Treat or wait? The annual ADHD question

With the start of September, all thoughts turn to . . . medicating our kids???  Well, as bad as that can sound to some, it IS time for the annual debate.  A question for which there is no clear answer.  Let’s examine several scenarios and I’ll give some suggestions . . .

We’ll start with an easy one . . . the very hyperactive and disruptive kid with focusing difficulties.  This is kind of a no brainer.  Despite what some detractors might say, these kids really, REALLY benefit from the use of medicine.  There are always ways the school environment can get tweaked to help them, but, for most, they will have significant difficulties no matter what you do.  It is important, in my book, to treat these kids aggressively with medication so that they can begin the year on a good footing.  If they can get into patterns of good relationships with both peers and teachers, and get into a good pattern of classroom behavior and homework achievement, it sets the pace for the rest of the year.  It creates a buffer to absorb difficulties that may crop up later in the year.  It gives them some sense of self confidence that keeps the bar high for later expectations.  As you parents out there know, the personality match between the teacher and the kid can have a huge impact on the quality of the year.  If the teacher must act the strong-man to manage behavior early in the school year, the likelihood of the kid liking the teacher and feeling comfortable with him goes way down.  That can sink the whole year.

How about those inattentive kids without behavior problems?  This is one of those grey areas that requires clinical finesse.  A lot goes into the decision about using medicine here.  How difficult is it for the kid to stay integrated into the classroom experience?  How much impact does the focusing issue have on knowledge acquisition and academic success? How important is the school year (eg, 11th grade is way more important than 7th grade).  Is the medication well tolerated or does it cause significant side effects?  I could go on and on . . . (as I said, this is a big grey area!).  In thinking about what to do, I consider as many of these factors as possible.  Most kids want/deserve a trial off medicine at some point in their academic experience.  Taking all these factors into account is very important as is the timing of the trial off.  For these kids without behavior problems, the start of the school year can be a good time, as long as their progress in school is carefully monitored and there is good communication between home and school.  What you don’t want is for half the year to go by, the kid to feel completely lost, and THEN have the teacher give a call to let you know about your summer plans . . . summer school.  As I mentioned above, a potential danger in this strategy is that a bad start can effect a whole year, even if caught early and with efforts put into recovery.   The alternative strategy is to medicate early so that the child gets a good footing for the school year, and then stop the medicine.  This, too, must be done carefully and communication between school and home needs to be good.  Sometimes, we do these trials off without the teacher’s knowledge.  It allows the teacher to be ‘blind’ to the condition and to give more unbiased reporting of events.  It then falls on the parent to touch base with the teacher about academic and social progress.  Since most kids with ADHD take stimulants medication that wears off at the end of each day, a change in ability to concentrate can be readily apparent to the teacher (and the parent during homework time).  

A strategy I will use for these mid-year trials off medicine is to gradually reduce the dose that is given to a child (eg, Adderall 20 mg for a month, then 15 mg for a month, etc,).  While more difficult to ‘catch’ the onset of difficulties, it does allow us to re-check the lower threshold for medication.  This can be especially powerful in kids who are motivated, maturing, and learning better ways to manage their own time and their own tendency toward being distracted.  It is always best to have a discussion about what the end-points will be that will trigger an increase in medicine.  If these end-points are written down, it will allow for a smooth and non-traumatic transition back to medicine.  The truth is that, for most kids, if they had trouble focusing and concentrating last year, they will have trouble this year.  The question will be how much trouble, and how will they deal with it.  Planning ahead for these contingencies will increase the chances for a positive outcome, whether or not it includes continued use of medicine.

If it is determined that medicine is still needed, it is also important to frame the re-start in a way that is not defeating for the child’s esteem.  It is not that someone “failed” the trial off medicine.  It is just that we need to keep the medicine in place for a while longer.  Reassure both the parents and the child that another trial off the medicine should occur in the future.  That the most important think is that the child does as well as he or she can in school, and that their experience of school be positive.  Just like “every day is a new day” with the stimulant medicine . . . every year is a new year at school and it presents another opportunity to consider a trial off the medicine.

–Dan Hartman, MD

Rash from Lamictal . . . do you have to stop it?

This letter brings up an important question about Lamictal . . .

I’m a 45 y/o female properly diagnosed and treated as bipolar for 1 & 1/2 years. Prior to this diagnosis, I was treated soley for depression for 10 years (the last 5 as refractory.) I am presently doing GREAT on Lamictal 200mg daily and Effexor 300mg daily. The problem? I’ve had a rash on my leg for 2 weeks and only today made the connection to Lamictal’s potential for a life-threatening rash. I can rule out contact dermatitis. I’m not experiencing SJS symptomes. I will contact my ANP on Tuesday for evaluation and probably drug discontinuation. My question? What titration schedule do you use to discontinue Lamictal? What titration schedule do you use to concurrently add another AED such as Topamax? I really appreciate your time and dedication to this topic! Have you had particular success with another AED? I can’t begin to tell you how well I have been doing since the addition of Lamictal. It changed my life. I hate to give it up.

It can be very discouraging to FINALLY find the medicine that works well, only to have that medicine turn on you.  As you know, this is more likely to occur with Lamictal than it is with other medicines.  The quick answer to the title question is . . . “yes, of course”.  But lets look at the issues involved in this medicine and the rash.  As is true with much of psychiatry, there is grey area that must be explored and considered.  

You can read the information in the dreaded “Black Box” yourself, the risk of serious rash in patients taking Lamictal for Bipolar Disorder is approximately 8 in 10,000 (0.08%).  The conventional wisdom is that there are certain factors that may increase your risk.  These include concomitant use of Depakote, exceeding the initial dose recommendations, and titrating up too quickly.  If there is any concern about a Stevens-Johnson reaction, the medicine must be stopped and immediate medical attention sought.  The more you read about this condition, the scarier it becomes.  Just to scare the crap out of you completely . . . here is a link:

http://www.emedicine.com/med/topic727.htm

Read at your own risk.

That said, what do we do with the young lady above?  

Most of the cases of rash and, especially, the serious varieties of the rash, occur in the first weeks and months of treatment with Lamictal.  The rash that is especially concerning is that which is associated with mucus membrane. Here, we have a rash that is occurring 18 months into treatment (unusual), and only on the leg (also unusual).  Given how this medicine has turned your life around, I would not be so quick to stop it.  The area of rash should be seen by someone who is experienced in rashes (often NOT the psychiatrist).  This may be a case for one of those rare emergency appointments with a dermatologist.  At the very least, I would get in to see your family doctor.  Rashes are kind of like headaches.  There are so many reasons for them, it is often hard to pin down the exact reason with any clarity.  It would be a shame (to say the least) to move away from what has been a life altering treatment for your Bipolar Disorder and not be certain that it is required.  If the pattern of the rash is static (not worsening) it may be reasonable to wait and watch.  It may be caused by something you were not aware of (it may be a contact dermatitis after all).  So, I’ll talk about the taper below, but, please, get in to see someone (not on the phone) and have the rash evaluated.  Make sure that the doc doing the evaluation clearly understands that taking you off the Lamictal may cause a return of serious depression.  It is a decision that cannot be made lightly.

Tapering the Lamictal can be done quickly or slowly without significant physical symptoms for most people.  As a general precaution, it is recommended that a taper be done over the course of two weeks or so (there were a couple of people in the initial Bipolar trials who had seizures on discontinuation but there were confounding factors that made it unclear if the removal of Lamictal was to blame).  When I am not in a hurry, I can sometimes take a couple of months.  I know you are looking for specifics, so I could guestimate that I might take off 50 mg every 5 days or so if I was in a hurry.  Now, what to do next . . . 

Tough call.  Plus, I have no other information about you except what is above.  Generally speaking, if Lamictal does not work, we use standard antidepressants along with mood stabilizers to help decrease the risk of hypomanic or manic episodes.  You are already on an antidepressant (Effexor).  You could add in an AED (anti-epilepsy drug) such as Depakote, but more and more I am adding in Abilify.  It is a great mood stabilizer, has a low risk of causing weight gain, and has been shown to augment the benefits of antidepressants.  There are some difficulties with it that I have outlined in other blarticles, but, overall, it is a great medicine for most people.  You can also add Wellbutrin in to the Effexor, but I would not do that unless you are on a mood stabilizer.  

Remember, you must be well monitored by your doc during this transition period, whether it is monitoring this rash or transitioning to other medicines.  

Let me know how things go.

–Dan Hartman, MD

Vyvanse was helping depression . . . now . . . aggravating mania?

James writes in to say . . .

I started having panic attacks and was very unsociable and kept to myself,all this started about 10 years ago. The doctors diagnosed me as bipolor,i’ve been on every med available for bipolar with no positive results. Last december my doc decided to try me on 20 mg 1 a day generic adderral. It turned my life around i was talking to people i had avoided for years and started back doing normal activities instead of cutting myself off from the rest of the world i also was not as angry as before. To start with one a day is all i could handle, it gave me more than enough energy. Now in august i am taking 4 a day and i feel almost like i did before i started taking them. I have severe headaches and mood swings,i also become very angry easily. My doc switched me to vyvanse, i am scared i will fall back in the rut i was in for all those years. Will vyvanse be as good as adderral, and how long should i take it before i notice a change? I wonder if i quit adderral for a couple of months and then start it again , will it give me the affect it originally did? My behavior is affecting my whole life. Is there any advice or anything encouraging?

James, I’m going to start with the assumption that your diagnosis of Bipolar disorder is accurate.  With that assumption in place, the medication used for Bipolar are quite varied so that it is a leap to say that you have tried “every med available” but I will even accept that as fact.  A question that is not answered is if you tried COMBINATIONS of medications.  For example, combinations of antidepressants, or antidepressants with Lamictal can be quite powerful.  It is also not unusual for patients to benefit from combinations when use of single agents is not helpful.  But let’s assume that combinations were tried but were not successful.  Use of a stimulant medication is a bit unorthodox . . . and brilliant!  Hats off to your shrink!

In cases of Unipolar Depression that is unresponsive to medication, there are a variety of augmenting strategies that can be used.  One of them is to use stimulant medication such as Ritalin or Dexedrine.  Adderall, of course, is a dexedrine-based medication.  Using stimulant medication in Bipolar patients can be tricky.  The risk of precipitating mood instability, irritability, or frank mania is uncomfortably high.  I can suppose that, at first, it was able to bump you out of your depression for a while . . . and then you became tolerant to it . . . and it was increased . . . and you became tolerant . . . etc until now you are on 80 mg daily (a whopping dose) and not getting benefit.  Is switching to Vyvanse any better?  Hhhhhhmmmmm . . . hard to say.  It is not a big difference.  Adderall is a combination of two amphetamine salts and two dexedrine salts.  Vyvanse is also a dextroamphetameine product. Not a lot of difference.  Might make a difference . . . but . . . maybe not.  Won’t know till you try.  

My preference would be to put a mood stabilizer on board (whichever one you tolerated best) and then challenge you with a stimulant.  This could be either with a dexedrine product like Vyvanse, or with a ritalin product (such as Ritalin LA or Concerta).  The hope is that the stimulant medication would provide the same mood boost with the mood stabilizer providing for stability and act as a buffer for the irritability.  One of the tricks we use with ADHD kids who develop tolerance is to switch between a Ritalin product and a Dexedrine product.  For some reason, this can work with some kids.  Will it help with you??? Maybe.  Certainly seems worth a shot.

Good luck and keep plugging away.  If your doc gets stumped, arrange for a second opinion.  There are always new options and combinations to consider as well as life-style changes and therapies that can be helpful.

–Dan Hartman, MD

Vyvanse–the medication you can’t get to

Just a short entry this evening.  A little bit of a rant and rave.  I’ve been trying to gain more experience with Vyvanse.  So far, the patients that I have taken it have given mostly favorable reviews.  Not perfect, but none of these poisons I prescribe are.  Problem is . . . the insurance companies keep telling me that I can’t prescribe it.

Or more accurately . . . I can feel free to prescribe it, they just ain’t covering it.

So when a parent of a 6 year old recently asked for Vyvanse, it was not available for use.

This is the problem with virtually all new medicines that come out.  The tiered approach to prescription coverage requires that you use (generally) older and (generally) cheaper medications from the same class before using the (generally) newer and (generally) more expensive medications.  From one perspective I do understand this.  Pharmaceutical companies are out to make the big bucks . . . and insurance companies are trying to make their bottom line look good at the same time.  Sorry patients . . . you lose.  So in the Vyvanse game, I have to show failure or intolerance to two older agents before Vyvanse will be approved by many of the insurance companies in my area.  My experience with stimulants is that for most people, they all work the same.  So do I NEED to prescribe Vyvanse???  No, I don’t.  I will prescribe Adderall instead and the kid in question will probably do just fine.  

But where is my opportunity for choice???

Where are my patient’s right to choose treatment for themselves???

–DH MD

Moving from Lamictal to Zoloft?

Mary writes in . . . 

I hate to say it, but I was relieved to hear that many others reported gettting acne (especially along jawline) from Lamictal. I complained about this to my Psyciatrist, but he said he never heard of that being a side effect. I, also was feeling so blah, lost my self-esteem and confidence to do my job (and quit) and could not get any endorphin release from aerobic exercise, listening to music & playing my trombone. I became so very depressed and stopped doing these activities which have been trustworthy coping strategies (am 47 yrs old). I told this to my Dr. and he insisted that I was not depressed which made me more depressed to have a Dr. who I thought understood me discount my feelings. Anyways, I have gone back to my former psychiatrist (reluctantly b/c have to pay out of pocket) b/c he has known me for almost 3 years and validated that I am depressed. I got off the 200 mg Lamictal within 1.5 weeks which gave me terrible anxiety. I tried Prozac which made it worse and went off of that. Now I have been on 50 mg of zoloft for 2 weeks & still feel depressed. I saw my Dr. today & he told me to bump the dose up to 100 mg and then to add Topomax. I fear adding a second drug especially a mood stabilizer since I had such bad experience with the Lamictal. I just want to be on one drug for now and only to be on an antidepressant for now b/c I have not been in a hypomaniac mood since January. Do you think going off the Lamictal too quickly caused me to go deeper into depression? Do you think I should wait and see if the Zoloft pulls my mood up? I am currently not working b/c of all I mentioned above and can barely take care of myself and my 5 yr. old daughter. People who know me would not recognize me b/c I have always been upbeat, positive and motivated. Now I can barely get up and take my daughter to preschool and then in another week get her off to K-grade. Oh, and yes, I have been getting talk therapy on a weekly basis for the past 4 years. Please advise…..I am in the process of trying to find a Dr. in my insurance network to get another oppinion. Thank you for your assistance….I am desperate!

Once upon a time we didn’t have Lamictal.  Hard to believe!  Seems like Lamictal has taken over the treatment for Bipolar Depression and is making inroads in the treatment of Unipolar Depression.  Despite it being a good treatment, it is far from the panacea that we would like it to be.  Failure to achieve success on Lamictal should not be viewed as a huge setback.  You still have many options!  Assuming that the diagnosis of Bipolar Disorder is correct, pharmacologic intervention needs to be done carefully, but it is hardly brain surgery.  

First and foremost, when treating Bipolar Depression with standard antidepressants, it is vitally important that a mood stabilizer be put into place.  Treatment with a standard antidepressant without a mood stabilizer in place increases the risk of precipitating hypomanic or manic symptoms.  My guess is you would not mind a little hypomania now, but in the long run it is not a good thing to foster greater mood instability.  There are many mood stabilizer options available so please explore other blarticles on the blog for those discussions.  Once the mood stabilizer is in place, the doc can treat you with standard antidepressants fairly safely.  The aggressiveness of the treatment is dependent on multiple factors, including what has worked in the past, how sensitive you are to side effects, how fragile your manic states are, etc.  It sounds like you are feeling very very depressed and in need of some fairly aggressive treatment.  It sounds like the Zoloft is being titrated fairly aggressively.  I like at least two (and preferably four) weeks in between dose changes.  Doing the math, it might be a while before you do feel better since it might take 200 mg of Zoloft to help your mood.  And if that does not do it, it might take the addition of an augmenting agent such as Wellbutrin, Lithium, or thyroid supplementation.

Now, you already mentioned that you are not happy about polypharmacy.  Sorry to hear that.  The unfortunate truth with Bipolar Disorder is that it is quite common for patients to need multiple medications to maintain stability.  The order that the meds are added must be carefully considered so as to minimize side effects, drug interactions or needless medication.  My personal preference is to get the mood stabilizer on board first in cases like this and then to add in the antidepressant medicine.  Seems like your expensive doc is adding the Topamax second.  I am not a huge fan of Topamax because I have not had great success with it as a mood stabilizing agent. It is generally well tolerated.

Lastly, could coming off the Lamictal quickly contribute to your depression.  Possibly.  I would have done it a bit slower (probably) and started the antidepressant during the taper of the Lamictal.  There is not difficulty with interactions between Lamictal and the antidepressants and, sometimes, the combination is useful in treating depression in some patients.

Remember to do all those things that are good for you . . . even if you don’t want to.  Exercise, fresh air, good food, music, vitamins and Omega 3’s (fish oil).  Even with aggressive treatment and good luck, turning this situation around might take some time.  Try to be patient.  My best wishes to you!

–Dan Hartman, MD

Neurontin as a first line agent . . . I Don’t Think So!

I received this question from a concerned consumer last week . . .

A week ago I was prescribed gabapentin, an anti-epileptic drug, for the off-label use of social anxiety and “affective mood disorder.” I have been concerned about this ever since I began my research on it a few days ago. Most of what I have read says that it should remain a second-tier drug until more controlled studies are conducted. While I am not sure if your comments on Trileptal holds true for gabapentin, it seems probable that they would. My concern is because although most of the studies I have read say that gabapentin, and other drugs of its type, are used off-label only when other medications have proved intractable, my psychiatrist prescribed them right off…as a first-line drug. “Front-line experience” is well and good, but it is still anecdotal. I feel rather like I am part of an informal experiment, sort of like a guinnea pig. He also did not inquire at all into my past to see if there were psychological roots to my anxieties. He said we would try the medicine first and then determine if “talking therapy” was needed. Should it not be the other way around? Should we not be trying to avoid medicinal intervention whenever possible? I am of the opinion that I need a second opinion…do you agree? I apologize if I am rambling. I actually did begin the medication and THEN began my research, so I am under the influence of its side-effects. I am at odds with myself as to how best to proceed. Thank you for your patience.

Well . . . not really a guinea pig.  The use of neurontin as a first line agent is not typical for the industry.  Not that neurontin is a big scary drug that will make you spout horns like some of the poisons we use.  More because it doesn’t work that well.  Neurontin is a medicine looking for a cause.  It got caught up in the wave of anti-seizure medicines being used for psychiatric purposes. Medicines like Depakote and Lamictal have earned their stripes and are commonly used and approved by the FDA.  Trileptal has not been approved, but has become a staple in our arsenal of medications because it works well.  Neurontin . . . well . . . it’s kind of that medicine that is used when you don’t know what else to do.  Despite initial claims of efficacy, there is virtually no data showing it can be helpful for psychiatric purposes.  When it is used (and, yes, I have used it this way) it is most often to address anxiety issues such as social anxiety or generalized anxiety AFTER other treatments have failed.  Because it has some efficacy for chronic pain syndromes (such as fibromyalgia), it is sometimes used in that population of patients earlier rather than later.  It is not used as a treatment for “affective mood disorder” . . . whatever that is . . .

My biggest concern is not that the medicine will put you at risk.  Neurontin is an innocuous drug that does not have a significant side effect profile.  Untreated anxiety, however, will put you at risk, as will untreated depression.  I am also concerned that you were told that “talk therapy” was a second line treatment.  It is VERY clear that social anxiety and depression are amenable to intervention with appropriate therapies (cognitive therapy is best), and I personally EXPECT my patients on medicines to be in therapy.  

Sounds like you might need a second opinion.

–Dan Hartman, MD

Another Klonopin Horror Story . . . why do I prescribe this stuff anyway???

I have had such an overwhelming number of negative comments about Klonopin lately, I thought I would feature it in another blarticle again.  I thought I would use the following comment sent in not long ago . . .

I started Klonopin 8 years ago for “Nocturnal Myoclonus”. I had heard they were difficult to get off but not to the extent I found.

Here goes:

Changing my life. Getting healthy. Lost a LOT of weight. Now time to get rid of the chemicals poisoning my body. Started on a Monday Cold Turkey. I know, STUPID. Hit some rough patches of trembing, anxiety and did research to take Benadryl, Clonodine (which I had for my BP), drank a lot of water. Long story short….went into a full blown “PSYCHOSIS”. It was early in the morning about the 8th day. My husband got up for work. I had a bad cold and felt awful. I have heard by some the “cold symptoms” could be part of W/D. After my husband left, I felt nervous and peeked out our blinds. To my horror, there was 4 people laughing and talking by my garage. I gasped and went to another room and looked on thefront porch only to find some ghastly looking people looking at me. I called my husband screaming and crying like a 2 y/o. He tried to talk me down to no avail. He stayed on the phone telling me he was on his way back and I just kept looking…NOT Believing my eyes!!! Everywhere were people.Not like monsters but some laughing and talking. Finally my husband got back home and I was telling him “watch out, they are waiting for you to kill you”. He opening the door and grabbed me, hugging me so tight and said I was trembing in horror. NO ONE IS THERE he promised. He gently took me outside as the sun was coming up….there was no one there. The type of hallucinations you get I found out later are “Light” based. Under sources of light images form in your brain and appear distorted. They came back the next night. Inside the house. I felt a horror, and a fear like none other I have known. I was actually relieved to research by googling “Hallucinations Klonopin”. The British study is excellent.

Needless to say. I am back on my medicine and will taper very slowly over months. I was also fearful of having a seizure (that is mentioned in the literature). I had huge twitches circling from my ankles, calves, thighs, and all the way back around. Please get back on them and see someone ASAP. I also developed severe tinnitus. Everything in my house seemed to make a buzzing or horn like sound. This is supposed to be caused by the hyper sensitive hearing while in W/D. And, from what I am learning , Most people never get rid of it. i sit here now hearing a slight sound of a car horn in my ears. I will pray for you. I see it has been a while and I hope you are ok.

Yikes!!!  This story is about as bad as it gets.  It reminds me of a book that came out in the 60’s or 70’s about a poor woman who came off Xanax cold turkey and went just bonkers (10 points to whoever can tell me the name of the book . . . I’m drawing a blank).  As if the issues of addiction, sedation, impaired memory, etc are not bad enough, coming off this stuff can be a nightmare.  

So why do I prescribe it???

Because it works.  

But lets be reasonable about this.  Like all medicine, it is not for everyone.  While most tolerate the medicine with minimal side effects, some have great difficulty even with the lower doses.  As with all benzodiazepines, there is a percentage that will develop tachyphylaxis (tolerance to the medicine).  These people require higher and higher doses of the medicine to maintain there level of benefit.  I have learned over time to abandon this tactic early rather than later when the dose of the medicine concerningly high.  When folks come in who looking for their 2nd or 3rd increase in the dose of Klonopin in as many visits, I start thinking about taking them off it completely (the patient is usually quite unhappy with me!!!).  It is way better to start the weaning process early, however, rather than to wait till the patient is on high doses for a long period of time.

But, as mentioned in many of the letters sent in, it is getting off the stuff that is the greatest difficulty.  This is especially true if you have been on higher doses for longer periods of time, but it can be difficult even if you have only been on the medicine for months (as opposed to years).  The biggest error in getting off is going too fast.  We live in an impatient world and people want change NOW.  Our biological system does not work that way.  Slow changes are accommodated much easier and the psychological burden of a slow change is much less.  As mentioned many times before, there is a difference between withdrawal effects and return of anxiety . . . and that difference can be difficult to tell in some people.  But always, always, always, the risk of difficulty is minimized when doses are changed in very small increments with lots of time in between the change.  Don’t get impatient.  Keep your eye on the goal of getting med free.  Make sure you are doing all the other things that are good for you (good food, exercise, therapy, etc).  When done right, the chances of getting off the medicine can be much higher and still leave you feeling good in the process.

–Dan Hartman, MD

Tapering quickly off Klonopin . . . or . . . how to drive yourself crazy and feel like crap

Dawn writes in . . . actually . . . shouts in . . . 

HI I WAS ON KLONOPIN FOR ABOUT 15 YEARS NOW AND I AM TRYIGN TO WEAN MYSELF OFF. I AM NOTICING I HAVE THE SHAKES, I CANNOT THINK STRAIGHT AT ALL, I CANNOT RETAIN MUCH OF ANYTHING, MY FACE GETS ALL TINGLY AND IT GOES NUMB.ALSO, MY MIND SEEMS OT FOCUS MUCH MORE ON OBSESSIVE THOUGHTS. SOMETIMES I EVEN FEEL LIEK IM GONNA LOSE MY MIND.I DONT FEEL LIKE MYSELF AT ALL AND I CAN DEFINATELY TEL LTHE DIFFERENCE BETWEEN A PANIC ATTACK, WHICH I GET EVEN ON THIS KLONOPIN, AND THESE OTHER ODD SIDE EFECTS. SEE, I AM DOIGN THIS MYSELF. I WAS ON 3 MILS A DAY AND NOW I WENT DOWN TO 1 MIL A DAY AND ITS BEEN ABOUT 3 WEEKS. I AM FREAKIGN OUT. BUT I DINT THINK IT WOUDL BE THIS BAD. MY DOCTOR HAD SAID GO DOWN FROM 3 TO 2. MAYBE I SHOULDA DONE THAT? I DUNNO.I JUST FEEL COMPLETELY NUTTY. I WISH IT WOULD GO AWAY :0(

Yyyyiiiikkkkeeessss!!!!

Dawn . . . get back on the klonopin . . . NOW.

As you all know by now, Klonopin is one agent in that wonderful class of medicines called benzodiazepines . . . the antianxiety tranquilizers.  They work well.   They work quickly.   And are dangerously seductive for people who tend toward the anxious.  While not the first line agent for anxiety in most cases, 15 years ago they were.  Since then, we have modified our approach as we discovered how effective the SSRIs can be in managing anxiety for most people.  But even tho’ the benzos are highly effective, they are far from the perfect solution for anxiety.  As Dawn describes so eloquently above, they don’t necessarily take care of all the anxiety (she has breakthrough panic) and they can be very addictive.  Once you are on these for years, you will have trouble getting off.  And 15 years on 3 mg is a long time . . . a verrrryyyy long time.

You mention that your doctor recommended that you go down to 2 mg and you decided to go to 1 mg on your on.  Well, Dr. Dawn, seems like you made a mistake.  I would urge you to listen to your doctor’s advice and increase your dose.  Call him ASAP and let him know what you did and how you feel.  Going down too fast on Klonopin after all that time is physically and psychologically dangerous.  You sound like you feel horrible.

How would I approach this if I was your doctor?

First off, I would explain that the likelihood of your anxiety getting worse is very, very high.  If you are on 3 mg of Klonopin and getting breakthrough  anxiety anyway, you are likely to have more breakthrough anxiety on less.  You better be prepared for it.  If possible, I would get you on an SSRI to manage your anxiety before we started down.  My guess is that either you are on one or they have been tried before (15 years on Klonopin is a long time).  Tapering down off Klonopin after being on it that long just takes time.  A long time. I would go down no faster than 0.5 mg every month.  If there were any withdrawal symptoms (and what you are experiencing are potentially dangerous withdrawal symptoms) I would slow it down even more, decreasing by 0.25 mg every month . . . or even slower.  If you experienced uncomfortable panic symptoms, I might also slow down the rate of taper.  

If the ultimate goal is to get off, it is best to go slow.  As a general rule of thumb, the higher the dose and the longer you are on it, the slower you must go in a taper of Klonopin.  Going too fast increases the chance that you will be uncomfortable and eventually give up on the taper and go back to the higher dose.  If you do, you may not have any interest in decreasing the dose again . . . and you risk feeling defeated because of it.  I think it is an admirable goal to try to be on less medicine.  But it is not always possible.  To do it correctly requires careful thought and planning, a great deal of patience, and is best done under the careful supervision of a doctor that you trust.  If you are getting advice from a doc you trust . . . take the advice.  If you don’t trust the doc . . . get a new doc.  Don’t take this matter into your own hands, however.  Getting off Klonopin can be tricky and dangerous and is best not done on your own.

–Dan Hartman, MD

Alcohol and Klonopin . . . decision time

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

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

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

So today is decision time.

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

Both she and I know that the alcohol must go.  

But will she have the courage?

Think some kind thoughts for her today.

–Dan Hartman, MD

When is Lamictal Good for Regular Old Depression?

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

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

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

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

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

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

–Dan Hartman, MD