Marks Psychiatry

A recent literature review showed that people who take Ambien at night for sleep are able to drive 5-6 hours later.  J. Jason Buckland, D.O. and associates reviewed 10 studies that involved driving tests after the administration of Ambien.  These studies showed that there is no residual impairments in the morning, approxminately 5-6 hours later.

Zolpidem, the generic of the short acting Ambien has a half life of 2.5 hrs.  The controlled release version, Ambien CR has a half-life of 2.8 hours.  What does this mean?  It takes roughly 3 half-lives for a drug to be eliminated from your body.  By two half lives, the drug level is at the low end of the curve (meaning little noticable effect if any).  So if a person only sleeps 6 hours, they have still passed two half lives of the drug and should show no impairment in their driving ability.  This is in contrast to drugs like Trazadone that has a half life of 4-7 hrs or Restoril which is 10hrs.  It’s the long half-life that can make people who take these drugs for sleep feel groggy in the morning.

Popularity: 63%

Researchers at Rochester Medical Center have seen good results in Provigil (brand name for modafinil) improving the negative side effects of chemotherapy that impact cognitive function. Chemo-brain is a term used to describe the foggy, fuzzy thinking and poor memory experienced by some patients after they have undergone chemotherapy.

The research group based their findings on a study of 68 women undergoing chemotherapy for breast cancer. They were treated with Provigil for 8 weeks to combat fatigue. However, the women found they had significant improvement in their ability to concentrate as well as memory and learning.

Provigil is a drug prescribed for excessive daytime sleepiness due to Narcolepsy (which is a problematic sleep condition) and shift-work sleep disorder. Provigil activates the brain in the same way as stimulants like amphetamines and caffeine. Why not just use Adderall or caffeine? Provigil does not have the negative effects on the heart as does Adderall so it is potentially safer.

The study uses a small group of patients and is funded by the drug company who makes Provigil.  Despite this, the results are promising. If future studies confirm that Provigil improves cognitive deficits due to chemotherapy, this could significantly improve the quality of life for patients undergoing chemotherapy.

Popularity: 28%

At the International Conference on Bipolar Disorder, Dr. Rasmus Licht of Denmark reported on a study of 155 adult patients with bipolar disorder. The patients were treated with lithium and lamotragine (lamictal). They found lamictal tended to be more effective in patients whose index episode was depression and lithium was better for patients whose index episode was mania.

Unfortunately, they found that by five years on the single medication, only two out of the original 155 patients were able to remain on one medication. The remaining patients failed treatment (had a relapse of symptoms) and this usually happened within the first 1 1/2 years.

Following bipolar patient’s progress for five years makes this study unique, and it supports the idea that the majority of patients require more than one medication to control their symptoms in the long run.

Popularity: 38%

Hoodia is a cactus-type plant from Africa that has many uses, however the native populations of South Africa have used it for indigestion or infection.  The plant Hoodia gordonii has been recognized as an appetite suppressant since the late 1970’s in Africa, but in the US there have been no definitive studies establishing it as a safe and effective appetite suppressant.

Despite this, media hype about the drug began around 2004 when 60 minutes aired a special on it’s effectiveness and since then others have followed suit such as the Today Show and Oprah catapulting it’s popularity.  To protect consumers, Hoodia exporters must be issued a CITES (the Convention on International Trade in Endangered Species of Wild Fauna and Flora) certificate by the office of Western Cape Nature in order for Hoodia to be legally exported abroad from Africa.   It is illegal to export Hoodia without this certification.

Why is a psychiatrist talking about Hoodia?  Having treated patients who took Hoodia (at their own initiative), I’ve seen how it has benefited most and also had some negative effects.  Most established appetite suppressants available in the US are stimulants and stimulants as a side effect can lessen one’s desire to eat.  It’s not clear what the active ingredient (P57) does, but I wouldn’t be surprised if it’s not a naturally occuring stimulant.  As such, it can also have the unwanted affects of agitation and anxiety.  If you already have anxiety, this could really worsen your condition.

Some people have dealt with this by taking less than the recommended dose.  The pills are usually capsules and can’t be split, but rather than taking it three times a day, some people have taken it once a day at the time of their worst cravings.  I have heard some people say Hoodia “takes the edge off” their cravings giving them enough contol to choose not to eat junk or munch unneccessarily.

We know there is no magic pill to control weight, as controlling your eating requires behavioral change.  So for some who recongize that long term control of eating is a lifetime, lifetstyle adjustment, Hoodia can be something that gets them started in the right direction long enough to get used to a new way of eating and using food.

Of course, as with any drug (and herbal remedies are drugs too, just naturally occuring ones), a person considering starting it should check with their health care provider prior to taking it.

Popularity: 29%

Medication discontinuation syndrome can happen when a person stops their medication abruptly. In general, medication should be tapered off slowly with medical supervision. But since we don’t know precisely how slow is slow enough for each individual, sometimes tapering off the medication can still result in some withdrawal symptoms.

Usual withdrawal symptoms are things like fatigue, irritability, diarrhea, headache, anxiety, or feeling like you have the flu. These symptoms typically last a few to several days.

There have been some who have experienced electric shock sensations when stopping Effexor and some other serotonin agents such as Cymbalta, Paxil, etc. This is very unusual, but I’ve heard patients describe it as a “brain shock” that was worsened with movement. In the literature, reports of these symptoms last up to 5 days.

The origin of these sensations is not entirely clear, but thought to be a form of paresthesia (which is the sensation of feeling tingling or creeping on the skin). Paresthesias result from our nerves being activated in a particular area when there is no apparent trigger for the activation – for example, feeling a pinprick on your skin when you haven’t been pricked by a pin.

The electric shocks have been helped by adding back the medication that was discontinued and tapering it more slowly or adding another long acting serotonin agent such as Prozac.

Therefore, stopping medication abruptly is usually not a good idea, especially if you have been taking a particular agent for a long time. It’s best to discuss a tapering schedule with your doctor so that you can have the smoothest transition possible.

Popularity: 25%

I saw a segment on The Today Show this morning about the millions of antidepressants prescribed. Questions arose as to whether or not this is an indication of Americans wanting a quick fix or are doctors over-prescribing the medications. This opens a pandora’s box of issues ranging from who should treat depression to the state of health care (e.g. doctor’s offices becoming mills where many patients are churned in and out with little time to talk). I could go on about many of these issues, but only have time for one today and that’s the issues of what is unhappiness versus depression?

People experience depression differently, but there are a set of criteria that we use to diagnose depression. But rather than list the criteria, let me paint a picture of a depressed person for you. Symptoms vary depending on the person and the severity of their illness, but generally speaking:

• people who are depressed may have trouble experiencing pleasure in anything
• their limbs may feel heavy
• they may sleep all day or have trouble sleeping
• they may have trouble thinking and concentrating such that it affects their work
• they may have constant anger and irritation that is unusual for them
• they may go days without bathing because they just don’t care
• some people describe noticing that colors look duller
• some even feel like life isn’t worth living

This is not an exhaustive list, but some the symptoms depressed people may experience.  This is in contrast to feeling down after a relationship breakup, or having trouble getting out of bed to go to a job you hate. No amount of medication is going to prevent people from feeling bad when bad things happen. I tell patients, whatever problems they have will still be there with medication. The difference is, for a person who is depressed, medication can strengthen their foundation so they can more effectively use their emotional resources to deal with their problems. Depression exhausts your emotional reserves so that you may be unable to handle the stresses of life in your usual way. There are some who have poor coping mechanisms and have trouble dealing with the day to day problems of life and are not depressed but may feel chronic distress. This person may respond better to therapy to help them handle their problems differently.

Popularity: 37%

I’ve always been a firm believer that brand didn’t matter much and you should save your money by passing up the $6 Advil for the $2 Ibuprofen. When I was in medical school and residency, we learned generic names for drugs so as not to give too much credit to the drug manufacturer and recognize the drug for it’s chemical properties (and not it’s brand name).

From time to time, I would hear of certain drugs that seem to be more effective than the generic version, however most of them were cardiac meds or non-psychiatric medications. Since the more popular antidepressants were developed in the 90’s, we (psychiatrists) didn’t have to think much about this issue because these drugs were still under patent until recently. Now some of the more popular antidepressants such as Prozac, Paxil, Zoloft and Wellbutrin are all off patent and available as generic.

What does this mean? (if you know about generics, you can skip this paragraph) Prozac is the brand name developed by Eli Lilly (the company who first developed and manufactured the drug). The chemical name is fluoxetine. Lilly paid for the development, research, and production of fluoxetine. To recoup their investment, they are allow protection for a certain number of years from any one else manufacturing fluoxetine. Once the patent expired, other drug manufacturers were allowed to produce fluoxetine and sell it. Now that’s there’s an open market for selling it, the price drops considerably.

Back to the original point…in my experience, most of my patients do just as well on the generic versions of their medications. Unfortunately I’ve had some for whom the generic was a negative experience. The most common things I’ve seen have been with sertraline (generic Zoloft) and buproprion (generic Wellbutrin). I’ve had a very few have a return of their depression when switching to sertraline and a few experienced ringing in the ears with buproprion. I emphasize this as happening only with a few patients out of many on these medications, but it’s been enough for me to reach the disappointing conclusion that for some medications, brand name does matter.

I still don’t think people should refuse to take generics, because it may not make a difference and the price differential is so great that it could be very expensive to refuse all generics to avoid the small chance that it generic may not work for you. Also, there may be a difference in quality of sertraline depending on the manufacturer and it’s hard to keep up with which company produces the version that works differently.

What’s the conclusion? If you switch to a generic or start a generic drug, you and your doctor should keep an eye out for a change in your status. Also, if you start on a new medication and it doesn’t seem to work or has bad side effects, think about whether switching to the brand version to see if it makes a difference before abandoning the drug.

Popularity: 26%

We in psychiatry have always said it took 3-4 weeks for an antidepressant to show a clinical effect.  Those who showed improvement in the first 2 weeks were thought to be having a placebo effect.  In the past 2 years, there have studies that have shown that patients can have a “real” response to antidpressants as early as 1 week after starting the medication.

When Lexapro became available in 2002, pharmaceutical reps said it was supposed to show effect in the first week.  At that time, that was the first antidepressant that made that claim.  I find the literature still unclear about what is an expected response time.  This is probably because there are other factors such as lack of support, ongoing stressors, variability in how drugs are metabolized that affect response time.

Also, another source of confusion may be in how we define “working”.  A clinical response is not the same as a full recovery, so a person may experience some lifting of their depressed mood in the first week, but still have considerable irritability, insomnia, anxiety, etc. for several more weeks.  Bottom line, I think the current literature supports early responses in the first week as being real and possible, but we still need to give the medications 4-6 weeks at a therapeutic dose to show a full response.

Popularity: 22%