Archive for the ‘Medication: Why Meds?’ Category

Brooke Shields, John Nash, and the national APA meeting

Two thunderous standing ovations highlighted this year’s APA meeting. They were as different as you could imagine. An intimate conversation with Brooke Shields about her battle against nature’s cruelest mood disorder – postpartum depression – and Dr. John Nash (A Beautiful Mind) reading a paper he wrote in which he describes his battle against schizophrenia through metaphors of economic theory and the complex mathematics of game theory (for which he received a Nobel prize). Each presentation was in front of hundred’s of physicians and other professionals. One was alternately funny and gut wrenching.  The other was a mind twisting exercise in obfuscation.

What they had in common was each individual had the courage and strength to open their heart and soul to the professional world so that their stories could help us help others.

Dr. Nash’s presentation was interesting at times and touching at times but mostly unemotional.  I wish he had been interviewed in front of the audience instead.

He likened becoming psychotic to part of his mind going on strike. The most provocative thing he said was that to him his new insight into mathematics and his paranoia were both novel ideas not shared by anyone.  The only difference was that one was true, was labeled genius, and was rewarded with the Nobel prize.  The other was not true, was labeled insanity, and got him committed to a locked psychiatric ward.

The schizophrenic mind can’t tell the difference. Of course sometimes ideas are true but sound crazy.  And for various reasons society is not ready for them and may even persecute those who dare to challenge the current version of truth (like the earth is the center of the universe).

I was the most moved by Brooke Shields. Maybe because I have helped women who struggle with postpartum depression for over 40 years. 

What can possibly be a more joyous time than having a new baby – looking into your eyes, cooing, and responding to your love?  What can be more painful than when you as a mother feel nothing, or rejection, or thoughts of harming this poor helpless creature?  What could be more shameful and guilt producing? 

Everyone is saying how cute and precious your baby is, and you’re thinking "I wish you would shut up," or maybe even, "Please take this baby with you."  And if you do share that you’re not feeling right they say, "Oh, it’s just ‘baby blues.’  It will pass. it’s normal." 

And you’re thinking, "You don’t understand. I want to die. I feel empty, hopeless, inadequate, overwhelmed."  Or if they suggest medication, what you hear is you’re weak or crazy or both!  When you’re a celebrity with fame and fortune, a loving husband, and all the trappings of a perfect life, but you feel like a total failure, you see no hope for even being o.k. again and thoughts of suicide come to mind.

As Brooke Shields discussed this torturous beginning to motherhood, the pain of her experience was palpable throughout the ballroom.  The first turning point occurred for her when she had sent her husband to get a changing table, but he returned empty handed.  He sat on the bed and broke down.  She had never seen him cry.  He said "I went to the store and there were all these mothers and babies and families, and they were so happy.  Why aren’t we happy?" 

I almost lost it, in fact it took several tries before I could comment to my wife without getting choked up.

She went on to describe how she got on an antidepressant and felt better.  She went back to California and stopped the meds and crashed again.  She describes driving in her car with the baby in the back and thinking, "I could speed up to 80 mph and run into a concrete wall and all this would be over."  Fortunately she called a girlfriend and told her how she was feeling, and her girlfriend made a date with her for lunch the next day. She said her girlfriend was so manipulative because she knew Brooke was compulsive about keeping her commitments and would have to wait until after lunch tomorrow to drive into a wall.  

Brooke called her  doctor who asked if she had stopped her meds.  She said yes and he asked, "Why?"  She thought, "Did I sleep through my 4 years at Princeton?"

So, she went back on meds, had some side effects, changed meds, and eventually, everything was okay. 

3 years ago she went through a 2nd pregnancy without all the stressors of her first pregnancy, which included 7 in vitro fertilizations, miscarriages, death of her father (prostate cancer), an emergency C-section, being away froms support people, and being clueless with expectations of being the perfect mother. 

She described how different this 2nd experience was.  When the OB handed her the baby in the delivery room, her husband was thinking "Please don’t start sobbing," but she felt joyous, relieved, then elated.  She said, "I started telling my girlfriends they could have some of my husband’s sperm (in vitro) if they needed it."  A happy ending.

She tells her story in the recent book Down Came the Rain.  She has done way more than her share in making women aware of what can happen and that treatment is available.  I felt so much respect and appreciation for what she has done.  Then I thought about Tom Cruise (see previous article). I wondered how many women were on the fence about mood disorders, psychiatry, and medication.  How many were influenced by him to not seek help?  How many mothers suffered unnecessarily, and how many babies didn’t bond with their mothers during those early critical developmental weeks and whose lives will be adversely affected forever?

At the same moment I wanted to sing Brooke Shields praises and kick Tom Cruise’s ass.

 

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What Is Psychopharmacology?

Psychopharmacology is the study of the use of medications in treating mental disorders. The complexity of this field requires continuous study in order to keep current with new advances. Psychopharmacologists need to understand all the clinically relevant principles of pharmacokinetics (what the body does to medication) and pharmacodynamics (what the medications do to the body). This includes an understanding of

  • Protein binding (how available the medication is to the body)
  • Half-life (how long the medication stays in the body)
  • Polymorphic genes (genes which vary widely from person to person)
  • Drug-drug interactions (how medications affect one another)

Since the use of these medications is to treat mental disorders, an extensive understanding of basic neuroscience, basic psychopharmacology, clinical medicine, the differential diagnosis of mental disorders, and treatment options is required. Psychopharmacologists also must be skilled in building and utilizing a therapeutic alliance with the patient.

Who Qualifies as a Psychopharmacologist?

In a generic sense, any physician who treats patients with psychotropic medication is a psychopharmacologist. Physicians who have completed residency training after medical school have a high level of understanding and expertise in pharmacology, including psychopharmacology. Psychiatrists (who have completed four years of advanced training after medical school) have an even higher level of understanding and expertise in psychopharmacology.

The term “psychopharmacologist”, however, may also be used in a more specific sense to mean a physician with training in advanced psychopharmacology. That is, some psychiatrists specialize even further in psychopharmacology through academic education, Continuing Medical Education (CME), or self-study.

Physicians who are certified by the American Board of Medical Specialties have demonstrated a high level of understanding and expertise in pharmacology and other areas of medicine. Only board certified medical specialists are eligible to take the ASCP’s Examination in Advanced Psychopharmacology. This rigorous exam covers all areas of psychopharmacology and requires a thorough understanding of the latest science that has relevance to clinical practice. The exam must be taken every 5 years.

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Vitamins & Supplements: Are they really worth it?

  We have heard it since we were kids, but do we really need to take our vitamins? 

The answer is yes. 
Most Americans don’t get the nutrition they need simply from the foods they eat, and supplements insure that our body meets its nutrient “quota” enabling our body to function optimally at the cellular level.  However, the vitamin and supplement industry is not regulated by the FDA, so there is no guarantee that products bought from grocery and health food stores are effective or contain the stated ingredients.    
Cooper Complete Vitamins are backed by Science.
That is one reason we decided to make them available to our patients. Reputable physician Kenneth Cooper created the Cooper Institute, a non-profit organization that manufactures, researches and publishes studies on Cooper Complete vitamins. He ensures regular testing to measure efficacy, potency and absorption of Cooper supplements.  Not only does Dr. Jones promote these vitamins, but he takes them himself and he furnishes them to his staff at no charge to promote wellness among staff members.  To encourage patients to take these supplements over other store bought brands, Dr. Jones decided to make these supplements available to his patients at a discounted price, so we offer the Cooper Complete© line of products for less than you can get them at most grocery stores and even less than the price from ordering them directly from his website. 
If you are interested in ordering supplements or would like more information about the supplements, please feel free to contact our office or e-mail us your request to info@askdrjones.com.  


Studies published in the American College of Nutrition and
the American Journal of Medicine found Cooper Complete multi-vitamin lowered: 
· Oxidation rates of LDL Cholesterol by 14%

· Homocysteine levels by 17%

· C-reactive Protein Levels by 32%

High levels of these values are all associated with increased cardiovascular disease risk.


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Medications and Stress Disorders

“I know I feel stressed most of the time. I know I am not as happy as I should/could be. I certainly don’t function at my full potential. My energy, sleep, sex life, etc., leave a lot to be desired. How do I make things better? Where should I start? If I decide to try medication, what kind of medication should I take?”

These are the underlying questions usually not in full conscious awareness that most people have when they go to see their doctor. Ted Mitchell, M.D., director of Wellness Programs for the Cooper Clinic in Dallas, says that 75-90% of all doctors visits are stress related. Stress overload and poor health habits are far and away the main cause of not only shortened life span but reduced quality of life.

Most individuals have at least one area in their life where they need help. Emerson’s advice is, “first be a good animal.”

Be physically fit. This includes keeping your blood pressure at 130/80 or better. Many people have high blood pressure or hypertension. Unfortunately, the majority don’t know it. If caught early blood pressure can be brought down to normal range.

This is especially true along with weight loss, added calcium, general stress management, relaxation, aerobic exercise, and muscle toning. But most of these changes take time and meanwhile high blood pressure is pounding the arteries in your heart, brain, and kidneys. Since your kidney’s monitor blood pressure and release hormones to increase it when it’s low, once high pressure damages your kidneys you will have chronic hypertension. Your kidneys will under read your pressure and constantly release hormones to raise it. To prevent these damaging effects of elevated pressure, you need to take medication, (usually starting with a diuretic and/or ace inhibitor). If adequate life style changes are made then medication can be phased out. But if they are not, or you waited too long you will need to be on medication for life.

Since blood pressure is easily measure and monitored it serves as a good model for physical health systems. The same principles apply to stress disorders – if you catch them early and make life style changes you may be able to fix the problem without medication or at least only need medication for a limited time. But just as high blood pressure damages the body, clinical depression and other major mental health disorders damage the brain. This may mean you will have to take medication indefinitely … or not … You of course have the right to choose an unhappy or unfulfilling, shortened life.

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Ask your doctor if this medication is right for you.

"Ask your doctor if this medication is right for you."

Is that statement in TV ads driving you crazy too? I especially love it when they mention a bizarre sounding medicine’s name but they don’t tell you what it’s for. They just say, "ask your doctor if it is right for you." If they tell you what it is for the FDA requires that they tell you its main side effects. I love it when they use an old technique taught to lawyers: if you have to concede a point that is not in your favor do it in a tone of voice as though it was in your favor, or is no big deal. So, they will add nonchalantly that it may cause cancer, heart attacks, strokes, seizures, sexual dysfunction, etc. They will then reiterate how much better your life will be while showing a happy couple skipping off to fun and frolic.

Another thing I love is that they tell you not to mix it with other drugs like MAO inhibitors or Thioridazine, (meds that almost NO ONE takes), or tell you not to mix it with generics of the same thing, or not to take if you are allergic to it. All of this is reverse psychology – it seems to be providing fair balance but it’s mostly irrelevant.

I won’t make the obvious criticisms of the FDA – they have already taken enough heat lately, and their credibility is finally being challenged in various arenas.

What about pharmaceutical companies? They are also taking a lot of heat. They are being criticized for spending more money on marketing than on research. But this is America. Every private enterprise has profit as its goal and without profit they go out of business. Also, in their defense, pharmaceutical companies not only bring us new and better medications, they also play a huge role in educating doctors and the public about the nature of illnesses, dysfunction, and the role of various treatments in health and quality of life.

There’s a lot of criticism about the increasing use of prescription and over-the-counter medications. "Prescription nation" and "Parenting with Pills", are just two examples. The underlying message is that if you would eat right, exercise enough, and have a positive attitude you wouldn’t need medications. To a certain extent this is true. There is no doubt that stress related disorders such as anxiety, depression, hypertension, etc., are becoming more common, starting at an earlier age, and more severe. Everyone of us could do better stress management and have a healthier life style, but STRESS appears to be here to stay for a while. We can be thankful that we have a lot of tools available to help us deal with stress. Some of these tools are medications.

I am adding five permanent sections to my web site on medication. They will be regularly updated as we get new information. I consider these sections some of the most valuable information on my website.

Medication: Why Meds?

Medication: Best Meds

Medication: How to Take

Medication: Side Effects

Medication: How They Work

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Take 2 Benadryl and call me in the morning …

Last week, a rep from a pharmaceutical company that manufacture a sleep medication was in my office.  He said, “You have a unique practice because you see a lot of patients with sleep problems.” I said, “WRONG! I see the same patients that all psychiatrists and primary care doctors see. The problem is most patients that have sleep problems don’t mention it to their doctors, and unfortunately, most doctors don’t ask.”

I believe all patients need to be screened for all common, treatable problems every visit.

Sleep is the first thing I ask about on my screening questionnaire. Two days ago I was seeing a patient who happened to be the wife of a primary care physician. She told me recently her internist put her on Prozac for anxiety and depression. She immediately developed a significant sleep problem as a side effect. She asked him for a prescription for Ambien. He told her he didn’t prescribe Ambien because it is “highly addictive,” but she could take Benadryl. (See previous discussion on “pre-extraction disorder” P.E.D.) There are several problems with her internist’s response. First, Ambien isn’t addictive at all. An occasional patient will develop a mild physical dependence after several months of nightly use, but physical dependence is a physiologic adaptation and has “nothing to do with addiction.” This is not just my opinion but that of Dr. Robert DuPont, the first director of the National Institute on Drug Abuse. Fifteen percent of patients taking Ambien for one year every night will have one to two nights rebound insomnia if they stop it abruptly. This is hardly addiction.

Addiction is compulsive use or behavior in spite of negative consequences.

The second problem with her internist’s recommendation is that Benadryl is a horrible sleep medicine. There’s no scientific evidence that it’s effective. It doesn’t provide normal sleep (Stage IV deep sleep and dream sleep), and it frequently leaves you with a hangover. Other than that, it was a great idea. The third, and most important problem with his recommendation was that his ignorance with regards to the importance of a good night sleep.  The effect of sleep loss was studied in healthy young men awakened after 5 hours of sleep.  After just one night, they showed decreased concentration, marked irritability and increased levels of cortisol, a stress hormone that suppresses normal immune function and contributes to abdominal weight gain.

I consider good sleep (7-8 hours) the most important part of stress management.

Longevity studies show that too much sleep is actually worse than not enough. In the short term, excess sleep drains mental energy. A national survey found that 10% of people have a chronic nightly sleep problem, but 2/3 of the adult population has at least occasional sleep problems.  The good news is that we have effective, safe medications that provide normal sleep and are totally out of your system in 5-8 hours.  The bad news is many doctors are afraid to prescribe them and most people don’t have access to them. 

I think every home needs to have Tylenol and a good sleep medicine on hand.

Most people need to have a good sleep medicine (Ambien, Sonata, Lunesta).  We weren’t made for this world. We adapted from 1000’s of years in a world where we were outside and physically active all day.  The bright sunlight regulated our sleep, energy, and metabolism. Whereas, now most people are mainly indoors and sedentary. Life use to be hard but simple.  Now, it’s extremely complex and changing at an exponential rate, but we still have the old adaptive mechanisms.  We respond to mental stress with the same flight or fight mentality, but these aren’t appropriate responses to today’s stress.  It’s like driving your car hard all day but not putting it in gear.  It’s not good for your car, and it’s not good for our bodies. We end up hyper aroused, can’t relax and have problems sleeping.  We need a new stress management technology, but right now, the best we can do is great medicines.  It’s just a shame that most people either don’t know about them or can’t get them because our medical system is broken and most doctors just don’t get it.

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Mental vs. Physical – What's the difference?

"Study Discovers Help for Hypochondriacs" headlined an article in the Dallas Morning News. "Advancement in Hypochondriac Therapy" announced a shorter article in USA Today. Both articles make the point that this condition is "mental not physical."

A quarter of the patients in the study dropped out after being told the problem is in their heads. Of the patients who were willing to attend 6 therapy sessions: 57% showed significant improvement and felt their quality of life was better (This is not to say normal.). 32% of patients assigned to the usual medical treatments had a similar outcome. These news reports were based on an article appearing week in the March 2004 Journal of the American Medical Association. The interpretation given for the patients who didn’t complete all their sessions or didn’t attend any was that "the treatment didn’t fit with their belief that their illnesses were real."

The problem I have with these reports is that it represents one of the most important issues in medicine. The idea that the mind and body are two different things is the old paradigm. This mind/body dualism goes back 3 1/2 centuries to Descartes. The new paradigm is that there is no mind without brain, and brain is part of the body.

Recently a patient of mine went through a life threatening illness and eventually heart surgery. He had a past history of serious depression, well controlled for years with maintenance medication, an antidepressant. He was so sick that he forgot to continue his meds, and his doctors did not see fit to prescribe for him or contact me. I explained to him that depression – which developed during his medical illness to the point that he said, "all I thought about was death" for several weeks – increases the risk of dying from serious illness 2 to 3 fold.

His response was, "I guess they took good care of me physically but not mentally." My response was "What’s the difference?"

So what difference does all this make? Why didn’t his doctors make sure he stayed on his antidepressant? His doctors increased his risk of dying. Why? Because many if not most physicians are still stuck in the old paradigm.

"For every twisted thought, there’s a twisted molecule; straighten the molecule and you’ll straighten the thought." But, responded the cognitive therapy oriented people – "If you straighten the thought, you straighten the molecule."

So, which is right? Both. There are numerous studies now for obsessive compulsive disorder and depression that adequate cognitive behavior therapy (CBT) can change the chemistry and functioning of the brain. Scans of brain functioning can be seen to return to normal for some patients. The right medication(s) at the right dose frequently return the brain to normal. Some patients do better on one approach and not the other. Some patients would do equally well on either, and some need both.

Why would anyone choose medication if cognitive therapy would work? The problem is that CBT therapy takes longer, costs more, takes a lot more time, it’s hard to find people who know how to do it, and it may not work. Medication is simple, quicker, cost less money and less time.

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