Psych meds: misplaced fear

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.

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.

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.

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.

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.

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.

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.

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.

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.

ECT: Shock Treatment

Shock treatment (Electroconvulsive treatment, ECT) sounds barbaric and if you or a loved one have ever been recommended it I'm sure it's extra frightening. On occasion I'll recommend for my patients to have ECT and I need to do a lot of teaching and reassurance. I will share with you what I tell my patients. If the proceedure is demystified it becomes less frightening.

The whole concept of ECT arose when while at an asylum two patients had grand mal seizures and for some unexplainable reason, they improved! That was an era when patients would be placed in asylums for years or forever and because of the stigma were often left and forgotten by their families. There were no psychiatric medications available; after all, psychiatric medications are relatively new to us, anti-psychotic have been around since 1945, antidepressants early 1960's, prozac 1986. Cold water treatments, spinning chairs, straight jackets and insulin shock were the mode of the day.

It was postulated that if a seizure was induced, the symptoms would remit and the patient would improve. Unfortunately, any ways were attempted to cause a seizures and there were deaths along the way. Placing electrodes on both temples with a jolt of electricity was tried and was found to be effective. I know a seasoned psychiatric nurse who tells me that in the 60's she, along with strong mental health techicians, would help hold the patient's arms and legs while they seized vigorously. In this day and age the treatment is done under brief general anesthesia and there is barely any movement. There is a brief pulse of electricity and you hope for a good seizure that lasts 45-90 seconds.

ECT is very helpful for stubborn, difficult to treat depression. As opposed to the typical antidepressants that have a likelihood of 60-80% of being effective with depressed patients, ECT is about 70 to 80% effective and these are usually the most recalcitrant depressions. It can work faster than antidepressants, sometimes improving depression, at least somewhat, after the first or second treatment.

Side effects are generally not too problematic. The general anesthesia helps prevent seizure-related problems like fractures of the vertebrae. The main concern the effect on memory and new learning. There are two ways of doing ECT, unilateral with one electode on the right temple and one on the forehead and bilateral with electrodes on both temples. Unilateral treatments seem less effective with more treatments needed to effect a change, but they do not cause as much memory loss. I have had patients that do well with regular ECT and memory is not effected whatsoever. If memory is affected, however, it generally improves gradually over the subsequent few weeks and up to 3 months. There are some who report that memory is indefinelty affected, however, neuropsychological testing does not support this. Recent studies indicate ECT actually improves memory, probably because depression so negatively impacts memory and as the depression improves, so does the memory. There have been brain biopsies studies of rats who have been given multiple, repeated ECT and no evidence of damage to the brain tissue itself has been found.

Overall, ECT is a great form of treatment. It is not a treatment that should be avoided, infact, it can be life saving. The only contraindication is anything that would increase intracranial pressure, eg. brain tumor. The ultimate question I am asked is that if a family member or I are recommended ECT would I agree to it, and the answer for me is...sure.

Benazir Bhutto, rip

How tragic when one voice of reason is snuffed out. No one has absolute truth that's why it is so important for a society to support and tolerate many ideas. That's what makes America great. The extremists prove over and over that America is a great and blessed nation...not always right or appropriate in it's actions but blesssed with diversity of people, culture and ideology. May Ms. Bhutto rest in peace, Pakistan be comforted and many in Pakistan live on to carry on Ms. Bhutto's dream.

Deal or no deal? Gambling and other Addictions

Addictions have a life of their own at times. It appears that what for one person can be a non-issue to another may be disaster. Take a beer, mixed drink, gambling, sex, food, or anything that is pleasurable, in moderation or controlled fashion is perfectly fine. Genetically, however, some people are programmed so that there are no breaks. Recent research indicates a different way the endorphins respond. It seems that there is a much more robust increase in endorphins to the point where the problem becomes more complex. The reactions are so intense that it feels like what heroine addicts experience. They become addicted to their own opiate system and it becomes what is called an "auto addiction." It's not their "fault" but it is a major challenge life brings that requires a lot of attention and hard work to reclaim their lives. Unfortunately, it affects all those who love them. It's hard to admit to the condition but once people do so and they get help it can be a life changing event.

Adoption: good idea or not?

As a child psychiatrist I see a lot of children who have been adopted, and with good reason. It is a major event in a person's life, how can it not be an enormously emotionally loaded event. Research notes that adopted kids have 9 times greater likelihood to have psychiatric issues. Reasons for this may be numerous. The developmental struggle when the adoptee is trying to develop their sense of identity, the genetics that are very strong (after all, the bio parents may have gotten in their predicament because they were impulsive, risk taking, unable to take care of their child, etc.), attachment issues if the child was old enough to expierence the separation and loss of the primary care-giver, etc.

It is important for people planning on adopting to realized that some of these factors are so strong that love isn't enough to change the emotional and behavioral ups and downs that may follow! It is important to realize that the decision to adopt will be life changing both for the better but also for the more challenging. Now, there are wonderful adoptive parents that have been challenged in tremendously painful fashion that have persevered and stuck with their child, working hard to overcome the challenges and getting to the point where there was a turn for the better years later as the child matured. I have been impressed and inspired by parents like these. Not everyone can do this, in fact I 'm not sure I would be strong enough. When parents have told me that their child has never told them they loved them and they are 8 years old, they have invariably told me this with tears in their eyes. Yet, two families that come to mind have been wonderfully blessed by their children who became awesome teen-agers and who were finally able to reciprocate and express their love to them. They are special young people who were blessed with parents who wanted them so badly and were willing to sacrifice for them. If you are thinking of adoption, go into it with open eyes but be willing to persevere no matter what life brings you, sometimes there are greater rewards in one's sacrifice.

Autism and Bipolar

Though i have not seen formal literature that supports a connection between autism and bipolar illness, i have seen too many kids with that combination. Though Bipolar illness is overly diagnosed these days, i have seen Kids with undeniable bipolar and undeniable autism. It has been noted long ago that autistic kids with aggression responded well to either lithium or antipsychitics, both of whom are treatments for bipolar.

Pot use in teens

It seems rare that I come across a teen who has not used pot. For the most part, most don't use excessively. When they do use regularly, however, a common scenario occurs: memory starts getting poorer over time, grades begin slipping and academics become less important and much of the teen's socialization centers around pot use. There is something called "amotivational syndrome" that occurs. A person begins to slowly sink into a sense of complacency and apathy, not caring about what used to be important to them. They feel lazy and unmotivated. What makes the problem worse is that the change is so gradual and not noticed. Because of how subtle and incidious the personality change is there is a denial of the changes that have occurred. It's often not until the person stops the use and is abstinent for a while that they will report noticing a difference. Often they notice that they can think better, clearer and they feel mentally sharper. They feel their energy level come back and they feel more alive. All this comes as a surprise because they were oblivious to the downward drift and the toll the pot was having on their body.

I have seen people who appear to have mood symptoms that appear bipolar normalize when they stop they use. Mood swings, anger control and unpredictability all improve. It takes pot a good 30 days to clear out of the system so the results aren't exactly overnight.

PMS medications

If you suffer from PMS, actually the proper term is PMDD: Premenstrual Dysphoric Disorder, taking care of yourself is very important for both yourself and your loved ones. You sometimes can't help your reactions and emotions no matter how much effort you muster. Afterwards you deal with the aftermath. No one is happy with the circumstances, especially you.

It's important to look into your various options. Consider the following:
1) natural products can be quite helpful. Evening primrose and vitamin B6 can be excellent. There are some preparations that incorporate several supplements at once and can be very helpful.
2) SSRI antidepressants such as Prozac and Zoloft can be very good. They can even be taken just the week prior to your menstrual cycle and discontinued upon start of flow with good results. Daily use can be good but not necessary if the mood issues are just menstrually related, If medications are necessary throughout the entire month, they can be increased for the week prior to menses if the regular dose is not enough to control premenstrual symptoms. The antidepressant option may not be good if there is a personal or family history of bipolar disorder, it can make things worse.
3) Oral contraceptives are sometimes helpful. The typical 1/35 pills, those which are the same color for 21 days with 7 days of placebo, carry a 10% risk of causing depression, however and so may complicate things, so be aware of these. The triphasic pills change color and hormone content every seven days and seem much better and a lower risk.
4) If there is no potential for substance abuse, the use of anxiety meds such as Xanx, Ativan or Valium can be helpful. There are addictive if used consistantly (daily) for three months or more, but used for one week out of the month on an ongoing fashion shouldn't be a problem. This option is not good if there is a personal or family history of substance abuse, you don't want to create a larger problem.

Medications for childhood depression

Important to consider if your child is depressed and may need medication is the following:
1) have you tried conservative approaches first, eg therapy, multivitamins with selenium, omega-3 fatty acids? Do not use St. John's wort unless you talk to a physicain first.
2) have you ruled out a physical factor, eg, low thyroid, drug use, medications such as oral contraceptives, antibiotics for acne, etc.
3) if there is bipolar in the family or you suspect bipolar illness in your child, see a child psychiatrist and not your family doctor of pediatrician! It may be more complicated and antidepressants may make things worse.
4) After the above has been considered, then just about any antidepressant should be ok. Prozac has been best studied and is great, so is Zoloft and Celexa. Wellbutrin can be good if there is ADHD also but sometimes isn't as good for depression.
5) though rare, antidepressants can increase suicidal ideation. This seems to occur more in kids prone to bipolar, hence #3 above. If this arises in you child, call your doctor immediately or have your child evaluated at your local hospital ER.

Most of all, invite open dialogue with your child and be observant. Always err on the side of caution and if you feel there is a risk of self harm or suicide, get help!

Autism and Aspergers medication considerations

Because we don't have medications that directly affect the actual root cause of autism and Aspergers we target symptoms and treat them accordingly. Sometimes the results can be surprisingly good and at other, modest at most. The key is to find the most appropriate medicine with the least side effects. The following are my first choices, based on effficacy and side effects. There are other options but these are my favorites.

For aggression:
Antipsychotics: all are ok, look at the ones with less side effects: Abilify, Seroquel have less side effects, other may cause weight issues (Risperdal and Zyprexa) and Geodon can have cardiac conduction issues
Anti-seizure meds: Trileptal, Depakote(watch for weight gain) and Topamax (watch for cognitive/memory decline)

For perseveration:
SSRI's: Prozac, Luvox-don't use SSRI's if there is a family history of bipolar
Inosital-be patient, stick with it, it may take 6 weeks to see results, don't be afraid to push up the dose to high doses

For hyperactivity and inattention:
Focalin-xr, Adderall-xr-both can be sprinkled if swallowing issues exist
Clonidine, though potentially too sedating has been surprisingly good for some kids
Consiider Provigil, especially if the stimulants not helpful

Don't over look the benefits of a casein-free diet! Casein is the fat in milk. It can be great for many kids, especially if there has been a history of colic and intolerance to milk as an infant.

Don't overlook the benefits of a sensory diet and OT interventions! Having an outpatient OT to guide you in your management at home can be invaluable. You may need to push your insurance carrier to cover it and you may need to ask your pediatrician or child psychiatrist to give you an order for it.