The first appointment with a psychiatrist is usually quite frightening. The decision to seek help is finally made after a long period of suffering with symptoms, not understanding it, not knowing how to explain it. After suffering for a long time seeking treatment feels so frightening and leads to feelings of vulnerability. I have had many people come to the office and express the feeling that being at the appointment is the ultimate acknowledgement of defeat and resignation to the fact that they have sucummed to mental illness after a very long time of resistance and fighting it, as though it is moral failure.
The whole idea of chemicals that alter your mood, thinking and behaviors are frightening to many people. The internet is full of the propagation of this fear (almost to the point of instilling paranoia) of medications, psychiatry, psychology, alleged "thought control", etc. In opposition to the medical community's attempt to help suffering patients, pop media preys on fears and guilt and offer no alternatives. Though our culture accepts mood and behavior alteration of Miller Lite, Starbucks, tobacco, and even marijuana, to some extent, Prozac, Zyprexa, etc becomes a dreaded and even hated concept. There isn't such a drive against alcohol which causes more illness and deaths than all the psychopharmacueticals will ever cause. Even caffiene is not benign, contributing to peptic ulcer, GERD and hypertension, but no one gets upset over Americans' increased dependance on it.
I have heard ministers discouraging their parishoners from taking antidepressants, as though it is a spiritual weakness that chemical imbalances occur.
I am not trying to belittle the point that all medications have the potental for harm, including death, but emotional illness can be even more devastating to patients who suffer and the families who are also affected. People die of mental illness every day and pop media and internet should be supportive of patients and help them in their quest for alleviating their affliction and not alienate them from a potential for remission.
Monday, September 28, 2009
Sunday, September 27, 2009
Sexual side effects of antidepresssants
Sexuality is an important aspect of who we humans are. It is important on a personal and emotional level and in our relationships and connections to our significant others. Depression quite often takes away one's ability to enjoy just about anything, including sex. Unfortunately, medications that treat depression all too often also squelch sex drive and the ability to orgasm. When depression improves and the desire to resume normal life activities comes back, the desire for sexual relations often does not. Most of the newer antidepressant medications work by focusing in on increasing the brain chemical serotonin and it appears that when this neurotransmitter is increased and there is too great of an imbalance between serotonin and another neurotransmitter, dopamine. That's when you get sex drive and orgasm problems.
Though an ideal option is switching to a medication that is as effective and has less side effects, often a particular anti-depressant's effect may be better than all others tried, however and the option to switch medications is not viable. Addition of a medication that may increase Dopamine may need to be considered in order to offset the imbalance and correct the problem. The following are options to consider:
Ginko biloba- natural option
Wellbutrin
Stimulant medications
Buspar
Amantadine
Viagra- this option has been helpful for women as well, works best for anorgasmia rather than lack of libido
There are probably other options I am leaving out but this is a good start. Don't be shy to bring up any concern you may have with your doctor.
Though an ideal option is switching to a medication that is as effective and has less side effects, often a particular anti-depressant's effect may be better than all others tried, however and the option to switch medications is not viable. Addition of a medication that may increase Dopamine may need to be considered in order to offset the imbalance and correct the problem. The following are options to consider:
Ginko biloba- natural option
Wellbutrin
Stimulant medications
Buspar
Amantadine
Viagra- this option has been helpful for women as well, works best for anorgasmia rather than lack of libido
There are probably other options I am leaving out but this is a good start. Don't be shy to bring up any concern you may have with your doctor.
Monday, September 14, 2009
Rethinking Atypicals
When the new "atypical" antipsychotics came out we were excited to see the problem of Tardive Dyskinesia was no longer the great worry. We became comfortable and complascent with prescribing the medications and we found them extremely helpful for not only psychosis but bipolar symptoms including mood lability, anger and insomnia. They, indeed, have been enormously helpful and a far cry from the older, side effect laden "typicals", but at what costs?
We have been aware of the risk of diabetes with these medications but we attributed it to the weight gain that fostered insulin resistance, as anyone who gains weight elevates their risk. We have been feeling secure in monitoring fasting blood sugars and Hemaglobin A1c as markers of a problem. This, however, as it turns out, may not be adequate or even helpful It appears that what the body does to compensate for the insulin resistance is increase the amount of insulin production from of the pancreas. Unfortunately, what we know of pancreatic functioning is that insulin production over time diminishes naturally with age. If we over tax the pancreas (with obesity, poor dietary habits, atypical anti-psychotic medications, etc) the risk of developing diabetes is much higher.
Given the above, we, as a profession, need to adapt our prescribing habits to what we are learning. We will need to go back to the old mentality of using anti-psychotic, whether typical or atypical, with caution. We certainly need to use them as necessary but maybe for shorter periods of time and with the expectation that if we can replace them with other medications (eg, mood stabilizers in the case of bipolar), we should plan on doing so. Perhaps adding adjunctive medications (though the fewer medications the better) or natural supplements (such as cinnamon) may be worth considering. The atypical antipsychotic medications are exceptionally good treatments and far better than the other older options and hopefully, the pharmaceutical companies can work further on identifying new medications with at least equal efficacy and less risk. In the meantime, we keep trying to understand what best to do to help our patients.
We have been aware of the risk of diabetes with these medications but we attributed it to the weight gain that fostered insulin resistance, as anyone who gains weight elevates their risk. We have been feeling secure in monitoring fasting blood sugars and Hemaglobin A1c as markers of a problem. This, however, as it turns out, may not be adequate or even helpful It appears that what the body does to compensate for the insulin resistance is increase the amount of insulin production from of the pancreas. Unfortunately, what we know of pancreatic functioning is that insulin production over time diminishes naturally with age. If we over tax the pancreas (with obesity, poor dietary habits, atypical anti-psychotic medications, etc) the risk of developing diabetes is much higher.
Given the above, we, as a profession, need to adapt our prescribing habits to what we are learning. We will need to go back to the old mentality of using anti-psychotic, whether typical or atypical, with caution. We certainly need to use them as necessary but maybe for shorter periods of time and with the expectation that if we can replace them with other medications (eg, mood stabilizers in the case of bipolar), we should plan on doing so. Perhaps adding adjunctive medications (though the fewer medications the better) or natural supplements (such as cinnamon) may be worth considering. The atypical antipsychotic medications are exceptionally good treatments and far better than the other older options and hopefully, the pharmaceutical companies can work further on identifying new medications with at least equal efficacy and less risk. In the meantime, we keep trying to understand what best to do to help our patients.
Wednesday, April 30, 2008
antidepressant induced depression
Though antidepressants can be life enhancing, they can also make matters worse. They can increase suicidal thoughts and cause more mood swings and anger-the symptoms that they may be intending to help! They can push some one into a raging, out of control state that only hospitalization can contain, so they need to be used with caution and prescribed judiciously.
It is especially dangerous when there is a possability of bipolar illness. In this context, antidepressant use can be like fuel poured on a fire. I have even seen many cases where the addition of antidepressants actually cause depression in bipolar patients and when they are withdrawn the depression begins to lift.
Don't get me wrong, I am an avid proponent of the use of antidepressants as I have seen lives of patients and family members devastated by ravages of depression turn around with antidepressant use use, but they must not be used without proper consideration of the risks and without close monitoring.
It is especially dangerous when there is a possability of bipolar illness. In this context, antidepressant use can be like fuel poured on a fire. I have even seen many cases where the addition of antidepressants actually cause depression in bipolar patients and when they are withdrawn the depression begins to lift.
Don't get me wrong, I am an avid proponent of the use of antidepressants as I have seen lives of patients and family members devastated by ravages of depression turn around with antidepressant use use, but they must not be used without proper consideration of the risks and without close monitoring.
Wednesday, February 27, 2008
Honduras Mission
A team of 26 flew into San Pedro Sula, Honduras and went to Pena Blanca to help the people of Honduras with the help of the folks at the Pan American Health Service. It was a very busy, exhausting experience but very worthwhile and fulfilling. We saw a total of 1,500 patients and dispensed thousands of medications including anti-biotics, anti-parasitics, analgesics, 20,000+ adult multi-vitamins and 20,000+ child multivitamins. We were ready for whatever the experience brought us and all worked very well together. We went on a pre-trip which gave us a very good idea of what to expect and how to plan for it. It was the organizational plan that did us the most good. We ran like a well-oiled machine. We were equiped and manned and ready when the first patients came to the door. Most of us were seasoned with at least one mission trip under our belts, the rest of us were ready and willing for anything. Though it was sponsored by the Adventist Health System it was ecumenical, all inclusive and all-accepting. We even had a Buddist physician with us.
Probably the most rewarding experience for me was seeing the good will and love the fellow team members had. They were dedicated, loving, gracious, and commited. they did it out of the goodness of their heart. Out of a sense of altruism that is not often seen on a day-to-day basis. Out of a love for God and man. They left the daily grind of taking care of their own needs to self-lessly giving and giving and giving. It gave me renewed hope in our human race.I was blessed by spending a week with these wonderful people.
Probably the most rewarding experience for me was seeing the good will and love the fellow team members had. They were dedicated, loving, gracious, and commited. they did it out of the goodness of their heart. Out of a sense of altruism that is not often seen on a day-to-day basis. Out of a love for God and man. They left the daily grind of taking care of their own needs to self-lessly giving and giving and giving. It gave me renewed hope in our human race.I was blessed by spending a week with these wonderful people.
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.
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.
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.
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