Sunday, January 13, 2008
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.
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.
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.
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.
Monday, December 31, 2007
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.
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.
Friday, December 28, 2007
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.
Wednesday, December 26, 2007
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.
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