30 Hour Famine World Vision

We often hear about how many problems that adolescents have in this day, problems with substance abuse, teen pregnancy,sexually transmitted diseases and educational failures so I would like to talk about something positive that many youth engaged in over the weekend. World Vision, a christian charitable organization ,sponsors each a 30 hour famine for middle school and high school age teens. Across the country young people participate in this activity which is designed to raise awareness of global poverty and provide the youth an opportunity to do something to make a difference.We had over 100 teens participate this year at our church. It is a yearly event that we have been participating in for some time now.

So what is the 30 hour famine? The youth spend the weekend together and fast for 30 hours to get some sense of what it is like for many that go hungry. During the weekend they participate in activities that both help the community as well doing awareness related activities. This year they made sandwiches for the homeless, refugee welcome baskets, worked at program that feeds the homeless and collected food for one of the local food banks. Afterwards they raise money for different projects. This year their goal was $7,500 dollars to buy insecticide treated mosquito netting for beds to give to the World Vision sponsored group End Malaria which is dedicated to the goal of eradicating malaria. The youth learned that 2,000 children die each day from malaria. The past two years they provided aid to two villages in Zambia to build wells for a clean water supply. Two years ago they had the neat experience of being able to talk with someone from the village they were working with by satellite phone.

So, kudos to all the youth across the country who participated in the 30 hour famine.

For information World Vision is accredited by the EFCA, the evangelical counsel for financial accountability which require programs to provide full financial disclosure to anyone who wants it including a financial breakdown of each project they are involved in.

Sex Education Abstinence Program

I read something encouraging in the news the other day. A study published in the February issue of the Archives of Pediatric and Adolescent Medicine reported the success of an experimental school based sexual abstinence program in Philadelphia.For reasons that have been unclear to me those who have been involved in the sex education field have been reluctant to endorse abstinence from sex as the best method of preventing unwanted teen pregnancy and sexually transmitted diseases. I understand and agree with the need to educate young people on how to avoid these complications by condom use if they engage in sex but I have never understood the black and white thinking that has resulted in hostility to the idea of abstinence.

The study reports on 662 inner city 6th and 7th graders who were assigned to one of four groups. Some were assigned to the experimental eight week hour long experimental classes only, some to traditional safe sex classes, some a combination of both and a fourth or control group taught general non sexual healthy behaviors. The program was designed not to tell the children not to have sex but to help them look at the pros and cons themselves to make their own thoughtful decisions. At the end of two years one-third of the abstinence only program participants said they had engaged in sexual activity since the classes ended vs approximately 50% in the other 3 groups.

To me this is very encouraging. Our young people need to know that everyone is not "doing it" and should receive support and encouragement to just say no. Adolescent girls especially need support in not giving in to excessive pressure as many engage in otherwise unwanted sexual behavior because they think they have to to keep their boy friends or they don't have the assertiveness and communication skills to stand up for themselves. I hope more research will be done in this area.

Thought for the day

"Destroy a single being's joy and you will work the ruin of yourself".

The Way of the Bodhisattva

Bipolar Disorder Part 7

This is the last in a series on bipolar disorder. We recently went over the medications used to treat this condition but now I would like to focus on what I call the "other two pillars" of treatment; avoidance of alcohol and substance abuse and management of stress and anxiety.

As I mentioned before the two main reasons that someone with bipolar disorder is not responding to treatment are they either are not taking their medication or there is a drug and/or alcohol problem. Over 50% of patients with bipolar disorder have some sort of a substance abuse problem and this must be dealt with for effective bipolar treatment to occur. Some people are sensitive to even small amounts of alcohol and even intermittent use can cause a problem with mood instability.

Handling stress and anxiety involves some simple things that are often overlooked. Deep breathing techniques are useful. Maintaining a regular sleep schedule and daily routines are good. Patients need to avoid periods of frenetic activity whether at work or home. Daily exercise is important as is good nutrition. Educating family members about bipolar disorder is needed. It is very useful to have a family member accompany the patient to medication follow-up appointment as they may notice early signs of mood disturbance, particularly mania which is not often recognized well by the patient. Learning to recognize early signs of mood disturbance is vital to ongoing recovery.. I always encourage my patients to learn as much as they can about the disorder. This is a lifelong disorder and there may be many different psychiatrists one could see over the course of a life. The only constant factor is the patient him/her self.

I hope this series on bipolar disorder has been helpful in some way. Again, any comments or questions are always welcomed.

Thought for the day

Compassion not judgment

Bipolar Disorder Part 6

Today I will continue to talk about medications to treat bipolar disorder. We have discussed lithium and the antiepileptic drugs and today we will review the third class of medications, the second generation antipsychotics which include some of the newer medications available to treat bipolar disorder.

The second generation antipsychotics are referred to as such in that although they initially came out to treat schizophrenia and partially work like previous antpsychotics in terms of blocking the neurotransmitter dopamine they have some different properties as well which sets them apart from the older antipsychotics or the "first generation". They have some action at serotonin type 1 and serotonin type 2 receptors as well as at dopamine receptors and they bind more at dopamine type 4 receptors and are less active at dopamine 2 receptors resulting in a much reduced tendency for neuromuscular side effects than our older drugs.

These medications include risperidone(Risperdal),quetapine(Seroquel),olanzapine(Zyprexa),ziprasidone(Geodon),Aripiprazole(Abilify), and the newest one paliperidol(Invega). They are very effective antimanic medications, we believe prevent mania and depression to some degree and unlike the other bipolar medications treat depression as well. These medications all have some different properties but tend to have the same set of side effects and risks so I will talk about them as a group.

The main side effects are neuromuscular side effects and metabolic effects. Like the older antipsychotics there is a small risk for a life threatening condition, neuroleptic malignant syndrome, as well as for tardive dyskinesias which are potentially irreversible abnormal involuntary muscle movements. The other much more common and troubling side effects are metabolic. They cause weight gain, increased triglycerides and increased blood sugar leading to possible cardiovascular disease and diabetes.They are not associated with birth defects if used during pregnancy though there is a national registry to monitor this. Geodon and Abilify have much less tendency than the others to cause this metabolic triad. So why use the others? Some people will not respond to Abilify or Geodon and do respond to the others. In fact I have never seen a patient whose acute mania did not respond to Zyprexa. Because of the least amount of side effects and risks I tend to use Abilify as first line treatment because if it works there are not the problems the more severe problems we have with lithium the, aniepileptic drugs s and the other second generation antipsychotics. Geodon could also be a first line treatment for the same reasons but tens in some people to cause sedation.

So, lithium, the antiepileptic drugs and the second generation antipsychotics are what we have available to treat bipolar disorder. I hope that there will be continued development of medications with greater effectiveness and lower side effects. Tomorrow I will talk about some of the non pharmacological treatments that are helpful in bipolar disorder.

Thought for the day

"He whose heart is in the smallest degree set upon goodness will dislike no one".

Ancient Chinese

Bipolar Disorder Part 5

This is the fifth in a series about bipolar disorder. I have been talking about the dilemma of finding effective medication without undue side effects or toxicity and talked before about lithium which remains the "gold standard". Today I will discuss three more medications, carbamazepine (Tegretol), valpoate (Depakote), and lamotrigine (Lamictal). All three belong to the class of medications referred to as AED's or antiepileptic drugs. They initially were designed to stop seizures in epileptic patients before they were found to have significant mood stabilizing properties. Again, like lithium we do not know the mechanism of action in bipolar disorder.

Tegretol was the first one of these three medications found to be effective in bipolar disorder. It does a good job of treating mania and preventing further manic episodes, is not so good at preventing depression and does not at all treat depression. It generally is fairly well tolerated in terms of day to day side effects and blood levels can be monitored. There is sometimes an allergic rash,it can cause hyponatremia or low sodium levels, and is teratogenic, potentially causing congenital abnormalities if taken while pregnant. It also reduces the effectiveness of birth control pills. The most serious potential side effect though is the possibility of bone marrow suppression, impairing the ability to make white blood cells needed to fight off infections so the white blood cell count needs to be monitored on a regular basis.

Depakote was the next AED available to treat bipolar disorder. Like Tegretol it is a very effective antimanic medication, can prevent mania from recurring but does less well in preventing depression and does not at all treat depression. It is as effective as lithium in treating mania and sometimes more effective. Common side effects can be weight gain (at times quite significant) and tremor. It can cause some hair loss, alter menses, increase risk of polycystic ovary syndrome and is very teratogenic. Like Tegretol it can be monitored with blood levels. Rare but serious side effects can be drug induced hepatitis or pancreatitis or quite rare liver failure. Liver function tests need to be routinely monitored.

Lamictal is much different than any other bipolar medication. It does not treat mania nor depression but is very effective in preventing further manic episodes as well as further depressed episodes. It is extremely well tolerated day to day, is not associated with weight gain, is not teratogenic, and is not associated with the risk of bone marrow suppression or liver problems. It has a rare (but potentially fatal) risk of inducing a Stevens - Johnson reaction which is a severe rash affecting not only the skin but the mucous membranes as well. Because of it's properties of preventing mania and depression it is often used as a second medication in many cases.

As I mentioned before these medications can sound quite bad in terms of side effects and risks but in most cases the benefits of preventing the devastating consequences of untreated bipolar disorder outweigh the risks. Tomorrow I will talk about the third group of bipolar medications, the second generation antipsychotic medications.

Thought for the day

"The thought never came to mind that I too am a brief and passing thing and so, through hatred ,lust, and ignorance I have committed many sins".

The Way of the Bodhisattva

Bipolar Response

A reader posted a question on our Facebook site asking about the difference between bipolar I disorder and bipolar II disorder. I have not yet gotten to that point in the series but I will answer briefly as well as I can.

What I have been talking about so far is what we call bipolar I disorder which has previously been called manic - depressive illness. Bipolar II disorder is a cycling mood disorder in which there are episodes of depression, including chronic depression with episodes of what we refer to as hypomania or "under mania". These are periods in which there are manic like symptoms but not of the severity of full blown mania and not resulting in so many life destructive events. Most people with bipolar II disorder spend the majority of their time in depression.

I hope this helps answer the question and we will discuss this more in detail on a later post.

Bipolar Disorder Part 4

This is the fourth in a series of didactic posts on bipolar disorder. I want to talk a bit about medication treatment as it is an essential component of treatment For patients making informed decisions about these medications requires education as many of the medications that we use to treat this disorder have significant adverse side effects, can be toxic, and can have long term negative effects on different organ systems. I call it the bipolar medication dilemma as there are no easy answers, there is no one size fits all treatment, and decisions need to be made on an individual basis taking into account health risks and other health conditions that a patient may have. It is a true dilemma as these medications that I will talk about have a lot of problems and yet without medication an untreated course of bipolar disorder is a disaster. So for now we have to use them. I would like readers to keep that in mind when I discuss all the potential negative effects.

There are four goals in medication treatment of bipolar disorder. We need to treat mania without causing depression, treat depression without causing mania, prevent depression, and prevent mania. It is unusual for one medication to carry out all four of these tasks so combination medication is the rule, rather than the exception which increases the potential for medication side effects. There are three different types of medication which have clearly shown effectiveness; lithium, anti epileptic drugs used to treat seizure disorders, and the second generation anti psychotic medications. I will talk about lithium to day and cover the others later.

Lithium remains the "gold standard " for treatment of bipolar disorder. No medication has been shown to more effective than lithium which we have had available to use since the mid 70's. Lithium is not a drug. It is a basic element which binds to other molecules to become a salt just as the sodium we use for table salt does. Usually the lithium we use comes in the form of lithium carbonate. The mechanism of action is unknown. It effectively treats mania and does work to prevent mania and depression but by itself is not a good antidepressant. We have more medications available to treat mania than we do bipolar depression. There is a narrow range between therapeutic levels and toxic levels so lithium blood levels do need to be obtained. Toxic lithium levels can result in kidney failure which is not always reversible. Lithium can cause diabetes insipidus which is the inability of the distal tubules in the kidney to reabsorb fluid resulting in excessive urination. Fortunately this can be treated strangely enough by adding a diuretic. Lithium also interferes with the release of thyroid hormone leading to hypothyroidism so thyroid levels need to be monitored. The most worrisome effect though is the evidence that long term lithium use (30 years or more) results in some kidney damage and impaired kidney function. We are now beginning to see this since we have had lithium available now for 35 years. No one really knows whether or not this will result in progressive renal failure or not. Some common day to day side effects are nausea, tremor, development of acne and weight gain.

So you can see that lithium has a lot of problems but I want to state again that it is very effective. It to me is still a "miracle" in that it can stabilize a disorder that otherwise would result in chronic mental illness and difficulty or inability to live in the community. I do not like to use lithium though for milder cases of bipolar disorder but for the more serious cases with the most complications or to use lithium when other treatments are not effective. I will talk about some of the other medication treatments in my next post.

Thought for the day

"Live a life worthy of the calling to which you have been called".

St. Paul