I had the pleasure of teaching a group of adult and family NP’s about depression and anxiety disorders last week. They have a large proportion of patients with mental health needs, who are unable to access specialty mental health care. Why is that? I was impressed with their questions and concerns about treatment of mental health needs in their care.
It is interesting, because others (specialists in psych) have questioned if primary care providers should be treating psychiatric patients without specialized knowledge and course work in mental health assessment, psychopharmacology, neurobiology, and treatment methods. While generally I agree that there is a great difference between a primary care provider managing psychiatric needs and a psychiatric mental health provider’s care, the reality is that they probably are not managing these needs by choice. I can see at least 4 reasons a lot of this care occurs in primary care by non-psych specialists:
1. Simple non-complex needs like depression improve with medications alone in some cases. (this of course ignores the fact that depression is a recurrent disorder that benefits from other therapies in addition to medication)
2. Psych specialty provider waiting lists are long (3-6 weeks consistently at least in Connecticut for adults, more than double this for children or adolescents). So many patients improve with meds within this time frame and lose the motivation to go for specialty care.
3. Lack of insurance coverage to cover specialty psychiatric care – this was reported by the students as being a common reason identified when they see patients… the question is why isn’t care being covered? What does this mean? Is it lack of mental health coverage (i.e. being told no, you will not be able to have that tx paid for by insurer), limits in coverage, or requirements to call in for approval ahead of time (which I don’t think should be required), or overall lack of insurance coverage (although they are at the primary care provider).
4. Stigma and stereotype of needing psychiatric care (despite the fact that probably 25% of all adults will at some point need some mental health care across their life). Unfortunately those with mental health needs remain second class citizens in health care.
So what is the real story? I thought we had legislation that changed things so that there was mental health parity? Why can’t people get their mental health care paid for? That would be a great study (there’s a good idea for your thesis!). I would love to hear from students and clinicians about the circumstances in which they see this happen every day.
Another area that came up as a concern for these primary care providers was what to do when a person is in both primary care complaining about mental health needs and in specialty care treatment for those same needs. The answer to this is simpler:
1. Have at least one psychiatric provider in their practice to manage these patients with complex needs. OR
2. Communication and collaboration between providers is essential. If someone is in specialty care and we see a problem with a physical condition then we should call the primary care provider. If the primary care provider sees unmet mental health needs they should contact the mental health provider. I realize this may mean that we have to manage the permissions to share information, but in this case it is imperative. Nearly every week my students tell me about their clients in the mental health setting that their preceptors are medicating for a variety of complex mental health problems who also receive some mental health meds from primary care. The common problematic agents are: benzodiazepines and other sedative hypnotics. This is particularly a problem in treating the dually diagnosed patient (mental health dx with substance abuse dx). Communication is very important. If the patient is in specialty care, then the primary care practitioner can’t be providing a different Rx to the patient for the needs already managed by the other provider. I am more confident that the psych specialty providers are not writing Rx’s for the medications to manage the physical care (I hope I am not wrong about this, as psych clinicians in general should not prescribe outside of their specialty area).
We are in an era where many Psych APRN’s are working 2 or more part time jobs to make a full time position. How could that be if there is a problem getting our patients into mental health care? Why are there waiting lists for people needing care? Why aren’t primary care practices hiring psychiatric providers like Psych APRN’s to help manage their patient’s mental health needs?
How could it be that the state of CT is cutting direct care psychiatric provider positions (or have a freeze on hiring clinicians) if there are waiting lists that preclude patients from getting the care they need? It isn’t just the state, other hospitals or facilities don’t seem to be hiring more psych practitioners either or making those providers full time. What is the deal?
How can these situations co-exist? How can there be a clear need for services, yet a lack of demand for full time workers in the area?
I suspect the culprit is a system forever in the mode of saving money and cutting spending, despite abundant needs in the population…
I would love to hear examples from those of you facing these problems… maybe it will help us to solve the problem! Please comment here or send me an email: joanne.iennaco@yale.edu
Sunday, January 31, 2010
Saturday, January 30, 2010
My Thoughts on 'Anti-Energy' Drinks
Let me be perfectly clear: I am not an expert on nutrition, nor do I research these agents or drinks. I do have an opinion though, which I shared on my blogs Wednesday and I will share today.
I was asked by someone if I knew anything about the effects of anti-energy drinks such as Drank, which just recently started being sold in Connecticut. The product contains three main ingredients: valerian root, rose hips and melatonin. Part of the question was if there was evidence of an effect of these ingredients on stress relief and/or relaxation. In addition I was asked if I know anything about the three main ingredients. I do not have special knowledge to answer these questions with, they are not my areas of study. They are excellent questions!
I do think this is an interesting twist on the use of nutrients and other agents in beverages. In fact I have not researched energy drinks to any great degree, except to look up some of the ingredients. I just have a long standing concern: people think just because something is a ‘natural’ substance (herb or vitamin or mineral) it is ok to take it however they wish. I also don’t think people understand the lack of protections we have, given the lack of required evidence of safety to put products like these on the market. People may also think because it is on the store shelf it must be safe.
Unfortunately the websites available about drinks of these kinds do not have specifics about the amounts of each ingredient. They do not identify specifically the labelling with nutritional information (at least that I could find on the website for Drank). I'll have to go to the store and see what the label says. Despite the ingredients mystery, they are very direct in suggesting this is a fun new way to relax though.
I do not know off-hand of the safety of the ‘anti-energy’ drinks. My concerns about safety would be similar to those of all energy or 'nutritional' drinks. Whenever we begin to use agents in food or beverage that are commonly consumed at meals or other times, we have to wonder about the effects of exposure (i.e. how many of these drinks might you drink in a day? What is the dose of the substance you get over the day?). Is it like water and you can drink as much as you want?. Over long periods of time and with penetration of these products in the marketplace there is increased population exposure. Because they are foods/drinks they are differently regulated. How many people do you know that would take 3 pills a day (valerian, rose hips and melatonin) without considering the safety? Drinking them seems to make them appear safe to people. That is my concern. What if they are on other medication? Could they interact and cause negative effects? Do they check with their health practitioner to be sure it won’t cause a problem?
The other concern is we may have studies of a substance like melatonin for example and consider it safe for some use in some dose, but are there potential interactions between the three substances in this particular drink? Also where is the long term evidence of safety of these substances (individually and combined) in such a common food/drink source? An absence of evidence does not equal an absence of negative effect. It just means we haven’t studied it in this way.
I suspect ‘anti-energy’ drinks will be popular in the marketplace… It makes you wonder whether people will be pumping up on energy drinks all day and then trying to settle down with the anti-energy drinks in the evening. I am sure the beverage industry is very excited about all this… It is like they are the new but unregulated pharma – without having to shoulder the costs of safety research and clinical trials.
I am sure I told you more than you are really interested in. I am not the ‘expert’ on these ingredients. There are many people I am sure who have much more knowledge than I do about these ingredients. (actually you might look at the medline plus search info for supplements from the national library of medicine, if you haven’t already found it). Here is the link to info about melatonin: http://www.nlm.nih.gov/medlineplus/druginfo/natural/patient-melatonin.html I would consider medline plus a trustworthy source of data on ingredients like this.
Of course as Mental Health Clinicians, we should also be inquiring about beverages like this, particularly given the lack of knowledge of amount of ingredient in each drink and that if one doesn't settle me down, maybe I will need a few... Something new to consider in our assessments.
I was asked by someone if I knew anything about the effects of anti-energy drinks such as Drank, which just recently started being sold in Connecticut. The product contains three main ingredients: valerian root, rose hips and melatonin. Part of the question was if there was evidence of an effect of these ingredients on stress relief and/or relaxation. In addition I was asked if I know anything about the three main ingredients. I do not have special knowledge to answer these questions with, they are not my areas of study. They are excellent questions!
I do think this is an interesting twist on the use of nutrients and other agents in beverages. In fact I have not researched energy drinks to any great degree, except to look up some of the ingredients. I just have a long standing concern: people think just because something is a ‘natural’ substance (herb or vitamin or mineral) it is ok to take it however they wish. I also don’t think people understand the lack of protections we have, given the lack of required evidence of safety to put products like these on the market. People may also think because it is on the store shelf it must be safe.
Unfortunately the websites available about drinks of these kinds do not have specifics about the amounts of each ingredient. They do not identify specifically the labelling with nutritional information (at least that I could find on the website for Drank). I'll have to go to the store and see what the label says. Despite the ingredients mystery, they are very direct in suggesting this is a fun new way to relax though.
I do not know off-hand of the safety of the ‘anti-energy’ drinks. My concerns about safety would be similar to those of all energy or 'nutritional' drinks. Whenever we begin to use agents in food or beverage that are commonly consumed at meals or other times, we have to wonder about the effects of exposure (i.e. how many of these drinks might you drink in a day? What is the dose of the substance you get over the day?). Is it like water and you can drink as much as you want?. Over long periods of time and with penetration of these products in the marketplace there is increased population exposure. Because they are foods/drinks they are differently regulated. How many people do you know that would take 3 pills a day (valerian, rose hips and melatonin) without considering the safety? Drinking them seems to make them appear safe to people. That is my concern. What if they are on other medication? Could they interact and cause negative effects? Do they check with their health practitioner to be sure it won’t cause a problem?
The other concern is we may have studies of a substance like melatonin for example and consider it safe for some use in some dose, but are there potential interactions between the three substances in this particular drink? Also where is the long term evidence of safety of these substances (individually and combined) in such a common food/drink source? An absence of evidence does not equal an absence of negative effect. It just means we haven’t studied it in this way.
I suspect ‘anti-energy’ drinks will be popular in the marketplace… It makes you wonder whether people will be pumping up on energy drinks all day and then trying to settle down with the anti-energy drinks in the evening. I am sure the beverage industry is very excited about all this… It is like they are the new but unregulated pharma – without having to shoulder the costs of safety research and clinical trials.
I am sure I told you more than you are really interested in. I am not the ‘expert’ on these ingredients. There are many people I am sure who have much more knowledge than I do about these ingredients. (actually you might look at the medline plus search info for supplements from the national library of medicine, if you haven’t already found it). Here is the link to info about melatonin: http://www.nlm.nih.gov/medlineplus/druginfo/natural/patient-melatonin.html I would consider medline plus a trustworthy source of data on ingredients like this.
Of course as Mental Health Clinicians, we should also be inquiring about beverages like this, particularly given the lack of knowledge of amount of ingredient in each drink and that if one doesn't settle me down, maybe I will need a few... Something new to consider in our assessments.
Wednesday, January 27, 2010
‘Healthy Drinks’ Mask High Caffeine Content
I was glad to see the Journal for Nurse Practitioners take up an important issue to our health and well-being: Energy Drinks. Pohler, H. (2010). Caffeine intoxication and addiction. Journal for Nurse Practitioners. 2010;6(1):49-52. http://www.medscape.com/viewarticle/714855
These drinks are marketed as a healthy alternative to other choices like soda and coffee, but in my view they potentially have many negative implications. For the past two years, I have observed a 7th grade boy purchase two cans of Red Bull each morning when I purchase my cup of coffee. 2 cans of highly potent, caffeinated Red Bull, which is advertised to “revitalize body and mind”. Some days he buys Full Throttle (which CNN tells me ( http://www.cnn.com/HEALTH/library/AN/01211.html) nearly doubles the dose of caffeine per can (cans are bigger)).
How commonly do children buy these drinks? I wonder a bit about the groups that are the highest consumers of energy drinks like Red Bull or Red Star or Liquid Cocaine? Are we (and our children) unwittingly getting hooked on high doses of stimulants in ‘healthy’ energy drinks? Let’s not forget the little ‘shots’ available for purchase too, so you can quickly get your stimulant without a lot of drinking… Also, check the label of your vitamins, as often vitamin supplements have caffeine in them as well. I had that experience a while back. It isn’t pretty to see me after a cup of coffee and a vitamin with caffeine. We need to look at the labels of the products we buy!!!
Caffeine is one issue, each 8.3oz can of Red Bull contains 75mg of caffeine. The other ingredients have potential effects as well. Here are the ingredients of Red Bull: Carbonated water, sucrose, glucose, sodium citrate, taurine, glucuronolactone, caffeine, inositol, niacinamide, calcium-pantothenate, pyridoxine HCl, vitamin B12, artificial flavors, colors.
I appreciate Pohler telling us that ingredients like guarana and cola nut are synonyms for caffeine in an ingredients list. She also details the physiologic metabolism of caffeine into byproducts theobromine and theophylline (which can be found on labels of nutraceuticals).
Consumers need to be aware of what they are ingesting. I found in the store some vitamin labels might list the name of a stimulant (like guarana or caffeine) and on the external package not print the amount (mg) in each tablet (which made me think at the time of purchase there was no caffeine in there). I didn’t recheck the bottle label inside the packaging until a few days later when I realized I was jittery and overstimulated and knew I hadn’t increased my coffee consumption. My One-A-Day multi-vit actually gave me as much caffeine as my morning coffee. Time to change vitamins, and be careful about reading those labels!
While I readily admit a ‘habit’ (do I really have to call it an addiction?) of a 16oz hazelnut coffee each day, I haven’t moved to even try a product like Red Bull. I am also reticent to drink Vitamin Water and other ‘nutritious’ drinks because the additives that make them ‘healthy’ are not familiar to me. What is taurine? (ok, I looked it up, it is an amino acid) And Glucuronolactone? (an artificially produced stimulant – so adds to the load of stimulant in Red Bull). I recognize some of the nutritional ingredients like niacinamide, pyridoxine and vitamin B-12, which worry me a little less. However it goes back to my argument about using nutraceuticals in general: where is the evidence to tell us the use of ingredients in this way is really healthy? In addition the labels don’t tell us how much of each ingredient we are ingesting, and we all know that many vitamins, minerals and nutritional products can have toxic effects if we ingest too much.
Health professionals are well aware that drugs interact with one another. In addition, at times substances that are seemingly ‘good’ for us have negative effects. This is the reason I don’t drink beverages like that. Nor would I allow my child to drink them! Particularly on a daily basis in high amounts. Do we have long term data on children's brain development to tell us this is not harmful? Do we have any long term data that tells us that these ingredients together won’t harm our kidney function in the future? Or other body systems? What happens 10 years out with daily high dose stimulant, taurine, glucuronolactone and other ingestion? (actually caffeine seems better to me given our lack of knowledge of these other ingredients and the high prevalence and long term use of caffeine in our culture… unless of course some of the common chronic illnesses are fed by caffeine – which of course hypertension is one).
Am I the only one who is worried about the marketing and unwitting consumption of ‘healthy’ beverages like this? I am pleased to see Nurse Practitioners considering the implications of stimulant beverage consumption by their clients. As mental health clinicians we can be no less vigilant...
These drinks are marketed as a healthy alternative to other choices like soda and coffee, but in my view they potentially have many negative implications. For the past two years, I have observed a 7th grade boy purchase two cans of Red Bull each morning when I purchase my cup of coffee. 2 cans of highly potent, caffeinated Red Bull, which is advertised to “revitalize body and mind”. Some days he buys Full Throttle (which CNN tells me ( http://www.cnn.com/HEALTH/library/AN/01211.html) nearly doubles the dose of caffeine per can (cans are bigger)).
How commonly do children buy these drinks? I wonder a bit about the groups that are the highest consumers of energy drinks like Red Bull or Red Star or Liquid Cocaine? Are we (and our children) unwittingly getting hooked on high doses of stimulants in ‘healthy’ energy drinks? Let’s not forget the little ‘shots’ available for purchase too, so you can quickly get your stimulant without a lot of drinking… Also, check the label of your vitamins, as often vitamin supplements have caffeine in them as well. I had that experience a while back. It isn’t pretty to see me after a cup of coffee and a vitamin with caffeine. We need to look at the labels of the products we buy!!!
Caffeine is one issue, each 8.3oz can of Red Bull contains 75mg of caffeine. The other ingredients have potential effects as well. Here are the ingredients of Red Bull: Carbonated water, sucrose, glucose, sodium citrate, taurine, glucuronolactone, caffeine, inositol, niacinamide, calcium-pantothenate, pyridoxine HCl, vitamin B12, artificial flavors, colors.
I appreciate Pohler telling us that ingredients like guarana and cola nut are synonyms for caffeine in an ingredients list. She also details the physiologic metabolism of caffeine into byproducts theobromine and theophylline (which can be found on labels of nutraceuticals).
Consumers need to be aware of what they are ingesting. I found in the store some vitamin labels might list the name of a stimulant (like guarana or caffeine) and on the external package not print the amount (mg) in each tablet (which made me think at the time of purchase there was no caffeine in there). I didn’t recheck the bottle label inside the packaging until a few days later when I realized I was jittery and overstimulated and knew I hadn’t increased my coffee consumption. My One-A-Day multi-vit actually gave me as much caffeine as my morning coffee. Time to change vitamins, and be careful about reading those labels!
While I readily admit a ‘habit’ (do I really have to call it an addiction?) of a 16oz hazelnut coffee each day, I haven’t moved to even try a product like Red Bull. I am also reticent to drink Vitamin Water and other ‘nutritious’ drinks because the additives that make them ‘healthy’ are not familiar to me. What is taurine? (ok, I looked it up, it is an amino acid) And Glucuronolactone? (an artificially produced stimulant – so adds to the load of stimulant in Red Bull). I recognize some of the nutritional ingredients like niacinamide, pyridoxine and vitamin B-12, which worry me a little less. However it goes back to my argument about using nutraceuticals in general: where is the evidence to tell us the use of ingredients in this way is really healthy? In addition the labels don’t tell us how much of each ingredient we are ingesting, and we all know that many vitamins, minerals and nutritional products can have toxic effects if we ingest too much.
Health professionals are well aware that drugs interact with one another. In addition, at times substances that are seemingly ‘good’ for us have negative effects. This is the reason I don’t drink beverages like that. Nor would I allow my child to drink them! Particularly on a daily basis in high amounts. Do we have long term data on children's brain development to tell us this is not harmful? Do we have any long term data that tells us that these ingredients together won’t harm our kidney function in the future? Or other body systems? What happens 10 years out with daily high dose stimulant, taurine, glucuronolactone and other ingestion? (actually caffeine seems better to me given our lack of knowledge of these other ingredients and the high prevalence and long term use of caffeine in our culture… unless of course some of the common chronic illnesses are fed by caffeine – which of course hypertension is one).
Am I the only one who is worried about the marketing and unwitting consumption of ‘healthy’ beverages like this? I am pleased to see Nurse Practitioners considering the implications of stimulant beverage consumption by their clients. As mental health clinicians we can be no less vigilant...
Thursday, January 14, 2010
Changing Perceptions: Clozapine no longer a 'last resort'
(Original Post Date: December 7, 2009)
A thanks to one of my wonderful students, for sending along this article about Clozapine. http://www.currentpsychiatry.com/article_pages.asp?AID=8165 We actually just attend the Yale Master Psychopharmacology conference last week, where the speaker on Advances in Schizophrenia, Dr. Cyril D’Souza, was quite clear in his preference to see patients treated with Clozapine. Interesting to see this publicized in this way, given the initial introduction of this drug with such care. When introduced, it was suggested as the drug for those treatment resistant patients, with I believe the understanding that those not responding to other agents might find benefit in the drug vs. the risk of potentially life threatening agranulocytosis. This was later widened to include those with schizophrenia or schizoaffective disorder who were a suicide risk. Use of the drug has led to individuals being treated with clozapine while closely scrutinized for the development of life-threatening side effects. More recent studies have suggested clozapine has antiaggressive properties(per Krakowski et al, 2006) and offers superior symptom management (per CATIE results).This article suggests thinking more broadly about the use of clozapine, given studies showing its efficacy. As I translate the idea: rather than thinking of it as a 'last resort', we should consider it a ‘second choice’ after a first trial of antipsychotic medication is not effective. It seems to me that clozapine needs a new marketing strategy. Although we should expect that if we begin to use clozapine in a larger proportion of the population we will see its side effect, agranulocytosis, occurring in greater numbers (i.e. it will have the same frequency, but if more of your patients are taking it, the likelihood you will see a case of agranulocytosis will increase.) Whenever we do prescribe clozapine, we must carefully attend to the potential it has for this side effect, and be sure that we monitor individuals closely.
Posted by Joanne at 12:57 PM
And thanks also for the comment, which shows your use of this clinical information!
Joanne, I wanted to share a recent and ongoing clinical case (without going into too much detail) that I have been a part of at my current clinical site in a forensic setting. The article that I forwarded to you I had also forwarded to my clinical preceptor, a psychiatrist. Not more than a week or two after this conference and stumbling upon this article did it come to our attention that one of the inmates, had presented a couple of months ago in the midst of an acute psychotic episode. It is likely paranoid schizophrenia but with a mood component thus our differentials of adding a bipolar diagnosis per history or leaning towards schizoaffective. This inmate, prior to arrival, had been misdiagnosed with mood and anxiety disorders only (as far as we could gather from collateral sources). Nonetheless, we started slowly titrating up on Risperdal. First 1mg BID and so on up to 6mg according to response; we also concurrently followed the antipsychotic with adequate amounts of Cogentin, Amantadine and even some Klonopin to aide with anxiety as well as hoping to prevent and treat some already apparent EPS. Along with this titration we slowly introduced Depakote as well to stabilize mood. As we responded to symptoms with the Risperdal increases, the psychosis almost completely cleared. The turn around was rapid and the medications effective. BUT, of course this was too good to be true and by this time EPS and Parkinsonian symptoms had become too much to bear. The inmate was at times unable to eat or take pills because of shaking so badly. We had of course had “the benefits outweigh the risks” talk prior to administering the medication, but it was at this point that we attempted to back off several of the meds. We switched from Risperdal to Abilify to see if this might help decrease the EPS, but no changes were noted. It struck me as we were sitting pondering this difficult case, "Why not Clozaril!?" With its very good side effect profile (except of course the life-threatening agranulocytosis, ha) it would give the antipsychotic and even mood stabilizing properties without the same high risk for EPS. At first my preceptor and the nurses were very hesitant and questioned this high-risk medication yet soon at least my preceptor was on board and telling me the more consideration, the more sure it might work very well for this particular patient. We began a titration down off all meds and did basically a washout (in the safety of an inpatient setting) while keeping low-dose Klonopin onboard. So, the current status is that some Parkinsonian symptoms seemed to have decreased but the resting tremor remains. We are weekly monitoring WBC levels (for agranulocytosis as Joanne mentioned) and titrating the dose up. So far so good! I’ll try and update to let you all know how things are progressing…..Thanks again Joanne for posting on this topic, it’s really interesting as well as clinically applicable. ☺ (Comment Date: January 13, 2010)
A thanks to one of my wonderful students, for sending along this article about Clozapine. http://www.currentpsychiatry.com/article_pages.asp?AID=8165 We actually just attend the Yale Master Psychopharmacology conference last week, where the speaker on Advances in Schizophrenia, Dr. Cyril D’Souza, was quite clear in his preference to see patients treated with Clozapine. Interesting to see this publicized in this way, given the initial introduction of this drug with such care. When introduced, it was suggested as the drug for those treatment resistant patients, with I believe the understanding that those not responding to other agents might find benefit in the drug vs. the risk of potentially life threatening agranulocytosis. This was later widened to include those with schizophrenia or schizoaffective disorder who were a suicide risk. Use of the drug has led to individuals being treated with clozapine while closely scrutinized for the development of life-threatening side effects. More recent studies have suggested clozapine has antiaggressive properties(per Krakowski et al, 2006) and offers superior symptom management (per CATIE results).This article suggests thinking more broadly about the use of clozapine, given studies showing its efficacy. As I translate the idea: rather than thinking of it as a 'last resort', we should consider it a ‘second choice’ after a first trial of antipsychotic medication is not effective. It seems to me that clozapine needs a new marketing strategy. Although we should expect that if we begin to use clozapine in a larger proportion of the population we will see its side effect, agranulocytosis, occurring in greater numbers (i.e. it will have the same frequency, but if more of your patients are taking it, the likelihood you will see a case of agranulocytosis will increase.) Whenever we do prescribe clozapine, we must carefully attend to the potential it has for this side effect, and be sure that we monitor individuals closely.
Posted by Joanne at 12:57 PM
And thanks also for the comment, which shows your use of this clinical information!
Joanne, I wanted to share a recent and ongoing clinical case (without going into too much detail) that I have been a part of at my current clinical site in a forensic setting. The article that I forwarded to you I had also forwarded to my clinical preceptor, a psychiatrist. Not more than a week or two after this conference and stumbling upon this article did it come to our attention that one of the inmates, had presented a couple of months ago in the midst of an acute psychotic episode. It is likely paranoid schizophrenia but with a mood component thus our differentials of adding a bipolar diagnosis per history or leaning towards schizoaffective. This inmate, prior to arrival, had been misdiagnosed with mood and anxiety disorders only (as far as we could gather from collateral sources). Nonetheless, we started slowly titrating up on Risperdal. First 1mg BID and so on up to 6mg according to response; we also concurrently followed the antipsychotic with adequate amounts of Cogentin, Amantadine and even some Klonopin to aide with anxiety as well as hoping to prevent and treat some already apparent EPS. Along with this titration we slowly introduced Depakote as well to stabilize mood. As we responded to symptoms with the Risperdal increases, the psychosis almost completely cleared. The turn around was rapid and the medications effective. BUT, of course this was too good to be true and by this time EPS and Parkinsonian symptoms had become too much to bear. The inmate was at times unable to eat or take pills because of shaking so badly. We had of course had “the benefits outweigh the risks” talk prior to administering the medication, but it was at this point that we attempted to back off several of the meds. We switched from Risperdal to Abilify to see if this might help decrease the EPS, but no changes were noted. It struck me as we were sitting pondering this difficult case, "Why not Clozaril!?" With its very good side effect profile (except of course the life-threatening agranulocytosis, ha) it would give the antipsychotic and even mood stabilizing properties without the same high risk for EPS. At first my preceptor and the nurses were very hesitant and questioned this high-risk medication yet soon at least my preceptor was on board and telling me the more consideration, the more sure it might work very well for this particular patient. We began a titration down off all meds and did basically a washout (in the safety of an inpatient setting) while keeping low-dose Klonopin onboard. So, the current status is that some Parkinsonian symptoms seemed to have decreased but the resting tremor remains. We are weekly monitoring WBC levels (for agranulocytosis as Joanne mentioned) and titrating the dose up. So far so good! I’ll try and update to let you all know how things are progressing…..Thanks again Joanne for posting on this topic, it’s really interesting as well as clinically applicable. ☺ (Comment Date: January 13, 2010)
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