In Relationships, We Either Trade Up or We Trade Down

Here’s a question I hear often when doing counseling and the issue turns to relationships:

How do I continue to pursue a relationship with my significant other while at the same time retain my independence?

My answer is always the same:

You’re asking the wrong question! Why? In relationships, we either trade up or we trade down.

A better question to ask would be: What criteria should I establish for choosing my partner?

Those that choose partners consistent with the values and attributes most important to them in a mate will want their new, enriched life more than they want their old one, so retaining independence becomes irrelevant. It’s trading up, out with the old life in favor of a new, more fulfilling one. No sacrifice required. On the other hand, those that sense that they are trading down to be with someone means they haven’t yet found the right someone. In this instance, independence should be the only thing they’re pursuing.

Augmenting Antidepressants with Deplin (l-methylfolate)

Vitamin B folate or folic acid – active in citrus fruits, legumes, green, leafy vegetables – is yet another arrow in the psychiatrist’s quiver for managing treatment – resistant depression (TRD).

Deplin (l-methylfolate) is a folic acid type of derivative. Deplin helps normalize amounts of the neurotransmitters norepinephrine, serotonin and dopamine when used in conjunction with antidepressants. Folate is also crucial to the production of S-Adenosyl-Methionine, or SAM-e, which aids in the synthesis of nerve cell membranes and activates norepinephrine, serotonin and dopamine – three neurotransmitters linked to depression. Numerous studies have found that depressed patients consistently have lower serum folate concentrations.

Escitalopram (Lexapro) Approved for Treatment of Major Depression in Adolescents

Escitalopram (Lexapro), has gained FDA approval for the acute and maintenance treatment of major depressive disorder (MDD) in adolescents ages 12 to 17 years.

“Adolescent depression can often be challenging to treat because there are limited treatment options that are proven to be effective and well tolerated in this patient population,” noted Graham Emslie, MD, professor of psychiatry at the University of Texas Southwestern Medical Center in Dallas, in an FDA news release.

Escitalopram (Lexapro) is the second antidepressant to be approved for major depression in adolescents. The first was fluoxetine (Prozac & others).

Metabolic Monitoring in Patients Utilizing Antipsychotics Considerably Lacking

Among insured patients initially prescribed second generation antipsychotics, monitoring of blood sugar and lipid levels falls very short of the 2004 American Diabetes Association (ADA) guidelines, researchers report. The guidelines are based on the considerable evidence that these medications can increase risk for cardiovascular disease by adversely affecting lipid and glucose metabolism as well as body weight.

By 2006, the study showed just over 10% of patients that were newly prescribed second generation antipsychotics received lipid profile monitoring and just over 20% received blood sugar monitoring. These numbers are abysmally low. And what’s to be said for the numbers regarding uninsured patients?

At a 2004 conference, four key organizations – the American Diabetes Association, the American Psychiatric Association, the American Association of Clinical Endocrinologists, and the North American Association for the Study of Obesity – recommended that all patients receiving these atypical antipsychotics have fasting blood glucose and lipid level determinations at baseline and after 12 weeks of treatment. Younger patients were the least likely to be screened and monitored, before and after the guidelines were issued.

So why aren’t these monitoring guidelines being followed. I’ll venture a couple of answers. First, these drugs are most often prescribed by psychiatrists, and psychiatrists tend not to treat the whole patient. Instead they tend to focus solely on what brought the patient to their office or to the hospital in the first place, such as a manic, psychotic or depressive episode, often overlooking the medical comorbidities in these patients. Second, psychiatrists often don’t have established relationships with primary care physicians for referral purposes. And outside of the initial screening and evaluation, psychiatric appointments are no more than 20 minute med checks. Rarely are “physical” systems issued stemming from the use of certain psychotropic drugs discussed.

When seeing a client for psychotherapy who is using a second generation antipsychotic, I always inquire as to whether or not they have had any glucose, lipid and cholesterol level blood work. If so, I ask them to obtain a copy of the reports for inclusion into my file for this client. If not, or if they can’t remember, I ask that they make an appointment with their primary care physician as soon as possible to have this done. If the client doesn’t have a primary care physician, I assist them with finding one.

I also send the treating psychiatrist a brief note asking that he or she consider the monitoring guidelines recommended for patients prescribed these antipsychotics. And when my client is coming upon a psychiatric visit, I write out a similar note, and give it to them to take along to the appointment. With some clients, I will even do a role play exercise prior to their appointment to help increase their comfort level with broaching this issue.

The bottom line is this: clients need to approach physician appointments with that time honored Boy Scout motto in mind: “Be Prepared.” And we clinicians can help by reminding them that if reasonable requests regarding their care are discounted or ignored, they probably need to transfer their care to someone else.