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

In a blue collar neighborhood that is so good at bustin’ people’s chops, he has opened the conversation about mental illness.  About Depression.  About Suicide.  The trifecta that he has struggled with for many years. And the neighborhood has rallied to his support.

He has been a vigorous fund raiser for the American Foundation for Suicide Prevention (AFSP), a national organization dedicated to educating the professional and non-professional public on issues related to Depression and suicide. They provide funding for scientific research, information for those who are struggling . . . and support for families left behind by suicide.

This past week, he and his family and friends participated and the annual “Out Of The Darkness” walk to raise money for AFSP, and last night held a spaghetti dinner fundraiser in a local church.  I was honored to attend this dinner and to have a chance to learn more about him and to see him in action.  I am moved and inspired by the work that regular folks do to make a difference about big issues.  Twenty years ago, there would be no mention about this subject.  It has always been true that everyone knows someone who has died by suicide.  Now, instead of looking the other way, we are being encouraged by brave souls like him . . .  to Look . . . to Talk . . . to Act . . . and ultimately . . . to Help.

At home later last night, my daughter suggested I look at the website for “To Write Love On Her Arms”, the way-more-cooler site that brings this message to a younger generation. And challenges them to look within . . .

What’s your biggest fear?

What’s your greatest dream?

The answers matter.

You matter.

I am passing along that challenge.

Look within.  Reflect on the story that you’re living.  Share your story.  Share your time.  Share your talents. Share your life.  Take a chance.  Make a difference.

–Dan Hartman, MD

PS:  Take a look at the websites for these organizations:

www.twloha.com

and

www.afsp.org

Kelly–I, too, have a problem with overly judgmental “I Know Who You Are And What Your Problem Is” type of docs.  None of the medicines I prescribe (including Klonopin) is a “bad” medicine.  The people who benefit from the medicines are not “bad” people.  They are people who have a problem that need our professional help.  The attitude that you experienced is not unusual, unfortunately.  Your issue with anxiety is an issue with anxiety.  One option is to confront the docs who appear to be making these judgments about you.  You could ask them if they understand anxiety.  If they have ever used Klonopin successfully to treat someone with anxiety.  If they have not, they are not the docs that should be in control of your prescriptions.  Assuming that you MUST be weaned off the Klonopin is not necessarily a clinical decision regarding the treatment of your anxiety.  It might be a judgment of the Klonopin as “bad” and something that MUST be removed.  I am concerned that you have not faired well with previous tapers.  The past does tend to predict the future, and unless there is something dramatically different with you or your life circumstance, the likelihood is that you will become anxious again as the Klonopin is withdrawn.  It doesn’t mean you are an addict.  It doesn’t mean you are bad.  It doesn’t mean that you have a “problem” with prescription medicine.  It means that you are an anxious person.

There is (obviously) nothing about being on Klonopin that prevents you from doing your job.  Being overly anxious might.  I would think long and hard before consenting to an unwanted decrease in the medicine that has been consistently helpful for you.  I would have as long and in depth a conversation as you can with your (probably overworked) psychiatrist about weaning you off the Klonopin.  You sound like a knowledgable person who knows yourself.  If your doc feels strongly about his clinical opinion, he should be able to convince you of it.  If he is unable to convince you of his opinion, then either you are unreasonable . . . or his opinion is wrong for you. It doesn’t mean that either of you is wrong or bad.   If your needs and expectations don’t jive with your doc’s . . . get a new doc.

Dan Hartman, MD

So sorry for the hiatus . . . and this entry is not a promise of more to come.  But I’m hopeful.  I been big-time busy over the last year or so.  Lots of challenges in the work sector . . . lots of challenges on the home front . . . life is just busy and full of surprises.  So what has finally got me back to the keyboard?  Being wrong.  As in mis-diagnosing a few people.  Now, I’m not confessing that I’m not a good doc.  I am.  But no matter how good you are, you always get pulled one way in a complicated case when you should go the other way.  The ambiguity of psychiatric diagnosis does not make anything easy.  Especially when there is a complicated mish-mosh of symptoms that easily fit into more than one diagnostic category.  And, you ARE allowed to have more than one psychiatric diagnosis.  But how can I be sure that a child who presents with ADHD symptoms . . . and anxiety, and depression, and a complicated home life, and a complicated school picture . . . actually has ADHD and that the “ADHD symptoms” are not just a result of the other stuff?????

One of the things that has kept me super busy is trying to integrate a new diagnostic system into my practice.  The Quotient ADHD Testing System is not exactly new (been around for a few years), but it is relatively new in my practice area.  It is the newest generation of CPT (continuous performance test) that have been used for years to aid in the diagnosis of ADHD.  Years ago I used the TOVA test.  It was quite innovative at the time, but, computers being what they were 15 years ago, you ended up with a long and complicated report that was difficult to interpret and difficult for parents to understand.  The Quotient test uses the same sort of technology . . . PLUS.  The PLUS here is the innovative inclusion of motion detection that allows for a highly accurate reading of physical head movement.  Using that data along with the visual response data allows for a highly accurate read on what someone’s pattern of ADHD symptoms are like.

But for me, the most exciting . . . and scary . . . part of including this system into my practice has been identifying those patients who I thought had ADHD . . . but have “normal” range Quotient tests.  This is a problem.  The Quotient test can, with no other information, predict with about 80% accuracy if a patient has an ADHD spectrum issue.  For those of you who slept through statistics class, that is called the “positive predictive value”, or PPV.  Having a PPV of 80% is really good for a psychological test.  Especially one that can be given in 15-20 minutes.  There are a lot of reasons why someone can LOOK like they have ADHD when they do not (hence, the risk of misdiagnosis). More importantly for today’s lesson, however, is the  ”negative predictive value” or NPV.  This is the likelihood that a NEGATIVE test (ie, one that does not show the characteristics of ADHD . . . a ‘normal’ test) accurately predicts that someone does not have an ADHD diagnosis.  The NPV of the Quotient test is 95%.  That is extraordinarily high.  That means if I take a kid off the street and give him a Quotient test and it comes up in the normal range, I can say (with no other info available) that I am 95% certain that that person does not have ADHD.  Be impressed.  In the world of psychometrics, that is almost unheard of.

So, what does that have to do with anything . . .

Suddenly, I am running the Quotient test on my patients and finding that some of them who I have been treating as ADHD for some time fall in the non-ADHD response pattern on the test.  YIKES??????  These kids have been on a wide variety of medicine . . . Adderall, Concerta, Vyvanse, Ritalin, etc.  Now all you out there know that I don’t think that any of these medicines are evil or bad.  They are a great tool to address a difficult problem.  But, what if I got the problem wrong?  What if something other than ADHD is going on?  This means that I have to dig deeper into these kid’s lives and look for other issues.  In some of these kids the issues are obvious, and treating what looked like ADHD was a simple part of a complicated treatment regimen.  For some, the answer is a bit more obscure.  I got some work to do.  But, thanks to the Quotient ADHD Testing System, I can, with reasonable confidence, allow them to avoid exposure to stimulant medicine and help them get to the core of their issues with focus and concentration.  Without the fall-back of an ADHD diagnosis (and ADHD medicine), both kids and parents must confront those other issues that are driving the inability to focus/concentrate and inhibit impulsive actions.  Double YIKES!!

So far, I have picked up quite a few kids that have been on stimulant medicine for years and have been able to taper them off their stimulants.  A few have gone back on because they began to do so poorly.  I have to work with them to try to figure out why the stimulants are so important to their overall success.  I will be trying to get these kids off stimulants in the future.  Most have been able to get off their stimulants and have done ok.  I have some stories that I will be sharing on this site in future entries.  Stay tuned . . . I’ll be right back!!

For more information on the Quotient ADHD Testing System, you can go to my website (www.philmontguidance.com)  and take a look at the video (I was on TV!!!).  You can also go to the Quotient website for more information.

www.biobdx.com/

–Dan Hartman, MD

PS:  Glad to be back

This hasn’t been easy for you, has it?  I think the root of the problem is not WHICH medicine you take, but WHICH doctor you see.  I don’t get from any of your comments the sense that you feel good about anyone that you have seen lately.  I don’t hear that they are inspiring confidence.  Above all, your doc should inspire confidence.  After all, this doc is going to be messing with your brain chemistry . . . better feel ok about them as a person and as a doctor!!!  You have been to three doctors lately and have gotten three different opinions . . . I’m not surprised.  The good news is that there is no such thing as a “good” medicine or a “bad” medicine.  Switching medicines can make a big difference, even when there is no good reason for it.  One medicine that inhibits serotonin re-uptake is as good as another . . . why would switching work?  No good reason . . . but it does.

It sounds like you have been through the mill with the medicine and, now, with doctors.  I can give you some quick thoughts about the meds you are on and the process of transition.  Effexor is not my favorite medicine . . . but it is a good medicine.  I have many people who have had great success with it and swear by it.  Side-effect wise, it is generally well tolerated.  The biggest problem with it is the high rate of discontinuation syndrome felt by patients who try to go off it.  This uncomfortable mix of physical symptoms is sometimes felt by Effexor-takers when they miss a single dose by as little as a few hours.  Going off it by taking that high a dose every other day and then stopping is likely to make you feel quite uncomfortable.  Interesting, the ‘antidote’ to Effexor related discontinuation syndrome is . . . Prozac!!!  I would not take you off both meds quite this fast, however, because of how long you have been on the medicine.  If someone has been on antidepressants for years, I will opt for a very slow taper down on the medicine.  Sometimes, this taper will take months.  Unless there is an specific reason to move more quickly, I have found it to be less uncomfortable for the patient, and less likely to be associated with a return of underlying psychiatric issues. So, assuming that you wanted to get off the Effexor, I might make a quick switch over to Prozac, and then make a multi-month taper of the Prozac.

Regarding you benzos, I am certainly more of a fan of Klonopin than I am of Xanax.  In making the switch, I typically keep the Xanax dose close to the original dose and add the Klonopin in.  The patient can then skip doses of the Xanax as they are able.  Most find that they don’t feel the “need” to take the Xanax almost as soon as the Klonopin is started.  The trick is to not get sucked into the feeling that you “need” them both.  The point of the Klonopin is to eliminate the need for the Xanax whenever possible.  Sometimes, both are needed and are beneficial.

Now, the Seroquel/trazedone . . . it really depends what the Seroquel was for.  If it was for mood stabilization or to enhance the benefit from the antidepressant, switching over to the trazedone might not do as well for you.  If it is strictly for sleep, then switching over to the trazedone might be good.  Trazedone tends to cause less daytime sedation than the seroquel.  If it turns out the Seroquel WAS helpful for your mood, you might not do as well without it.

I am not hearing anything particularly scary with the changes that have been outlined by your new psychiatrist.  My biggest concern would be the number of changes going on.  Whenever possible, I try to keep the number of changes down to a minimum.  One or two at most, avoiding three or more changes unless there is a very specific reason to do so.  If all these changes are made quickly, it will be impossible to know what caused what if you start to do poorly.  Perhaps a conversation with your new doc about slowing down that pace of the changes is in order.

It is important to remember that, just because they have difficulty with a medicine, they are NOT bad people.  The spin on benzos is that they are BAD and people on them are BAD.  It is like alcohol and narcotic pain meds.  The drugs are not bad . . . the people are not bad . . . but there are clearly some people who should not drink and there are some who should not take pain meds or benzos. Some people’s biology leads them to be especially prone to anxiety and also prone to the development of tolerance.  Since the subjective experience of fear . . . panic . . . is intolerable to us all, the drive to take more of what did stop it in the past is huge.  Depression feeds panic and panic feeds depression.  The rate of suicide in patients with both is tremendously high.  Severe, unbridled anxiety MUST be aggressively addressed and managed.  That said, there are clearly patients who should not be put on benzodiazepines.  It is difficult to spot them until they start their pattern of misuse of the medicine . . . but once spotted, they need to be detoxed and not given another chance to be on the medicines without the presence of carefully crafted supports and checks on misuse.

It is painful for me to watch someone who clearly needs and benefits from judicious use of benzos continually refuse to take them as prescribed.  I had a wonderful lady recently who decided that she was going into rehab to stop using the Ativan that I had been prescribing and the alcohol she had been drinking (. . .that I didn’t know she was drinking . . . not a lot, but still a big no-no).  She got out of rehab a nervous anxious mess.  Off the benzos and alcohol (yipeee!!!), but a nervous, anxious and non-functional mess.  Not what I would call an improvement.  She has had an excellent track record of doing all the right things.  She goes to therapy, works to keep her stress level down as best as she can, has been stable on a solid dose of an SSRI . . . but is still an anxious mess.  Having failed all standard and non-standard pharmaceutical interventions for anxiety, I did the obvious.  I put her back on the dose of Ativan that has worked for her in the past.  With a very modest dose of the meds (Ativan 0.5-1 mg 3x daily) she does GREAT.  As long as she doesn’t beat herself up about it.

It concerns me that certain classes of psychiatric medicine and the people who take them get demonized and judged.  What does that say about us as a people and as a society?

–Dan Hartman, MD