Add it to the Drinking Water

So Roy sent me the link, but he couldn't post it?
Mind Hacks tells us that where there are higher levels of naturally occurring lithium levels, the suicide rate is lower. Referring to a study in the British Journal of Psychiatry, Mind Hacks states:

"This new study suggests that even trace amounts might have an influence on the whole population level, and this is not the first time this link has been made."

What do you say, should it be pumped in?

Here's When You Need A Psychiatrist

Have we written this one yet? I seem to think that Roy, our Consultation-Liason Boy, may have done this.

This is just my opinion, it's written with the non-shrink doc in mind, and it assumes access to psychiatric care:

So when should a patient be referred to a psychiatrist for care?

• When their distress due to psychiatric illness is such that they can't contain it and are driving the primary care doc nuts.
• Any patient with the new onset of a psychotic illness should initially be stabilized by a psychiatrist (this is just my opinion) if they are willing to go. Psychotic illness: any illness accompanied by hallucinations and/or delusions. Psychosis is frequently seen in Schizophrenia and Bipolar Disorder, but can also be seen with depression, delirium, and a host of other non-psychiatric illnesses. If the patient's hallucinations are caused by a brain tumor and they resolve with removal of the brain tumor, then the psychiatrist may not be necessary. Maybe Roy can write us a "causes of psychosis" post.
• For depression: my conservative rule would be to refer after the patient fails one antidepressant medication given at a therapeutic dose for long enough. What's a therapeutic dose: I go as high as a) the patient will tolerate or b) to the highest recommended dose (which ever comes first). If a patient can't tolerate more than 50mg of zoloft, well, this isn't a full trial. Switch to another med and try to get the patient up to a full dose. Wait AT LEAST four weeks (the mantra is 3 to 6 weeks) on a good dose. It's not uncommon to get a patient who has been on small doses of many anti-depressants, none for very long. And primary care docs aren't the best at augmentation strategies.
• Any patient with Bipolar Disorder needs a psychiatrist to stabilize them, and a psychiatrist available for management of episodes. If someone has been stable on Lithium for the past 8 years, they don't need a psychiatrist to prescribe it.
• When prescribing that first antidepressant, ask every patient with depression if they've had a manic episode: "Have ever had a time when your mood was too good, when you had excessive energy and needed less sleep, when you talked faster than usual, your thoughts raced, you were more impulsive than usual with regard to spending or sex?" Anyone who doesn't look at you like you're nuts for asking this needs to be questioned in more detail about manic episodes. If the patient has a history of even one manic episode, you're dealing with Bipolar Depression and prescribing antidepressants could be very risky-- not a bad time to refer.
• Don't prescribe Xanax for a chronic anxiety disorder. It's hard to treat patients who get dependent on xanax and it's hard to refer them if they end up on high doses.
• Any patient with a recent serious suicide attempt or recent psychiatric hospitalizations should be stabilized by a psychiatrist.
• Any patient with any psychiatric disorder that is compromising their ability to function, who does not improve after two to three months of treatment, should be referred for psychiatric care-- so OCD or Panic Disorder that is not getting better quickly.
• If a psychiatric disorder puts anyone's life at risk, it's probably more than a primary care doc wants to or should deal with.
• Any patient who is being treated by a primary care doc for a psychiatric illness should be asked if they want to see a psychotherapist (a shrink or a psychologist or a social worker or a nurse therapist). The patient may say that the pills have cured their depression and they don't need to talk. In the absence of information, this should be respected. But the gentle offer of a psychotherapy referral should be made early.

Sorry, a little haphazard, maybe Roy can come in and add an addendum....

And Now a Word or Two about Mood Stabilizers

I came to talk about mood stabilizers and figured I'd start by summarizing our sidebar poll "What is Your Favorite Mood Stabilizer?" Only every time I come on, the poll has gotten more votes, so I guess I'm waiting for the mood stabilizer poll to stabilize.

Here's where we're at so far:

What's Your Favorite Mood Stabilizer?

Lithium	32 (22%)
Depakote (Valproate)	27 (19%)
Zyprexa (Olanzapine)/ other atypical anti-psychotics	29 (20%)
Carbamazepine (Tegretol)	1 (0%)
Gabapentin (Neurontin)	9 (6%)
Lamotrigine (Lamictal)	44 (30%)

143 votes, Lamictal has been consistently in the lead since the beginning. Both surprising and not surprising.

I talked about How A Shrink Chooses an Antidepressant. I have less to say about how a Shrink Chooses a Mood Stabilizer. In fact, I'm not really sure. I'll tell you how This shrink chooses a mood stabilizer. It's not that much different, so click on the that post for more details.

• History of Past Response.
• Family History of Response
• Patient Preference. This is a big one with mood stabilizers. The gold standard is Lithium and some patients just won't hear of it. They think taking lithium means they're really far gone, that it's heavy duty stuff, that it means they're crazy.
• Medical issues: lots of them with mood stabilizers.... lithium can effect the thyroid and kidneys, it interacts with lots of other meds, depakote can effect the liver, so can tegretol, lots to think about, lots to monitor.
• How strongly I'm convinced that the patient has had a full blown manic episode. Plenty of people say "I'm Bipolar" but the history doesn't reveal a story for episodic, syndromic co-occurance of the hallmark symptoms of mania: elevation in mood or irritability, increased energy/ decreased need for sleep, quickening of thoughts or speech, impulsivity with regard to spending, sexuality, religion, hallucinations, grandiose delusions, inflated sense of worth or well-being. None of these symptoms alone are enough to diagnose mania, ya gotta have a few and they have to occur at the same time as the other symptoms. Lots of people shop impulsively to cheer themselves up, lots of people have periods where they feel more energetic and productive, lots of people get happy when they win the lottery. It's sometimes hard to get a history for a syndromic diversion from a baseline (or pre-morbid) personality.
• If I think someone definitely has bipolar disorder, and there isn't a reason not to use it, I start with Lithium. It's a good mood stabilizer. It's cheap. I'm familiar with how to use it. It's also a good anti-depressant augmenter. Despite all the hype about the awful side effects (weight gain, nausea, tremor, cognitive slowing, renal and thyroid impairment), I've seen lots of people have good responses and not have any side effects, so I start with that assumption and I use low doses. If the patient gets better, I don't push the level, even if it's really low. If the patient has intolerable side effects, I try another preparation of lithium (eskalith, lithobid), and if that doesn't work, I stop it and try another med. Why do I like lithium? I think because I've heard enough people put up resistance, then try it and come in saying "I feel normal for the first time." The down side is that you have to do bloodwork every 3-4 months even if the patient is well and has no symptoms.
• If I'm not so sure about the manic component as a real, syndromic entity, and the primary complaint is depression, I start with Lamictal. The upside-- it's well tolerated, people like it, there's no routine labwork and there's no stigma. The down side-- slow going to build up from a dose of 25mg to the therapeutic range of around 400mg. Another down side-- that fatal rash risk. And the final down side-- I've heard a couple of anecdotes of patients who have ended up in the ICU with rashes, liver zorkout, life-threatening problems. Not a lot, but it only takes one such story to make you hold your breath when you write a prescription and I have a friend who says "I'll never be able to prescribe Lamictal again." It's not science. I actually tell patients this story-from-hell when I prescribe it, and they'll still take it over lithium. Mostly, it's a good medication, it's well tolerated, and it helps.
• If a patient doesn't want Lithium, I prescribe depakote. It's associates with it's own issues, including weight gain, needs lab monitoring, and if the patient doesn't have insurance, it's expensive and hard to get samples of.
• I haven't prescribed tegretol in ages and I wondered if the reason it's so unpopular on our sidebar is because it isn't used so much.
• I prescribe anti-psychotic medications to people who are agitated, acutely suffering, not sleeping, in need of something quicker than lithium/depakote/ or lamictal. These medications work, they're well-tolerated, patients like them. And I worry about the metabolic effects and wish there was some free ride.
  
• Sometimes I use one of the older anti-psychotic-- navane may be my favorite
  
• If there is no history of substance abuse (---hmmm, that's rare in people with bipolar disorder), I may prescribe some ativan or klonopin for the short term.
• I haven't used Trileptal, I don't know why. I have a patient or two on Neurontin, I stopped prescribing it when studies showed it didn't help with mood stabilization. Perhaps I was wrong. And I haven't seen very many people tolerate Topamax, though I have seen it work wonders for migraines.
  
• Lithium is my favorite.

Okay-- I know there are lots of people out there who've had bad experiences with lithium. I'm not advocating that anyone re-try a medication they didn't tolerate. I'm just suggesting that everyone responds differently and before the medication is prescribed, your doc doesn't have any way of knowing if you will have problems or be one of those people who has a wonderful response and no side effects.

And to one of our anonymous commenters who wrote in:

Anonymous said...

I hope you have a really great reason for purposely for gathering useless data.

Yes, anonymous, I had a really great reason: I was curious, wondered if I'd learn something (and I did) and I thought I'd use the information for a blog post. Rest assured, I have indeed gathered completely useless and out of context data. It still makes me happy when my useless information is quoted by the Wall Street Journal.

Pill Line

[Posted by ClinkShrink]

Happy Birthday, Siggie!

I found a pertinent Freud quote in honor of the day, particularly relevant to correctional work:

The first human who hurled an insult instead of a stone was the founder of civilization.

And now for something completely different....

Imagine working in a hospital where the patients change rooms every night and your unit gets 350 new admissions every day. Imagine dispensing medication to hundreds of inmates who come to your pharmacy twice a day to pick up their psych meds. I think of medication times (or "pill line" in correctional idiom) as a kind of March of the Penguins for prisoners. When people wonder why inmates don't always get their medications, I can tell you that some inmates decide they just don't want to face the daily migration. Sometimes they don't want to get up out of bed, or they don't want to take the chance of missing commissary or they have a visit scheduled. Maybe they are afraid of being ridiculed by other inmates. Maybe it's raining out and they don't want to cross the recreation yard. Maybe they are afraid of having confrontations with other inmates during the hour-long wait in line. More likely, the medications work so gradually and the effects are so subtle that they think treatment simply "isn't worth the hassle".

When I read about the effort required to persuade patients to take Lithium my first thought was, "That's so true!". But in addition to dealing with medication side effects, I also have to convince them that going down to get the medication is worth it. Fortunately, I have some research on my side. In the early days of lithium research the first research subjects were prisoners with a history of violence. Lithium was found to cut the rate of infractions in half. This is a strong selling point for my patients---"take your medicine because it's a good way to stay out of trouble."

Peace and Lithium

It was a hard winter. It started even before that, perhaps in October, right before I left to work in Baton Rouge-- one patient had a serious suicide attempt, several were in crisis, even the patients who were fine were having trouble getting out the door at the end of the sessions. "Treatment-Resistant Depression" had become one of my favorite terms, but there were also a few people with mania and psychosis who were having a tough time. So it continued through the winter-- one patient called at least 10 times a day (I finally told her to stop; this improved the quality of my mental health remarkably), another e-mailed, up to 4 times a day, patients called-- or worse, their relatives called-- they cried, sometimes they even sobbed.

I mentioned it to a few colleagues and they all had the same response: My practice, too! One friend told me her emergency phone line usually gets 2 calls a month, now she was getting 3 a day, including calls from a patient on another continent, all while she'd taken on 3 news patients that week and her husband was out-of-town, leaving her with their 2 young children to negotiate. She beat me out for the Most Suffering Psychiatrist award and I brought her chocolate. Something in the air? Yet one more effect of Global Warming?

I felt discouraged, overwhelmed, and I wondered for the first time if I really loved psychiatry as much as I thought. One friend, a bit more seasoned than I, expressed surprise that it took me this long (I've been in practice since 1992), another wrote, "I wonder why I ever thought sitting with troubled people would make for an interesting career." I quoted her often. Was something different about my world, I wondered, or was I just perceiving everything differently-- after all, I am a psychiatrist, I do work with troubled people, at any given time someone out there is in crisis, maybe I was more sensitive, maybe it wasn't Global Warming.

In March, I went to an all-day seminar on Bipolar Disorder. Ross Baldessarini talked about the wonders of lithium. I've used it a fair amount to as an augmenting agent, but more recently, I think I'd forgotten about it, or given in too easily to patient's initial refusals. I started to re-think all my troubled people, ah, I gave more of them lithium. It's definitely helped a few, including one of my more distressed patients who had been refusing it for months before.

Things are quieter now; I'm not sure if it's Springtime, the longer days, the alignment of the moon, or more lithium.

Lithium is a hard sell. To listen to the experts, you just start people on it. I've found it takes at least 3 separate discussions to get someone to try it. In the last weeks, one patient called me in tears insisting I'd made her so much worse just by suggesting she take lithium, another man started shaking and said, "Doc, you're making me really nervous." Lithium has gotten a bad rap over time, and for some reason it's so much easier to get folks to try anti-psychotics. "It's an element, natural, just a salt" has gotten me nowhere. In a few cases, I've resorted to asking patients to take one pill, just one pill, and call me right after they've swallowed it. The first dose is the hardest, or so it seems. I have to promise I'll let them stop if they have side effects (or as I sometimes put it, "intolerable" side effects) and I keep the levels low, sometimes really low.

"You have no new messages." I love the sound of the mechanical lady on my voicemail. Is it just the calm before the Manic storm, I wonder. Maybe, but for the moment, I'll take it.