The Ten Percent Solution

Duane and others have mentioned this "10% rule," which essentially suggests making small changes in medication doses over extended periods of time (~1 year). A 10% decrease in dose every 4-6 weeks is often quoted. It's a rule that makes a lot of sense.

In response to a change in the brain's biophysicochemical stew (meds, trauma, chronic stress, etc), it generally takes neurons a couple weeks to fully generate new or recycle old protein machinery -- to adapt to changes. This duration can be shorter for some proteins, longer for others. Thus, small changes would be expected to minimize the shock to the system. This just makes good homeostatic sense.

There are problems with this as dogma, however. There is not useful research, at least that I am currently aware of, to demonstrate whether the "best" interval percentage change is 10% or 5% or 25%. We also don't know if the "best" interval is one week, two, four or eight. Or which medications and their affected pathways are best tapered at what intervals and amounts. Please share original source (ie, PubMed) links to peer-reviewed research below if you have relevant references.

You Need Help!

Sometimes in my real life it becomes obvious that a friend or acquaintance is having a problem. Either they are wearing obvious signs of mental illness or they just show signs of being 'stuck' in life or, worse, of moving backwards. Often they don't see it. I suppose there is the outsider's vantage point of making a judgment that may reflect my own value system and not their reality: to me, I may see someone who has family and job and connections who sees leaving those things as a healthy escape and their withdrawal as a good kind of comfort with keeping their own company. Usually these aren't my close friends, but what do you do when you notice that someone in your life is changing and might possibly benefit from help?

In general, I've found that "You need help" is not helpful. People hear this as an insult, not as a kind suggestion from a concerned friend. And from a psychiatrist friend it may be worse and easier to blow off---shrinks think everyone's crazy, they push drugs, they think everyone needs therapy, they see the world in a skewed way (at least this is how the commercial runs).

So I wondered: how do people let their friends know they need help in a way that inspires them to get it in the absence of a crisis? If you're in treatment because someone else suggested it, what enabled you to hear the suggestion without being wounded or insulted?

Guest Blogger Dr. Gerald Klee on Martin Luther King Jr., Riots and Psychiatric Hospitalizations

Oh, I so wanted to put this up yesterday! A day late, but....

Dr. Klee writes:

Today, April 4, 2008, is the 40^th anniversary of the assassination of Martin Luther King, which was immediately followed by widespread rioting in cities throughout the US . Baltimore was one of the cities most seriously affected by riots. This tragic situation provided an opportunity to study how admissions to public mental hospitals would be affected by such an emergency. The following 1998 article from The Maryland Psychiatrist summarizes a report by Klee and Gorwitz in Mental Hygiene, Vol. 54, No. 3, July, 1970. The findings, though limited are quite interesting and counterintuitive. For example, psychiatric admission fell during the days of crisis, while General hospitals reported increased admissions of patients with delirium tremens during the same period.

It occurs to me that this story may still be relevant. How well prepared is our present health care system to handle the effects of future civil emergencies.

Riots and Mental Illness

by Gerald D. Klee, M.D. Editor

The Maryland Psychiatrist [Spring/Summer 1998; Vol. 25 No. 1]

Psychiatric Hospital Admissions During The Baltimore Riots of 1968

How would a widespread civil emergency affect psychiatric hospital admissions? Would they go up or down? Would there be differences in demographic characteristics or diagnoses of those admitted? Our efforts to make predictions may be more successful if we have access to biostatistical data from previous events.

The Baltimore Riots of 1968 provided an unusual opportunity to conduct such a study in Maryland.¹ Following the assassination of Dr. Martin Luther King, Jr. in April of 1968 there was rioting in more than 130 cities in the U.S. Baltimore was one of those most seriously affected, with widespread rioting, looting, and burning during the four-day period from Saturday, April 6th to Tuesday, April 9th. The National Guard was mobilized and a curfew was imposed in the city and adjacent areas. Many arrests were made. Daily life was affected in many ways for nearly all residents of the area, black, white, and others.

Events of this magnitude were bound to have many effects on mental health. Soon after the riots occurred, Klee and Gorwitz studied the effects they had on mental hospital admissions.¹

Summary of Methodology and Findings

Our data were obtained from the Maryland Psychiatric Case Register, a ten year (1961-1971) joint project between the Biostatistics branch of the National Institute of Mental Health and the Maryland Department of Mental Hygiene. I was the psychiatric consultant to the project. There was an active psychiatric advisory board with representation from the Maryland Psychiatric Society (MPS). With the exception of office visits to private psychiatrists, all psychiatric admissions and discharges in the State were reported to the Case Register. In this investigation, admissions from Baltimore City to the three state hospitals serving the area were studied. In addition to the four days of the riots, periods of two weeks preceding and following the riots were examined. The number of Baltimore City admissions during the two-week period before the onset of the disorders and after their conclusion did not differ markedly from comparable figures for the prior year (1967). There were distinct differences in admission patterns during the four-day emergency, however, both as compared with the preceding and the following time periods and also with the comparable period of 1967.

At that time, Maryland ’s psychiatric hospitals had been experiencing a consistent increase in admissions of approximately 10% per year. (The revolving door was already in motion.) While this pattern continued during the pre and post riot periods, there was a sharp drop in admissions during the four days of crisis. In 1967's comparable Saturday-Tuesday period, there was a total of 65 admissions to these hospitals. Adding the noted 10% increase brought the number of expected admissions to 71, but the actual number of admissions dropped to 50. Further variations were found on the basis of race and diagnosis as well as place of residence. While there were 27 black admissions for the four-day period in 1967, this decreased to 18 in 1968. The comparable figures for white residents were 38 and 32. Thus, while a drop in admissions was noted for both races, this decline was more marked for blacks. In 1968, 31 of the 50 patient admissions were diagnosed as alcoholic as compared with only 26 of the 65 admissions in the prior year.¹ Concurrently, there was a sharp decline in admissions with psychotic diagnoses (9 in 1968 versus 24 in 1967; statistically significant, using Chi-square test).

In 1967's comparable Saturday-Tuesday period, two thirds of the 65 admissions were from inner city areas where much of the rioting occurred in 1968. During the 4 days of disturbances, however, only half of the 50 admissions were from this part of the city. Some of the admissions were related to the civil disturbances. For example, some patients were picked up by the National Guard for violating curfew and were found to be mentally disturbed.

The data presented are one-dimensional and represent only a fraction of psychiatric episodes that may have occurred during this period. We have no information on the number of cases dealt with solely by the police and the jails. We did not examine short- and long-term mental health effects that did not result in treatment episodes.

While the sample in this study was small and not all of the comparisons were statistically significant, the results show interesting trends and are counterintuitive.

Comment

The study provides an interesting vignette of a major historical event in Maryland history. One would expect to observe changes in psychiatric admission rates during a widespread civil disturbance affecting nearly every aspect of life within the city. It is unlikely that anyone could have predicted a drop in admissions and the other changes that occurred. In hindsight, there are many possible explanations for the findings. For example, the rise in admissions of alcoholics was thought to be related to sudden curtailment of supplies of liquor as liquor stores and bars were closed. General hospitals reported increased admissions of patients with delirium tremens during the same period. Other civil emergencies may occur in the future. How well prepared will the psychiatric system be to deal with them?

1. Effects of the Baltimore Riots on Psychiatric Hospital Admissions; Gerald D. Klee, M.D. and Kurt Gorwitz, Sc.D.; Mental Hygiene, Vol. 54, No. 3, July, 1970

Is THIS SSRI Withdrawal Syndrome???

Forgive the silly pic, I couldn't resist stealing it even if it doesn't quite fit.





This is a clinical case, but it's not my patient-- it's a little more personal than that, but still, no distinguishing characteristics, the names have been changed to protect my friends. You might ask why I'm rendering a clinical opinion on someone who is not my patient, who I haven't really examined but for pieces of a brief phone conversation, and that would be a good question. That can be it's own post, maybe one day when Roy is let out?

So I get a call from a dear friend from another state. Her father died last year shortly after being diagnosed with a terminal illness. Her mother happened to see her own GI doc and mentioned that her husband was dying. The story goes, "He told me it would be a rough time for me and prescribed paxil, it helped a lot." I personally don't prescribe medications simply for Hard Times or uncomplicated grief, and I didn't ask for a retroactive history, symptom list or mental status exam. She took paxil, it helped, time passed, she was doing better. So my friend's mother...let's call her Sally... spoke with her primary care doc who had her taper down off paxil cr 12.5 mg by taking one every other day then stopping.

The day after stopping she began to feel sick. Roughly 4-5 days later she was brought to the emergency room: she felt awful. Sally had a bad cold. She had a bad headache. She was confused, she began hallucinating. "Hallucinating? --She saw people moving, she woke someone in the middle of the night asking what a non-existent noise was, she insisted something wasn't written on a paper that was, repeatedly, until it was pointed at for her. Everyone was worried. I should mention that Sally is in her 80's, but she lives alone, drives, takes part in a number of organizations, and is the proud user of some of my favorite hair chemicals. She's not usually confused and she looks years younger than she is. She also suffers from a chronic GI problem, I don't know the rest of the medical history other than Hypertension and that med had been changed recently, too. And I don't know about past psychiatric history, but there's no psychiatrist in the story.

In the ER many tests were run, a brain CT was done. Nothing. The psychiatrist came and proclaimed "Paxil withdrawal." Relatives looked it up on the internet, all these symptoms have been described. She went home to wait it out, but she was feeling worse and worse and now developed a cough. Her primary care doctor said she could go back on Paxil but would then need to remain on it for life, and she didn't want to do this. Friend read on the internet that she could take a single dose of Prozac, which has a longer half-life than paxil, leaves the body more slowly, also increases serotonin levels, and this would help. Primary care doc agreed to call in a few prozac pills.

What did I think? Would this prozac thing work? He only called in 10 mg, was that enough?
Given that I didn't see the patient, I thought a lot, and I'll tell you my thoughts, as I told them.

1) This could be paxil withdrawal, though I personally have never seen anyone hallucinate and the hallucinations sounded a bit too close to delirium for me (Sally sounded fine on the phone). I was much more worried that something else was wrong, that an infectious process might be missed, that this could be related to her GI disease. This was my number one concern, though I was repeatedly told the ER did lots, all tests were fine, that 3 doctors had confirmed this was Paxil withdrawal.

2) Okay, so take a dose of paxil-- if it's withdrawal the symptoms should go away, soon and dramatically. Sally didn't want to do this because then she'd have to stay on paxil forever. No no no no no, I said, it would just be helpful to be sure that's what it was. She could take one dose, be sure she was okay, than happily withdraw. Or she could taper more slowly using 10mg and then 5 mg dosages.

3) Sally took the Paxil. She didn't know if she felt better-- not a good sign. The next day she took it again, she still had URI symptoms, now she had a low-grade temp. Confusion occasionally. The headache was better.

4) Friend wanted to give Sally the dose of Prozac. I said not to-- her symptoms had not resolved, I didn't think this was paxil withdrawal, adding Prozac would not help and she would be subjected to any side effects or adverse effects of the new medication.

The days went by, Sally did better, but hasn't returned to baseline. She's stayed on Paxil. She's staying alone most nights, still gets confused, and honestly, I haven't had an update in days.

The answer? I don't really know. I doubt that it was SSRI withdrawal given that some of the symptoms were not the usual and that she didn't get noticeably better after taking the Paxil. Though I do imagine this could explain part of the picture. Bronchitis (or pneumonia-- I don't know if a CXR was done)? Exacerbation of GI illness wouldn't explain headache, cold symptoms, but might explain some GI symptoms that developed after the Paxil challenge, the low grade fever, the likely delirium. Hopefully they're all doing better.
---
And just in case you thought I forgot my Novel obsession, here what people are saying about Double Billing over on The Interactive Novel Project:
Parked : "Now, you have my attention! Kudos! The first chapter just didn't hit me like the second one did. "
ClinkShrink: Wow, is that an improvement over the first chapter! The first chapter was just too short and sketchy and I felt no pull for the character. This is totally different. Very cool.
emy I. nosti: Love it. I'm hooked.

Why Docs Don't Like Xanax (some of us)

[BTW, you might also be interested in checking out our related podcast, #19: Xanax Blues.]

This is in response to JW's question below about the "rules" docs use about prescribing Xanax/alprazolam. Not all docs feel this way, but here's how I think about it. Of course, I am not suggesting that, if you are taking this anti-anxiety drug, you should stop it. I'M NOT. Talk to your doctor if you have concerns.

The half-life for Xanax is short... on the order of 6-20 hours. Halcion is the only similar sedative that has a shorter half-life (and that one has even more problems). Thus, it doesn't stick around long. It is also quite lipophilic, meaning that it quickly gets into the brain. So, it has a quick on, quick off way of working. Sounds great, right?

The quicker a drug works, especially one which makes you feel good in some way, the more addicting it is, as the cause (taking it) and effect (feeling it) are close in time, making it very reinforcing. This is fine if you just take it on those rare anxious moments where you need something to get through it. However, since it works so quickly, many folks start taking it more and more often, until it gets to the point that they are taking it daily. Then they start taking it as soon as they feel it wear off. Before you know it, you are taking it 3-4 times per day. Now, that's not the big problem.

The big problem is all because of your brain's laziness. See, your brain makes it's own natural Xanax-like substance, called GABA. GABA works by inhibiting the brain's natural tendency to speed up. It's like a brake pedal, where the accelerator is stuck in the pedal-to-the-metal mode. GABA keeps your brain from over-working. Xanax (and other sedatives, and alcohol) works by acting like GABA in the brain (sort of). If you start taking it daily, your brain starts thinking "I guess I don't need to make so much GABA because this Xanax stuff is here, so I'll only make 20% of what I usually make." It takes a week or more for your brain to stop making the GABA (which is why just a few days on Xanax won't lead to much trouble), and a week or more for it to start making it again when you stop taking the Xanax.

Here's where the trouble begins. If Xanax wears off in just a few hours, but it takes a week for your brain's natural Xanax to kick back in, what happens in the interim? Withdrawal. What does that feel like? It feels like a panic attack, but worse. High blood pressure, rapid heart beat, tremors, confusion, delirium, hallucinations, seizures. What do folks do when they feel a panic attack coming on? Take another Xanax.

As a hospital-based physician, I see lots of folks, often older, who wind up with severe withdrawal problems from Xanax. It's usually because they run out of the drug, decide to cut back or stop taking it, or something else happens (eg, stroke, get sick) and they forget to take it. Or they don't tell their surgeon they are on it, and 2 days after their hip surgery I get called because they are hallucinating.

Some prescribers think it is a good antidepressant (it's not). Or that, because of the short half-life, it's not as addictive (it is).

So, here are my rules of thumb about Xanax:

1. Avoid it.
2. Keep the doses small.
3. Do not use in older folks or forgetful folks (more likely to forget it, thus more likely to have problems).
4. Do not use in anyone with a history of alcoholism or addiction (yes, that means you have to ask).
   
5. Tell folks to avoid from daily use.
6. If they are on it, warn them that stopping it suddenly, even for a day or two, can result in confusion, hallucinations, seizures, and even death.