Post Traumatic Stress Disorder: The Controversy

Post Traumatic stress disorder has stirred up a rather frothy debate over the last few years, especially around the definition of the traumatic event that precipitates the symptoms. It is by no means controversial that extremely traumatic events (combat veterans experiencing the perils of war, physical abuse, sexual abuse, natural disasters) should qualify as criterion, but what about purely psychosocial events without some type of physical injury? In DSM IV, an individual is not required to have directly experienced the trauma. In fact, the individual can merely witness it or just hear about it.

Of concern, has been a persistent expansion of what I refer to as “criteria creep.” Namely, an expansion of what constitutes a sufficiently serious enough trauma to categorize an individual’s symptoms as PTSD, as opposed to understandable feelings (anger, anxiety, agitation, irritability, frustration, etc.)  Examples include: watching a movie or a television show that is distressing, witnessing a real-time violent event, or hearing condescending comments about oneself.   

So does PTSD even exist? In a study conducted by researchers at McLean psychiatric hospital in Belmont, Massachusetts and reported on in the J. Anxiety Disord. 2007; 21: 176-82, one hundred and three subjects were asked if they had ever experienced a traumatic event. Even if they answered no, they were asked about symptoms of PTSD. Of those that had a traumatic experience, 78 percent also met symptomatic criteria for PTSD. Of those, who had never had a traumatic experience, 78 percent met symptomatic criteria for PTSD!

What does this mean? PTSD is not necessarily a post traumatic disorder, but instead a non-specific constellation of symptoms that often occur with or without trauma. It may therefore be inaccurate to assume that the symptoms are caused by trauma.

PTSD earned DSM diagnostic criteria after an analysis of the thoughts, feelings and behaviors of soldiers associated with the Vietnam War. Interestingly, reports indicated that approximately 33 percent of Vietnam veterans suffered PTSD at some point. Only 20 percent had ever seen combat.

Suggestions are being made that DSM V tighten up criteria such that only those that directly experience trauma can be assigned a diagnosis of PTSD; doing so will aid in demystifying what constitutes a sufficient trauma, and even more importantly, what doesn’t.

The Benefits vs. the Risks of ADHD Drug “Holidays”

The issue of drug “holidays” – a short-term, deliberate discontinuation of ADHD medication – is also known as a structured treatment intervention. These so-called “holidays” can take place over a weekend, a full week or an extended school vacation. There is no definitive conclusion as to the benefits or drawbacks to drug holidays. Some prescribers maintain that because ADHD is a chronic disorder, suspending treatment is not in the patient’s best interest. But for parents that are concerned about “over-drugging” their children, drug holidays can be a welcome relief, even if only a perceived one. There are essentially three purposes for initiating a drug holiday:

• - To demonstrate the clinical need for medication to be continued
• - To provide a temporary respite from side effects such as anxiety, insomnia, gastrointestinal disturbances and weight loss
• - To satisfy the notion of caregivers that medication should not be used if it can be avoided

Some studies have found that weekend holidays from methylphenidate psychostimulants reduced insomnia and appetite suppression without significantly increasing ADHD symptoms. These side effect improvements were reported by parents, and extended to the Monday following the weekend, as reported by teachers. However reports by physicians that treat ADHD indicate that patients can experience difficulty adjusting to re-dosing for one to three days after their drug holiday is completed. Drug holidays also mean that the child will likely suffer from the symptoms of ADHD at a time when he or she would want to be able to enjoy time with family and friends. These relationships run the risk of becoming strained because of the child’s symptoms, particularly if medication discontinuation extends beyond a weekend.

Clinically, I am not a fan of drug holidays. In my estimation, the risks of symptom reemergence far outweigh the relatively short term benefits associated with a decrease in side effects in a child that has been responding favorably to psychostimulant medication. It is important to note that symptom return is rapid for most following drug stoppage, albeit somewhat delayed in the patient using the longer acting stimulant preparations. There is also little disagreement in the clinical literature or among clinicians experienced in treating ADHD regarding long term weight and height issues. That is, although weight loss and growth suppression can be consequences of stimulant use, these consequences are typically not long term, in that as children age throughout the developmental cycle, they tend to “catch up” in both weight and height.

Gradual dosage reduction over time seems to be a more viable option than the “cold turkey” discontinuation approach – even if it’s just for a weekend. The bottom line: The discontinuation of stimulant medication in a child for whom the drug has been effective means a re-experiencing of the nightmarish symptoms that plagued both the child and family.

The Challenges of ‘Father Time’

Both medical and non medical clinicians will likely be seeing more elderly patients as the oldest of the “baby boomers” are on the cusp of retirement. In the United States, people aged 65 and over make up just 13 percent of the total population, but account for 30 percent of all prescriptions written.

Changes in mental status can be drug related. For example, benzodiazepines (Valium, Xanax, Ativan), can cause drowsiness, confusion, prolonged sedation and memory loss.

Watch for signs of noncompliance. It sometimes takes longer to see a therapeutic effect with psychotropic medications used in seniors, placing them at risk for abruptly discontinuing their medications due to slowed response rates. Advancing age is often accompanied by less patience. Older adults should be encouraged to continue to take their medications unless otherwise instructed by their physician or other prescriber to discontinue.

Memory tends to decline with age also. Encourage aging patients to enlist the aid of a family member to help them keep an updated list of medications with them at all times. Other family members should have this list also.

Elderly patients may be obtaining their prescriptions from more than one pharmacy. Encourage them to use only one source for the purchase of all medications – prescription and over-the-counter. All major pharmacies have computer software than can scan for potentially problematic drug interactions.

Finally, watch for additional medications prescribed to ameliorate the side effects of an already prescribed drug. For example, a sleep aid may be prescribed to offset the side effect of insomnia from an antidepressant. This can set up a potentially dangerous and vicious cycle of polypharmacy, and should be brought to the attention of the patient’s prescriber immediately.

Bipolar Mania and Medication Noncompliance: A Peculiar Treatment Challenge

One of the most significant challenges I face as a pharmatherapist is getting my bipolar clients to continue taking their medications as prescribed. More often than not, the culprit driving inconsistent usage patterns is the thrilling and invigorating manic “high.”

The manic phase of bipolar disorder carries a peculiar treatment challenge that most other mental disorders do not: Because mania is a desirable and enjoyable state for many, if not most patients, medication noncompliance is a particular hazard during these manic episodes. Repeatedly starting and discontinuing mood stabilizers results in erratic blood levels of these medications and a subsequent decrease in their overall effectiveness. This, in turn, can lead to an increased susceptibility for the occurrence of future episodes, a progressive worsening of symptoms and a heightened mortality risk. Clinicians should continually emphasize the serious risks of noncompliance with these patients and focus on coaching them to take these medications as prescribed.

Enlisting the assistance and cooperation of the bipolar client’s family members can prove to be a significant asset toward gaining medication compliance. Family members are our de facto healthcare specialists and are too infrequently utilized by prescribers and therapists as sources of information regarding the client’s progress (or lack thereof). They are often first to recognize the warning signs of symptom reemergence and can serve as our first-line allies in getting their de-compensating, medication noncompliant bipolar loved one back on the road toward progress.

What About That Antidepressant You’ve Been Prescribed?

1.  First and foremost, you should know that depression is a real illness, not a character flaw or a weakness. In this regard, it is no different from diabetes or hypertension, and it is highly responsive to appropriate treatment, which may include more than just medication alone.

2. You should know what to expect from antidepressant medication. At least 50 percent of individuals who will respond to antidepressants begin to demonstrate improvement within a week of treatment initiation. Likely you’ll begin to notice an increase in your energy level first, followed by a gradual improvement in mood and overall physical functioning.

3. Typical side effects. All antidepressants have similar efficacy, but most antidepressants have different side effects. Your prescriber should have informed you about the typical side effects of the antidepressant that was chosen for you. If not, there are countless sources where you can find this information. My book, Psychopharmacology: Straight Talk on Mental Health Medications, (Pesi, 2008) discusses the side effects of all of the widely used antidepressants. It is important to understand that many of the side effects you initially experience will diminish over time. So stay with it!

4. Antidepressants are not habit-forming or addictive, so you won’t get “hooked” on them.

5. If the first agent prescribed does not help you after an adequate trial period, others may be tried. Until science unlocks more of the mysteries of the brain, we’ll just have to live with a “no one-size-fits-all” approach.

6. Take enough for long enough. The best chance you have of getting an antidepressant to work for you is to continue taking it day by day unless the prescriber recommends otherwise. Keep a running diary of the symptoms you’re experiencing. For example, if before starting the medication you felt sad, empty, had lost interest in pleasurable activities, were sleeping poorly and losing weight, make notations in your diary as to which of these symptoms are improving and which ones are not. Keep your doctor informed, schedule follow-up appointments and make sure to report any bothersome side effects that continue to persist.

7. Never abruptly discontinue an antidepressant. Although not considered dangerous, some people who suddenly stop these drugs report “shock-like” sensations in their extremities, particularly the hands and feet. Discontinuation of antidepressants is best done gradually to spare the consumer this unnecessary upset.

8. Take your medication at the same time every day, whenever possible. If you miss a dose and then take it within one to three hours after the regularly scheduled time, that’s fine. If you remember having skipped the drug several hours later, then take it at the next regularly scheduled time.

9. Too much information can fuel a climate of hypervigilance and alarm. Reading up on your medication on the internet or devouring every word of information stapled to the prescription bag can worsen your fears. Most of what you read will never happen, and all of that extraneous information is really for the prescriber, not the consumer.

10. Beware of direct-to-consumer advertising. Remember that the media is not necessarily on your side, they’re out to sell their product and will glorify its benefits while casually mentioning its risks. It’s perfectly okay to ask whether a specific antidepressant may be helpful, but optimally the decision as to what drug is best for you is between you and your doctor. And that decision optimally will hinge on your personal and family history of depression as well as any previous experiences you may have had with antidepressants.

Antidepressant treatment has come a long way. Gone are the days of debilitating side effects and other complications that in some instances were worse than the depression itself. And remember that finding the drug that is right for you should always include and value your input into the decision making process.

If the Depression Continues, Then What?

I remember all too well years ago the advertisements in psychiatric journals stating that antidepressants will “restore the person within the patient,” and although these medications have indeed made a dramatic difference in the outcome of depressive illness, they are by no means the miracle drugs that some thought them to be. In fact, a paltry 30 percent of depressed clients achieve remission (defined as a 50 percent reduction in the severity of symptoms via rating scale determination) on their first antidepressant trial with competent care.

Throughout the many years I have been treating depressed clients, I have come to think of depression not as a diagnosis, but instead as a constellation of symptoms with many possible causes. So what is the clinician to do after a patient did not benefit from the first antidepressant trial? The following list should be considered, but it is by no means exhaustive.

1. Wrong diagnosis. Many subtypes of depression require treatment strategies that extend beyond a simple course of traditional antidepressant therapy. These subtypes include: seasonal affective disorder, atypical (anergic) depression, depression due to medical illness, comorbid substance abuse and bipolar depression, to name just a few. Conventional antidepressants (SSRIs, SNRIs, Wellbutrin) are typically not efficacious in bipolar depression. In the presence of nonresponse, the clinician will be well advised to reevaluate the initial diagnosis.
2. Check the dose. Has the medication possibly been dosed too low? Has the client actually taken the medication as prescribed and for a long enough period of time (at least four weeks)? More often than not, a failure to respond may be due to inadequate compliance.
3. Monitor for substance abuse. I’ve worked with few depressed clients who honestly report their use of alcohol or other illicit drugs. This is the ten ton gorilla in the room that must be addressed. Ongoing substance abuse in depressed clients sabotages their response to antidepressant medication – period!
4. Augmentation. Augmentation refers to the addition of medication from different chemical classes or to the combination of antidepressants. Drugs that can be added to antidepressants include: lithium, thyroid supplements, stimulants, and second-generation antipsychotics. An increasingly common antidepressant combination is Cymbalta + Wellbutrin.
5. Mechanical strategies. When pharmacological augmentation strategies don’t work, consider electroconvulsive treatment (ECT), transcranial magnetic stimulation (TMS), or vagal nerve stimulation (VNS).

The challenges inherent to treating clinical depression render it a particularly appropriate condition for a collaborative model of care. Non-medical clinicians and prescribers must work closely together to ensure the best possible results. Medication treatment and psychotherapy work hand-in-hand for providing hope to our clients, and well intentioned clinicians understand that when collaboration is frequent, meaningful and goal-directed, treatment outcomes are enhanced.

Is Your Teen or Child Buying Prescription Drugs Online?

Sixth-graders are ordering prescription medications over the Internet — illegally. And their parents haven’t a clue.

That’s one of the shocking facts in “You’ve Got Drugs!” an annual report on Internet access to controlled substances from Columbia University’s National Center on Addiction and Substance Abuse. The report, released late last year, also points out that while 18 U.S. states either have or are considering laws that restrict the sale of prescription drugs over the Internet, researchers were able to locate 365 Web sites offering the medications. Of these sites, 85% do not even require a prescription. Some even sell online-only consultations with physicians willing to write prescriptions that consumers can fill at their local pharmacies.

To be sure, many online pharmacies are legitimate. But this type of illegal activity places their reputations in jeopardy. That’s because federal laws and regulations lack both the teeth and the funding to stop these illegal sales.

It is no startling revelation that kids these days are Internet-savvy. One 16-year-old who started ordering illegally off the Internet at age 11 put it this way to the Columbia researchers: “I doubt laws will work because if there is a will, there is still most definitely a way. You find ways and means to get whatever you want.”

This reminds me of a television commercial that ran several years ago, asking: “It’s 10 p.m., do you know where your kids are?” Now the question is, it’s the Internet – do you know what your kids are doing there?

It’s hard enough raising responsible kids without having to worry about what they’re doing behind our backs. Without a doubt, the Internet is a prolific 21st century marvel when it comes to accessing information and the advancement of learning for children. These benefits come at a price, however. The Net is also the largest playground ever for kids to encounter all sorts of temptation.

If your kids have purchased drugs illegally via the Internet, or if you suspect they are trolling Web sites tempting them to do so, here are some options for action:

• - Option 1: Talk to your kids. Explain what’s wrong with buying medications illegally, in terms they can understand. Tell them in no uncertain terms that you strictly forbid them to buy drugs on the Internet. Be specific about the consequences (your choice here), and make it clear that disciplinary actions will be enforced on the very first violation.
• - Option 2: If you suspect or find out that option 1 isn’t working, move the computer out of the kids’ bedrooms and into common spaces (living room, kitchen, etc.). Tell them that the computer will remain in a common area for a set period of time, so that you can monitor their Web use.
• - Option 3: If options 1 and 2 aren’t working, check the computer’s browser history. Yes, this is spying. But if you believe your child is really involved in an illegal activity, you have an obligation to investigate.
• - If options 1, 2, and 3 fail, install parental blocking software or Internet filters. These programs let you create a list of Web addresses and keywords the computer will be unable to open; some also generate reports on Internet use and block certain types of interactions. Popular brands include Net Nanny, Safe Eyes and CyberSitter, and they typically sell for $30 to $60. This is your last resort, short of banishing the computer from your home.

In spite of these actions, as the above mentioned 16-year-old pointed out, “If there’s a will, there is still most definitely a way.” Still, you need to do the right thing. Perhaps your kids will thank you later. Either way, raising children and teens to act responsibly and enforcing appropriate behavior, are the toughest tasks you will ever take on.

Medicating Pediatric Bipolar Disorder: Challenges and Concerns

There’s little doubt that the diagnosis of childhood-onset bipolar disorder is on the rise. Office visits by children diagnosed with bipolar disorder multiplied 40-fold from 1994-2003. Disagreements abound as to what this means. Some researchers view the trend as a sign of progress: A disorder that has long gone undiagnosed in children is now being better screened and treated. Others, however, are more skeptical; they perceive the trend to be an example of gross over-diagnosis.

In truth, bipolar disorder is quite difficult to diagnose in children, and the presentation of childhood mania differs dramatically from adults. Children in the manic phase of the disorder tend toward extreme agitation and destructive outbursts, as opposed to the euphoria more common among adults.

The most widely used medications in the treatment of pediatric bipolar disorder are lithium and Depakote. Although studies confirm the effectiveness of these medications, their safety is questionable due to the life-long nature of bipolar disorder. Long term lithium use is linked to weight gain, acne, tremors and kidney dysfunction. Prolonged Depakote use is associated with pancreatitis and liver failure. Both medications require stringent blood-level monitoring. The bottom line: The benefit-vs.-risk of medicating childhood-onset bipolar disorder is a considerable concern.