Dr. Ney’s Depressing Weight Loss Diet

By kney

May

11

What’s that you say? Diets don’t work for you. Why can’t you just get a pill? OK, OK, OK, repeat after me: There is no weight loss pill, there is no weight loss pill, there is no weight loss pill. But, you exclaim, my girlfriend, sister, mother, aunt, boss, whoever took a pill, and she lost TONS of weight. Remember what I told you yesterday about the primo medical study, the double-blind placebo-controlled study? All those studies show–all together now–there is no weight loss pill.

Now don’t think I’m not sympathetic. Like I said I’ve been on a diet for 55 years now. I am so sorry but there is no weight loss pill.

So what are people being prescribed? Probably the pills that come closest to actually working are phentermine (Adipex) and phendimetrazine (Bontril). You’ll probably lose weight while you are on them but studies show that you’ll gain it all back as soon as you stop them. Patients say, “Well it will help jump-start me.” What’s the point of a jump-start if you’re just going to go backward as soon as you stop? Oh, and BTW, side effects include irritabilty, tremor, elevated heart rate, elevated blood pressure, dry mouth, headache, and insomnia. Now you can up the ante and try various of the amphetamines, benzphetamine, dextroamphetamine or methamphetamine. In my state (Alabama) it’s actually illegal to prescribe these medications to lose weight. And, yes, you read it right, methamphetamine. That stuff Hitler took and the Hell’s Angels make. You know, addiction, brain damage, skin sores, meth mouth, no teeth… Back in the sixties, all these were used to lose weight. It didn’t work out so well.

Another weight loss medication is orlistat, available in prescription as Xenical and over the counter as Alli. This medication blocks fat absorption with, unless you are very very careful, some interesting effects. Can you say uncontrollable blue diarrhea? Oh my. THAT was fun.

For a while, we were enthused about topiramate (Topamax). There are some studies showing that it helps patients with Binge Eating Disorder. The problem is that most of us don’t have Binge Eating Disorder, so it really doesn’t work that well for most overweight people. The other problem is the side effect of confusion and mental slowing. This medication is nick-named Dopamax. I tried it for about a week and decided I’d rather be fat than stupid.

Some researcher somewhere had a bright idea. If pot gives you the munchies, why don’t we block the pot (cannabinoid) receptor and see if we can get the anti-munchies? There were a number of medications developed but none of them worked well enough to get approved by the FDA.

Now there is one piece of good news. One interesting thing you can do chemically to lose weight is get enough sleep. There are two appetite regulatory hormones that we know of, ghrelin which makes you want to eat and leptin which decreases your appetite. Turns out that if you are sleep-drprived, you will secrete more ghrelin. Leptin is secreted during slow wave sleep (deep sleep). So don’t take a pill but do go to bed on time to take advantage of your natural appetite regulatory hormones.

Next up, more depressing weight loss information….

Psychiatric Medication and Weight

By kney

May

10

OK, OK, OK, I know, I know, I know. You’ve gained a TON of weight since you started antidepressants. MUST be the pills, could not POSSIBLY be the Oreos. You haven’t changed the way you eat AT ALL. Alas, dear reader, I’m 55 years old and have been overweight for, oh, I don’t know, 55 years? I’ve been on every diet known to woman, and I can tell you with absolute certainty–I’ve never gained a pound I didn’t earn.

Blame our modern society. We were not designed to live in a world where food high in fat and simple carbohydrates is available in unlimited quantities. We were designed to live in a world in which the next famine was right around the corner. Better eat all the calories you can now, you don’t know when you’ll get food again. Your body doesn’t know that McD’s now has a 24 hour drive through.

Everybody likes to trash my favorite restaurant, McDonald’s. Shameful of them to offer Supersize Big Mac Extra Value Meals (YUM!!!). Oh, never mind that we scarf them down by the billions and billions, and McD’s wouldn’t sell them if we didn’t buy them. Newsflash, they are a company not your mother. Their job is to offer you a product you want to buy, your job is to show a little self-restraint.

But self-restraint is hard, blaming McD’s or the pill is easy. OK, OK, OK, now that I’ve had my temper tantrum, it IS true that certain psychiatric medications are associated with weight gain. There seem to be several ways this can happen. Depression and anxiety can (but don’t always) decrease your appetite. If you treat the illness, your appetite comes back, and you should return to your previous weight. So the pill is not exactly causing weight gain, it’s returning you to normal, and, since you are a living, breathing American woman, that means you would now like to lose 10 pounds.

Certain medications work at the same molecule where allergy medications work. For some reason antihistamines increase your appetite. What’s that you say? You haven’t changed your eating at all? Here’s the problem. We all snack. When you snack, you don’t really count that food. What’re the jokes? Cookie fragments have no calories, food consumed while standing doesn’t count. If you just eat one extra Snicker’s Bar a day, you’ll gain close to a pound a week. Because so much of our eating is mindless and automatic, unless you’re journaling every bite, you can’t say for sure that your eating pattern has not changed. It’s far more likely that you’re just having an extra bite here and there and don’t realize it (Sorry!!!!)

Some of the other medications we use seem to be associated with a condition called Metabolic Syndrome. Metabolic Syndrome is characterized by excess weight around the middle, high blood pressure, high blood sugar, high triglycerides, low HDL (the good cholesterol). The body’s handling of sugar is abnormal. So if you eat a slug of sugar like a Coca Cola or a candy bar, your body overproduces insulin, your blood sugar falls and you feel hungry again in no time. It’s wicked hard to lose weight once you get this syndrome because of these sugar and insulin problems.

So, what medicines are the worst offenders? For metabolic syndrome, it’s a group of medicines called the atypical antipsychotics. The worst is olanzapine (Zyprexa)–which, of course, is the one that works the best. Aripiprazole (Abilify) and Quetiapine (Seroquel), both heavily advertised as an adjunctive treatments for depression (meaning they are medications you add to your antidepressant, not use alone), also fall in this category. Risperidone (Risperdal), also is an excellent adjunctive treatment for depression, but it’s not advertised because it’s available as a generic.

Other bad weight gainers are: citalopram (Celexa), paroxetine (Paxil), tricyclic antidepressants like amitriptyline (Elavil) and the old MAOI’s (hardly ever prescribed anymore). Mirtazapine (Remeron) is one of the worst ones for weight gain I’ve ever used. The mood stabilizers lithium and divalproex (Depakote) as well as many of the antiepileptic drugs also cause weight gain.

Sigh, I’m ready for some good news, aren’t you? Bupropion (Wellbutrin) and fluoxetine (Prozac) are actually associated with weight LOSS. So are topiramate (Topamax) and zonisamide (Zonegran). We talked about the stimulants yesterday. Most of the other antidepressants are weight neutral. For many of them, researchers compared the weight gained on the medication with the weight gained on placebo when neither the doctor nor the patient knew which the patient had received. BTW, this is called a double-blind placebo-controlled trial and that’s the primo experiment in medicine. But I digress. So, in the study comparing weight gain on medicine versus placebo, everyone gained weight–why am I not surprised?–but the weight gained was the same whether the patients got medicine or placebo.

So this is all well and good, but what’s a girl to DO? I know, I know, I know, you’ve gained a TON of weight since you started antidepressants…. Dr. Ney’s depressing weight loss diet will follow tomorrow.

Adderall Abuse

By kney

May

8

OK, OK, OK, so here’s my sad story. I’m in a rest area off I65 and I overhear two women talking. One is complaining about not being able to lose weight. The other tells her, “Here’s what you do. Go to your son’s pediatrician and tell him your son is having trouble in school. He’s misbehaving, getting out of his seat, talking too much and not following directions. He can’t concentrate and is easily distracted. Your son’s doctor will prescribe him Adderall and that stuff’s great for losing weight.” Oh dear, oh dear, oh dear, where do I start?

First off, is she joking? It didn’t sound like it. It sounded like she was casually advising her friend to commit, oh, I don’t know, a FELONY. Out loud, in a public place, no shame at all. Secondly, is this good parenting? I mean, is she really advising her friend to pull this scam in her son’s presence? Presumably he’ll be at the appointment, too. Hmmm, what important life lessons will this behavior teach him? I’ll leave THAT to your imagination. Finally did it ever dawn on her or any of my patients for that matter, that there might be a reason why Adderall is a Schedule 2 controlled substance? Like, maybe, it’s a powerful and addictive medicine?

If you take Adderall for conditions for which it is indicated (e.g.. ADHD or narcolepsy), you will notice side effects of increased energy and decreased appetite. Generally people enjoy these particular side effects. Headache, irritability, anxiety, tremor, insomnia?–not so much. However, as often happens with side effects, a person tends to acclimate to them. Then my patients come to me and say, “I don’t think my Adderall is working anymore.” If we escalate the dose, it will have the same effect as drinking too much coffee when you are trying to stay awake all night. My patient will be awake but jittery, irritable, prone to errors, as well as nauseous and half sick. Even when it’s unintentional, this is a form of abuse. At this level of medication, my patient will be too tired and/or sleepy to function if she skips her dose, otherwise known as withdrawal.

If you take Adderall for a medical reason, you should use the lowest dose that will control your symptoms. In other words, don’t chase the energy and don’t chase the high. This is easier said than done since many patients associate the high and the energy with the desired effects of the medication. In an interesting study, teenagers with ADHD were given either Adderall or placebo early in the morning. Now, most patients will tell you that Adderall “wears off” after 4 to 6 hours. These teens had a driving test 16 hours after taking a dose of stimulant or placebo. The teens who had taken the Adderall were better drivers than the teens who had taken placebo–even 16 hours after receiving the medication. Maybe the feeling of being on the drug wears off after 4 to 6 hours, but clearly the desired effects of the drug persist long after.

There can be serious side effects of Adderall. Too high a dose can lead to psychosis in anyone. However patients with illnesses that are characterized by psychosis (bipolar disorder, schizophrenia, schizoaffective disorder) are particularly sensitive to this side effect. This is a serious bummer since, genetically, ADHD likes to hang out with bipolar disorder. Kinda like blond hair and blue eyes–you don’t always see them together but you sure see them together a lot. BTW did you know that Adolph Hitler abused methamphetamine, a close cousin to Adderall? How’d THAT work out?

Recently there has been some data suggesting a link between Parkinson’s disease and amphetamines. Patients who were prescribed Benzedrine and Dexedrine–both part of the “salts” in mixed amphetamine salts, otherwise known as Adderall–were 60% more likely to develop Parkinson’s disease. There has been a similar study comparing patients admitted to the hospital for methamphetamine dependence, cocaine dependence and appendicitis. The patients admitted for methamphetamine dependence were more than 70% more likely to develop Parkinson’s disease than the other two groups. The authors of this study caution that the dose of amphetamine used by methamphetamine addicts is much higher than that prescribed to patients, and so the study may not apply to people using the medication. However, Adderall is being passed out like candy these days. Patients keep pushing to get higher doses. Scams to fake symptoms and get prescriptions abound. I think it is just a matter of time before we start hearing about some very unpleasant consequences to the overuse of this medication.

Bipolar Disorder

By kney

Mar

19

“My boyfriend looked it up on the Internet, and he says I have Bipolar Disorder ’cause I’m so moody. I mean, like, one minute I’m fine and then for no reason, I’m shaking and crying and yelling at him.” OK, OK, OK, so let’s pretend for a minute that there really isn’t any reason for your outburst, he didn’t really spend all the rent money on Lortab, Soma, and Xanbars, then stay up all night texting his ex, then call you Bipolar when you got mad at him…. How do we know if you have Bipolar Disorder or not?

The last post was about diagnosing depression–unipolar depression. Uni for one and polar for pole or extreme mood state. Bipolar Disorder, which used to be called Manic Depressive Illness, simply means bi–two–polar–extreme mood states. Most patients with Bipolar Disorder spend most of their time in the depressed state but then have another abnormal (Did I mention how much I hate the words ‘normal’ and ‘abnormal’? But I digress….) mood state. We call this second state mania, and it can be high, irritable, or agitated. Remember depression? That mood could be sad, depressed or down but also numb, irritable or agitated–uh oh, I feel more confusion coming on….

When people are high or euphoric, they feel happy, excited, on top of the world. They are overconfident. Energy is elevated, and they need much less sleep than usual. Their thoughts race. They might have more religious interests or sexual feelings than are usual for them. They might overestimate their resources of time, energy, money or skills. People make errors based on these intense feelings, we call this poor judgement. They might spend too much money or have affairs they ordinarily wouldn’t. They talk too much–revealing thoughts, feelings or information they shouldn’t to inappropriate people like coworkers or even complete strangers. People often enjoy feeling this way. The problem is that the feeling doesn’t last, then you have to clean up the mess you made.

Edna St. Vincent Millay wrote a poem about mania:
My candle burns at both ends.
It will not last the night;
But ah, my foes, and oh, my friends-
It gives a lovely light!

But the situation is a bit more complicated than that–you knew I was going to say that didn’t you? That’s because the manic (or second pole of the bipolar disorder) doesn’t HAVE to be high or euphoric. It can also be irritable. People with this kind of mania can come across as mean, demanding, entitled, rageful, and arrogant. They can be kind of scary. (All right, they can be really scary.) To complicate matters even further, mania can look like very severe anxiety. People feel agitated, like they can’t stand to be in their own skin. Thoughts are racing and confused. They feel unbearably keyed up, unable to sleep or calm down. These patients, unlike those in the previous two types of mania, are desperate for this feeling to stop. Because people in this state are so miserably uncomfortable, they are often also depressed. We call this condition a mixed state or dysphoric mania. I’ve mostly seen this state when bipolar people have been treated with antidepressants alone for a long period of time.

So back to our patient (not a real patient, BTW, just a mixture of things I’ve heard a lot from a lot of different patients) Is her boyfriend right? or just a jerk? Well he may or may not be a jerk, but he’s wrong about her diagnosis. The moods of Bipolar Disorder, called episodes, last for days or even weeks or months. An episode may be precipitated by stress, but once it is established, it is relatively resistant to changes in the environment. There is a form of Bipolar Disorder called ultradian cycling characterized by frequent changes of mood throughout the day. But this condition is quite rare. Far more common causes of this kind of moodiness are A. a really bad relationship or B. a personality disorder (so-called Cluster B) or C. both of the above.

Why do we care? Because if we call this condition Bipolar Disorder, we are going to use powerful and expensive medications that cause not only cause weight gain, diabetes, excessive sedation, and a host of other scary semi-permanent side effects but will also be ineffective, when what we really need to do is follow Paul Simon’s carefully crafted treatment plan: “Slip out the back, Jack, making new plans, Stan, don’t mean to be coy, Roy, just listen to me. Hop on the bus, Gus. Don’t need to discuss much. Just drop off the key, Lee. And set yourself free.”

Depression

By kney

Mar

16

The problem with depression is that EVERYBODY is an expert–which is, of course irritating to those of us who ARE experts–but I digress. That is, everyone has experienced the feeling of depression. I like to describe it as hopeless, helpless, and worthless. Just think of the first time your boyfriend or girlfriend dumped you for your best friend, that’s depression.

Problem is, the feeling of depression is not the same as the disease of depression. Bob Golden, one of my teachers during residency, used to say, “Not everyone who is depressed has depression and not everyone who has depression is depressed.” Confused?!? The important thing is to distinguish the feeling of depression from the disease of depression.

The disease of depression is an abnormal mood state that lasts most of the day for weeks on end. The official diagnosis requires two weeks, but, untreated, the disease of depression often lasts 9 months or more. Now, to complicate matters, there’s another form of depression called dysthymic disorder which is a low level of depression that lasts for years–but more on that topic later.

Now, the abnormal mood state might consist of sadness, hopeless, helplessness, or worthlessness. It might be characterized by inactivity or crying spells. But I’ve had plenty of patients who complain of numbness, a feeling of ‘I don’t care’ or, especially in men, irritability. Some patients feel anxious and agitated. The key description of an abnormal mood state is that you just don’t feel like yourself.

The more I treat depression, the more I realize that it’s not just a mood disorder, it’s also a thought disorder. The official diagnosis has criteria of poor concentration, indecisiveness, and psychomotor retardation (what the heck is that?!?) People with depression complain of distractibility, confusion, and feeling overwhelmed, muddled and disorganized. I notice that when their depression is treated, they solve problems that seemed impossible when they were depressed. These thinking problems occur because perceptions are colored by the negative mood but also because thinking itself is slowed and confused.

OK, OK, OK, so what is psychomotor retardation? When I look at a patient, I have some idea of a ‘normal’ rate of speech, a ‘normal’ reaction time, a ‘normal’ speed of movement. If the patient is slowed from my perception of ‘normal,’ I say that person has psychomotor retardation. Have I ever mentioned to you how much I hate the word ‘normal?’ Implicit in the term is the idea that abnormal is bad. Have you watched any reality shows lately? Do you REALLY want to be ‘normal?’ But I digress…. Here’s the problem with the whole ‘psychomotor retardation’ concept though. I often see patients who don’t look abnormal in the speed of their movements or speech, but when I see them well, I realize they were actually quite slowed down–for them. Bottom line, as a criterion, this one has limited utility.

People with depression have disturbances of sleep. OK, prepare for more confusion. They might complain of insomnia or they might sleep excessively (hypersomnia, if you want to get fancy). The classic sleep problem for depression is early morning awakening, but I hear all kinds of sleep complaints. The complaint of fatigue goes along with the sleep disturbance. The fatigue of depression can be quite dramatic. I get many patients sent over from their family doctors whom they consulted because they were sure they had cancer or some other dread disease because they were so fatigued.

I did my undergraduate studies at the University of Pittsburgh in the dark ages. We walked to school barefoot in the snow uphill both ways AND we didn’t even have Prozac, but I digress…. I had a professor who suffered from a severe depression and was participating in some early clinical trials at the Western Psychiatric Institute, a pretty snazzy place associated with the medical school there. He wore this box that measured movement on his wrist. His treatments were considered successful if activity increased during the day (increased energy) and decreased at night (improved sleep). I thought that was pretty nifty. OK, OK, OK, so I’m a science nerd, I can’t help it…

People with depression have disturbances of appetite. In our usual psychiatric muddle, food intake and weight can go up or down. Almost always, though people with depression are not enjoying their food like they usually do. People with depression don’t enjoy most things like they usually do. One of my favorite patients measures her degree of depression by how much she is shopping–a woman after my own heart. Other patients talk about not wanting to socialize as much.

The old analysts used to describe depression as anger turned inward. Certainly, people with the disease of depression don’t like themselves very much. They feel excessive guilt. (I once asked a woman if she were experiencing excessive guilt, and she replied, “You don’t have children, do you, Dr. Ney?” And she wasn’t very nice about it either. So I don’t ask that question anymore.)

The suffering of depression can be severe. I’ve had patients who recovered from severe depressions and later got cancer and had chemotherapy with all the nausea, vomiting, hair loss, and misery of that. They’ve actually told me that the depression was worse than the cancer. The disease of depression is obviously not the same as getting dumped by your high school sweetheart.

The severity of the suffering, combined with the inability to see solutions to problems, combined with a sense of worthlessness and guilt can be severe enough to cause suicidal thoughts and feelings. Suicidal ideation is a whole topic to itself–more on that later.

So, there are nine criteria to diagnose depression: abnormal mood, decreased pleasure, appetite disturbance, sleep disturbance, fatigue, poor concentration, guilt or low self-esteem, psychomotor retardation, suicidal ideation. If you have 5 or more of these (one of the 5 must be abnormal mood or decreased pleasure) for 2 or more weeks, bingo! you get a diagnosis of Major Depression. Other labels you may have heard for this condition include clinical depression, endogenous depression, or chemical imbalance. Notice this well! There is no blood test, scan, written test or other objective measure that tells us if you have the illness of depression. This lack of objective measures is hugely important when we start talking about treatment–which we will and soon.

Stress

By kney

Feb

5

You want to talk about stress? Don’t tell me, I’ll tell you! This is about the zillionth time I’ve tried to write this post, lost them all, don’t know where they’ve gone. But I digress….

So your doctor told you it’s all in your head, referred you to a shrink, prescribed an antidepressant, hurt your feelings, made you mad…. What do you do now?

There are a number of syndromes out there that are hard to diagnose because there are no blood tests or XRays to show what is wrong. These conditions are called depression, conversion disorder, fibromyalgia, chronic fatigue, somatization disorder, and on and on. Many people think these conditions are “not real”, or “all in your head” or “made up”. Your doctor has a hard time with these conditions because he tends to feel helpless when he can’t figure out what’s wrong or what to do about it. Most people don’t like that feeling, doctors more than most. So they engage in that all-American pastime, blame someone else. (Have you been watching the presidential campaigns lately?) Unfortunately, that someone else would generally be YOU. Now your doctor feels better, but you definitely feel worse.

However, just because there isn’t a way to measure your symptoms does not mean they aren’t real. I come from the Vietnam era (I know, I know, I know, I look seriously GOOD to be that old). Everyone thought the symptoms the Vietnam vets blamed on Agent Orange were “not real”, “all in their heads”, “made up” and treated them with total contempt. Last time I checked, there were more than 20 conditions including diabetes and prostate cancer, caused by exposure to Agent Orange. So don’t treat yourself with contempt just because medicine doesn’t yet know how to diagnose or treat your symptoms.

Nonetheless, many of these conditions ARE exacerbated, if not caused, by stress. Oh, and by the way, so are diabetes, asthma, hypertension, and cardiovascular disease. How can stress make you ill? Well, for one thing, you have to change your idea of stress. We tend to equate stress with the time pressures of our overscheduled lives. However, stress is a biological concept relating to threats to the survival of ourselves or our offspring. So that letter from the IRS threatens your ability to provide food, clothing, and shelter for yourself and your family, but a good tussle with influenza is also an example of biological stress.

Now, what happens when I encounter stress? Let’s say I look in the corner and see a snake. Multiple physiologic changes occur JUST AT THE SIGHT of the snake. My heart rate shoots up. My breathing quickens. Blood flow is diverted from my digestive and reproductive systems to my muscles that tense in preparation for fight or flight. My body empties its waste so I can run faster (uhoh!). My immune system is activated to respond to a possible wound. Emotions and perceptions change. Time can slow down, my ability to feel pain is altered.

Now, let’s suppose that my bratty brother Eddie has put a FAKE snake in the corner, just to tease me. What will change? Exactly nothing. There’s no danger there–it’s “all in my head”. But those physiologic changes are real, whether or not the snake is real.

Our bodies were designed to deal with the stress of the real snake, the kind of stress we faced for all but the last 50 or 100 years of our history. The stress was well defined but often time limited. Stress we’ve been dealing with in the past 50 or 100 years is more like the fake snake, nebulous and chronic. The bad news is that this stress can make you sick, often in ways that we don’t yet know how to measure. The good news is that management of the stress can significantly improve your health and well-being.

Sleeping Pills

By kney

Jul

24

Oh dear! I certainly have been gone for a long time. I would say time flies when you’re having fun except I haven’t been having fun–but I digress. I was going to tell you about sleeping pills. I divide these into two categories. One, pills that make you sleepy and two, pills that take away the underlying cause of the sleep problem. Take Tylenol PM for example–wait, wait, don’t it yet, it will make you sleepy. Tylenol PM contains an antihistamine, diphenhydramine, that makes you sleepy and a pain reliever, acetaminophen, that relieves the aches and pains that keep you awake.

Things that actually make you sleepy include molecules that work at the GABA receptor–barbiturates, benzodiazepines, and nonbenzodiazepine hypnotics. Melatonin and Rozerem act at the melatonin receptor to produce sleep. Anesthetics like cloral hydrate–think Caylee Anthony–and propofol–think Michael Jackson–produce sleep with potentially disastrous results as evidenced by recent news stories–but again I digress.

Barbiturates have a notoriously narrow therapeutic index. This refers to the difference between the amount of the medication needed to achieve the desired effect and the amount of medication that will kill you. You want this to be WIDE, not narrow. Add that to the problems with rapid development of tolerance and addiction, and these are not exactly what you would call wonder drugs–think Judy Garland and Marilyn Monroe. Low doses are still used in medications like Fiorinal for the treatment of headache, but these agents have mostly been replaced by safer medications for sleep.

Back when I was a girl we did think benzodiazepines were wonder drugs. Examples include Valium (diazepam) and Librium (clordiazepoxide) and newer agents like Ativan (lorazepam), Klonopin (clonazepam) and, everybody’s favorite, Xanax (alprazolam). Three of these have been marketed specifically for sleep, Restoril (temazepam), Dalmane (flurazepam), and Halcion (triazolam). Notice that lots of these end in pam? Sometimes we call them the pams. These agents both reduce anxiety and cause sleepiness. Now you might think these are the same things, you know, like, man, downers? But if you think about it, they are two separate things. I can be calm and sleepy, but I can also be calm and alert. I can be nervous and alert, but I can also be nervous and sleepy (I hate it when that happens. Oh, but this isn’t about me.)
Now the molecules that make you relatively more calm than sleepy are marketed for treatment of anxiety and those that make you more sleepy than calm are marketed for sleep. But all of them do both things. (Unless of course you’re one of those contrary 0.1 percenters who get agitated on them. There’s always got to be a rebel without a clue, doesn’t there?)

So why aren’t they wonder drugs? Well, there’s that little addiction problem. There’s a reason you get solicitations to buy them over the internet, you know. Also if you take a high enough dose for long enough, you can sieze and die if you stop them abruptly, ruining your psychiatrist’s whole day, I might add.

So, the busy little beavers at the pharmaceutical companies have been working overtime to come up with better stuff–I did say there’s a fortuna to be made in sleeping pills, didn’t I? So they came up with Ambien (zolpidem), Sonata (zaleplon) and Lunesta (eszopiclone). These molecules also work at GABA but are more and more refined. They are still addictive, but in my experience much less so than the benzodiazepines. Because they are short acting, they are less likely to cause morning drowsiness but more likely to quit working in the middle of the night. They are much more expensive than the benzodiazepines which are pennies a pill. They tend to work well at first then stop working. I get many more complaints of sleep walking and hallucinations with these pills.

Finally, there’s melatonin and the melatonin acting agent Rozerem (ramelteon). These two don’t work for most people, but I always try them anyway because there seems to be a small subset of people who do really well on them. Rozerem is the beginning of a new class of agents that work on the molecules in the brain that specifically regulate the sleep wake cycle. There are tons more in the pipeline. You can count on that.

Next, medications that do other things and make you sleepy too–it’s a TWOFER!!!!

The Problem with Sleeping Pills

By kney

Jun

8

OK, OK, OK, I know, I know, I know. You’ve tried all those things to sleep better and you STILL cannot sleep. Whaddya think I am? Dumb or sumpthin? I know you haven’t tried all those things, and do you know how I know? I haven’t either. Oh, but then this isn’t about me, is it.

So you want a pill for sleep. And not that over the counter stuff either. OK, OK, OK, so–sleep medications. First of all, there are some potential problems with ALL sleep medication. Tolerance means you need a higher and higher dose for the medication to work. Sometimes the medication quits working altogether. Rebound means that if you skip the medication, not only do you have your ordinary insomnia, but now you have insomnia related to discontinuing the medication. Sometimes the medication lasts too long, which translates into a drugged or hungover feeling for part or all of the next day. Sometimes it doesn’t last long enough, which means you’re wide awake at 3 AM. (This is the problem with everyone’s favorite nonprescription sleep medication–alcohol.)

There are some weird phenomena related to being awake and asleep at the same time. You can sleepwalk and not remember what you did. 9 times out of 10, this translates into getting up, preparing, and eating a snack. The next day you are puzzled to find a paritally eaten peanut butter and banana sandwich in bed with you. People who claim to commit a crime like holding up a liquor store, are almost invariably lying. Still, you can’t blame a criminal for trying can you? Well, actually, I guess you can–but I digress. Scarier still are the hallucinations which are really just waking dreams. None of this has implications for your mental health–you haven’t suddenly developed a psychotic illness–you just might not want to take the medication if you have these particular side effects. Of course, the worst problem with sleep medicine is taking too much, stopping breathing and then, the big sleep.

The busy little pharmaceutical company beavers have been working overtime to make good pills that don’t do these bad things. As we get more sedentary and disconnected from our normal biological rhythms, we have created a huge market for good sleeping pills–in other words, there’s a fortuna to be made. But enough for now, I’m sleepy.

Sleep

By kney

Apr

26

Man, if I could put a boat in a sleeping pill, I’d be really rich. Why did I sleep so well in Fiji? I know, I know, I know, you think I’m just writing this post to brag about my vacation in Fiji. Busted. Just be glad I haven’t figured out how to upload my photos, because then I’d really be obnoxious. But I digress.

It turns out that my sleep hygiene was much improved during my Fiji vacation. Don’t ask me why, but sleep hygiene is what they call the stuff you do to sleep better. So, in no particular order, why I slept well in Fiji:

Limited caffeine. We had coffee for first and second breakfasts, but not after that. (You KNOW a vacation is good when you get first AND second breakfast.) Regular moderate exercise. Four to five dives a day amounts to a good five hours of swimming, most of it not all that vigorous. Dark room. Cool temperature. No TV. No alcohol. Lots of fish, fruits and vegetables, not much sugar. Consistent sleeping and waking times. Only sleep in bed, all other activities elsewhere. And then there’s that gently rocking boat….

You thought I was going to say no stress. Wrong. Diving in a wicked bad current with sharks and barracudas all around is a great definition of stress. How about night diving? How about looking around and not seeing your dive buddy or anyone else for that matter? How about a current driving you into the coral and knowing if you bang against it, you’re going to destroy 100 years of fragile growth and qualify for the title of environmental terrorist? How about–but I digress. So how do you sleep with all that stress?

You guessed it! Stress management–duh. First of all, there was the post-game. You can’t imagine you’re the only one stressed out, when everyone is talking about how tough the dive was, how scared they were and so on. Then there was the feedback. You gain a sense of control when you have a plan to manage future stress. Then there was the encouragement. Guess who was voted most improved diver? (OK, OK, OK, I know I was the worst diver there, but I take all compliments.) Oh, and by the way, other ways to manage stress? Healthy diet, regular exercise, adequate sleep. Do you ever get the feeling you’re just in a big circle?

Too bad I can’t put it in a pill….

NonStimulant Medications for ADHD

By kney

Apr

19

OK, OK, OK, I know, I know, I know. I was going to write this over a month ago. Well, better late than never. I actually don’t know if that’s true all the time. There might be a situation in which it’s better never than late. Hmmmm. But I digress. Some patients, for example those with heart conditions or chemical dependency, should not take stimulants. Non-stimulant alternatives for these patients include the centrally-acting antihypertensives and Strattera.

We have been using two centrally acting antihypertensive medications (blood pressure pills) in children for years. They are Tenex (guanfacine) and Catapres (clonidine). Both of these medications have recently been re-released in extended release preparations, Intuniv (guanfacine) and Kapvay (clonidine), the primary advantage being that they both are more expensive than their generic alternatives. These medications tone down the outflow of sympathetic (fight or flight) signals in the brain. We really have no idea why that helps symptoms of ADHD. Neither of them works as well as stimulants and both take a while to become effective. My ADHD patients tell me, “Dr. Ney, if I were good at waiting, I wouldn’t be seeing you for ADHD.” True enough. These medications can lower blood pressure resulting in fatigue or dizziness as a side effect and they can make you sleepy–which is a side effect we can sometimes put to good use. They’re not approved for use in adults but I often use them off label in patients who should not take stimulants.

Strattera or atomoxetine is a norepinephrine transport blocker (increases the norepinephrine signal in the brain) that has also been shown to help with the symptoms of ADHD. This medication works but again takes a while to kick in. My experience is that it has the most side effects and is the most expensive of the medications that have been shown to be helpful for ADHD. It’s still a good thing to try in people who can’t or shouldn’t take stimulant. Most people prefer stimulant medications, but there are some people who do better on atomoxetine, clonidine or guanfacine.

The antidepressants Effexor (venlafaxine), Wellbutrin (bupropion) and Norpramin (desipramine) have all been tried for ADHD, but there’s no good evidence that they are helpful. However, remember that comorbidity thingy–if you treat someone’s co-occurring anxiety or depression, you are bound to improve their ability to concentrate.

Last word: bibliotherapy. Check out ADHD Friendly Ways to Organize Your Life and Driven to Distraction