Imagine your self as a tree. You require soil, water, and sun.
How does water ascend from the soil all the way up to the tips of your leaves?
A small portion of the energy may come from your roots.
The pathways inside of you are mainly conduits for the water to rise, and cannot really pump the water upwards.
Most of the energy comes from the sun, from energy that causes evaporation in our leaves. This creates suction. This energy is so powerful that it can draw water up to the top of a 100 metre redwood tree.
reference:
http://www.sciam.com/article.cfm?id=how-do-large-trees-such-a
I see this as an analogy to energy and motivation in our lives. We can't provide all of our own energy and motivation. We must be involved in external things which draw action out of us, as the sun and its evaporative effects draw water all the way up a very tall tree. This leads to continuous "columns" of action, beginning at the roots, ascending to the outer portions of our selves. Others (other relationships, other involvements in community) are necessary to keep this cycle going. It is very hard to generate your own motivation all alone--"root pressure alone" can only go so far.
Many of my patients with low motivation and energy try very hard to initiate activity. A turning point can often be when they become involved with others, or with a community, or with some other external structure, that can help keep this "column" of motivation rising to new heights.
Friday, August 8, 2008
Tuesday, August 5, 2008
Discontinuing Benzodiazepines
Benzodiazepines are common sedative drugs which are prescribed to treat anxiety symptoms and to treat insomnia. The most common of these are lorazepam (ativan), clonazepam, temazepam, diazepam, and many other drugs ending in "pam". Some of the newer sleep medications such as zopiclone are quite similar pharmacologically to benzodiazepines, and in my opinion may as well be included in this discussion, despite their supposed reduced risk for dependence problems.
These drugs can be powerful life-saving agents, in treating seizures, in treating alcohol withdrawal, in surgical anesthesia, and for numerous other applications.
For insomnia and anxiety they are best used for very short periods of time, usually only for days or a few weeks.
It is very important to note that there are some people, in my opinion, who do better to continue taking benzodiazepines on a long-term basis to treat chronic anxiety symptoms. There are some "anti-benzodiazepine" groups out there which I think fail to acknowledge that some people really do benefit from long-term benzo treatment. There are many more people, in my opinion, who do well to use benzodiazepines repeatedly, for brief periods of time, during symptom exacerbations. The "anti-benzodiazepine" groups are too dogmatic, in their criticism of this class of medication.
Yet, for many people, longer-term benzodiazepine use does not help, but instead causes more problems. The benzodiazepines cause more physical and psychological dependence than most people realize, and therefore can be difficult to discontinue.
If you want to discontinue a benzodiazepine, here are some of my suggestions (once again, all of these ideas need to be employed in collaboration with a trusted prescribing physician):
1) Do it extremely slowly, especially if you have been on it for a long time. Do not stop suddenly. I would suggest 5-10 % dose reductions every 1-2 weeks. I have recently discovered that so-called "compounding pharmacists" are available who will prepare individualized doses of medication--for example in a liquid form --so that you can do tiny dose reductions of benzodiazepines very conveniently and precisely.
2) Consider switching over to diazepam (Valium), at a dose which has an equivalent effect for you to start off with. (there are tables to refer to, which show approximately how much diazepam is equivalent to doses of other sedatives or benzodiazepines). The advantage of valium is its much longer period of metabolism in the body, which can then soften the effect of small dose changes.
Once again, 5-10 % dose reductions every 1-2 weeks (you can use the higher reduction more frequently if you are tolerating the taper more comfortably).
Addendum: a recent review in the Cochrane database (an excellent collection of evidence-based research studies) suggests that switching to long-metabolizing benzodiazepines such as diazepam may not be necessary. However it is pretty clear that tapering slowly is important. (Denis et al, Cochrane Database Syst Rev. 2006 Jul 19;3:CD005194)
3) Often times, the first 50% of your dose reduction will be easier and quicker, and the last few milligrams of your dose can be hardest to taper. So you may need to taper more slowly during this final stage. Once you get down to about 0.5 - 1 mg of diazepam daily, you can discontinue entirely (diazepam comes in 2 mg and 5 mg tablets).
4) Sometimes an adjunctive drug such as an anticonvulsant can make the tapering process a little easier, although the evidence is weak and shows that the benefits are not consistent or robust for everyone. It may help a particular individual though. Examples of suitable anticonvulsants are carbamazepine, gabapentin, pregabalin, and others. The usefulness of carbamazepine was affirmed in the above-mentioned study by Denis et al.
5) Antidepressants such as SSRI's may be helpful to treat the underlying anxiety or other symptoms that the benzodiazepine was prescribed to treat in the first place. However, one should not expect that SSRI treatment will treat or reduce benzodiazepine withdrawal symptoms. Sometimes the SSRI may actually increase some of the withdrawal symptoms, if the SSRI is itself slightly interfering with sleep or causing physical side-effects such as restlessness or nausea.
6) I would like to emphasize that, in most cases, all other available treatments for anxiety, agitation, irritability, or insomnia should be optimized before resorting to benzodiazepines. These include healthy lifestyle change (e.g. moderating stress, exercise, eating well, etc.), cognitive-behavioural therapy, meditation, and non-addictive medication (e.g. SSRI antidepressants). The only exceptions to this would be in cases of alcohol withdrawal, seizures, or highly agitated acute manic or psychotic states, in which benzodiazepines (sometimes at high doses) could be extremely important and necessary.
These drugs can be powerful life-saving agents, in treating seizures, in treating alcohol withdrawal, in surgical anesthesia, and for numerous other applications.
For insomnia and anxiety they are best used for very short periods of time, usually only for days or a few weeks.
It is very important to note that there are some people, in my opinion, who do better to continue taking benzodiazepines on a long-term basis to treat chronic anxiety symptoms. There are some "anti-benzodiazepine" groups out there which I think fail to acknowledge that some people really do benefit from long-term benzo treatment. There are many more people, in my opinion, who do well to use benzodiazepines repeatedly, for brief periods of time, during symptom exacerbations. The "anti-benzodiazepine" groups are too dogmatic, in their criticism of this class of medication.
Yet, for many people, longer-term benzodiazepine use does not help, but instead causes more problems. The benzodiazepines cause more physical and psychological dependence than most people realize, and therefore can be difficult to discontinue.
If you want to discontinue a benzodiazepine, here are some of my suggestions (once again, all of these ideas need to be employed in collaboration with a trusted prescribing physician):
1) Do it extremely slowly, especially if you have been on it for a long time. Do not stop suddenly. I would suggest 5-10 % dose reductions every 1-2 weeks. I have recently discovered that so-called "compounding pharmacists" are available who will prepare individualized doses of medication--for example in a liquid form --so that you can do tiny dose reductions of benzodiazepines very conveniently and precisely.
2) Consider switching over to diazepam (Valium), at a dose which has an equivalent effect for you to start off with. (there are tables to refer to, which show approximately how much diazepam is equivalent to doses of other sedatives or benzodiazepines). The advantage of valium is its much longer period of metabolism in the body, which can then soften the effect of small dose changes.
Once again, 5-10 % dose reductions every 1-2 weeks (you can use the higher reduction more frequently if you are tolerating the taper more comfortably).
Addendum: a recent review in the Cochrane database (an excellent collection of evidence-based research studies) suggests that switching to long-metabolizing benzodiazepines such as diazepam may not be necessary. However it is pretty clear that tapering slowly is important. (Denis et al, Cochrane Database Syst Rev. 2006 Jul 19;3:CD005194)
3) Often times, the first 50% of your dose reduction will be easier and quicker, and the last few milligrams of your dose can be hardest to taper. So you may need to taper more slowly during this final stage. Once you get down to about 0.5 - 1 mg of diazepam daily, you can discontinue entirely (diazepam comes in 2 mg and 5 mg tablets).
4) Sometimes an adjunctive drug such as an anticonvulsant can make the tapering process a little easier, although the evidence is weak and shows that the benefits are not consistent or robust for everyone. It may help a particular individual though. Examples of suitable anticonvulsants are carbamazepine, gabapentin, pregabalin, and others. The usefulness of carbamazepine was affirmed in the above-mentioned study by Denis et al.
5) Antidepressants such as SSRI's may be helpful to treat the underlying anxiety or other symptoms that the benzodiazepine was prescribed to treat in the first place. However, one should not expect that SSRI treatment will treat or reduce benzodiazepine withdrawal symptoms. Sometimes the SSRI may actually increase some of the withdrawal symptoms, if the SSRI is itself slightly interfering with sleep or causing physical side-effects such as restlessness or nausea.
6) I would like to emphasize that, in most cases, all other available treatments for anxiety, agitation, irritability, or insomnia should be optimized before resorting to benzodiazepines. These include healthy lifestyle change (e.g. moderating stress, exercise, eating well, etc.), cognitive-behavioural therapy, meditation, and non-addictive medication (e.g. SSRI antidepressants). The only exceptions to this would be in cases of alcohol withdrawal, seizures, or highly agitated acute manic or psychotic states, in which benzodiazepines (sometimes at high doses) could be extremely important and necessary.
Discontinuing Antidepressants
Antidepressants usually should never be stopped suddenly. Also, if you are taking an antidepressant it is important to take it daily without skipping doses.
If the antidepressant level in your body drops suddenly, it will not cause a sudden plunge into depression as a result -- the impact of antidepressants on mood disorders occurs over a period of weeks or months.
But if the level drops suddenly, it will cause a withdrawal syndrome. Symptoms include nausea, anxiety, insomnia, abnormal physical sensations in the body, and a variety of others. For some people these symptoms are no more than a nuisance which passes easily after a week or so. But for others it becomes an intolerable syndrome, which furthermore can magnify previous symptoms of depression and anxiety. The withdrawal syndrome may fool you into thinking that you require the antidepressant on an ongoing basis (since you feel awful when you stop it), when in fact you may be ready to discontinue as long as you do it gradually.
--by the way, I am not advocating that people try to discontinue antidepressants if the medication is helping--in most cases I advise people to stick with an antidepressant that works for them, and if their symptoms are recurrent or chronic to consider a long-term course of the medication--
Most of the SSRI antidepressants (e.g. paroxetine, fluvoxamine, sertraline, citalopram, escitalopram) and other antidepressants such as venlafaxine, can cause a withdrawal syndrome. Paroxetine and venlafaxine seem to be particularly notorious.
There are various reasons to discontinue a medication. Sometimes people want to stop because they have been feeling better for a good long time, and want to see if they can stay well without a medication. For others, the medication is not working, or is working questionably well, and it is time to make a change in plan. For others, they are simply fed up with taking pills, and want to stop.
If someone does want to discontinue, I have a set of suggestions that makes the process easier (these are ideas that need to be applied with guidance from your prescribing physician):
1) if the medication has only been taken for a short time (a few weeks or less) usually it can be discontinued very quickly, and a problematic withdrawal syndrome is not very likely
2) if the medication has been taken for a long time, then I recommend an extremely gradual tapering. Most tablet sizes permit easy dose changes of only 25-50% at a time. These changes are too large. I suggest shaving off tiny amounts, and sticking with the new lower dose for up to a week at a time before reducing the dose further. Sometimes, a 10% dose reduction every week is best tolerated. For a tablet, this may mean cutting off about 10% of the tablet with a sharp knife. Fortunately, with antidepressants, the EXACT dosage is much less critical than for other medications (such as hematological drugs, etc.), so this relatively imprecise method of dose reduction is appropriate for this purpose, in my opinion. Some antidepressants come in capsule form (e.g. venlafaxine and sertraline). In these cases, I have recommended that people take the capsules apart, to carefully remove a small percentage of the contents, during their taper (venlafaxine XR 75 mg capsules have approximately 200 little granules inside; one could take out 20 granules for a 10% dose reduction).
3) If this process--of gradual tapering--is not working out, I have a second method which can often help: fluoxetine (Prozac) is the one antidepressant with an extremely long period of metabolism in the body. So it does not have a sudden withdrawal syndrome. Fluoxetine can be added to another antidepressant regimen, at which time the other antidepressant can be tapered much more easily. After this, fluoxetine itself is much easier to taper and discontinue, as it "tapers itself" out of the body gradually over about 4 weeks. Once again, this would have to be attempted only with close guidance from your doctor, because sometimes (rarely) adding a second antidepressant can cause other problems (e.g. a "serotonin syndrome").
If the antidepressant level in your body drops suddenly, it will not cause a sudden plunge into depression as a result -- the impact of antidepressants on mood disorders occurs over a period of weeks or months.
But if the level drops suddenly, it will cause a withdrawal syndrome. Symptoms include nausea, anxiety, insomnia, abnormal physical sensations in the body, and a variety of others. For some people these symptoms are no more than a nuisance which passes easily after a week or so. But for others it becomes an intolerable syndrome, which furthermore can magnify previous symptoms of depression and anxiety. The withdrawal syndrome may fool you into thinking that you require the antidepressant on an ongoing basis (since you feel awful when you stop it), when in fact you may be ready to discontinue as long as you do it gradually.
--by the way, I am not advocating that people try to discontinue antidepressants if the medication is helping--in most cases I advise people to stick with an antidepressant that works for them, and if their symptoms are recurrent or chronic to consider a long-term course of the medication--
Most of the SSRI antidepressants (e.g. paroxetine, fluvoxamine, sertraline, citalopram, escitalopram) and other antidepressants such as venlafaxine, can cause a withdrawal syndrome. Paroxetine and venlafaxine seem to be particularly notorious.
There are various reasons to discontinue a medication. Sometimes people want to stop because they have been feeling better for a good long time, and want to see if they can stay well without a medication. For others, the medication is not working, or is working questionably well, and it is time to make a change in plan. For others, they are simply fed up with taking pills, and want to stop.
If someone does want to discontinue, I have a set of suggestions that makes the process easier (these are ideas that need to be applied with guidance from your prescribing physician):
1) if the medication has only been taken for a short time (a few weeks or less) usually it can be discontinued very quickly, and a problematic withdrawal syndrome is not very likely
2) if the medication has been taken for a long time, then I recommend an extremely gradual tapering. Most tablet sizes permit easy dose changes of only 25-50% at a time. These changes are too large. I suggest shaving off tiny amounts, and sticking with the new lower dose for up to a week at a time before reducing the dose further. Sometimes, a 10% dose reduction every week is best tolerated. For a tablet, this may mean cutting off about 10% of the tablet with a sharp knife. Fortunately, with antidepressants, the EXACT dosage is much less critical than for other medications (such as hematological drugs, etc.), so this relatively imprecise method of dose reduction is appropriate for this purpose, in my opinion. Some antidepressants come in capsule form (e.g. venlafaxine and sertraline). In these cases, I have recommended that people take the capsules apart, to carefully remove a small percentage of the contents, during their taper (venlafaxine XR 75 mg capsules have approximately 200 little granules inside; one could take out 20 granules for a 10% dose reduction).
3) If this process--of gradual tapering--is not working out, I have a second method which can often help: fluoxetine (Prozac) is the one antidepressant with an extremely long period of metabolism in the body. So it does not have a sudden withdrawal syndrome. Fluoxetine can be added to another antidepressant regimen, at which time the other antidepressant can be tapered much more easily. After this, fluoxetine itself is much easier to taper and discontinue, as it "tapers itself" out of the body gradually over about 4 weeks. Once again, this would have to be attempted only with close guidance from your doctor, because sometimes (rarely) adding a second antidepressant can cause other problems (e.g. a "serotonin syndrome").
Sunday, August 3, 2008
Forest Paths Metaphor
One's life, or mind, or brain, is like a forest with many paths.
There is some literal truth to this metaphor, in that the connections in the brain that form memories and patterns of behaviour, most likely exist as pathways between many different neurons, with the pathways consolidated and strengthened further every time they are activated.
Some of our forest paths may be well-trodden, but lead us into dangerous territory every time (maybe into poor relationships, addictions, recurrent self-destructive thoughts, depressive symptoms, or other harms to self).
But it is not easy to navigate new paths. The familiarity, ease, and convenience, of the old paths makes them the most likely to take.
You may need to do hard work forming new paths in your forest, resisting the urge to take the old familiar ones.
The old paths may never "close up" entirely. Look at the paths in a literal forest outside. Even paths that are overgrown for years are still apparent, and if someone was to make a new path in that area, chances are they might choose that same old overgrown one.
But old paths gradually weaken, if they are left untrodden. You may need to leave them dormant for years (imagine those protective fences they put up in forests to protect "ecologically sensitive areas" from being trampled by hikers--put some of those up in your own mind and in your own life).
There is some literal truth to this metaphor, in that the connections in the brain that form memories and patterns of behaviour, most likely exist as pathways between many different neurons, with the pathways consolidated and strengthened further every time they are activated.
Some of our forest paths may be well-trodden, but lead us into dangerous territory every time (maybe into poor relationships, addictions, recurrent self-destructive thoughts, depressive symptoms, or other harms to self).
But it is not easy to navigate new paths. The familiarity, ease, and convenience, of the old paths makes them the most likely to take.
You may need to do hard work forming new paths in your forest, resisting the urge to take the old familiar ones.
The old paths may never "close up" entirely. Look at the paths in a literal forest outside. Even paths that are overgrown for years are still apparent, and if someone was to make a new path in that area, chances are they might choose that same old overgrown one.
But old paths gradually weaken, if they are left untrodden. You may need to leave them dormant for years (imagine those protective fences they put up in forests to protect "ecologically sensitive areas" from being trampled by hikers--put some of those up in your own mind and in your own life).
What to expect from an antidepressant
Here is what to expect and to watch for when starting an antidepressant:
1) some people will have an immediate positive effect from an antidepressant, they will notice improvement in mood or anxiety right away.
2) most people, though, will notice very gradual improvement, and it will require at least two weeks at a full dose to have a substantial change in symptoms. Some people may require a longer period of time, up to 2 or 3 months or longer, to notice a benefit.
3) many people have their worst side-effect problems in the first 1-2 weeks of starting an antidepressant. Side effects might include sleep problems, nausea, sweating, or increased anxiety (there can be many more side-effects too). Usually these side effects settle down after 1-2 weeks.
To reduce the likelihood of this being a problem, I usually start most people on a tiny dose of an antidepressant (for example, 1/4 tablet daily), to allow people to adjust more gradually. The advantage of this is less side-effects, but the disadvantage is that it could take longer to experience a benefit. Studies show that the most significant and consistent positive effects of antidepressants begin at a full daily dose (usually one tablet daily of most antidepressants).
4) Some people may have severe side-effect problems. If this happens, I usually recommend that they discontinue the medication, so that we can make a new plan. People who have bipolar disorder, or who may have a higher risk (e.g. through family history) of developing bipolar disorder, have a higher risk of severe side-effects from antidepressants, and have a higher risk of experiencing a manic episode as a result of taking an antidepressant.
5) In all cases, I like to see and hear from people frequently whenever a new medication is started, so that any possible problems can be addressed early. Sometimes side-effects can quietly pass, other times it might be best to back off, stop the medication, and try something else.
6) The benefits of antidepressants can sometimes be subjectively obvious, other times they may be quite subtle. Others around you may notice beneficial effects before you do yourself. It may be only after a few months that you can look back and see (and feel) that things are better.
7) There is evidence that antidepressants reduce the risk of relapse in recurrent depression (probably about a 50% reduction). For some people, even if they may not need the antidepressant to treat current, acute symptoms, they may benefit from continuing the medication so as to prevent relapse. Of note, studies also show that psychotherapy (CBT in particular) reduces relapse rate by about 50% as well in recurrent depression. And there is evidence that the combination of medication + psychotherapy is synergistic, and may reduce the relapse rate by 75%. Reference:http://garthkroeker.blogspot.com/2009/03/long-term-antidepressant-therapy-to.html
8) Sometimes you need to try several (or many) different antidepressants, before finding the one that suits you best. Different medications in the same class (e.g. the various different SSRI's) can sometimes "suit" people quite differently. For many of my patients, a combination of two antidepressants, or sometimes more complex combinations of other medications, ends up helping best. In these situations, I do think it is important to give each medication trial a good, thorough try (usually at least two months) before making major changes.
1) some people will have an immediate positive effect from an antidepressant, they will notice improvement in mood or anxiety right away.
2) most people, though, will notice very gradual improvement, and it will require at least two weeks at a full dose to have a substantial change in symptoms. Some people may require a longer period of time, up to 2 or 3 months or longer, to notice a benefit.
3) many people have their worst side-effect problems in the first 1-2 weeks of starting an antidepressant. Side effects might include sleep problems, nausea, sweating, or increased anxiety (there can be many more side-effects too). Usually these side effects settle down after 1-2 weeks.
To reduce the likelihood of this being a problem, I usually start most people on a tiny dose of an antidepressant (for example, 1/4 tablet daily), to allow people to adjust more gradually. The advantage of this is less side-effects, but the disadvantage is that it could take longer to experience a benefit. Studies show that the most significant and consistent positive effects of antidepressants begin at a full daily dose (usually one tablet daily of most antidepressants).
4) Some people may have severe side-effect problems. If this happens, I usually recommend that they discontinue the medication, so that we can make a new plan. People who have bipolar disorder, or who may have a higher risk (e.g. through family history) of developing bipolar disorder, have a higher risk of severe side-effects from antidepressants, and have a higher risk of experiencing a manic episode as a result of taking an antidepressant.
5) In all cases, I like to see and hear from people frequently whenever a new medication is started, so that any possible problems can be addressed early. Sometimes side-effects can quietly pass, other times it might be best to back off, stop the medication, and try something else.
6) The benefits of antidepressants can sometimes be subjectively obvious, other times they may be quite subtle. Others around you may notice beneficial effects before you do yourself. It may be only after a few months that you can look back and see (and feel) that things are better.
7) There is evidence that antidepressants reduce the risk of relapse in recurrent depression (probably about a 50% reduction). For some people, even if they may not need the antidepressant to treat current, acute symptoms, they may benefit from continuing the medication so as to prevent relapse. Of note, studies also show that psychotherapy (CBT in particular) reduces relapse rate by about 50% as well in recurrent depression. And there is evidence that the combination of medication + psychotherapy is synergistic, and may reduce the relapse rate by 75%. Reference:http://garthkroeker.blogspot.com/2009/03/long-term-antidepressant-therapy-to.html
8) Sometimes you need to try several (or many) different antidepressants, before finding the one that suits you best. Different medications in the same class (e.g. the various different SSRI's) can sometimes "suit" people quite differently. For many of my patients, a combination of two antidepressants, or sometimes more complex combinations of other medications, ends up helping best. In these situations, I do think it is important to give each medication trial a good, thorough try (usually at least two months) before making major changes.
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