The legal system has again failed and is directly responsible for the hung jury in Collin County, Texas. The Dallas Morning News front page article for Friday, 2-24-06 reads "Jurors deadlocked in Plano mother’s murder trial."

This whole story is so bizarre, that unlike the recent memoir "Pieces," this one couldn’t have been made up. Ironically, the most bizarre part of the story for me is the closing statement by the prosecutors. But first, I need to paint the setting.

A jury of 5 women and 7 men have had to endure a long painful trial. They have spent over 21 hours in 2 days deliberating, unable to reach consensus. The facts are not in dispute. In November 2004 Dena Schlosser cut off her 10 month old daughter’s arms at the shoulder. (related December 2004 blog) The jury has to decide unanimously whether she is guilty of murder or not guilty by reason of insanity. What I think is insane is the law that forces the jurors to make that choice.

There is no question that Ms. Schlosser had a severe mental illness with delusions, hallucination, and bizarre behavior that came on during the postpartum period. She had somewhat brief and inadequate psychiatric treatment. She was also a strongly religious person whose preacher doesn’t believe in mental illness and attributed her sick behavior to demons. Her husband was similarly clueless.

The defense put on several witnesses, including psychiatrists, who said she was insane and didn’t know right from wrong. In what appeared to be a concession, the prosecutor did not put any mental health witnesses on the stand to dispute the insanity defense. Maybe they couldn’t find a single mental health professional who agreed with them.

In their closing statements, prosecutors told the jurors that the psychiatrists who testified for Ms. Schlosser made their decision before they examined her. Quoting The Dallas Morning News article,

"They said the crime was so horrible that the psychiatrists, like many people, already believed that only someone not in her right mind would sever a baby’s arms."

Excuse me if I’m missing something. Can anybody think of a scenario where a woman IN her right mind would commit such an act? And the ulterior motive was ….?

The problem is the legal options. Ms. Schlosser IS GUILTY … BY REASON OF INSANITY (according to the law, this option does not exist). She needs to be in a psychiatric treatment facility. Her treatment needs to be monitored by the court, and if she’s ever deemed able to be released, her ongoing treatment would need to be continued for life - with parole revoked if she doesn’t comply. One option would be controlling her psychosis with mandatory injections, which are long acting and given monthly.

To add misery to insult, the jury is being put on a guilt trip. The judge told them if they didn’t make a unanimous decision, another trial and jury might not either. It would cost the tax payers a lot of money to retry her case.

They have already told the judge there is no chance they will all agree. That means to get a verdict, at least one of them will have to vote against their conscience and then have to live with that too. Wasn’t going through this trial traumatic enough? At least the law was recently changed to allow the prosecutor and defense attorney to negotiate an agreement, presumably "not guilty by reason of insanity." Be honest, is this nuts or what?

Question: I have been on Effexor XR 150 mg for 5-6 months now, but am disappointed with the weight gain - esp. around the belly. I was wondering if I can ask my doctor about Wellbutrin XL to help counteract that. What are your thoughts on that?

– Mona

Answer: All SSRI’s and SNRI’s can cause weight gain. Sometimes, increasing the dose of Effexor to 225 mg will make it easier to control weight, since it mainly increases Norepinephrine effect at the higher dose. Adding Wellbutrin is more likely to help (either 150 or 300 mg). Wellbutrin XL is probably better but not in generic. Taking Wellbutrin in a.m. and Effexor around supper time decreases overlap.

Question: I read on your site that people that suffer from anxiety have increased serotonin, and SSRI’s reduce the amount of serotonin in the body. I suffer from GAD that manifests itself with my racing heart rate.
I have been taking Effexor now for about 3 weeks, and it seems like my heart rate has decreased. But I am still thinking the norepinephrine is going to keep my heart rate high. So, I was wondering, do SNRI’s reduce the amount of serotonin and norepinephrine?

– Ryan
Answer: SNRI stands for Serotonin & Norepinephrine Reuptake Inhibitor. SNRI’s initially increase synaptic serotonin and norepinephrine, but over time, they down regulate both systems (especially in anxiety disorders where both systems are upregulated). In conditions or areas of the brain where activity is too low, the SNRI can increase activity of serotonin and norepinephrine. In this sense, reuptake inhibitors can be thought of as modulators.
The degree to which norepinephrine is regulated by Effexor is dependent on dose. At 37 to 75 mg per day, norepinephrine effect is probably not clinically significant. At 150 mg norepinephrine activity is significant, and at 225 mg it’s probably equal in effect to the serotonin modulating effect.
Serotonin can also increase heart rate. Modulating serotonin and norepinephrine should help assuming that GAD is the cause of the rapid pulse.

Last Friday, February 10, 2006, headlines reported "Warnings advised on ADHD drugs." A 15 member advisory committee recommended (by a vote of 8-7) to the FDA that a black box be added to the labeling of stimulants used to treat ADHD. Concern about serious cardiovascular side effects is mainly due to the report of a small number of sudden deaths in kids and adults who were taking stimulants. The biggest problem with this proposal is … There is no good scientific evidence that incidence of these very serious events is any greater in patients taking stimulants than in the general population. Last February, Health Canada (Canadian equivalent of FDA) took Adderall off the market because of a similar concern. (see 2-14-05 Blog) But further study of the facts led them to put it back on the market a few months later. A reanalysis of all the facts last year by the FDA found no convincing evidence of serious risk. Adderall XR already carries a black box warning that abuse or misuse could cause serious side effects. The label also warns of possible risk of sudden death in patients with structural cardiac abnormalities. Advanced arteriosclerosis, moderate to severe hypertension (especially if not controlled), and hyperthyroidism are contraindications for use of amphetamines. When trying to decide whether to take a medication, ask two important questions: What are the benefits? What are the risks? In my opinion, based on over 30 years of experience, the benefits far outweigh the potential risks. Stimulants are clearly the most effective treatment for ADHD. Untreated ADHD markedly increases alcohol and drug abuse, reckless driving accidents, lost jobs, divorce, stress, and reduced self-esteem. We have 70 years of research and clinical experience with stimulants. Taken under medical supervision, any risk of serious side effects is extremely small. I feel confident that Shire, McNeil, and other pharmaceutical companies that market stimulant medications will keep us informed of any new information or cause for concern. In the meantime, I continue to believe these medications are safe. Links Shire press release, 2-10-06 CHADD.org statement

Last week, RandomHouse.com posted "a note to the reader," written by James Frey. It will be added to future printings of A Million Little Pieces.

When we put the pieces together he’s given us, what picture do we see?

Take One: Give the Guy a Break!

Taken as a whole, Frey’s note expresses a sincere sounding apology, an explanation of the embellishments and a re-affirmation that the book represents the "subjective truth" of his fight against alcohol and drug addiction. His purpose was to write a book to encourage other addicts to fight against their demons. He also hopes to help the families of addicts to be more understanding and empathetic. He closes with "I am deeply sorry to any readers …" This is the picture Frey says we should see. But …

Take Two: Get Honest!

The very 1st sentence reads,

"Pieces" is about my memories of my time in a drug and alcohol treatment center.

It should have read "was inspired by …"

In the second sentence, he says, "… I embellished many details …"

When 6 hours in a police station becomes 3 months in prison, somehow the word "embellish" doesn’t quite capture the spirit. What if Lance Armstrong hadn’t really had metastatic cancer but an abscess leading to septicemia requiring 3-4 days in the hospital?

The third paragraph begins,

"I didn’t initially think of what I was writing as nonfiction or fiction, memoir or autobiography. I wanted to use my experiences to tell my story … I wanted to write, in the best-case scenario, a book that would change lives."

Had he actually set out to write a memoir, he might have said instead, "I wanted to write in the most honest way I could."

When he says, "I wanted to write a book that would detail the fight addicts and alcoholics experience …", I translate that to, "I didn’t think my story was interesting enough or dramatic enough to have an impact."

Later in the statement, he says,

"I made other alterations in the portrayal of myself … that made me tougher and more daring and aggressive than in reality I was, or I am. … My mistake, and it is one I deeply regret, is writing about the person I created in my mind to help me cope, and not the person who went through the experience."

This admission to me contradicts what he says later, "It is a subjective truth."

I certainly agree with his concluding comments "that drug addiction and alcoholism can be overcome, and there is always a path to redemption if you fight to find one."

He ends with, "Thirteen years after I left treatment, I’m still on the path, and I hope, utimately, I’ll get there."

What could possible be wrong with his final sentiment?

Drug and alcohol problems come in many different levels of severity. There are certain genetic variants that make addiction extremely hard to overcome. Addiction is about denial (deception of self and others) and dyscontrol (lack of control). Many people, maybe most, need AA or least the AA philosophy to fight their demons. Relapse is the rule not the exception in hard core addicts.

James Frey went into rehab at age 23. He had graduated from college. He spent 6 weeks in rehab and supposedly has had no relapses. Neither he nor his mother thought there was any risk in light of the current onslaught of criticism.

When I start putting the pieces together, the picture I get is - he used drugs and had a drinking problem but he wasn’t a hard drug addict or alcoholic.

If I’m right, then should his road to recovery be a model for others to follow? Should others expect to spend 6 weeks in rehab and then go on to be successful? When others fail to achieve this relatively rapid success, are they less adequate or less committed to fight the fight?

You can have cancer and it can be spread to your lungs and brain. This is not necessarily a death sentence. It’s even possible that you can completely recover and go on to great achievements and help change the world. We know this because we know Lance Armstrong’s story. Unfortunately, I don’t believe we really know James Frey’s story.

Question: I have been on Synthroid for three months, just bumped up to .1 three weeks ago. Since starting the meds, I continue to gain weight–faster than before I started them. My face, hands stomach and feet are always swollen. I exercise every day (60 mins on treadmill) and eat well, drinking lots of water.
So what’s the deal? Is my thyroid in some kind of shock following treatment? Will it ever improve?

– Babs
Answer: I’m assuming your thyroid level was low when you started Synthroid. It builds up slowly over 5 weeks. Initially, it will boost your T4 and usually, secondarily, T3.
But if your initial problem was secondary hypothyroidism (i.e., TSH wasn’t significantly elevated - basically, the rheostat in the hypothalamus is set too low), when you add Synthroid (T4), the hypothalamus starts to suppress your own production of T4 to compensate. At sub-optimal doses of Synthroid, you could actually end up with less than you started with (and subsequently gain weight, develop edema).
Columbia Thyroid Clinic uses body weight in pounds to determine approximate goal dose of Synthroid in micrograms (e.g., If you weigh 150 pounds, you end up on 150 micrograms of Synthroid - same as .15 mg).

Some people do better on a combination of T4 and T3: Synthroid (T4) with either Armour (T4+T3 - available in generic, so a cheaper option) or Cytomel (T3 - more expensive). 1 grain (same as 60 mg) of Armour approximately equals .075 Synthroid; .025 mg Cytomel approximately equals .1 mg Synthroid. The goal dose is a combination of the two. For example, 150 pounds - .075 mg Synthroid + 1 grain (60 mg) Armour. Or, more commonly - 1/4 to 1/2 grain Armour and .125 to .112 of Synthroid.

So in your case, I would assume your dose is too low and you would probably do better with adding Armour and/or increasing Synthroid. If thyroid is too high, you usually have symptoms of being hot, shaky, sweaty and/or having palpitations.
When getting lab work in the morning, don’t take your a.m. thyroid that day until after blood is drawn, and be sure to get free T4 (and free T3 if taking Armour or Cytomel).

For weight loss purposes, people usually do better with their free T4 in the upper part of normal range and usually do better with some T3.

Question: I have been on Prozac for several years. Recently I suffered a rather sudden and dramatic increase in depression — not crying or irritable, just totally flat line; I found it impossible to function.
My doctor increased the dosage which did not appreciably help. She then switched me to Cymbalta (30 mg. for 1 week and then up to 60 mg.). One thing to note is that I did not stop taking or decrease the Prozac first, I just switched one day to Cymbalta. During the first week I had no problems with the drug, but no real change in my depression either.
Four days after starting the 60 mg. (and when I first started to think there was an improvement in how I felt) I suffered a strange occurrence as I was dozing in & out of sleep first thing in the morning. Impossible to truly describe, but it felt like someone set off a very bright flash bulb inside my brain. This was not an external visual thing, totally “in my mind.” It was so fast and startling that I bolted straight up and cried out. I thought that a blood vessel had ruptured or I had suffered a small stroke (actually, I thought my brain had exploded but obviously since I was thinking, that hadn’t happened!) It happened two more times, just as I was falling asleep again. That night (or around 5 a.m. the next morning) I suffered 4 more of these events, and again early the next morning.
They seem to be increasing in the “violence effect” in that it seems like my whole brain lights up and I lunge awake. I do not recall any pain — just a brief state of panic. I am fully aware afterwards and I am able to think and speak coherently. I discovered this morning that while just falling asleep again, I was somehow able to sense one coming and stopped it by waking myself up first. Sorry for the long description — it’s too weird to describe.
My question is: could this be an effect of taking Cymbalta while the Prozac was still in my system (I read where you stated Prozac stays in the body for a rather long time)? As unlike any type of seizure I’ve ever heard of, could it possibly be a seizure symptom from only the Cymbalta? My own doctor has never heard of such an “event” and told me to quit taking the Cymbalta (immediately) to see if this went away. I was concerned about stopping cold turkey but am more concerned about waking to this worsening symptom one more time. Can you shed any light?

– S.S.
Answer: Since Prozac gradually leaves your system (over 6 weeks) and Cymbalta builds up more quickly (3 days), it is possible that your symptoms are due to an interaction of your two medications (due to excess serotonin levels).
I agree with your doctor that it’s not a typical presentation of symptoms and I’m not sure what it was. I am confident that it wasn’t due to withdrawal or discontinuation effects from Prozac. Rebound can cause significant symptoms, especially with Paxil or Effexor, and probably more common in kids and teens due to their faster metabolism. I also agree with getting off the Cymbalta although a slight taper might have been better.

The fact that you have been on Prozac for years means that you are not super sensitive to serotonin although it’s possible that your serotonin level was higher on the combination of Cymbalta and gradually reducing Prozac. Serotonin can produce vascular related side effects such as the auras before a migraine. Sometimes these “pre migraine” symptoms don’t progress to an actual headache.

Cymbalta modulates serotonin and norepinephrine. It may be that you don’t tolerate the norepinephrine. You might have had hypnogogic and hypnopompic hallucinations that occur going into and coming out of sleep. They are actually considered normal phenomena although the frequency and severity of your episodes was certainly not normal.

There’s no way to be sure what the exact cause was - either in terms of what the meds were doing or what was happening in your head. In my opinion, the safest thing to do would be to use meds that work through different mechanisms like Lamictal. If episodes persist you should see a neurologist for evaluation and testing or have a sleep study.
Good Luck!
Dr. Jones

Question:  I am searching for help with an issue my adult son with a history of ADHD has run into.  As an adult, his physician put him on Paxil for his ADHD as other medications for ADHD were not as effective.  My son is functioning very well, has never been depressed, suicidal or any other issues associated with taking Paxil.  Seven months ago, my son had a flight physical by a certified FAA medical examiner, told the physician he was taking Paxil and the physician passed him, thus allowing my son to proceed with obtaining his private pilot’s license.  Now, seven months later, after he has completed all requirements, and has been flying the FAA sent him a letter stating they would not allow his medical exam due to him taking Paxil. 

My question is: Is Paxil used to treat adult ADHD?  What other drug could be used?  We have always been told that he does not produce enough dopamine therefore resulting in a chemical imbalance.  With the Paxil he is able to maintain focus and carry on a very normal, busy, independent life of a 32 year old single male.  Any information or help you may offer us would be greatly appreciated as we are going to try to fight this issue.  Personally I feel it is discrimination against ADHD. - S.B.

Answer:  Consensus of experts in the area of ADHD is that there are imbalances in the dopamine and norepinephrine brain systems, primarily due to genetics.  There are many sources of evidence to support this view.  There is disagreement as to whether the problem is primarily in the dopamine system or whether it’s primarily in the norepinephrine system or equally both.  It will probably turn out to be mainly dopamine in some people who are ADHD and norepinephrine in others and both in still others.   The problem is compounded by many factors, one of which is that dopamine and norepinephrine impact each other and may be high in some areas of the brain and low in others. 

There is currently no scientific evidence that serotonin modulators such as Paxil help ADHD.  Paxil has a very weak modulating effect on norepinephrine, but this is not believed to be clinically relevant (unless one takes very high doses).  Most SSRI’s, including Paxil, will actually lower dopamine levels.  Norepinephrine modulating antidepressants, tricyclics (desipramine, imipramine), Strattera (actually approved for ADHD but not depression, higher doses of Effexor (150 mg and above), Wellbutrin, and theoretically Cymbalta can help ADHD - though on average 1/2 as effective as stimulants. 

Your son benefits from Paxil.  What does this mean?  My guess is that your son is not ADHD, or at least that’s not what Paxil is helping.  Many other things can cause some of the symptoms of ADHD.  Sustained concentration requires ignoring distractions, either in the environment or from the mind (“What if …?”).  Anxiety means “danger” and danger means monitoring the environment more closely and thinking about all the relevant “What ifs.” 

Clinical depression involves deficiencies in one or more brain transmitter systems that frequently interferes with focus.  Also, calm, sustained focus activates more left brain functions, but stress, anxiety and depression activate the right brain more.  I recommend a complete reevaluation before any other steps are taken.  Dealing with the FAA reminds me of my days as an Air Force psychiatrist.  You can’t let logic or fairness cloud your thinking.  It’s all about the regulations.  How to deal with them would need to come after the evaluation.

Question: Is there anything wrong with using stimulants just to help you study?
Answer: It use to be thought that if stimulants calmed you down and increased your focus and performance, it meant you were ADD. We know now that anyone can improve their focus and short term retention by using stimulants.

A recent study of diversion of stimulants in college found that the overwhelming majority of the time, it was to help study, not for recreational purposes. This is considered by main stream medicine to be misuse/abuse of medication and is illegal. When reported in the media, this has been referred to as “cosmetic pharmacology.”
My guess is that most of the time there are no adverse consequences, but there are situations where it can be harmful without medical supervision. “I only need the medication to …” study for exams or to write a paper or read a boring assignment becomes “I only need it to …” prepare a brief, write a report for my boss, do my taxes, etc.
Being ADHD means it’s hard to focus on anything you’re not interested in, it’s hard sticking with something over any length of time, and it’s hard to finish things because the final details get monotonous and time consuming. A lot of people with moderate severity ADHD do fine with day to day functioning, especially if they’re bright and have good social skills. They may not realize they are ADD, but they know that stimulants help them when higher levels of focus are required.
You don’t have to meet full diagnostic criteria for ADHD to warrant treatment. ADD NOS (not otherwise specified) is a category that roughly means some significant ADD symptoms.
It would not be acceptable medical practice for any physician to prescribe any stimulant just to help study in the absence of any ADD symptoms.