Wednesday, January 16, 2008

Symbyax, the miracle pill

In psychiatry most medications take a while to work. It's not uncommon to have to wait 7 to 10 to 14 days until you see some relief of symptoms, especially when it comes to depression. One of the most impressive meds that are available is Symbyax, Symbyax is actually a combination of Prozac and Zyprexa, both Lilly drugs. It is out with an indication for bipolar depression, which is often a complicated disorder to treat. What has been awesome abouth this medication is that people often find significangt relief from their depressive symptoms in as little as 24 to 72 hours! I have had some of the most dramatic benefits in spme of my most depressed and overwhelmed patients, one of whom I saw tonight.

I like to compare Symbyax to a rueben sandwich. a rueben sandwich has components that individually I don't like and yet it is deliciious when it's put together as one package. Not that I don't like Prozac or Zyprexa, but I have had patients that have been on Prozac without benefit and Zyprexa without benefit, but in combination it works great.

A couple of cautions need to be considered with Symbyax, however. Any time you add an antidepresssant to someone with bipolar it is important to watch for manic activation. Generally the Zyprexa protects against it but the antidressant can still cause and increase in anger, mood swings and make things worse over all.

Another problem is sedation and weight gain with the Zyprexa. The problem with weight gain is that the more overweight a person is, the more risk for diabetes. There have been two case reports (of tens of thousands who have been on this medication) of patients developing a severe diabetic reaction (ketoacidosis) upon starting the medication with no wieght gain. This is highly unusual, however, but still very concerning. Sometmes, moreso in males than females, there is some weight gain and then it plateaus at an ok level. The risk of weight gain seems to be about 18%, so 82% probability it won't happen. If there is too much weight gain, this medication may need to scrapped, or, if it is important to continue the medication, there are other medications that can be used to offset the increase in appetite such as Topamax or Symmetrel.

Sunday, January 13, 2008

teen pregnancy: best outcome

Teen pregnancy is a period of crisis, both for the kids involved as well as their parents. It is probably the most stressful event that can occur in a youth and parent's life. When I council kids on pregnancy issues I always contrast the excited expectation my wife and i had as soon-to-be parents, with my home ready to recieve this precious new gift. My family so excited to welcome a new addition. This is in stark contrast to an unwed couple who is scared of their parent's reaction. Who share the news of pregnanacy with fear, anxiety and dread. That the child is not seen as a welcomed addition but an unexpected mistake. Children coming into the world deserve the best, not starting off on the wrong foot.

When youngsters opt to keep their child I recommend that they try to finish their education and get more than a high school diploma if possible. It is important that they not have another child until they are good and ready for the next: more mature, emotionally and finacially settled, married, etc. When this occurs it is best for everyone, the parents, the child and the rest of the family. Everyone makes mistakes but it is important not to fall into the same traps and try to limit the consequences as well as make the best a difficult situation.

LPHA: what a concept!

When I was in a staffing, new forms were passed out after this particular meeting. There was a line for me to sign that ended with LPHA. That was a foreign concept to me. "What is this?", I asked. I was told that it stood for "Licensced Practitioner of the Healing Arts". What a wonderful concept. I thought I was a physician and a doctor but the term "practitioner of the healing arts" had connotations of what I did for a living was to be gentler, more compassionate, more sensitive to another's need and pain. Indeed, I trained and was taught a healing art. What a wonderful concept. It is my prayer that God helps me to be more compassionate, gentler and sensitive.

Wednesday, January 9, 2008

Remeron, low profile but great option

Remeron has little name recognition. When you mention Prozac, Zoloft, Wellbutrin or Cymbalta to the average person, they can automantically tell you a thing or two about the medication or the commercial they saw, not so with Remeron (mirtazepine). Remeron's patent time was up sooner than most and it went generic earlier, something about it not getting marketed soon enough. Because it is out in generic form it will never get as much flashy advertising as the next new kid on the block. Antidepressants represent a large sector of pharmaceutiical monies so ads to promote them are quite prevalent.

Remeron is a great medication in my opinion. It works quicker than most (for severe anxiety I have seen results within one or two days and for antidepressant effects 10-14 days), it is very effective, even with previous medication failures, it doesn't seem to induce mania as much bipolar patients, it's great for anxiety and great when insomnia is problematic. I have had great sucess with both depression and anxiety. I have seen significant improvement in panic attacks that have been resistant to other treatments. One aspect that is unusual about this medication is that it seem to "plug up" anxiety receptors in the brain (competitive inhibition, for those of you who want a more technical term) and therefore approach anxiety in a different way than other medication. Like the SSRI's (Prozac, et al), it also increases seratonin. Unlike the SSRI's, however it doesn't adversely affect sex drive or function.

The downside to this medication is that it can be quite sedating and weight gain is possible. As far as the sedation is concerned, I didn't like the medication at first because my patients called me up the next day and told me that they had to call in to work beccause they couldn't wake up until noon the next day. I heard this so often I gave up on the medication. I was convinced to give it another chance when researchers were finding that the higher the dose of the medication the LESS sedation there was and that the extreme sedation was typically just a couple of days. It was therefore now recommended to be started at the middle dose (30mg) and not the low dose (15mg) and if sedation occurred, an increase of dose was recommended. It was counter-intuitive, but you know, it worked! It is typicially recommended to be started on a Friday night with the admonition that not much be scheduled for Saturday or Sunday morning in case it was too hard to get up. By Monday it should be better. Indeed, the strategy works! The increase in appetite was also supposed to be better at the higher doses but I really don't think that's true, at least in my patients. Appetite increases are the exception rather than the rule, however, so don't let that possible side effect get in the way of trying out a potentially great medication.

Wednesday, January 2, 2008

Paxil: a mixed blessing

Paxil and I have a love-hate relationship. First of all, when Paxil came out on the market it was welcomed because it is always great to have another choice of medications for our patients' well-being. It has been an excellent medication. It is very effective and sometimes nothing is as effective. Later, however, the luster began to fade and it's shine became duller. Though my patients found it quite effective, many came with embarrassment to tell me they no longer had a libido, or that they could no longer orgasm, or a one gentleman so horridly described it: "you could put a nail through it and i wouldn't feel it". Sexuality is such an important part of who we are as human beings and often so vital in our relationships that after such a good response to depression we needed to seek a cure from the side effect. We've tried numerous medications to counteract the adverse reaction but with limited avail. :(

Another problem was it's short half-life which means it is eliminated rather quickly from the bloodstream. This created severe withdrawl symptom. Not dangerous, mind you, but aweful. If nothing is done, it may last 1-2 weeks! That's a long time to feel miserable. Slow taper downward is very important.

Weight gain also happened in a few here and there.

To me it was a sad ending to a great start...but it can, for some, be just the right medication. One man's ceiling can be another man's floor.

Prozac: an ode to the wonder drug

I almost remember the day when Prozac was just put on the market like some people remember the day they heard the news of the attack on Pearl Harbor, the Kennedy assination, Pricess Di's death and 911. Prior medications were aweful. They all had nasty side effects that made them intolerable, they had to be slowly titrated to therapeutic levels so patients could tolerate them and they were all poisonous. A few days dosage of pills were lethal in overdose. I would prescribe the pills with trepidation because of my fear that in a suicidal state the cure could be used as the instrument of death.

As opposed to the above, however, Prozac was a safe, one size-fits-all option. A patient could start the medication at the right dose from the first day. People had overdosed on 2-3 months supply of the medication and no one died. It helped depression, anxiety, OCD, migraines, chronic pain, bulemia, etc. It was a wonder drug. I would have to say it was truly a major break through in alleviating pain and suffering of depressed patients and the families who were also affected. Amongst my collegues we affectionately called it "Vitamin P".

"New and improved" SSRI's came along, first Paxil, then Zoloft, then Luvox, then Celexa, the Lexapro, all following the same path that Prozac forged.

In my mind, though some of the newer medications are also good and helpful, my first love shall always be Prozac.