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

Hard on the Liver??? . . . Good for the mood???

My mother has cirrhosis of the liver and also severe depression. She is 70 yrs. old What would be the safest med for her to take??? She seems to be unable to live and manage her issues due to depression.

In general, depression in the elderly can be very difficult to treat.  As with children, they are very often NOT the masters of their environment as much as we “adults” are.  They are increasingly dependent on others for their needs and look forward to a future where that dependence grows.  They have a variety of aches and pains and, again, look forward to a future where that pattern of aches and pains tends to grow.  Add to that the growing number of peers/family/friends that have passed on along with a growing sense that your time is coming soon . . . lots of reasons to feel sad.  Sometimes, that normal stage of life sadness that must be addressed can move over into true clinical depression.  The criteria are the same as depression in the adult population, but the presentation can be a little different.  Too often, the presentation of the depression is chalked up to “grandma getting older . . .” .  This can include reductions in appetite, increase in sleep, worsening concentration, etc.  Older folks can truly look and act quite demented when, in fact, it is not related to an organic cognitive decline, but be part of the depressive syndrome.  Because of the overlap of depression with “normal aging”, dementia, medical illness, and side effects from medicine (an often missed cause of mood issues in older adults), it is imperative that you have your mother seen by a psychiatrist who is competent in the management of older adults.  There are some psychiatrists who specialize in the management of the geriatric population (there is a Board Certification that is now available), many general psychiatrists have extensive experience and good clinical skills and can do just fine.  As in the search for a psychiatrist for anyone, it often takes a bit of searching and probing to find the right fit.  If your parent is very dependent on you, you might even go in with them to the interview to make sure that all the information is given to the provider.

As far as medication for depression in the elderly, most of the SSRI’s are just fine.  Of that group, I tend to use Zoloft and Lexapro more often that the others.  Prozac is just so slowly metabolized, anyway, and in someone with a compromised liver, I would shy away from that.  Paxil and Prozac tend to have more drug-drug interactions than Zoloft and Lexapro.  Of the antidepressants in general, Cymbalta is the medicine to stay away from if you have compromised liver functioning.  Studies have shown significant delay in metabolizing this medicine effectively, making it more difficult to manage and it can possible be damaging to the liver if liver disease already exists.

–Dan Hartman, MD

Approaching the (possibly) Unapproachable Doctor

I am a 33 year old female diagnosed with major depression 7 years ago and ADD about 5 years ago. I’ve been on several Tricyclics, SSRIs, Cymbalta, Effexor, Wellbutrin, Tegretol, Abilify, Provigil, Klonapin, Synthoid(for slight underactive thyroid possibly contributing to depression),Yaz (for possible PMDD contributing to depression), and Concerta, plus more (many of these I’ve tried in combonations under my psychiatrist’s orders as well). I’ve never been on any MAOIs. I am currently taking 100 mg of Pristq, 50 mg of Vyvanse, and 100mg of Trazadone for sleep, as well as a multivitamin and a b-12 supplement. I was hospitalized in October 2008 as I’d decided that I wasn’t going to try and deal with my depression – I wasn’t going to live anymore. When I began taking Concerta about 5 years ago, it really seemed to help with both depression and ADD. However, it pooped out on me along with Cymbalta after awhile. For about two years now, I’ve been feeling emotionally numb along with depression and ADD. I no longer aspire about my future nor do I enjoy the things I use to. I’ve isolated myself from friends/family and any type of social functions, including church. I feel as though I’m slowly waisting away and my children suffer because of this. I read constantly about different medications and the effects (good or bad) they’ve had on others on your blog as well as other blogs. I’ve been doing research on the dexedrine lately and it seems that many individuals have had success with this drug for both ADD as well as depression. However, I can’t seem to encourage my psychiatrist to try it in my ‘cocktail’ to see if it will help. I’ve never abused or attempted to abuse any prescription or illegal drugs so I’m uncertain why my psychiatrist won’t try it as my depression is classified as atypical or treatment resistant at this point. He wants me to stay on this current ‘cocktail’ of meds until May 2009. If there are no changes, he’s going to refer me for ECT – which I’m not totally against because nothing else seems to be working. I’m just surprised he’d consider ECT prior to trying Dexedrine. I would never tell any professional how to do his/her work, but I should have some say so in my personal treatment options as long as they’re within good reason. What is the best way to approach my psychiatrist with my concerns without seeming as though I’m questioning his/her professional or knowledgable approach. Or worse, ruin any rapport we’ve established thus far? I thought your suggestion to the gentleman that adding a small dose of dexedrine to enhance his Vyvanse could be beneficial was interesting. I would like for my psychiatrist to consider this as I just want my passion for living, dreaming, exploring and loving back. Any advice you can give me will be greatly respected and appreciated. P.S. Have you prescribed the EMSAM patch? If so, what has been your patients’ overall experiences with it?

Sorry for the long comment above, but I thought it very clearly highlights a dilemma faced by many.  How do you contribute to your health care decisions without insulting your health care giver.  This is just as true in other branches of medicine as it is in Psychiatry.  People are more inclined, however, to hand over their back surgery to their orthopedic surgeon without a lot of questioning than they are to hand over the management of their mood to a shrink.  Not that your mood is any less complicated than your back is . . . but their is something so . . . personal . . . about your mood and emotions that people do not want to let go of the control of them.  And, in my humble opinion, you should NOT just hand the decision process over to anyone.  Part of getting better from this depression thing involves taking control over your life.  Not sitting around waiting for it to get better.  That includes having some control over the medication management of your illness.  

The entry above has multiple questions to it, but their are overriding themes.  Clearly, many medications have been tried with partial or incomplete response.  The order, combination, etc of meds is not highlighted, so that no conclusions can be drawn from the entry EXCEPT that you are with a psychiatrist who is willing to try different things and experiment.  That is good.  As annoying as the “wait till May” thing might be, it might be good clinical judgement.  Giving a medication regimen a chance to work is imperative, especially if you have failed multiple other trials.  That might be what he is doing here.  Is it time for ECT?  Not if you are willing to take an MAOI.  I have no experience with the EMSAM patch, mostly because my patients with treatment resistant depression have no interest in the MAOI diet (quite restrictive, but doable).  

I would also suggest that you be straight forward with your psychiatrist about this.  Praise him for his efforts and for the rapport that you have with him.  If you want ECT to be the LAST thing on the to-do list, tell him that.  There clearly are other options to be tried.  Either with his knowledge or without his knowledge, I think it is time to get a second opinion.(  (I personally love it when difficult cases go for second opinions–I don’t claim to have all the answers).  Find someone else in your area that does medication management (local hospitals or university centers are often a good place to look) and get an appointment to meet with them for one or two visits.  You may need to pay out of pocket for it but the insights into your illness might be worth the money, if only to know that your current psychiatrist is covering all the bases.  Make sure you take with you a COMPLETE chronological listing of the medications and combinations of medications you have taken over time.  If you are not sure of dates, you can often get that information from your pharmacy.

Good luck and HANG IN THERE.  Sometimes it takes a long time to find the right combinations of medicines and circumstances that make you feel better.  

–Dan Hartman, MD

Depression Not Getting Better, But Not Out Of Options

Over the past 2.5 years I have been on and off 7 different antidepressants (5 SSRIs, one SNRI) but my doctor has not been satisfied that the benefits outweigh the risks/side effects. He says he is out of drug options and is looking to my psychologist to help me. For about the past year and a half I have consistently struggled with a heightened sensitivity to trauma, TV news, movies, sudden noises (jumpy) that significantly limit my lifestyle. I recall after one antidepressant telling my doctor I now know what anxiety is. Could antidepressants cause these problems – longterm? I have been off the last antidepressant (Trazodone) for about a month.

You raise a number of interesting points with your letter.  Let’s jump to the last issue first . . . can antidepressants cause long-term anxiety issues?  As I have noted in other entries, one of the side effects of antidepressants can be heightened anxiety.  This is typically an early onset side effect caused, presumably, by the rapid increase in the amount of neurotransmitter present between nerve cells.  Remember, the “RI” in “SSRI” stands for “re-uptake inhibitor” . . . a blocking of the recycling channel nerve cells use.  When the recycling is blocked, levels of neurotransmitter between cells goes up.  This provides for the clinical benefit from the medicine, but can also lead to the side effects.  If the anxiety side effect is not too much and you can wait it out, it will often decrease over time.  This does not always happen tho, and sometimes, the anxiety is just too much.  Some people benefit from really, really low starting doses of a medicine that is titrated up very, very slowly.  This can allow your body to get used to it gradually over time.  It may take a longer time to get to the dose that is effective, but it can work.  Some people are just sensitive to the medicine.  

Can the anxiety that is “caused” by the medicine continue when the medicine is stopped?  Not likely.  Once the medicine is gone, the medicine is gone.  We are all changed by our life experience, however.  If you had a particularly traumatic experience from a medicine . . . or a car crash . . . or a soured relationship . . . it can hang with you.  Therapy is absolutely important through the process of treatment, and can help limit the progression of symptoms.  It is difficult (if not impossible) to know if significant anxiety symptoms might have come out over time anyway.  People with significant depression often develop significant anxiety at some point in the illness.  

So, where do you go from here????

I agree with the therapy.  Get yourself a good therapist.

I have no information about your SSRI trials.  Remember, a good trial consists of enough meds for long enough.  If you did not tolerate or were not prescribed medicine with these guidelines in place, then you must start all over (with someone new).  I have several concerns about your brief description of your medicine.  There is little reason to give trials of five SSRI’s.  Generally speaking, if one of my patients does not tolerate or benefit from two SSRI trials, I move on.  I am glad that you had an SNRI trial (again, no idea if it was a complete trial).  But, if that does not work, there is still a huge list of options available for your potential benefit.  That would include use of Wellbutrin to augment the SSRI or SNRI, use of mood stabilizers like Lithium or Abilify, addition of thyroid hormone, stimulants, Provigil, nutritional supplements . . . LOTS OF OPTIONS.  

My point is, don’t despair.  Get yourself a therapist that will work with you on addressing the behavioral and emotional experiences that you are having.  But get yourself in with a psychiatrist who will be thinking creatively (and systematically) with you.  It appears to me (from your brief description) that you have many options left and no reason to think pessimistically.

–Dan Hartman, MD

Worked The First Time . . . Why Not The Second?

“Confused” writes in with a question . . .

In the past I have been prescribed Klonopin 1mg 3x a day.   This worked well for me until I built a tolerance. Several years have passed, I never experienced addiction or withdralls. I have been prescibed this medicine again for panic attacks, anxiety & being social phobic. Klonopin work for 2 days at .5mg, my Dr. changed the medication to Xanax at .25mg same thing worked once then completely ineffective even when we kicked it up a notch. Is there any reason why these meds will no longer work for me? Or are there some better than others? I just do not understand this. Please advise?

While you are not completely clear about the dose of Klonopin that was most recently started (0.5 daily????   0.5 3x daily???) it seems likely from your language that it was a lower dose than what was needed years ago.  Sound like your doc is being conservative.  Likewise with the switch to Xanax.  The 0.25 mg dose is very low.  Even if you “kick it up a notch” it is still low.  Judging form the information at hand, I would guess two possible reasons for your lack of benefit:

1.     You need more.  If 3 mg daily was needed a few years ago, it is likely that 3 mg will be needed now.  Since you did not have issues with addiction or withdrawal before, I would suggest that you and your doctor be more aggressive.  Going up to 2 or 3 mg daily does not bother me.  Going above that is when I start to have red flags sproing up.  But, some people need more.  Sounds like you might be one of those people.  

2.      Generic woes . . . I know, I know . . . all generics are supposed to be the same and they are all supposed to be equivalent to brand name . . . la ti da . . . how many stories have YOU heard about this not being true???  If you really want to see if it works, try a brand name.  For some it is way too pricey . . . but what price would you pay for peace of mind?  Whenever I have a patient on generic medicines and I really need to make sure the medicine does not work, I will switch over to brand name for a month or two.  If it doesn’t work, then the medicine clearly will not work.

If you poke around on this site and others, you will certainly see that medicine like Klonopin is not the only kind of medicine for treating anxiety.  I would certainly suggest that you try one of the antidepressants (either in conjunction with or instead of the benzos).  Remember to talk to your doc about all the safety issues involved in use of both kinds of medicines.

—Dan Hartman, MD

Prescribing Outside The Box

Kurt writes in with a very common question:

I was prescribed 70mg Vyvanse for debilitating chronic fatigue. The 70mg was totally ineffective. At 6′2″, 220 pounds, I think the dosage was too small. My psychiatrist will not increase the dosage. I self-titrated and found that 210mg will get me through the working day but I’m exhausted by 6:00PM. Can Vyvnse be prescribed above 70mg?

Short answer . . . NO!!!! . . . . . . . well . . . . . maybe.

Now, back to reality . . .

This simple question is actually a very, VERY complicated question that involves hoards of lawyers, government agencies and reams of legal pads that, in the end, leave us doctors and you patients buried up to our you-know-what in red tape and potential litigation.  Bottom line is that all medicines that are used on the market come with prescribing limits and recommendations. Deviating from those FDA approved limits and guidelines is not automatically a risk . . . but it is outside the bounds of safety as defined by the FDA . . . and you know how reliable THEY have been. Many medicines are used in this manner, but it is important for the patient to know that the doctor is operating outside of the FDA guidelines for the medicine.  There is a concept of the “standard of practice” that gives relative legal safety for the use of medicines outside of the FDA guidelines.  Because approval often lags way behind clinically accepted usefulness, use of medicines can become the standard even without approval.  A good example of this the use of Tenex for irritable kids.  Tenex is approved as an anti-hypertensive agent for adults but is rarely, if ever, used for that.  For the last 15 years or so it has been used extensively for irritable ADHD kids . . . because it works so well.  Unfortunately for the company who held the patent, the patent expired just as this use was identified and they reaped none of the benefit of it.  They also had no incentive to run the studies that could be brought in front of the FDA for approval for that use.   Use of Tenex is now a standard of practice, but it is not approved for that use.  Another interesting example is Depakote.  Again, Depakote has been used as a mood stabilizer for 15 years or more, but only received FDA approval as a mood stabilizer for Bipolar Disorder five or six years ago.  The science finally caught up with doctor and patient experience.  If we limit ourselves to FDA approved uses only, we in the world of psychiatry will find ourselves very limited.  Lets use Kurt’s experience as an example.

Kurt presented to his doctor with symptoms that were diagnosed (according to Kurt) as “debilitating chronic fatigue”. He was prescribed Vyvanse . . . OOOOOOPPPPPSSSSS, Vyvanse is not approved for chronic fatigue. We are already outside the limits of FDA prescribing practices that approve its use only for treating ADHD.

Kurt is an adult . . . OOOOOPPPPPPSSSSSS, Vyvanse only received approval for use in the 6-12 year age group at first.  If Kurt received his first prescription before April 23, 2008 he was DOUBLY outside the FDA guidelines which initially only included kids with ADHD that were ages 6-12.  To be honest, I can’t find any notation that indicates approval for use in kids ages 13-17 either.  Interesting.

Kurt likes mega-doses of Vyvanse . . . OOOOOPPPPPPSSSSSSS, 210 mg is three times the FDA recommended maximum dose!!!  

Alright, alright . . . enough fun.  What are we to do here . . . like in a practical sort of way.  

First off, what is the diagnosis?  Does Kurt actually have ADHD or does he have chronic fatigue?  I would strongly suggest that he get a comprehensive physical exam (should be done before the use of stimulants anyway) to make sure that nothing is being missed. How much sleep are you getting?  What is the quality of your sleep?  Evaluation of your sleep in a reputable sleep center is mandatory to make sure that your fatigue is not based on poor quality sleep.   If it is determined that you have ADHD, then there is a wide range of options that can be used to treat it, including Vyvanse.  If it is chronic fatigue, there are other meds that can be used.  Medicine such as Provigil can be very helpful for treating chronic fatigue without as high a risk of cardiovascular issues in adults.  It also does not have the late day “let down” that is not uncommon with stimulants.  If your issue is really poor quality sleep, there are ways of improving that without medication (and sometimes with medication).

Stimulant medication such as Vyvanse are used (off-label) to treat symptoms of chronic fatigue.  You may have over-shot your dose and may be taking way, way too much.  That’s what happens when you have to go up in 70 mg increments.    I do prescribe over the FDA limits for a medicine.  But it must be done carefully and thoughtfully.  In adults, it must also be accompanied by significant monitoring of blood pressure, EKG etc to make sure that your risk of catastrophic cardiovascular events are not raised excessively.  Your doctor is not being a stick in the mud, he is just trying to practice safe medicine.  Don’t give him a hard time.  That said, your condition may be helped by prescribing outside the FDA box.  You must understand that when you accept doses above these guidelines, you are accepting additional risk.  You may need to find a doctor who will work with you, but it is YOU who must be willing to accept the risk.  

But, as mentioned above, the first thing you need to a good physical work-up to make sure an underlying medical issue is not being missed and to make sure that you are physically healthy enough to accept doses of stimulants above that which is the accepted FDA limits.

–Dan Hartman, MD

 

What is Causing What? . . . Multiple Factors Contributing To A New Mom’s Woes

I am a 27-year-old female with an extensive psychiatric history. I have been on almost every type of medication except tricyclics and stimulants.  I am diagnosed with Bipolar I and Borderline Personality Disorder.
Currently, I am seeing a new psychiatrist who is “pill-happy”. I feel like she doesn’t listen to me. Right now I am taking Effexor XR 75 mg twice daily, Wellbutrin SR 100 mg twice daily, Xanax 0.5 mg four times a day, and Lamictal 100 mg nightly.  I have major fatigue. I have a seven-month-old son and I have absolutely no energy – I give it all to him, and ignore myself. I never leave the house, skip showers, and have become incredibly antisocial.
My questions:
With all of this medication, why do I still feel awful? My moods have stabilized some, but my fatigue is relentless.
How do you feel about prescribing low doses of stimulants such as Adderall for fatigue and major depression?
I have elevated liver function tests; could that be from all the medication?
This lack of energy is a new symptom for me since having my son in May.
Oh, and one more question – I have a slight tremor in my hands that is noticeable to people. I find it hard to feed my son off of a spoon because my hand shakes too much.
Of course, I’m going to bring this all up with my doctor, but I’m looking for someone else’s opinion.  Thank you!

My, oh MY . . . lets pick a complicated one to kick off the New Year!  Well, perhaps not so complicated, but clearly you are in the middle of a difficult patch.  One of the tricky things to remember when you are a parent is that life is all about balance.  Any one of the many aspects of your life can easily sop up all your energies and lead you to ignore other parts of your life.  It doesn’t take a rocket scientist to see that this is not a good idea . . . but it might take a shrink (!).  This is normal for the time of life.  Usually we have people around us who are supportive and helpful and allow us to be balanced.  You don’t talk of many supports.  If this is true, then it is IMPERATIVE that you take your life by the reins and lead it to where you want it to go.  First off, go get a shower.  No skipping of showers.  Gotta keep yourself clean.  Second.  Get out and go for a walk.  Take the kid out with the stroller . . . I don’t care if you are in the tundra . . . bundle up that baby and to for a walk.  Those two things alone will start the process of psychic healing–getting to a place where you feel like you are doing normal things in a normal way.  Plus, you will be taking better care of your son, which is obviously very important to you.  Third, you MUST have one person to whom you can intrust your son, be it a friend, a family member or a neighbor.  Set up a regular arrangement with this person so that you get out and away from your son for at least a few hours a week.  It will be good for both of you.

I will assume that both the medicine and the baby are new since May.  I don’t know if you were on medicine prior to or during the pregnancy.  It is clearly different, and that is of concern to me.  It is HIGHLY important that you get a full and complete physical examination and a full panel of blood work to make sure that there is not other factors going on.  Everything from hidden viral infections to low grade thyroid abnormalities can present in this fashion and aggravate underlying psychiatric issues in a big way.  Since this this blog lives in the unreal world of internet-land, let’s pretend that you have gotten full medical clearance and there is no evidence of underlying medical issues.  Your fatigue is either the medication that you are taking, or a symptom of your depression.  Of the medicine you are taking, the Xanax is the most likely  culprit for the sedation with Effexor being second.  Other benzodiazepines might substitute for the Xanax (Klonopin is the most logical choice), but might not give the same relief from the anxiety and may still result in sedation.  Higher doses of the Effexor might cover the anxiety . . . but if it is partially to blame for the sedation, it might make that worse.  For Bipolar Depression, I am a big fan of Lamictal.  Helps improve and stabilize mood and is rarely a cause of sedation.  You are on a relatively modest dose of the Lamictal (100 would be a baseline from which I would increase).  For seizure control, you can use up to 500 mg (and I have seen 600 given to one patient). Increasing the dose of the Lamictal may allow you to reduce the doses of the other medicine you are on.  

I am not a big fan of stimulants for fatigue in Bipolar patients.  I worry about inducing more mood instability.  I would prefer to treat the mood disorder, limit the use of sedating medication, and use behavioral interventions.  The other factor here is your diagnosis of Borderline Personality Disorder.  This is a complicated personality structure that can, in some, increase risk of dependency issues.  That could also create difficulties in the long run with stimulants.

Hand tremor?  Could be the Effexor.  Could also be an underlying medical issue.  GO SEE YOUR DOCTOR.

Liver function test elevations?  Could be any or all of the medicines . . . but could also be an underlying medical issue. GO GO GO SEE YOUR DOCTOR.  

Really, the more I think about this case and the more I write, the more I want you to see your family doctor for a good head to toe evaluation to make sure that there is not something being missed.  Now that you have a child, you can not take chances like you did before.  Communicate all of these issues to your doctor, see your psychiatrist and get some answers.  

In the mean time, go take care of yourself.  That doesn’t take any more than common sense and may do you a world of good.

–Dan Hartman, MD

Tapering off Celexa (or any antidepressant) when you get pregnant

Please can you tell me how to alleviate Citalopram withdrawel? I need to reduce asap as I’m pregnant but doctor says just redude by 10mg every other day whereas Pharmacist says it’s not good to take during preganancy, So I want to stop taking it….any help appreciated.

So much controversy exists over the use of antidepressants during pregnancy.  In the olden days (about five years ago) the conventional wisdom was that you avoid use of antidepressants during the first trimester (the time when organogenesis–the development of organ systems of the body–is completed), but then you were OK.   Then there were scattered reports that there can be third trimester effects, with use of the antidepressants associated with a risk of the newborn having difficulties with agitation and breathing.  Now, to complicate the issue further, there are studies that show minimal effect on the developing fetus during the first trimester.  

Now, you have two opinions about what to do with your antidepressant.  From a purely theoretical perspective, your pharmacist is absolutely right.  From a clinical standpoint, your doctor is absolutely right.  So what do you do?

Well, this humble psychiatrist tends to be very practical.  Yes, in theory it is best to get off the medicine as quickly as possible.  As you mentioned, this can be associated with some difficult withdrawal effects, although this is less common with Celexa than with some of the others.  Your individual reaction is really our guide here.  Getting off by 10 mg every few days is pretty quick, but you might be fine.  You give no numbers, so I will pretend that you are taking 40 mg daily as treatment for your first bout of depression.  I would have you drop to 20 mg daily for 5 days, then 10 mg daily for 5 days then stop.  If you felt crappy, I would slow it down some.  

Bottom line with depression and pregnancy is that some women who are pregnant need antidepressants and some don’t.  Unbridled depression and anxiety has also been show to increase the risk to the pregnancy, so just getting off the medicine is not always the answer.  You must take clinical issues into account and modify the clinical recommendations as needed.  I would urge you to be in close contact with your psychiatrist.  I would double urge you to be in therapy as that, by itself, will decrease the need for medicine.

Good luck and congratulations!!!

–Dan Hartman, MD