important.  Without it, there is a randomness to the use of medicines that, in the long run, will not be beneficial to the patient.  It is important that each medicine tried be given in as high a dose as possible and given enough time to work before calling it a failed medication trial.  Too often I see patients who have had multiple brief medication trials with sub-therapeutic doses.  This can leave the patient with persistent symptoms and great frustration . . . and a hopelessness about their situation.  When they come into my office . . . I have to start all over again.  Doubly frustrating for them.  But even when the psychiatrist follows a coherent algorithm  and the patient is very cooperative, there can be residual symptoms of depression.

Thus, the importance of the second part of your comment . . . why more “natural” solutions and talk therapy are not tried enough.  I know of no psychiatrist who does not advocate non-medication management of symptoms of depression.  Getting people to follow through on these recommendations is another story altogether.  Use of therapy, exercise, nutritional supplements, meditation, spiritual practices, various cognitive strategies,  etc have all been found to be  beneficial.   But it requires WORK on the part of the patient . . . perhaps when they feel unmotivated and disinterested.  In the brief time I have with my patients I try to advocate for these practices, but patients rarely follow through.  But they are quick to come back to me and complain that the medicine is not working.  

Like all good things in life . . . a little work is often involved in the development of good mental health.  But it is something that must come from the inside and cannot be forced upon a person.  I am open to any ideas you might have to motivate positive behavior in my patients.

–Dan Hartman, MD

Driving Miss Daisy . . . aka watch what your doin’ with them meds!

So . . . I got in my car the other day and, much like every other day, put on my blindfold and sped off to work . . . 

“WHAT?????” you might be rightfully saying . . . “put on your blindfold and started driving?????” . . . “you CRAZY!!!”

Well, of COURSE I didn’t cover my eyes and start driving.  That would be foolish.  That would be dangerous.  I could hurt people . . . you have to see where you are going.  Have to be able to read the signs.  Steer clear of the pot-holes.  Know when to stop.  Know when to go.  And . . . especially important . . . when to realize you are going in the wrong direction.

I met with the parents of a young lady the other day.  I will call her Daisy.  Daisy has had a long history of low grade psychiatric issues that have worsened significantly over the last several months.  The parents are at wits end because of the escalation of her difficulties.  The piece of the story that bothers me the most is how she has floated in and out of several psychiatric hospitalizations and day program stints and has not gotten much better.  And she is, from their description, really, really ill.  The doctors have not been available and there has been a series of fairly rapid medication changes that leave her parents scratching their heads and wondering what is going on.  All this treatment, all this time, all these medications have had little positive impact on how well Daisy is doing.  In the short time I had with them, however, their story hung together and, even without speaking to the patient, I believe I have a fair idea of what is going on with her.  And I have concerns about how she is being medicated.

The details of her presentation and the details of her medication trials are not important here.  It is the process.  In this age of HIPAA and attempts to strictly protect a patients confidentiality, we sometimes miss opportunities to gather information that could, in some circumstances, save lives.  There is NO substitute for good history gathering. Without it, a physician is prescribing like he is playing darts.  And the consequences of this somewhat random application of psychoactive chemicals can be devastating.  Mental illness is much like rolling a boulder down a steep hill.  Once it gets rolling, it is hard to stop.  And getting the boulder back up on top can take a lot of time and effort.  It is imperative, therefore, that all efforts are employed to get accurate and complete information prior to the introduction of medications to a patient.  Once an accurate diagnosis is made, it is imperative that medications be given time to work.  Sometimes the medications are switched after only a day or two . . . as  if 48 hours constitutes an adequate trial of any medication.  We all know that it can take weeks to get benefit from some medicines.  Yet, it is not uncommon for patients to enter my practice from an inpatient hospitalization having had three or four “medication trials” in the space of a week.  This makes no sense (at best) and is potentially dangerous (at worst).   I HOPE that the doctors that do this are knowledgeable enough to know that this is not good clinical practice.  I can only imagine that they are under tremendous pressure to do something . . . ANYTHING . . . to justify continued treatment in the inpatient setting (authorization for inpatient stays are metered out a day at a time by the insurance company and the hospital must justify each day;  medication adjustment is one of the best justifiers for continued stay).  Taking a day or two to get information and plan treatment is not supported in the current health care environment.  Yet the failure to do this has, in this case, resulted in numerous additional inpatient days and partial-hospital days.  When Daisy does come out of the hospital, it is likely that she will need another partial hospital stay.  When she is done with that, she will likely need intensive outpatient treatment, as well as frequent visits with the psychiatrist.  I suspect that much of this could have been avoided with more time devoted to history-taking.  

Basic third-year medical student stuff.

How could we have let these most basic principles slip by us in the name of (supposed) fiscal responsibility?

–Dan Hartman, MD

Mother’s Day . . . yahoo . . .

I’m not answering questions today.  Just thought I’d ramble.  Here in the States, we are celebrating our mothers today with a Hallmark-inspired day known as Mother’s Day.  While it is a wonderful and delightful day for some of you, for most, it is a day filled with mixed emotions and pitfalls.  No person in this world (except, perhaps, our new president) is infused with more hope or expectation.  These expectations are easy to fulfill when the kids are young.  Parents, in general, are GODS to the young kids.  The bringer of all good things.  Even if you mess up big-time, the capacity for young children to forgive is quite extraordinary (and a good example for the rest of us).  As the kids get older however, they get increasingly critical of you and everything that you do.  They look for and pounce on inconsistencies and errors.  There is a certain glee that comes to an adolescent’s eye when they ‘catch’ mom in a contradiction.  When mom is less than available.  Less than prophetic.  Less than saintly.  As adolescents become more aware of themselves and their own difficulties in dealing with peers, responsibilities and expectations, it is far easier to look for a cause outside of themselves rather than taking an honest assessment, forgiving yourself, and moving forward.

If my life is a mess . . . it must be MOM’S FAULT!!!! 

“If only she was less annoying” . . . “if only she was smarter” . . . “if only she would leave me alone” . . . “if only she would trust me more” . . . 

For moms, it is a catch-22.  If you do those things that you know in your heart are best for your kid, there is a good chance that your gonna catch some heat for it.  In my experience (both in my house and in my practice), it has NOTHING to do with what is said.  I can give the same message to my teenagers and it will be viewed as supportive, helpful, reasonable, etc.  My wife says it and it is . . . nagging . . . not-understanding . . . unreasonable . . .

And I have GOOD kids.

Looking back on my own childhood growing up with two older brothers provides me with some insights and perspective.  Mom was a professional woman at a time when that was rare.  That just meant that she worked long hours (always brought home work to do) and still had to be a June Cleaver and make sure dinner was on the table, the house was clean, the laundry was done.  My dad didn’t lift a finger.  And we boys were unruly and difficult to train.  I learned from my oldest brother who approached my mom with a salt and vinegar attitude and was in a constant state of tension with her.  What I learned . . . was to run under the radar and be nicer.  To this day, I will still hear about how difficult mom was (although he will now admit how difficult he was as well).  My experience of mom was different.  To me (my perception), she was kind and reasonable.  I think it had to do with me being kind and reasonable to her.

Did I make sure that I showed her how much I cared on Mother’s Day.

No.

Not till I grew up.

I have watched my oldest daughter’s attitude change toward my wife as she has moved from the difficult and rebellious teen that she was (and MAN was she difficult) to being a wife and mother with all the stress that that brings.  She has a new found appreciation for my wife and calls her frequently to touch base and to get advice.  Not that she takes it, mind you . . . but she does call and ask.  It’s a start.  And even tho’ my brothers and I went through a long period where we did not keep in contact with mom very often, as we got older and had our own families, we were able to see her in a different light.  We were able to see that life is full of so many difficulties, so many difficult decisions to be made, that it is impossible to please young people with any regularity.  As we got older . . . and our kids got older . . . mom did become the valued matriarch.  We were able to give her the respect she so richly deserved.  When she passed away, I am sure she knew that she was respected, appreciated and loved.  But it took time.  Years.  My wife’s mother died when my wife was 19.  And the relationship that her mom had with all of the kids became frozen.  There was no chance to move forward.  To heal wounds and find that common ground.  My wife has been able to do this.  Despite her mother’s various difficulties and ailments (and from her description my mother-in-law was a difficult person in many ways), my wife has developed a good perspective and can forgive and love her mother.  Not all of the siblings have been able to do this.  Some are still very angry and negative.  

And for what purpose?

My best wishes go out to my wife and to all mothers out there.  You have a difficult job with great rewards in the end.  The road will be difficult and long.  Be patient with your kids . . . and patient with yourself.  Give yourself the extra dose of forgiveness and understanding that your kids may not be giving to you right now.  Know that success as a parent is not measured by perfection, but in doing a better job than your parents did for you.  Take the best that your parents had to offer you and pass it along.  Try not to pass along the mistakes.  And teach your kids to forgive.  To forgive you.  To forgive themselves.  To allow their “human-ness” not to get in the way of expressing love, thanks and appreciation.  Someday . . . they, too, will be old enough to have their own kids.  Someday . . . they will understand.

–Dan Hartman, MD