Some things you may not know about antidepressants.

Antidepressants have been around for fifty years. The first one was imipramine. How they work on the brain and central nervous system has not really evolved  much over the last fifty years. Our understanding of why and how they work has evolved, and the bottom line is we still don't know exactly why or how they work. They tend to effect neurotransmitters in the brain, that is the chemical connections between nerves. The three big neurotransmitter we know the most about are serotonin, norepinepherine and dopamine. The old and most of the newer antidepressants inhibit reuptake of these neurotransmitters into the pre-synaptic nerve. The original theory on why they work was related to the fact that you kept more serotonin or norepi around and this somehow helped treat depression.
Then in the 80's, 90's and into this century more attention was paid to the area on the nerve cell where these chemicals bind to. The so-called synaptic neuroreceptor.
For a long time it was felt that because you kept more of the neurochemcial around and it moved forward from the presynaptic to post synaptic nerve site, that somehow the neurorepceptors got desensitized or "downregulated".
Over the last 10 years the theory has evolved even more as to why these things work to treat depression and many anxiety disorders.
Now the science has led us to believe that the binding of the neurochemical (caused by keeping more of the chemical around) cause changes within nerve cell and somehow this affects the genetic coding of proteins within the cell, (remember RNA and DNA?) and somehow this causes an uptick or a positive swing in encoding for proteins within the cell that help protect the cell and treat the depression or anxiety problem.
The theory continues to evolve.
Some other facts- most antidepressants are prescribed by primary care physicians, internists, obgyns, and even pediatricians. Yes psychiatrists prescribe them all the time, but there are a lot less psychiatrists, and in terms of total volume of scripts, more come from primary care.
For many reasons, culturally speaking, it is much more socially acceptable to be depressed now. We are more open to talking about it and being aware of it. Depression is still debilitating and potentially fatal and we have a long way to go. Primary cares screen for it better now.
Within the demise and so called restructuring of the health care system in this country, there is much buzz and initiatives to screen earlier, treat and be aware of depression and its consequences.
The problem is now in screening for it, there is a tendancy to diagnose most mental health problems and simplify them simply into depression. The screenings will pick up symptoms of depression, but often not the specific and primary mental health problem. for examply Bipolar disorder (horribly misdiagnosed) and often missed and PTSD or post traumatic stress disorder, to name just a couple.
There are a whole host of antidepressants out there, the SSRI's which were developed back starting in the 80's with prozac, then in the 90's and into this century. Zoloft, Paxil, Luvox, Celexa and Lexapro.
The SNRI's which stands for selective noradrenergic serotinergic reuptak inhibitors, Effexor, Cymbalta, Pristiq. Basically these work pretty similarly to the old imipramines and elavils of the 60's and 70's, with a couple huge differences. The newer ones have way less side effects, and they are not so lethal alone in overdose. They are also felt to be more effective by many, compared to the old ones, -which may be a product of the fact that they are eaiser to take and tolerate and stay on since the side effects are better. The key to antidepressants working, is staying on the meds. They don't work if you don't take them.
Antidepressants have been used to treat chronic pain almost for thirty years. It was generally off label meaning the FDA did not approve or recognize these things in use for chronic pain. Then the popular media campaign came that "depression hurts" and cymbalta being approved for various pain problems a few years ago. Sometimes they really work well and sometimes not for chronic pain.
You do get more physical aches and pains and such if you are depressed. That is not new and has been known like forever in the medical world, well at least the psychiatric medical world.
Antidepressants are not there to hurt a patient or make them worse, and they do save lives. We are taught as a society to be afraid of them, suspicious of them and wary of them. Popular culture and media and the government regulation and subsequent media fiascos make this worse.
Conversely we are also taught and expect that these meds are a panacea, a cure a fix it all for all of our emotional and psyhoclogical pains. That simply isn't true. But with those two polar ends of the spectrum suspicion, fear,  and an attitude of this "should fix everything', you have the perfect storm.
There are many other antidepressants out there I did not mention, so that block certain receptor sites like Remeron and Serzone and Trazedone. They have also been around for years. Wellbitrin tends to block reuptake of dopamine and norepi. Some people generally like Wellbutrin becouse it does not affect weight gain like some of the others can. It sometimes does not work so well for anxiety symtoms often associated with depression.
There is a ton of information on antidepressants on the Internet. We tend to love the devaluation of them, and when we find a negative article on them we like to say "Aha I knew it" as if they are bad and there is some awful conspiracy. Some psychiatrists have even made a cool name for themselves in devaluing them. Very politically correct. We also tend to devalue them in this way:
Think about it: the average family doctor has a few weeks of training in psychiatry but they prescribe the most antidepressants.  Non-physicians prescribe them- nurses practicioners, in most states and also psychologists want to prescribe them and in a couple states they are actually legally allowed to.
 We convince ourselves that is all okay. It is not. This comes from the shortage of psychiatrists. Most doctors don't want to go into psychiatry. For a lot of reasons. It is very little pay compared to most medical specialties, with health care reform that will only get worse. Also people don't always get better, it takes a long time and a lot of psychiatric problems tend to be chronic and recurring.
so you will see more unqualified and marginally qualified people prescribing and treating psych disorders.
The sell-out blogs jump on the politically correct bandwagon of supporting psychologists and the so-called mid-level practitioners, prescribing, as well as non-psychiatric physician. With that comes an underlying devaluation of psychiatry in general. You are not allowed in this day and age to even consider that maybe a specialist in psychiatry should be treating many psych problems out there. That is so politically incorrect, you get lambasted and you are very unpopular, so most doctors can't even speak up any more. It is just the way the world is. But with the sort of disdainful reduced attitude towards psychiatry and mental health issues in general, and the lack of accurate information that is truly disseminated, it is easy to see why we are so wary of psych treatment.
Before I get hate mail yes there are good nurse practicioners out there, just like there are good physicians out there.
Generally the popular buzz is "doctors don't talk to their patients, but nurses do". I am sure that is true in some case, but we like to convince ourselves that this is the norm. It is probably going to get worse with health care reform.
Antidepressants are used in Alzheimer's, People with AD can get depressed, it make the AD worse. They often can't articulate it to us, becouse of the dementia, so it is often overlooked. You generally have to use much smalled doses of antidepressants in the elderly (like any med) sometimes if not carefully prescribed or prescribed wrong they can make things worse, and if diangosed right and carefully monitored they can help tremendously.
There is much more to talk about with antidepressants, the suicide issue (horribly misunderstood) side effects, target effects, (what they are actually supposed to do. All of the natural remedies, (chemicals also like the meds) they are a financial; boom to many and severly unregulated, but as a fairly uninformed society or shall I say misinformed, if we hear the world "Natural" we are profoundly reassured.  Stay tuned.

Pending Book Tour and other Musings

Book tour in Florida next week. I will be  doing a reading and signing and talking about the book and all about AD next week. It's weird but I was trying to figure out which sample pages of the book I would read for the book signing. I read a part about some mean laughing on-lookers at my mother's inappropriate social behavior, when I took her to a restaurant when I was seventeen, that one seemed okay. I guess it covers some of those universal concepts of Alzheimer's family members, the ignorance of the fellow human being manifesting as mean-spiritedness-

but then I read one about a patient I had, whose wife had AD. It was quite a few years ago, I actually got choked up reading it. I have had thousands of scenarios like that. You don't get to get choked up as a doctor-ever, no matter how much it goes against your human nature. This is especially true in psychiatry. I guess that is one of the reasons so many people hate psychiatrists- shrinks. I spose oncologists get to cry with their cancer patients and that is cool, but psychiatrist don't get to. 

I know crappy therapists get to cry with and hug their patients, but it does not work in the end, It is boundary less. It looks coll on TV and for Hollywood. But it is not the right thing to do. You get to convey compassion and empathy without crying with your patient, most psychs don't get good at that, easy to throw meds at people. Part of the reason psychiatrists are seen as such heartless bastards. 

So why don't you get to be emotional?  Well it may seem kind and sensitive, but in the end, the patient is not going to know where they and you start and stop, it conveys a pseudo-trust, but ultimately the patient can't trust you, I mean your affect (emotions) will be as sad and anxious and uncertain as theirs. Unconsciously the patient thinks they have to take care of the therapist or doctor. The patient does not feel safe, it feels out of control, for them.  They don't teach boundaries so well anymore, in fact you have to work at it to find good psychotherapy training in this day and age.  Oh and shared experience is not the same as empathy. That is a toughy for most people to get. The ultimate sign of a good doctor, conveying empathy and positive regard to your patient without loosing your emotions and boundaries. 

Yep I hear 200 tragic, painful, anger-provoking, tear-jerking stories a month. you get to be sort of an emotional factory worker, an empathy machine, cause it is the right thing to do. You owe 1,000%, you took an oath, and people depend on you with their lives.

Anyway I am amazed as I read parts of this book I wrote, some of it years before and can still become choked up. 

Blogging about Alzheimer's and Social Responsibility?

     After Joe P's last post a couple of weeks ago, I started thinking about the purpose of this blog. Joe says people with AD read the blog (I am not sure who besides Joe) but then again it is a blog. Joe's posts have been fantastic and articulate, I know he works hard on them and for someone with AD, he challenges all of our stereotypes of an Alzheimer's victim.
     I wish there was a way I could get rid of Joe's disease to make him well again, for every victim and every family I wish I could do that. If someone waved a magic wand and said change your blog or stop blogging or jump this high and you will cure Alzheimer's- wouldn't that be fantastic? Joe talks of the frustration in reading this blog, not always understanding what I am posting. This shows the same frustration and the helplessness and out of control feeling I felt with my mother many years ago, as she succumbed to the disease. I still feel it for Joe and the five million other people suffering with the disease and the 40-50 million loved ones affected. All those feelings.
     I know if I tried to change the blog it would not stop the out of control disease. I wish I could.
     The posts are getting a little hard for him to read and of course being a person who happens to be a doctor and a physician and basically spending all day, every day trying to help people giving all of one's inner strength to others to help and heal them (because that is what being a real doctor actually does, ( contrary to our societal prejudice and stereotyping of physicians and psychiatrists.), I started thinking are my sometimes angry, even sardonic, sarcastic yet honest posts not nice? not helpful? not therapeutic?
     Do we blog for ourselves or do we blog for everyone else?
     I am not interested in making anyone feel bad or confusing them-with hard to read posts or in any other way, so honest to God, if you read this blog and you are a caregiver or a victim in early Alzheimer's stages and you read this and it makes you upset in any way, DO NOT READ IT. That is not the intent.
     I promise that there are thousands of blogs out there written in so many different ways, some offensive or hard to understand and some much more self-help and user friendly than this one, and everything in between.
    I hope it helps some people by providing info, knowledge or wisdom or experience, but that was never really the primary goal. In fact the primary reason for blogging was to just write, to blog. I know sometimes the posts are helpful, filled with info that might not appear on other blogs. Sometimes it is just writing and publishing, and it is about the reader, like a book, a connection for better or worse, between a writer and a reader.
     Other people get to blog freely, so why can't I, freely and honestly? Pressure and a conflict in myself.  If I blog as a person who happens to be a physician, do I have an ethical obligation (that others don't) to always try to make my blog helpful to people? Thereby compromising my integrity, freedom and honesty? People complain so much that physicians are not human and disconnected, so if you are human like in this blog: I have learned that people are not always happy with that either. People are not really comfortable letting go of their stereotypes of docs.
As much as people have their terrible misguided animosity towards physicians or psychiatrists, based on their own terrible experience that they expected or they heard about from someone else, would it be better to start over and lie (like some many blogs out there and pretend I was something other than what I am?) I guess I just can't do it.
     I promise not all psychiatrists are low life weasels, but so many people need to hold onto that, serves some purpose. Frankly it gets a little old. Truly it upsets some people if you even try to defend your profession, you just can't win.
    My book like the blog, sort of lets people in on quite a few things, that are totally upsetting to read about and certainly not something the medical world openly discusses. People don't like that part, it makes some mad, I get so tired of pretense and lack of honesty, so someone needs to talk about things.
    This blog is not really clinical, it is just my thoughts and feelings, not meant to be above or below any one's intellect. Its just how I think as a human being, we all get some slack don't we? I mean sometimes it is clinical but sometimes it is just thoughts, that's the beauty of blogging isn't it?
     When I went into psychiatry, 20 years ago, I really thought it was the most humane of medical specialties in so many ways. It took many years to figure out what a scapegoat the entire profession is. Think about it, people bring their terrible upbringings to you- pain, trauma, abuse, in-humanness, terrible experiences, with an expectation that another person will fix it all. Do you think a little of the pain, rage and anger,  if not like all, gets displaced onto that "SHRINK" especially when they can't fix it all. Throw in the wonderful world of psychopharmacology and there you have it.
     Perhaps the toughest part of the work, the most emotionally grueling aspect, is that as a doctor you basically give up most of your life in an effort to help others, you must treat everyone with the same empathy and compassion and positive regard, no matter how much your moral compass disagrees or disagrees with the actions of that person you have taken an oath to care for, you still care.
     In other words think about it, you get to (you must) treat a child molesting, murdering, rapist, in the same nonjudgmental compassionate way as you would that sad depressed old lady who is now widowed and whom basically gave up her whole life serving others and is now suffering with Alzheimer's disease- and do all that in the span of a half hour.
  
       Remember we are all connected by this disease, 5 million people have Alzheimer's. I hope this blogs helps somebody, if only by enlightenment, validation or simply, entertainment. I have considered the original intent of the blog, and always struggled with the moral or social responsibility or obligation I might have in blogging, I mean I'm not practicing medicine, I'm just blogging. Somehow by speaking the truth, my Truth, am I violating that social responsibility, probably not, I am just letting some people down maybe, by challenging some of their pretenses. If as a blogger I do have some higher ethical obligation to do whatever I can as a blogger (who happens to be a person and a doctor) wouldn't everyone who blogs, every human being have that social responsibility and ethical obligation as a human being to help others in some way? Yes? or No?