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...BECAUSE IT'S STYLISH TO TALK ABOUT MENTAL HEALTH, ESPECIALLY HOW WE MAINTAIN OUR OWN.

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medication

MedicinePsychiatry

The Drug Rep Dilemma

written by freudandfashion
The Drug Rep Dilemma

I attend pharmaceutical dinners every once in awhile because: 1) I like to stay up to date with all the new drugs (or just a slightly modified version of the generic, but with a much fancier name and packaging); 2) Though I’m several years out of med school/residency, one thing I have maintained from those formative years is the mentality where I’d never pass up a free meal.  I know that pharmaceutical sales representatives (also known as drug reps) have been banned and limited in several institutions, and I completely understand the reasoning (it has been shown that drug reps’ marketing tactics influence physicians to write prescriptions they typically would not write, thus boosting pharmaceutical sales).  However, I also think it’s important for physicians to be self-aware of their existence and influence in order to make conscious decisions on their own.

A few months ago, I attended a pharmaceutical dinner sponsored by the manufacturer of one of the newest psychiatric medications.  These dinners always feature a physician, who describes the medication (the pharmacology, indications, side effects, etc), explains the existing research in support of the medication, and leads a discussion and answers clinical questions.  My initial impression of the night’s presenting physician: charming, and since his introduction boasts the research he conducts at a prestigious university, he must be highly reputable and intelligent.  But, as his talk progressed, I realized how narcissistic and full of sh** he was.  I sat in the very front, yet chuckled to myself and assumed every other clinician in this room picked up on his suave, yet unconvincing tactics.  I mean, who was this guy trying to fool by flaunting his European accent and stories of trips around the world??

However, I looked around the room and the entire audience of doctors and other clinicians were laughing and smiling in awe.  I tried to hide my disdain and cringing facial expressions, but I sat at the very front of the room, so I’m sure others noticed. Or maybe not…I mean, everyone in the room was mesmerized by this guy!  I figured that I should refocus my thoughts and give him another chance and caught up just in time to hear about his trip to Europe.  I shook my head and thought to myself, “wow, can you believe this guy?  And he gets paid tons of money to attend this dinner and talk about himself?”  I smirked and assumed his current, pointless story-telling (aren’t we supposed to be discussing the medication?) would be convincing enough to prove his bullsh**, fake persona, so I turned to look at the audience assuming others would catch on.  Still, all smiles.

At the end of the dinner, I found myself in a dilemma as I had to pass this man on my way out as I left the dining room.  I contemplated whether I should act just as fake as his schmoozing and say something along the lines of “hey, great presentation” or should I challenge some of the comments he made?  I settled for a more neutral comment and told him “thanks, you are very entertaining” as I shook his hand and smiled.

Then, I realized at that very moment I became just like everyone else in the audience who commended and complimented him.  For a temporary, quick second I even contemplated prescribing the medication.  The thought of prescribing the medication was short-lived, for, after I left the restaurant, I snapped out of it and wished I gave him a piece of my mind.

I thought, “oh well, instead I’ll just stick with my guns and won’t be overly influenced to prescribe the med, unless clinically indicated.” (I’d never deprive my patients of a medication that might possibly help).  I now realize even more why pharmaceutical companies used to frequently provide fancy trips, extravagant dinners, and expensive novelties before policies/rules became more stringent.  The speakers and drug reps can be quite hypnotic and mesmerizing, but it’s our duty not to be fooled by any marketing tactics.

Or have I already been swayed?

July 2, 2015 11 comments
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MedicinePsychiatry

Why Am I So Tired?

written by freudandfashion
Why Am I So Tired?

{Rancho Cucamonga, California}

As I struggled to get up this morning and hit the snooze button multiple times then proceeded to turn off my alarm clock on accident (thus waking up several hours later), I contemplated reasons why I’m feeling so tired today.  I’m sure several of us try to diagnose ourselves, and sometimes jump to the worst conclusions as to the causes of our tiredness.  But before you start self-diagnosing, here are a few potential causes that I generally explore with my patients before resorting to lab tests and referring back to their primary care doctors:

1.  Are you getting enough sleep?  Lack of sleep is an obvious cause, but you’d have no idea how many people actually believe they’re inhuman and should be able to get by on less sleep without crashing.

2.  Is your schedule constantly changing?  Our circadian rhythm acts as an internal clock that guides our sleep-wake cycle.  Any disruption as a result of a change in schedule or activity (ie, I have several patients whose job schedules constantly change, such as firemen, dispatchers, etc; or college students studying late night for exams; or recent travel to a different time zone) can disrupt your cycle, thus causing you to feel more tired than normal during the day.

3.  What type of food do you eat?  If you start your day with a meal chock full of refined carbs (bagel, doughnuts, croissants, etc), your insulin levels skyrocket, thus feeling sluggish.  Also, not eating enough food is an obvious reason for low energy levels.

4.  Do you rarely exercise?  Just turning up your current level of activity up a notch (ie, if you’re sedentary, start walking, etc) has been shown to increase your energy levels.

5.  Do your workouts involve exercises that your body’s not quite yet conditioned to?  I, myself have tried various types of workouts programs and generally struggled to adjust when I first started, which is to be expected.  In the past, I’ve done boot camps and Crossfit, which I truly enjoyed, yet my recovery times were quite long (in addition, I also had to change my nutrition to adequately fuel my body).  Thus, I had several days where I’d want to nap or veg on the couch all day (leg days tend to be the worst!).  I have several patients who feel abnormal because they’re making great efforts to drastically increase their physical activity, yet don’t realize that feeling tired during the recovery phase is normal.

6.  Did you forget to take your medication?  Thyroid medications (such as levothyroxine), stimulant medications (such as those used to treat ADHD), antidepressants (such as buproprion) can drop your energy levels if not taken regularly.

7.  Is it a medication side effect?  If you were recently started on new medications and notice that you’re feeling more tired lately, then check with your doc (or search online as most people do) to check if lethargy is a possible side effect.

8.  Did you cut back on your regular caffeine intake?  Somnolence is a common symptom of caffeine withdrawal (in addition to headache, irritability, decreased concentration, etc).

9.  Did you overexert yourself with activity recently?  Work, running errands, planning a big upcoming event, etc — it’s normal to feel exhausted and need time to regroup after a busy day (or days) of activity.  Know your limits as to how much activity you can handle, or go easy on yourself if you’re not as productive on subsequent days.

10.  Are you working on some difficult material in psychotherapy?  Since I am a psychiatrist, I usually explore this possibility.  Processing difficult emotions can be draining.  I’ve experienced this firsthand and used to take naps after my Saturday sessions with my therapist.

11.  Is tiredness a sign of depression?  If tiredness is also accompanied with symptoms such as loss of interest in activities you normally enjoy, isolation, sadness, etc, then lack of energy might be a sign of depression.  Reach out to your doctor, especially if symptoms don’t improve and start impacting your ability to carry out your daily activities.

If the cause of tiredness is not apparent, then make sure to contact your medical doctor to discuss your symptoms.  However, more often the cause of tiredness is not a major medical issue.  In my practice, I find that the most common cause of lethargy is related to schedule and unrealistic expectations that we place on ourselves to be superhuman (I’m definitely guilty of this) and accomplish so much in one day without allowing adequate time to rest and refuel, thus leading to excessive stress, insomnia, poor eating habits, subsequent depression, etc.  Listen to your body — if rest is needed, allow yourself enough time to reset, relax, and gain your energy back.

Photo by Marlon Santos

June 3, 2015 5 comments
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Psychiatry

Antidepressant Awareness

written by freudandfashion
Antidepressant Awareness

I have a love/hate relationship with antidepressants, specifically selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs).  Basically, I love them when they actually help my patients, but hate the intolerable withdrawal that may occur when taking patients off of them.  If you’ve ever contemplated abrupt discontinuation of an antidepressant, consult your doctor before stopping them altogether, particularly if you’ve taken them for at least six weeks.

In my practice, I never hesitate to prescribe antidepressants when indicated, however, I always warn my patients of potential withdrawal effects that may occur if the medication was to be discontinued in the future.  Informed consent and patient education should be given before a physician prescribes any new medication.  Over the course of my training and practice in psychiatry, my observations of the negative impact of weaning off antidepressants shocked me, mostly because I never learned about the phenomena in textbooks the way that I learned about other withdrawal syndromes (such as alcohol, opioid, methamphetamine, etc).  From flu-like symptoms to acute somatic pain symptoms  — I witnessed a full range of issues (see below for a more extensive list).  The unfortunate thing is that patients often internalize the symptoms and believe there’s something wrong with them, though typically the only factor that changed since the last visit was lowering the antidepressant dose.

A telling statement was hearing a patient say that getting off an antidepressant was worse than getting off heroin.  Antidepressant discontinuation is no joke.  And the unfortunate thing is that many people aren’t aware of the negative withdrawal effects that may occur from lowering the dose or discontinuing the antidepressant.  I was fortunate to have an amazing mentor during residency training, who taught me that “slower is better” when it came to lowering the dose of antidepressants.  A literature search for any research articles regarding weaning off antidepressants yields little results, therefore, guidance on how to take patients off of them is minimal.

I am NOT writing this post to bash antidepressants especially since they have improved the quality of life of many.  However, I AM writing this post to raise awareness because I see this issue OFTEN.  And if this information encourages one person to advocate for him/herself and the symptoms they experience, then mission accomplished!

Possible Antidepressant Withdrawal Symptoms:

  • insomnia
  • agitation
  • worsened anxiety
  • resumption of depressive symptoms
  • headache, “brain zaps”
  • stomach upset
  • flu-like symptoms
  • increased pain
  • tiredness
  • nightmares
  • dizziness
  • suicidal thoughts

 

March 20, 2015 21 comments
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Psychiatrytherapy

Mind Over Meds

written by freudandfashion
Mind Over Meds

{Claremont, California}

Some of you may have noticed that although I am a psychiatrist, I rarely comment nor write about my thoughts on psychiatric medications in my blog.  I did write a post as a resident physician-in-training in 2010 titled Pill Pusher, which briefly describes my general approach to simplify, minimize, and streamline medication regimens to the least amount of meds needed to provide symptom relief.  In some cases, I have successfully worked with my patients to wean off and discontinue all of their psychiatric medications, though the process requires much patience, toleration of uncomfortable withdrawal symptoms, and numerous non-medication approaches to maintain stability off of meds.  And most importantly, I believe a trusting doctor-patient relationship is needed to provide education of potential withdrawal symptoms, encouragement to push forward, and processing fears that may arise from being off medications for the first time in years.

Now, please do not mistake me for a protester against pharmaceuticals — I witness the positive impact that medications can have on enhancing the quality of life of my patients on a daily basis.  However, I do not attribute the improvements primarily to medications.  My treatment plans generally promote the development of insight and self-awareness of mood patterns, anxiety triggers, etc, and oftentimes explore how past suppressed emotions may contribute to current symptoms, all of which are topics I aim to emphasize in my blog.  Medications may stop working or provide temporary relief, but knowledge of one’s self can last a lifetime.

Photos by Marlon Santos 

December 20, 2014 2 comments
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