I’m having trouble holding my tongue here . . .

This fellow you are planning to marry is not a nice person.  Perhaps you are were having trouble seeing that in the past, but it is clear as day now.  The typical marriage vows include phrases like . . . for better or worse . . . richer or poorer . . . sickness or health . . . Perhaps he hasn’t thought this marriage thing through.  And perhaps you have not as well.  You have been diagnosed with a potentially difficult medical condition that is  manageable, but only with effort, patience and support.  There is always the potential for difficult times.  Medication works very well and we can often find a medicine or cocktail of medicines that work to stabilize mood with a minimum of side effects.  Sometimes sex drive is effected, but not for most people with Bipolar Disorder. If part of your manic symptoms included periods of hyper-sexual behavior, that CAN get a person in trouble sometimes.  It is a part of the symptom complex that he might enjoy . . . but it must be controlled.  That is certainly possible (if not likely) without compromising your intimate relations with a partner.

But do you really want this guy to be your partner?  From your brief description, he is “really mean”, threatening (“he’ll cheat”), unsupportive (“possible leave me and my two kids”), “insulting” and “a selfish piece of shit”.

You can’t help but hate him.

You are going to marry this guy?

I urge you to look at my November, 2011 blog entry on “In Sickness And In Health . . . Lessons Learned From My Patients”.

This does not sound like the kind of man who is going to stand by you and help you and your children be the best that you can be.  Put the wedding on hold while you get yourself together and reassess your life.  If he can’t hang in there while you do that, you don’t want to be tied to him for the future.

Good Luck.

–Dan Hartman, MD

Wellbutrin immediate release tablets (75 and 100 mg tablets) has been in a generic form for ages.  Not coincidentally,  a “sustained release” formulation of Wellbutrin . . . Wellbutrin SR . . . became available shortly before the immediate release preparation went generic.  This did represent a significant advantage over the immediate release tablets, because it allowed us to push the dose up without requiring more than two doses per day (three doses per day is impossible to remember consistently).  It also spread the peak blood level out so that side effects were less for many people.  But drug patents don’t last forever . . . and shortly before the SR version went generic . . . lo and behold . . . the extended release version . . . Wellbutrin XL . . . came out.

In some ways, the XL version does represent a step forward.  For someone on a higher dose, it allows once a day dosing (highly desirable).  The maximum dose allowable for the SR was 200  mg at a time.  If I prescribed more than 200 mg at a time, it would have to be in a split dose to minimize the risk of seizures. With the XL version, I could prescribe up to 45o mg to be taken at one time.  So the XL does represent a step forward . . . in certain circumstances.  Does it represent something more than convenience?  Not really.  For ALL sustained release products, the difference is in the packaging of the product . . . not in the product itself.  By packaging, I mean the coating or other technological advances that allow the active ingredient to be released more slowly than in a standard immediate release version.  ”Regular” Wellbutrin dissolves and enters your system fairly quickly.  The dissolution of the SR and XL preparations happens more slowly, so absorption takes place over time.  You theoretically get the same amount of medicine (and the same amount of benefit) but with a slower and more gentle peak to the blood level.  This theoretically results in fewer side effects and greater tolerability.  This can be very important on the higher end of the dosing spectrum . . . and much less important at the lower and middle parts of the dosing spectrum.  Does it matter if someone gets Wellbutrin SR 150 verses Wellbutrin XL 150?  For the vast, vast majority of patients . . . no.  A rare patient will experience more sleep difficulties taking 150 XL compared with 150 SR.  The buproprion that is in both, however, is equivalent, and the form of delivery is so similar, there is little chance that one will result in a outcome different than the other.

Now is the generic Wellbutrin comparable to the brand only Wellbutrin?

That has been the source of much angst and will need to be explored in another discussion . . .

–Dan Hartman, MD

One gentleman in particular caught my eye.  It was clear from his body language that this was not his first choice of Saturday morning activities.  He mostly held to the periphery of the gymnasium, aloof from the tables in my vicinity at least. But not totally disinterested.  He was obviously observing the scene and the comings and goings of the health fair participants.  Since my table was near the door to the exit, he was often near to my table, but conspicuously avoidant of me and my table.  Even the oft’ replenished pile of chocolates did not bring him over.  So I finally went over to him . . .

“I can tell this is not your first choice for a Saturday morning!” I quipped.  He smiled and said “no . . . not really”.  Then he looked me full in the face and asked . . . “so what does it mean to be emotionally well?”

What a great question.

Too often, the difficult times and the difficult emotions of our lives fall into diagnostic categories.  These attempts to classify and categorize are not meant to be judgmental by those of us in the mental health care field.  We are just trying to understand where someone is at so we know how to help them.  What is emotional wellness?  It certainly includes the ability to feel profound sadness at times.  Profound euphoria at times.  Anger . . . irritability . . . anxiety . . . panic . . . the full experience of human existence.  While these emotions can be disturbing to ourselves and to those around us, sometimes they are the “normal” for the moment.  A sign of “emotional wellness”.  In discussing this with him, he clearly became more at ease.  I think he was waiting for me to speak and act like the “psychiatrist” he thought I was. Instead . . . I think I convinced him of my humanity and (perhaps) the humanity behind those of us working in the mental health field.  He was able to talk about himself a bit.  The difficulty he had reading when his mother (the English teacher) made that a priority.  How he spent his life reading the words, but not reading the paragraph . . . not reading the story.  His difficulty in reading was balanced by his high proficiency in math that eventually led to his attendance of a prestigious university and a successful career as an engineer.  He had an easy smile and was pleasant to talk to.  He had a long marriage and good kids.  He seemed like a guy I’d share a beer and a ballgame with.

Did he have a diagnosis?

Probably some reading-something-or-other disorder.

Was he emotionally well?  Hard to say with one brief conversation.  Overall, he seemed as emotionally well as the rest of us at the health fair.  He had obviously had his share of ups and downs.  His share of struggles.  He seemed to be centered and content. I got from him that his aloofness was not based on a fear of me and what my table represented, but a sense of being “OK” with who he was.  An interesting paradox of life is that our emotional health can increase as our bodies age and breakdown.  As we become less able to do the things of our youth, we can become wiser . . . more contemplative, more contented and more grounded.   We gain a perspective of life that would have suited us well when we were young.  Truly, youth is wasted on the young.  We all know people who age well . . . who gain that sense of emotional wellness even as their physical health wanes.  People who can weather the difficulties that life has to offer and still have a positive sense of themselves.  Not as emotionally perfect . . . but as emotionally well.

So what does it mean to be emotionally well?

I’m not sure I can define it, but, in the words of Justice Stewart . . . “I know it when I see it”

–Dan Hartman, MD

–Dan Hartman, MD

If you think I am over reacting, consider this . . .

Access to out-patient mental health services in the Philadelphia area (my geographic home base for those of you who don’t know), has shown a gradual erosion over the last 5-10 years.  As with all care, the cost of copay’s and out-of-pocket expenses has increased.  A patient’s cost to access mental health services has risen disproportionately, however, resulting in a greater financial burden.  This extra burden often comes at a time of reduced emotional resources (from the mental health issue) and can significantly limit a patient’s ability to get the treatment that is needed to restore full functioning.  The latest maneuver that I have seen the insurance industry do is to write health care policies for people that EXCLUDE access to mental health care.  Yes . . . EXCLUDE access to mental health care services.  Repeatedly, I have run into the situation where a patient comes for treatment only to find out THEN that he or she has NO MENTAL HEALTH CARE COVERAGE.  Somehow, that detail was left out of the information when the “choice” of coverage was reviewed.

Consider the statistics.  It is estimated that 47% of the population in the United States will meet criteria for a mental illness at some point in their life.  The lifetime risk of Depression is 17%.  An anxiety disorder is present in 51% of patients with Depression.  Lifetime risk of Bipolar Disorder is 4%.  Lifetime risk of Schizophrenia is 0.7%.

In comparison, 26 million people in the US have been diagnosed with Diabetes (8.4%).  Epilepsy will be diagnosed in 3% of the population at some point in their lives. Chronic kidney disease will effect 16.8% of the population at some point during their lives.

How do you think it would go over if Aetna started writing policies that restrict access to Diabetes care??  What if a patient with Grand Mal seizures was not covered??

The exclusion of mental health care coverage is blatant discrimination against a substantial portion of our community that remains largely anonymous because of fear of discrimination or ridicule.  But let’s face it . . . everyone of us knows someone who has had to deal with a significant mental health care issue.  EVERY ONE OF US.  I dare you to go eyeball to eyeball with that person and tell them that you support the exclusion of mental health care coverage that they need to get treatment for their issues.  I DARE YOU!!!!

Can’t do it or don’t want to do it??

Well, that is what you do when you remain silent.

I challenge all of you to contact your employer and/or the human resource department at work and make a stink if mental health care is excluded from coverage in any of the benefits offered there.  I challenge you to contact your federal, state and local representatives and demand an end to discrimination against your family, friends and neighbors with mental health care issues. Share this blog with everyone you know and ask them to speak up as well.

If you are not sure how to contact your congress persons, go to www.congress.org and put in your zip code. Send them an email.  Give them a call. Don’t remain silent.

The government and the insurance industry will listen if enough of us speak up for what is right.  If you don’t do this now, you may find yourself without the resources YOU need when it is time for you or a loved one to get help.

–Dan Hartman, MD

But what of the spouses of MY patients?

For many of my patients who battle severe mental health issues, the lifeline provided by their husband or wife is the only thing that keeps them going.  Becoming severely depressed or overwhelmingly anxious can lead a patient to be unable to work . . . unable to socialize . . . unable to participate in a relationship in much the same way that a physical illness can.  But with the admission of a severe mental health issue comes the stigma of having a mental health issue.  Even in these “enlightened” times where it is clear that mental health issues result from organic dysfunction of brain tissue, people with mental health issues are viewed as flawed, not sick.  This thought process is insidious and can destroy a relationship from the inside out before it is even recognized for what it is . . . an unconscious (and societally sanctioned) view that someone with mental health issues is flawed and unacceptable. People with mental health issues typically end up isolated from others and on their own.  You’ve heard the statistics about the percentage of homeless people who have mental health issues.

How many of you out there have friends or relatives who’s relationships broke up because one of the partners got severely depressed, anxious or otherwise incapacitated due to a mental health issue?  I see it all the time in my practice.

Now, how many of you have friends or relatives whose relationship broke up because . . . one of the partners got cancer . . . or had a heart attack . . . or a stroke . . .

Not so many, huh?

What would you think if Mark Kelly turned and walked away from his wife because it was “just too hard to deal with”.

What would you think of a man who left his wife because she got breast cancer and he “couldn’t deal with it”.

What would you think of a wife who left her husband because he couldn’t work and provide for the family because of a severe back injury?

I have been blessed to have a number of couples in my practice who have held together despite one of them having severe mental health issues.  In their interactions, I see shades of Mark Kelly.  They are pushing their spouses to be their best, but are understanding of their spouses’ struggles and limitations.  They don’t lose track of where the relationship was . . . and view themselves as partners going forward into an uncertain future . . . and hoping for the best.  They struggle.  They have their good days and their bad days . . . good weeks and bad weeks . . . but they hang in there.  Many benefit from their own treatment, since the rate of depression in spouses with mental health issues is quite high.

But what could help them the most is an outpouring of understanding from those around them.  If you had a relative battling a serious medical illness, you would make an extra phone call.  Send over a casserole.  Write an encouraging letter.  Drop by and say “hi”.  If you know someone who is struggling with mental health issues, reach out and let them know that they are not alone.  That someone out there loves them and values them.  That somebody cares.  In this age of enlightenment about the root causes of psychiatric conditions, it’s time we start acting enlightened.  It’s time to stop looking the other way.  It’s time to stop soothing our discomfort with mental health issues with sarcastic jokes and comments. It’s time to be kind to those around us who have nervous system dysfunction that manifests as changes in mood or behavior.

–Dan Hartman, MD

Can you ride it out?

Who knows . . . It is kind of like getting on a roller coaster and not knowing where it is taking you.  And your doc doesn’t know either.  At the same time, you might be able to get by with less medicine, but you gotta take it slow.  Going slow will help minimize the risk of withdrawal/discontinuation symptoms . . . but it doesn’t mean that you are going to be stable off the meds.  Here are some other thoughts about what can help . . .

1.  Make sure you have people around you that you trust and that can flag you if things start going poorly.  Write yourself a note that tells you to listen to a friend . . . and give it to that trusted friend.  When that friend starts to think you are going off the deep end, they have to tell you so and give you the note so YOU tell YOU so.  Hopefully you will believe yourself if not a close and trusted friend.

2.  Make sure you have a good line of communication with your psychiatrist.  You might even sign a release that allows a trusted family member or friend to communicate with the doc.  That way, even if you pull away from the doc, your friend will step in and communicate.

3.  Take care of yourself . . . eat enough . . . sleep enough . . . meditate and pray enough . . . go have some fun . . .

4.  Take your vitamins.  Specifically Fish Oil (you should be taking 1000 mg of DHA–read your fish oil labels!!!) and Vitamin D

–Dan Hartman, MD ]]> http://www.thesidewalkpsychiatrist.com/is-it-worth-it-to-stop-your-medicine-only-time-will-tell/feed/ 0 http://www.thesidewalkpsychiatrist.com/maintenance-treatment-for-depression-medicine-tms-whatever-works/ http://www.thesidewalkpsychiatrist.com/maintenance-treatment-for-depression-medicine-tms-whatever-works/#comments Sun, 30 Oct 2011 14:27:41 +0000 doctordan http://www.thesidewalkpsychiatrist.com/?p=529 I had to field a call the other day from a local Children and Youth worker.  Nice lady . . . but not terribly informed about mental health issues . . . specifically Major Depression.  She was calling about a patient of mine who is trying to get custody of her grandchild after the child’s . . . → Read More: Maintenance Treatment For Depression . . . Medicine . . . TMS . . . Whatever Works]]> I had to field a call the other day from a local Children and Youth worker.  Nice lady . . . but not terribly informed about mental health issues . . . specifically Major Depression.  She was calling about a patient of mine who is trying to get custody of her grandchild after the child’s mom essentially abandoned him.  The kid was in a temporary group home awaiting clearance to go to live with his grandmother (my patient).  I can understand her lack of knowledge.  C+Y workers do good work but are not necessarily trained in mental health issues.  My gripe is that when my patient had her clearance interview with the C+Y psychologist (who I assume is trained in mental health issues), she was given a hard time about being on antidepressants for such a long time.  She was a bit rude about it with my patient as well.  When the C+Y worker called, she, too, questioned why someone would need to be on antidepressants for years at a time.

I don’t mind being questioned . . . but these people sound like they never met someone with chronic, recurrent depression before.  Like people only get depressed once in a lifetime!!!

Oh, if only my work . . . and my patient’s lives . . . were so easy.

Everyone who has an episode of Major Depression who gets better (regardless of why they got better) has an elevated risk of having another episode of Major Depression.  When a patient goes through several cycles of getting depressed and then better . . .  getting depressed and then better . . . getting depressed and then better . . . we start to think that maintenance treatment is necessary to maintain health.

So what is maintenance treatment.

Typically, when patients get better on an antidepressant they find that a moderate dose of that antidepressant can help them stay in that good place.  It is not unusual for the dose of medicine that KEEPS you better to be lower than the dose needed to GET you better.  So, for example, if you get “un-depressed” with 150 mg of Zoloft, a maintenance dose of 100 or 50 mg might be all you need to keep the Depression Demon away.  Each case is different, of course, with it’s own collage of complexities. Generally speaking, we stick with what works for patients who need maintenance treatment.

This is true for patients who need more intensive interventions to get better.  It has been known for years that certain patients only respond to ECT (shock treatments).  Those patients will sometimes only STAY better if they get maintenance ECT treatments . . . once a month, for example.  Those of us using TMS (Transcranial Magnetic Stimulation) to treat Major Depression are still working out the process of providing maintenance treatments. There are clear indications that  it can work very effectively for some patients.  The biggest advantage of using TMS to keep the Depression Demons away is the lack of side effects.

Bottom line is . . .  we gotta do whatever works.  The advantages of maintenance treatment far outweigh to disadvantages to those who’s lives are impacted by symptoms of recurrent Major Depression.  Be it medicine or TMS . . . you gotta do what you gotta do.

–Dan Hartman, MD

From a practical standpoint, however, we on the front lines of mental health treatment have to deal with this in a productive way.  So what are our options . . .

1.  As faithful blog readers may remember, Adderall is a dexedrine based product.  Switching to another dexedrine based product is a reasonable step.  Your two options are:  a) the long acting brand-only Vyvanse, or b) the short acting immediate release dexedrine.  Why these two products (similar in composition to Adderall) are still available is beyond me, but so far I have heard of no shortages.  I have written about Vyvanse before, so you know it is a medicine that I favor.  But , being brand-only, it can be more expensive on your co-pay, and is certainly much more expensive than generic Adderall for the insurance company to pay for.  Short acting dexedrine is more typically used as a “booster” in the afternoon for when kids or adults are coming down off their Adderall-XR.  It can extend the benefits for focus and concentration and still be out by bedtime for sleep.  Dexedrine taken in the morning, however, will be out by noon, and will require a booster of more dexedrine at lunch time in school . . . and then again in the afternoon . . . kind of like 1993 before the advent of long acting stimulant agents.  Remember the long lines at the school nurse’s office at lunchtime . . . ???  I wonder if we are heading back in that direction for a while!!!

Since all these products are based on the same raw materials, I wonder how long it will be before there is a shortage of these products as well.  Thats why it may make more sense to consider . . .

2)  Switch to a Ritalin based product.  Methylphenidate (aka Ritalin), is “the other stimulant”.  So far, I have not heard of shortages of any Ritalin-based product from patients in my practice, but there are rumblings out there in the press.  Since most kids will do well with any stimulant product, it is typically not a big deal to switch.  It does require that adjustment period where the correct dose is determined.  That can be a process that takes weeks or months to determine, although there are ways to shorten it (see below).  Products based on methylphenidate include Concerta, Metadate, Ritalin-LA, Daytrana patch, and Focalin.  Some are generic . . . some brand only.  While there is no absolute conversion between a dexedrine based product and a methylphenidate based product, it is understood that dexedrine is more potent and you need numerically more mg’s of methylphenidate to get the same benefit as you get with a dexedrine based product.  The long-release products make the titration a bit more tricky, but nothing beyond abilities of the average shrink.

3)  Strattera.  Rarely my first or second choice . . . hence it comes in as #3 here.  Strattera is great when it works . . . but just does not work as often as the stimulants.  The typical trial of Strattera can take 4-6 weeks . . . valuable weeks at this stage of the academic year.  For some, though, it may be the best next step. Especially if previous trials of stimulants have not been well tolerated.

4)  Homeopathic or natural remedies.  Ok, this is where I go out on a limb . . . but not too far.  I have seen reports and have spoken to one . . . (1) . . . parent who’s child got much better on a homeopathic remedy.  I am sure there is much more information out there than I am aware of.  Like most psychiatrists out there, I have been, a student of standard western medicine.  But I have been as frustrated as many of you at the side effects and difficulties associated with many of the standard medicines for ADHD.  That, and the recent shortage of Adderall, has me investigating some options.  I will give no opinions at present because I don’t know enough . . . but stay tuned!!!

The other point I will throw out there is the availability of the Quotient ADHD testing system to accurately test for the core symptoms of ADHD.  I have spoken about this before, and there is plenty of info on my website about it, so if you are unfamiliar . . . go take a look.  What the Quotient has to offer is a rapid assessment of the benefits of an intervention for ADHD.  Whether someone is switching to another stimulant, to Strattera, or to a natural remedy, use of the Quotient allows for objective documentation of the intervention’s benefits quickly and accurately.  This can help prevent the real danger inherent in medication switches–months of academic down-time while the new intervention is tried.  Like I’ve said before . . . childhood is short.  You don’t want a child under-treated for their ADHD because of the potential risk of academic difficulties, self-esteem loss and anxiety.

Aaaaaaaahhhhhhhhhhh . . . . . . You all out there remember being a kid?

This is the story of two of my patients.  One of them I have seen for most of his life.  One, for just over a year.

I started seeing Mike when he was six years old or so.  Brought in by his mother, he was having all the classic problems that a child with ADHD has.  He was inattentive and distracted.  He was disorganized and was losing things.  He couldn’t sit still and would get in trouble for talking and playing when he was supposed to be sitting still and doing his work.  He was described as “lazy” when, in reality, that “lazy” was the standard disengaged and distracted “ain’t too interested in doing something I can’t pay attention to” thing we here in mental health land can easily diagnose as Attention Deficit Hyperactivity Disorder.  Mike was started on stimulant medicine and did great.  Over the years, he would come to see me every two or three months.  Medicine would be tweaked to ensure adequate coverage of his symptoms.  The occasional typical adolescent issues would surface and recede, but, by and large, he did very well.  He applied to colleges and got in, and has gone on to successfully complete a rigorous academic program in the field of his choosing.  Throughout the years, he would continue to come in and see me . . . and I would continue to provide treatment for him.  And he has been successful.

Paul is relatively new to me as a patient.  He was the sort of “getting by ok” student that often runs under the radar.  His tendency toward inattention and difficulty with task completion was evident for years, but he always did “well enough”.  Well enough, anyway, to avoid seeking treatment.  But the standard comments of his being “a bit lazy” and “not living up to his potential” were always there and always haunting him, contributing to his sense of not-being-good-enough.  Still, he did do well-enough to get by, and he, too, went to college.  But that is where he hit the brick wall.  Even though he was intellectually capable of performing adequately in college, the pace of the work was too much.  Old insecurities from years of struggling to succeed surfaced as his performance lagged and his grades plummeted.  Eventually his mood symptoms reached the point of Major Depression.  He had to return home and seek a medical withdrawal and . . . finally . . . ended up seeking treatment.  Initial treatments for his mood disorder were not well tolerated.  It was only after an astute colleague suggested that we send him for a Quotient-ADHD test that we stumbled upon the root of the problem.  Paul, after all these years of struggle and failure, was diagnosed with Attention Deficit Hyperactivity Disorder.  With this information in hand, appropriate medication and therapy interventions were developed . . . and Paul has thrived.

He is now taking a full roster of classes at the local community college (and getting all “A’s”) and getting ready to apply to local 4-year colleges.  He can attend to the tasks necessary to make this successful and can utilize his strong work ethic to work independently and proactively in his classes.  And he has no symptoms of a mood disorder . . . without the need for antidepressant medicines.

These two cases bring so many thoughts and questions to mind . . .

How would Mike have faired if he had not started in treatment at an early age . . . and how would Paul have done if he had?

How would Paul be today if he had not serendipitously come to my practice for treatment.  What if he had not had the benefit of the Quotient-ADHD testing system that can look below the presenting mood symptoms for those core neuropsychiatric symptoms of ADHD.  Would he still be muddling through with unpleasant trials of antidepressants?

What if ? . . . . What if? . . .  What if?????

These two scenarios highlight the importance of early diagnosis and treatment for ADHD.  Both of these young men are fortunate to have had their conditions identified and treated.  So many others are not so fortunate.  So many others suffer needlessly.  Untreated ADHD increases the risk that a child or adult will experience clinically significant Major Depression, anxiety and substance abuse issues.  Untreated ADHD increases the chances that you and your child’s life will be one of unfulfilled dreams.

If you have any suspicion that you or your child (or some other family member) might have ADHD symptoms . . . get them tested . . . and get them treated.  Assuming that “it will all work out ok” without intervention is taking a needless chance with someone’s life and future happiness.

It is a far, far better thing that I do, than I have ever done; it is a far, far better rest that I go to, than I have ever known.

–Dan Hartman, MD