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

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