Sunday, February 28, 2010

Disapointing News

There is a journal article in the February issue of the Journal of Psychiatry on rates of Tardive Dyskinesia with the Atypical Antipsychotics. And it finds that they are not much better than the older antipsychotics, as was previously thought.

I didn't read the whole article, only the summery on Medscape, so I don't know all the details. They do say at equivalent levels (presumable of D2 blockage). Perhaps the atypicals can be used at lower equivalent dosages? And did they look at Seroquel separately? There is some theoretical reason to think it might be better. I never understood why the other atypicals would be better.

We do know that the atypicals are less likely to cause short term extra-pyramidal side effects- and that was thought to indicate a decreased propensity for longer term tardive dyskinesia. But it doesn't. And, I have to say, that I had EPS side effects on Risperidal and Geodon (although not as bad as Haldol)

If this is true, we should be seeing an explosion of tardive dyskinesia among the non-schizophrenic, as the atypicals are now being used for everything from anxiety to mood disorders to insomnia. Where is it? Is it too soon for TD to have developed? Maybe these drugs haven't been on the market long enough. Or maybe this is just one study, and isn't the whole story.

The study did find that risk of TD with antipsychotic use was much more likely among the schizophrenic than the non-schizophrenic- I think previous studies had found the reverse. So I am a little confused.

But I am all the more determined to get off of my Abilify. That will still leave me with a little bit of Zyprexa. Maybe someday I'll get off it, but not soon I think. In the mean time I'll keep taking all my antioxidents and lots of vitamin E at night with my Zyprexa. I'm hoping they will prevent TD.

I wonder if this study will change prescribing patterns. I have long thought that doctors are much to quick to prescribe antipsychotics to non-psychotic people. I have met doctors who will not prescribe benzodiazapines, but they will put you on an antipsychotic for your anxiety instead- something I think is totally backwards.

It would have been nice if the atypical antipsychotics could be the new wonder drugs in psychiatry. I have not been manic since Zyprexa, it has been my wonder drug. But as time goes by, and I start to forget how bad it was to be manic, I start to wonder at what cost I take this drug.

Saturday, February 27, 2010

Patients Who Break My Heart

I'm having a lot of these recently. A lot of late-state Multiple Sclerosis patients. One who is clinging on to indepedent living by a thread, and I don't know how much longer he can do it. And one who is so involved I am teaching her how to use a mouth stick. At home, she spends her days in bed. And a stroke patient whose vision is so affected that, while he might be able to go back to work eventually, he'll probably never drive again. And he lives alone. Lots of changes are going to have to happen in his life.

I am biased. When someone is approximately my age, it affects me more. I remember my first ICU evaluation. It was a woman with a devastating stroke, who was exactly my age. People my age aren't even supposed to have strokes! Or so I thought, before I went into this field. I had tears in my eyes as I did the eval, and hoped no one noticed. But she did amazingly well in rehab. The arm never came back, but she is walking and back at home with her kids and out in the community.

Working in this field grounds me. I often say that if I was a wedding planner, if I worked with happy people all day, I'd have to shoot myself! Instead, I am reminded daily that I have no monopoly on sufferring or difficulty. I can't feel too sorry for myself- although I have moments when I still manage to, but not many. Everyone has their own story, their own trials, their own battles, their own joys.

And I am inspired daily to see patients who manage to have good and productive lives despite considerable disability. I am constantly amazed to see how two people with the same level of physical disability live completely different lives, have different levels of handicap. There is a concept called "resiliance" that is being talked about a lot recently. How well you adapt and respond to adversity.

I think that depression is the opposite of resiliance.

Friday, February 26, 2010

Snow Day #2

OK, I wimped out. I made the mistake of watching TV news this morning, and of course they always have to play everything up. Dire warnings, don't go out unless you have to. Pictures of cars on the side of the road and accidents.

So when I called in to say I'd be late, and they told me that my first patient had cancelled, I decided I wasn't going in. Not for two patients, who might not even show up. So I gave word to cancel them, and I'm staying home. Thank God for the great office staff who actually made it in on time.

But it really doesn't look too terrible outside. Not good, but not a blizzard either. I've driven in worse. Why did I get all scaredy-cat now? Because I had many years of not driving while living in cities, I just went back to driving this past April. And I haven't done any winter driving in almost 10 years.

When I think about all the meds I was taking 10 years ago, I probably shouldn't have been driving at times- although I was very careful not to take certain meds before I drove. And then there was my manic driving, when I could not stay within the speed limit. I got 3 speeding tickets. Of course lots of people speed without the excuse of mania.

Now I am a much better driver, and much more comfortable driving. And not manic, and not taking any benzodiazapines. And I have a great little car, a Honda Civic, which I am leasing. I wouldn't want anything smaller, living in the northeast where I have to deal with snow occasionally.

So how to enjoy my snow day? I'm definately putting on my boots and getting outside. Maybe I'll walk to the chinese restaurant for lunch. And I'm going to study. I really have to study.

Thursday, February 25, 2010

Snow Day

Today we had snow. I've lived in upstate NY, and life there just goes on, but here people aren't so used to it. I saw all of 3 patients today, and some therapists saw less. Yes, I work in outpatient, where patients have the option of coming. The inpatient therapists had a full caseload.

It was a fun day at work, very laid back. A lot of joking and playing around. A lot of catching up on some paperwork that really needed attending to. Plus were were told to call tomorrow's patients to reschedule or cancel therm- but 3 of mine are still coming in.

Tomorrow may be worse. The snow is supposed to continue all night, and the temperature is supposed to drop- the roads will probably freeze. But I have every intention of going in to work tomorrow. I don't want to take another PTO day for a snow day. I have 3 patients to treat, and paperwork to do. But I'm going in a little late, after my parking lot has been plowed and the roads are cleared.

I wonder if we jumped the gun with cancelling tomorrow's patients. Maybe it won't be so bad. Or maybe it will. Weather is just not an exact science.

So tonight I'm relaxing with a cup of hot chocolate and watching the olympics. The wind is picking up outside, and it gives me a cozy feeling to listen to it, dry and warm. I haven't been saying this a lot in recent months- but sometimes life is good. If only for a moment. What is life but moments?

Monday, February 22, 2010

Good Day at Work

I had a good day at work, a good occupational therapy day. I had enough patients, but not too many. Enough time to give my patients what they need. Good patient interactions.

I had a discharge today, one of my long-timers. Someone who has really come a long way- one of the people who reminds me why I do this. I'll miss her.

I think the day was almost all stroke patients today, which can be very intense. Plus I had one workmen's comp patient, and the case manager came today to observe therapy, which can be a little awkward. But I think it went OK.

This evening I am exhausted, but not from work. It is that time of the month, and when I get my period I always have 2-3 days when I get really severe exhaustion. I feel like I can't move. Usually it comes with depression, this time it did not. I just have the exhaustion. This is why I take the pill so I only get my pill every 3 months. I couldn't deal with this every month. I used to spend a lot of days in bed. Or, I used to get crazy every month. To say nothing about the cramps I get- but now I've discovered Aleive, and if I take it at prescription strength, I'm pretty OK.

So no, I didn't make it to the gym, or clean, or study hand therapy this evening. I just sat in front of the TV and melted into the couch. Until I finally got enough energy to get up and eat, and now to sit in front of the computer before I take meds and go to bed.

I hope I have more energy tomorrow. One of my co-workers is out, so I will have some extra patients, it is going to be a busy day. Not like today. I have a feeling I won't have so much time for giving my patients the individual attention I want to tomorrow.

When I am treating orthopedic patients, I don't mind treating more than one patient at a time. In fact, the idea of just treating 1 hand therapy patient at a time, all day long, sounds really boring to me. But most of my caseload is neurological right now, and I feel very differently about that. My neuro patients I do wish I could give one-on-one treatment for all of their sessions. Unfornately, most places don't work that way anymore.

The stroke patients coming to outpatient therapy are getting more and more involved, as patients get kicked out of inpatient rehab quicker and quicker. Many of them come to us and they can't walk, they can't transfer independently, they can't dress themselves, they can't sit unsupported- I am starting to feel like I'm doing inpatient rehab at times. And I just feel bad for the patients, because outpatient doesn't give them the intensity of therapy that they need. They need more- and we are their last stop.

Of course some patients will continue to improve on their own, after the end of therapy. These are usually the higher functioning patients. The patients who have less function, and can do less on their own, they are much less likely to make gains on their own- and more likely to decline after discharge from therapy.

Sunday, February 21, 2010


I finished my taxes today using Turbotax. And with my dad's help, too. It was a little complicated this year because I moved from one state to another and changed jobs. Plus I did some home care work as an independent contractor.

Turbotax gives you a lot of prompts and asks you a lot of questions. At one point, it asked me if I am disabled. And I kind of wanted to say yes, but I kind of didn't. It is really a very good question. Am I disabled? Prehaps the better question is, "How disabled am I?" It isn't all or nothing.

When I clicked on the "learn more" link, it didn't sound like I qualify- or if I did, that it was going to help my tax situation any. But it didn't stop me from thinking.

I have been on social security disability. But for the past 6 years I've been able to work full time- although sometimes only hanging on by a thread. Really, there are times I don't know how I have kept going. It is my patients, really. When I have a patient in front of me, I can pull it together. I can do what I have to do. Now, the paperwork may start to slide when things get bad. It is not so compelling as patient care.

I actually have two disabilities. I have my mood disorder, and I have a learning disability, of some sort. I've been told I have dyslexia, ADD, and a variety of other things. But of course I don't have all of these things- I just have one brain that we try to put labels on. I just have a bad brain! I have bad brain syndrome.

What does it mean? It means I don't always know my left from my right and my handwriting is lousy. It means I am terribly disorganized, and constantly struggling with that. And mostly, it means that I am extremely slow with my paperwork. When the paperwork is not that bad, this isn't so much of a problem. But the worse the paperwork, the more of a problem, the more of a disability it is. So, long hours, but I manage.

And to the IRS, I am not disabled. I don't have any expenses that I can deduct due to my disability- although really, I think that my meds and therapy co-pays should qualify. And unfortunately, I owe a little bit to the IRS. And I owe one state, get a refund in the other. In the end, I actually come out a bit ahead.

But money is tight- and it is going to be tight for the next year and a half. Because I am going to be studying for the CHT exam- and until then I can't do a lot of home care or take a second job. But, I am going to have to do that in the future to pay off my debt and to save more for retirement. If I can just make it until then!

And I hope that this "disabled" person can study for and pass the CHT exam while at a job that is taking 10+ hours most days because of all the paperwork.

Saturday, February 20, 2010

Comfortably Numb?

I read Medscape. It is a really good website geared towards doctors with the latest medical news. Recently, it referenced a recent article in the British Journal of Psychiatry, which found that people on SSRI's experienced feelings of detatchment, personality changes, and a decrease in both positive and negative emotions.

Wow. I love it when the doctors finally figure out what any patient could tell you.

But that made me think. And introspect. And in recent months, I think my level of numbness has increased- to the extent that I had really not realized because I was so numb. And I've recently added medications to deal with a depression. But the depression is over, it is time to come off these added medications.

I have no illusions that I will ever be medication-free. But I think that I really only need a subset of the meds that I now take- and I don't know which of those meds I really need. That's the problem. I can make my educated guesses, but in the end there is a certain amount of trial and error involved in seeing what I can reduce or get off of- and I need to function at a very high level to work. Therefor, there is this slow accrual of medication. Something gets added, and it stays there.

The last two medications I have added are Abilify and Provigil. I have to say that Abilify did really save me. I was having an exremely bad depression, I was about to quit my job I was so depressed. But the depression is over- and if I didn't need it in the past, I'm going to take the guess that I don't need it now. I'm feeling just too numb.

The Provigil I really hope is not contributing to the numbness. Because it is really helping with my concentration and energy. I have ADD, and can't take stimulants because they raise my pulse rate too much.

How is this numbness affecting me? First of all, I am a procrastinator. I need a certain amount of anxiety to break through this and actually get things done. I went on Effexor half way through graduate school for OT, after a suicidal depression. And after I went on it, I noticed that I was getting to class late and not getting assignments done on time- and not because I was depressed, just because I wasn't "inspired" to do things. I needed that anxiety.

I need strong emotions to function. And recently, I am not functioning at all outside of work. And it is no longer due to depression- I am not in mental anguish. Quite the opposite, I am just fine with sleeping all weekend and doing nothing. I need to not be OK with that.

So I am going off the Abilify, knowing that it is there if I need it, the next time things get bad (which they will, they always do eventually). I'm not foolish enough to do it overnight, much as a part of me wants to. I take 10mg now (5mg 2x/day), and I'm going to go off 2.5mg/week. Assuming the depression doesn't come back of course.

My depressions are so bad, they have taken away so much of my life- is it surprising that I'm willing to give up a little of myself to keep them at bay? That's the deal I made with the Effexor. The best antidepressant I've been on in some ways, but it also gave me the numbness. But not so much that feelings couldn't break through- it just took a little more.

But now I feel like nothing is breaking through. So I need to do something.

You may ask, did I talk to my psychiatrist about this, no. I'll tell him at the next visit which isn't for a couple of months. But he is very good about this type of thing. As long as I'm being responsible, he doesn't mind me adjusting my own meds. Warning: not all psychiatrists are like this! Some are real control freaks. And if you are not stable, or don't know what you are doing, adjusting meds on your own without talking to your doctor is a really bad idea.