Saturday, January 30, 2010

Prozac is Talking -- Anybody Listening?

Anybody know this story?  You get a new prescription.  Responsible consumer that you are, you read carefully the PI [prescribing information] sheet.  It says, "If xx happens, call your doctor immediately."  Sure enough, xx happens.  You call your doctor, who does not call back.  After persistent calling over several days, the doc says, "Really?  We'll keep an eye on it."

The other day, I had a nosebleed that wouldn't stop.  The PI sheet says my new med can interfere with platelets, admittedly not very high on the list of side effects.  But I contacted the doc.  "Really?"  she said, "Where did you hear that was a side effect?"  My answer, "On the PI sheet you gave me."  It turned out, my blood work was fine, and the humidifier took care of the nosebleeds.

No harm done.  Right?

On the other hand, five years ago my GP had me on Prozac.  After a couple months, I couldn't sleep, was irritated, agitated, couldn't concentrate, had thoughts of harming myself and others.  The PI sheet said I should tell my doctor.  My doctor increased the dose.

Thus began a series of antidepressants, and a downward spiral that has ended with disability.

Actually, my GP was operating by the book.  Eli Lilly wrote the book.  They convinced family practitioners around the world that SSRIs were safe, effective, and an easy solution to an easily diagnosed condition.  After I quit Prozac for a different side effect, and after the second SSRI also made me worse, she followed standard procedure, and sent me to a psychiatrist.

Eventually out of self defense, I started reading more than the PI sheets.  I read the research.

Does anybody out there have a doc who reads the PI sheets?

This is what I read in the doctor's information about Cymbalta (an SNRI), the December 2005 version:

The following symptoms, anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia (psychomotor restlessness), hypomania, and mania, have been reported in adult and pediatric patients being treated with antidepressants for major depressive disorder as well as for other indications, both psychiatric and nonpsychiatric.  Although a causal link between the emergence of such symptoms and either the worsening of depression and/or the emergence of suicidal impulses has not been established, there is concern that such symptoms may represent precursors to emerging suicidality.

Consideration should be given to changing the therapeutic regimen, including possibly discontinuing the medication, in patients whose depression is persistently worse, or who are experiencing emergent suicidality or symptoms that might be precursors to worsening depression or suicidality, especially if these symptoms are severe, abrupt in onset, or were not part of the patient’s presenting symptoms.

These paragraphs were found on pages 7-8 of the 27 page document, appearing after the black box warning about children, the drawing of the molecule, the pharmocodynamics, the pharmocokinetics and the clinical studies.  It didn't just jump out at you.  This version for doctors was published right after the drug companies lost the battle they fought tooth and nail against those black box warnings.

December, 2005 was exactly the month when my second psychiatrist prescribed Cymbalta for me, (relapsed after a period of remission,) some time after the widely reported controversies and clinical studies that led the FDA to require the warning.  She pulled the samples out of her sample cupboard.  Didn't the sales rep give her the doctor's prescribing information?  Didn't she read it?

That psychiatrist didn't answer phone calls about side effects.

Do Antidepressants T(h)reat(en) Depressives? is a review of literature (published in 2006) that exonerates antidepressants from the charge of causing suicidal ideation and behavior.  However, its authors, Z. Rihmer and H. Akiskal do cite several clinical studies from 1999-2005 that identify a particular population besides children at risk: those with bipolar, Bipolar II, anxious depression and mixed state depression.  All these are on a continuum of cycling depressions, with bipolar at one end and recurrent depression at the other.

The continuum's middle, especially Bipolar II is the most treacherous ground.  People with this type of mood disorder are already at an elevated risk for suicide.  Each hypomanic symptom increases the risk of suicidal ideation by 4.2%.  Rihmer and Akiskal report that those who take antidepressants double their risk of suicidal ideation, self-harm and completed suicides over the risk to those with bipolar and triple the risk to those with simple major depressive disorder.

And how was this population and this elevated risk identified?  Largely, by the list of side effects themselves that they experienced, Cymbalta's list above.  Bipolar II is diagnosed after treatments for other diagnoses fail.  A friend discovered that her psychiatrist had added Bipolar II to her diagnosis.  When questioned, the psychiatrist said, "Oh, that simply identifies how you respond to antidepressants."

In fact, Baldessarini, Tondo and Hennen found in 1999 that women with Bipolar II were not correctly diagnosed for an average of eleven years.  (Half of all suicidal acts occurred in the first 7.5 years of 19 years that were included in the study.)

Let's put all this together.  Well, first -- let us recognize that most people with Bipolar II do survive the disease without self harm or suicide.  And with proper treatment, including the correct meds, they can thrive.

That said, Bipolar II is a particularly dangerous form of mood disorder.  People with Bipolar II, already at a higher risk of suicide, increase their risk when they take antidepressants.  Nevertheless, they often do take antidepressants, because Bipolar II is notoriously difficult to diagnosis.  But a major clue to diagnosis is the side effects experienced when taking antidepressants.

In other words, Prozac is talking to you.  So are Zoloft, Celexa, Lexapro, etc. (SSRIs).  Cymbalta and Effexor (SNRIs) are shouting.  If you take antidepressants and are experiencing anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia (psychomotor restlessness), hypomania, and/or mania, your life is at risk.

  • Take an online screening for Bipolar II, a Mood Disorder Questionnaire (MDQ).  Get the people who live with you and/or are closest to you to answer it with you.  You won't recognize symptoms of hypomania.  They will.
  • Then get a psychiatrist to give you a thorough and careful screening for Bipolar II.  This will take time.  If you have to go out of network to find a psychiatrist who does more than the fifteen minute intake, pay the extra.
  • Ask whether you should quit your antidepressant.  Ask for a mood stabilizer.
  • Check out McMan's Depression and Bipolar Web and its various pages for more information.  This site has more information than Depression and Bipolar Support Alliance (DBSA).  Oddly, National Alliance on Mental Illness (NAMI) has no information on Bipolar II at all.
Because Prozac is talking.  You better listen. 
 
The Scream by Edvard Munch

4 comments:

  1. Hi Willa,

    I enjoyed the benefits of Prozac for major depressive symptoms for 12 years. When the Prozac "pooped out" I was "upgraded" to a diagnosis of Bipolar. I then began the medication merry-go-round that comes like an appetizer that doesnt quite satisfy while waiting for an actual meal. In my case the "meal" never did arrive, and after 2 years of med compliance I was left without any positive results and numerous unlivable side effects that ended as soon as all medication was stopped. That was 3 years ago.

    Prozac was speaking to me during all those years. I just didnt know what it was saying. I have since that time done extensive research on psychotropic medications. Now the medications are talking plainly, and my response is "thanks, but no thanks".

    ReplyDelete
  2. Hi, Sharon --

    I am not one to talk about compliance. But I would go for a more nuanced response. I decided to try no more than three different medications per year. I gave my body a break and did cleansing in between. And yes, I also got better every time I went off meds. But I didn't stay better.

    I finally found a psychiatrist who really does pay attention to side effects. [Note to psychiatrists: Compliance isn't a power issue. It is about weighing costs and benefits. You can be involved in the decision, if you respect the patient's experience of costs and benefits.] It took a while to build enough trust in the new doc, and a deeper plunge into my illness, and a lot of discussion about the doc's response time to concerns I might have before I was willing to try something new. The new med hasn't cured me. But it has helped.

    The thing is, they do come up with new meds. Some of the meds are overhyped turkeys, but occasionally they come up with a winner.

    Medication isn't the only tool in the handbag. I am sure you have a long list of things that help. I do too. But medication is still an important tool. If there isn't one out there that works for you now, then respect your body and soul. Abstain, and blessings on your journey. Me, I am glad that I gave it another shot.

    ReplyDelete
  3. Hey, Willa. Another great piece. And many thanks for the shout out.

    ReplyDelete
  4. Appreciated your responsible comment in reference to what appeared to be a non-nuanced approach from my short comment to your blog.

    The confines of "commenting" did not allow me to elaborate on the complicated and very nuanced approaches I took (and continue to take) during my 15 years of using psychotropic medications. I am very compliant when working with medical professionals concerning my medical care. During the two years I was working with a psychiatrist we developed numerous medication protocols, to which I carefully adhered. That said, I have found that for me I am better off without the psychotropic medications. Major depression is difficult to combat, and the use of medication for short term relief needed to, for instance, hang onto a job or maintain the momentum while career building, may be a necessity. I no longer have those concerns, so I can successfully use alternative approachs which accomodate the natural rythms of depression.

    Compliance was never an issue for me. In fact, just the opposite. Because I was so compliant, and took careful written notation of my reaction to the medications, I had a very thorough documentation of my personal response profile. This enabled me to do accurate cost/benefit anaylsis from both a short-term and a long-term perspective. I now have the same cost/benefit anaylsis using alternative treatment methods, and I like the results much better. I have not ruled out any future usage of psychotropic medications, but for me, those are protocols of last resort. So far they have not been necessary.

    Thank you for your thoughtful response to my comment. I look forward to reading future articles on Prozac Monologues.

    Sharon

    ReplyDelete