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When is hospitalization necessary? What does it offer?
Hospitalization is the highest level of treatment. It is reserved for the most severe forms of mental illness. One criterion used for determining necessity of hospitalization is the presence of suicidality. Having suicidal ideation does not automatically dictate a hospital stay, but it does prompt an inquiry into the patient’s level of risk to harm him or herself (or others).
Hospitalization may also be indicated if a person’s functional impairment is so poor that he or she is unable to adequately care for him- or herself (e.g., unable to get out of bed, not eating), such as in someone with severe depression. Most often, depressed individuals are willing to be hospitalized if recommended and thus do so voluntarily. There are situations, however, when the physician believes hospitalization is necessary but the patient refuses.
This is more likely in cases of mania during which one rarely wants to be hospitalized. The physician then needs to decide if the person should be admitted involuntarily. Criteria for this process vary from state to state, but it is generally not easy to admit someone against his or her will. Most states have mental hygiene laws in place to protect patients’ rights. Typically, dangerousness to self or others is the criterion required to commit someone. In that light, hospitalization for mania is usually due to potential for aggression, psychosis, or severe functional impairment that puts the individual at risk. Mental hygiene laws usually have an appeal process available for those committed involuntarily, and a reassessment is typically required within a specified time period as to necessity for continued hospitalization.
Can I drink wine with my mood stabilizer?
There are two parts to the answer to this question. The first part has to do with alcohol’s effect on the brain of someone with bipolar disorder and the second part has to do with any drug–drug interactions between alcohol and your medication. First of all, alcohol is the last thing you want to put in your body if you suffer from bipolar disorder. Alcohol negatively affects the very chemicals that your mood-stabilizing medication is trying to normalize. Alcohol is a depressant.
Alcohol is a euphoriant. Alcohol can worsen anxiety. Alcohol can worsen irritability. When alcohol is on board it acts as a sedative and can cause some areas of the brain to shut down their control of other more “primitive” areas of the brain, increasing impulsivity and reckless behavior. When alcohol washes out of your system your brain’s activity level increases overall so that your moods end up cycling more rapidly and irritability and dysphoria can increase. Sleep is compromised as well, increasing your chances of relapsing into mania or depression.
In terms of any potential interactions between alcohol and bipolar medications, the answer is more complicated. With some medications like anticonvulsants and benzodiazepines the risk is serious insofar as there is a cumulative sedative effect of the two leading to an increased probability of intoxication and possible respiratory suppression. With other medications, such as the atypical antipsychotics, the risk of having a seizure, while small, is increased. With certain antidepressant medications, such as the monoamine oxidase inhibitors, the risk is serious, as the interaction with some forms of alcohol, particularly red wines, can lead to malignant hypertension, which is potentially life threatening.
With tricyclic antidepressants, the risks are again due to their sedative effects, which are additive to alcohol, and thus cause intoxication and its incumbent risks more readily. Finally, with the newer SSRIs, the additive effects are much less noticeable, as these medications are not found to be sedating nor to affect cognition and motor coordination adversely. Given both the potential for worsening illness, as well as exacerbating symptoms, it is best to avoid alcohol altogether.
Scott’s comments:
The first time I had alcohol while on medication was on my wedding anniversary.My wife and I was staying at a beautiful resort, and decided we’d celebrate with a glass of wine at dinner. That night I had the most incredibly violent dreams that I’ve ever had. My sleep was interrupted with horrible nightmares about bloodshed and killing. The next morning I discussed this with my wife-it was enough to make me swear off alcohol.
Term:
Malignant hypertension – elevated blood pressure that is acute and rapidly progressive with severe symptoms, including headache.
Are there long-term dangers to taking medication?
With the recent press regarding the link between Vioxx and heart disease, and the alleged link between antidepressant medications and suicide, fear of long-term adverse effects has grown, particularly for newer medications. With respect to psychiatric medications, this fear includes the belief that medication is a form of mind control that can have permanent long-term effects on one’s personality and mind. This particular idea is categorically false. No medication has that level of control over one’s mind. With respect to potential long-term adverse effects of various bipolar agents, however, one should be aware of each agent’s particular issues. The most common and/or concerning issue for each is the subject of the following paragraphs. The list is otherwise too long; refer to the package insert for each drug for a complete list.
Lithium
Lithium is the most well known in terms of potential adverse effects. First, it is important to note that blood levels need to be monitored regularly. Lithium has a very narrow therapeutic index-that is, the blood level for minimum effectiveness and the blood level for potential toxicity is fairly narrow. Second, there are three potentially long-term adverse effects of which to be aware and to understand: hypothyroidism, kidney damage, and weight gain. There are a number of risk factors for developing hypothyroidism. They include having a prior history of thyroid problems, being female, being overweight, having a family history of thyroid problems, having rapid-cycling bipolar disorder, and requiring higher doses of lithium. When hypothyroidism develops as a result of lithium it is generally reversible, unless antibodies to thyroid are present. The best indicator for presence of antibodies is family history. If hypothyroidism occurs, thyroid replacement may be indicated. The most common problem that occurs to the kidney in response to lithium is the inability to concentrate urine and preserve fluid over time. The risk of this is both dose and time dependent. That is, kidney toxicity generally occurs after taking higher doses of lithium for many (ten to fifteen) years. Chronic renal failure can occur at this time; lithium needs to be discontinued once this has happened. One should avoid taking nonsteroidal anti-inflammatory medications for extended periods of time as these medications increase the blood level of lithium and can also adversely impact the kidneys.
Weight gain associated with lithium is a slow onset effect. It occurs for a variety of reasons, including the initial increased thirst associated with lithium, the possibility of hypothyroidism from lithium (which can also cause weight gain), and the effect of lithium itself on metabolism. Risk factors associated with weight gain include being young, overweight, and female. The odds of gaining weight are about 50/50.
Terms:
Therapeutic index – the ratio between the toxic dose and the therapeutic dose of a drug, used as a measure of the relative safety of the drug for a particular treatment.
Hypothyroidism – decreased or absence of thyroid hormone, which is secreted by an endocrine gland near the throat and has wide metabolic effects. When thyroid hormone is low, metabolism can slow, leading to symptoms that can mimic clinical depression.
Depakote (valproate)
Depakote (valproate) has some immediate and long-term adverse effects. The immediate concern for various blood disorders prompts monitoring of a complete blood count. Thrombocytopenia, a drop in platelets (important in blood clotting), is a not uncommon effect. This is easily reversible by stopping the medication.
Hepatitis and pancreatitis can also occur early on in treatment, and for this reason liver function tests should be performed regularly.Women of childbearing age should be cautioned, as Depakote (valproate) is associated with a higher incidence of birth defects. A more common, less dangerous, but more distressing problem is alopecia, or hair loss. This is also reversible with discontinuation of the medication.Weight gain is a potential problem, and Depakote (valproate) may play a role in the development of polycystic ovarian syndrome.
Terms:
Thrombocytopenia – an abnormal decrease in the number of platelets in the blood.
Hepatitis – inflammation of the liver, caused by infection or a toxin.
Pancreatitis – inflammation of the pancreas
Equetro (carbamazepine)
Although reported infrequently, serious adverse organ system effects have been observed with the use of Equetro (carbamazepine). Early in treatment a rash is possible. Most rashes are benign. Should signs and symptoms of a severe skin reaction such as Stevens-Johnson syndrome appear, Equetro (carbamazepine) should be withdrawn immediately. Blood cell problems are the most well known complications. Both leucopenia (loss of white blood cells) and thrombocytopenia can occur. In addition, the liver can be adversely affected, resulting in hepatitis and jaundice. Equetro (carbamazepine) levels, a complete blood count, and liver function must be monitored throughout treatment in order to detect as early as possible signs and symptoms of a possible blood or liver problem. Equetro (carbamazepine) should be discontinued if any evidence of a significant problem appears. Long-term toxicity studies in rats have indicated a potential carcinogenic risk; however, no evidence exists that this medication is carcinogenic in humans. In women of childbearing potential, Equetro (carbamazepine) should be avoided whenever possible or prescribed as monotherapy because the incidence of congenital abnormalities in the offspring of women treated with more than one anticonvulsant is greater.
Terms:
Stevens-Johnson syndrome – a severe inflammatory eruption of the skin and mucous membranes that can occur as an allergic reaction to a medication.
Leucopenia – an abnormal lowering of the white blood cell count.
Atypical Antipsychotic Medications
Although the FDA treats the atypical antipsychotics as a class in terms of side effect profiles, all coming with the same warnings on their package inserts, they do not all demonstrate the same adverse effects equally. The most concerning class effect is the development of metabolic syndrome, which is characterized by a number of metabolic changes, including weight gain and elevated cholesterol, triglycerides, and fasting blood sugars. Some patients have gone on to develop diabetes.
A few have developed diabetic ketoacidosis, a medical emergency stemming from extremely high blood sugars. Not all of the atypical antipsychotics appear to cause this problem to the same degree. The two worst offenders are Clozaril (clozapine) and Zyprexa (olanzapine). This is unfortunate, because Clozaril (clozapine) is the most effective antipsychotic on the market, and many clinicians swear by Zyprexa (olanzapine) as being the second most effective and perhaps best-tolerated agent. In the middle are Risperdal (risperidone) and Seroquel (quetiapine).
Geodon (ziprasidone) and Abilify (aripiprazole) appear to have no effect on the development of metabolic syndrome though both have been known to cause weight gain to a lesser degree than the others. All of these medications have been known to lead to cerebrovascular events in the elderly, and so their use in this population should be minimized. They also appear to increase the rate of mortality from all conditions in this population for unknown reasons. Finally, while the development of extrapyramidal side effects and tardive dyskinesia is greatly reduced in this class compared to the older typical antipsychotics, it is not nonexistent. Again, it appears some are more likely than others to cause extrapyramidal problems, particularly Risperdal (risperidone). Risperdal (risperidone) also can elevate prolactin, which has a number of adverse consequences, including breast growth, lactation, and decreased libido.
Terms:
Extrapyramidal – the parts of the brain responsible for static motor control. The basal ganglia are part of this system. Deficits in this system result in involuntary movement disorders.
Antipsychotic medications – affect these areas, leading to extrapyramidal side effects, which include muscle spasms (dystonias), tremors (Parkinson’s), shuffling gait, restlessness (akathisia), and tardive dyskinesias.
Tardive dyskinesia – a late-onset involuntary movement disorder, often irreversible, typically of the mouth, tongue, or lips, and less commonly of the limbs and trunk. These movements are a consequence of long-term antipsychotic use but are less commonly observed with the newer, atypical antipsychotics.
Selective Serotonin Reuptake Inhibitors (SSRIs)
SSRIs have been on the market since the introduction of Prozac in the late 1980s. Numerous studies have attempted to link them to long-term dangers such as cancer or other medical conditions aside from their psychological effects. None of these studies has yet held up to any scrutiny. All of the studies linking SSRIs to suicidal behavior analyze data at the beginning of treatment and most likely represent an unidentified side effect that can be associated with suicidal behavior. Such side effects could be increasing anxiety and insomnia or an extrapyramidal side effect that causes patients to become uncomfortably restless (akathisia).
Another factor that may be involved is the improvement in energy levels that often occurs before an improvement in mood, which may result in increased motivation and energy to act on suicidal desires. This is why close monitoring during the initial phase of treatment with these medications is imperative.
Terms:
Akathisia – a subjective sense of inner restlessness resulting in the need to keep moving.
Objectively, restless – movements or pacing may be signs of akathisia.
