I formerly had patients who wanted their medications added to the water supply. Now, they are afraid of the water. Congressional hearings, recent studies, and recent celebrity rants (see Tims article at the end of this issue) have patients generally worried about the safety of all medications. This kind of apprehension and worry has always been the case for psychiatric medications. Sadly, this is now worsened by the current climate and requires a renewed discussion that seeks to separate fact from fiction.
Antidepressants and Suicide
A black box warning has been added to the product description of all commonly used antidepressants. Patients are warned that antidepressants may contribute to suicidal ideation. Doctors are warned to watch for induction of suicidal ideation in patients newly initiated on antidepressants. This issue was brought to a focus by congressional hearings that looked at whether antidepressants worsened or caused suicidal ideation in children.
This is really not a new issue. I was trained in the 70s that depressed patients were at risk for worsening of suicidal symptoms after starting antidepressants, as this was a common symptom of depression. This was because the patient could experience an increase of energy before their mood improved. Thus, they may have the energy to act on their suicidal ideation before the depression lifts. Thus clinicians and families were encouraged to supervise severely depressed people more, with hospitalization utilized for this purpose. In todays managed care environment, these patients are treated in more outpatient settings, such as partial hospitalization programs, where adequate monitoring is less guaranteed.
Secondly, antidepressants can cause severe anxiety/agitation in some patients early in treatment. Anything that makes suicidal/depressed patients more anxious will increase suicidal risks. Antidepressants can also induce mania in bipolar patients that were mistakenly diagnosed as depressed. I personally worry that many of the cases of children/adolescents that worsened with antidepressants may be in this category. This is based on the fact that severe depression in children is highly likely to be bipolar disorder, not just depression.If a bipolar child is given any antidepressant alone, a mixed (dysphoric) manic state with severe agitation and suicidal ideation can result. Suicide risks are high in this situation.
Atypical Neuroleptics (Antipsychotics) and Diabetes
Atypical neuroleptics such as Zyprexa, Geodon, Symbyax, Clozaril, Abilify, Seroquel, and Risperdol are commonly used in psychotic disorders and bipolar disorder. Debates have raged over the last two-three years about whether any or all of these drugs predispose patients to diabetes or lipid difficulties. An Internet search of most of these drugs will find class action litigation sites"something not reassuring for patients.My response to my patients is twofold. Both bipolar and schizophrenic patients have higher incidences of diabetes than the general population. So it is not clear whether this is a disease state variable versus a drug variable. Secondly, many patients on these drugs gain weight dramatically, which increases Type II diabetes risk. However, where there is much smoke, there is usually a pilot light"so these patients need monitoring of weight, blood glucose and cholesterol in a schedule that reflects their risks based on family history and general medication status.
Stimulants and Cardiovascular Disease
One week before writing this, Adderall XR was removed from the market in Canada (immediate release Adderall was never available in Canada). This was based on 20 reports of sudden deaths in Adderall patients in the worldwide literature over several years. Our FDA did not concur with this ruling, as patients were on other drugs and had other medical reasons for potential cardiovascular problems. At this time, no plans were in place to suspend Adderall or other stimulant sales in this country.However this raises a good debate. Too many doctors do not check blood pressures in patients, especially adults, on stimulants. Approximately once every three months, I have to take someone off stimulants due to blood pressure elevations. I would hate to think of what would happen if I never checked. Stimulants have a long track record of safety and the 20 cases are very small compared to the millions that have taken these drugs"even if the stimulants were totally responsible. However, proper monitoring is crucial to insuring safe usage of these drugs.
In addition, Strattera added a warning about liver problems that was based on two case reports of reversible liver disease at the time of this writing. This occurred in a 13-year-old child and a 37-year-old man. Again, at least eight million people have taken Strattera, so these numbers have not earned too much fear. However, patients with liver problems should not take this drug and many doctors are checking liver enzymes at least once.
Mood Stabilizers and Major Organ Disease
These concerns here are not really new. We have known for years that Lithium Carbonate can potentially slow the function of the thyroid gland or kidneys. We have known that Depakote/ Valproic Acid can affect the liver or rarely the pancreas. Tegretol (Carbamazepine) has long been known to potentially affect the bone marrow and white blood cell counts when the prescription is initiated. This is why monitoring of these drugs is so very important. I saw a new patient who had been on Lithium for three years without any bloodwork for two years. This is not the fault of the Lithium.
The Bottom Line
Part of my internship was spent in pediatrics treating cancer patients. Treating psychiatric diseases reminds me of this process a great deal. The diseases (cancer or psychiatric disorders) are nasty and potentially life threatening. The treatments (chemotherapy/psychotropic meds) can be very effective in killing the disease, but can also kill the patient if not done properly.
Doctors must monitor these drugs properly. Patients must keep their appointments and follow their doctors instructions. It is amazing to me that a minority of my patients will wait months for an appointment and then not follow my written instructions or keep their follow-up appointments.
Psychotropic medications, like chemotherapy, can be very helpful when necessary, but also very hurtful when used casually without discretion. If all of the current debates about the safety of our pharmacological systems promote more safety, instead of fear, then the debates will ultimately save lives and help many. Doctors must teach about and monitor these medications. Online counseling is always available to help you out.
Patients must actively participate in their treatment, but not get creative about their medication regimens. Psychiatric medications are never safe when used inappropriately. However, psychiatric diseases are never safe when not treated appropriately.
