Depakote and Hair Loss

Did you know that Depakote (divalproex sodium) can cause hair loss? I have been on the drug for years and did not learn this fact until Tuesday, when I attended a second opinion psychiatric appointment at the University of Michigan.

I have been losing an alarming amount of hair on a daily basis for the past year. I told my primary care provider and the psychiatric nurse practitioner who manages my medications for bipolar disorder, but neither of them seemed concerned or told me that it is a side effect of Depakote. It’s common for 15+ full strands of hair to come out at a time when I wash my hair, comb it, or run my hand through it. I used to have lots of hair, but now it is average in quantity and more comes out every hour.

According to the Mayo Clinic:

Divalproex sodium is used to treat certain types of seizures (epilepsy). This medicine is an anticonvulsant that works in the brain tissue to stop seizures.

Divalproex sodium is also used to treat the manic phase of bipolar disorder (manic-depressive illness), and helps prevent migraine headaches.

I see that “hair loss or thinning of the hair” is listed as a more common side effect that usually doesn’t require medical attention. I’m not sure how many people would be okay with this side effect, but I am not. The following statistics can be found in “Dose-dependent valproate-induced alopecia in patients with mental disorders,”which is published on the National Institute of Health website. [1] Note: alopecia is the medical term for hair loss.

  • “A prospective study of 78 subjects who were receiving valproate found that hair loss occurred in 6% of patients.” [2]
  • “When used as mood stabilizer therapy, up to 12% of patients who are receiving valproate experience temporary alopecia.” [3]
  • “Valproate can result in dose-dependent alopecia in up to 12% of patients, including up to 28% of patients who are exposed to high valproate concentrations.” [4]
  • “A double-blind, concentration-response clinical trial of divalproex sodium monotherapy reported that alopecia occurred in 4% of patients in the low plasma valproate group (25–50 μg/ml), compared to 28% of patients in the high plasma valproate group (85–150 μg/ml).” [5]

Basically, the article argues that, “alopecia may develop in patients with chronic exposure to high plasma concentrations of valproate,” and it “resolved in all cases after dose reduction or treatment discontinuation.” Here’s another scholarly article on the subject. An article published in 2011 in Current Psychiatry states that:

Hair loss appears to be dose-related and may be more common in women than in men. Usually patients will report gradual but steady hair loss, commonly beginning 2 to 6 months after initiating treatment. Complete hair loss is rare and new hair growth typically begins approximately 2 to 3 months after alopecia onset.

The article takes it a step further, explaining that:

Valproate can cause telogen effluvium, a non-scarring form of alopecia that occurs by precipitating the follicles into a premature rest phase.

In addition to reducing the patient’s dosage (when feasible), the author recommends being gentle on hair (avoiding harsh chemicals or styling tools), taking the drug with food (encourages proper absorption of nutrients that help with hair growth), and supplementation with biotin, zinc, and selenium. [6]

So, I’m getting my bipolar ass off of this drug with the help of my new psychiatrist. There are a number of other side effects that I discovered on the Mayo Clinic’s website that I also experience: occasional swelling of the feet, confusion, cough, joint pain, mental depression, nervousness, pinpoint red spots on the skin, quick to react or overreact emotionally, rapidly changing moods, tightness in the chest, trouble sleeping, changes in patterns and rhythms of speech, clumsiness or unsteadiness, racing heartbeat, feeling warm, redness of the skin on the face, frequent urge to urinate, swollen and inflamed skin lesions, low energy, pounding in the ears, restlessness, seeing and hearing things that are not there, slurred speech, sweating, swollen joints, trouble with speaking, continuing ringing noise in the ears, loss of memory, weight gain, back pain, dry eyes, dandruff, dry skin, and earache. [7] Yeah, NOPE.

I bought a “Hair, Skin, & Nails” supplement with biotin, selenium, and zinc in it and I am tapering off the Depakote. I’ll let you know if my hair stops falling out.

References

  1. Takashi T , Hidekazu G, Tadashi Y, Katsuya T, Kenji S, Yukinao K. Dose-dependent valproate-induced alopecia in patients with mental disorders. Indian Journal of Pharmacology. 2015 Nov-Dec; 47(6): 690–692.
  2. Calabrese JR, Markovitz PJ, Kimmel SE, Wagner SC. Spectrum of efficacy of valproate in 78 rapid-cycling bipolar patients. Journal of Clinical Psychopharmacology. 1992;12(1 Suppl):53S–6S.
  3. 4. McKinney PA, Finkenbine RD, DeVane CL. Alopecia and mood stabilizer therapy. Annals of Clinical Psychiatry. 1996;8:183–5.
  4. Mercke Y, Sheng H, Khan T, Lippmann S. Hair loss in psychopharmacology. Annals of Clinical Psychiatry. 2000;12:35–42.
  5. Beydoun A, Sackellares JC, Shu V. Safety and efficacy of divalproex sodium monotherapy in partial epilepsy: A double-blind, concentration-response design clinical trial. Depakote Monotherapy for Partial Seizures Study Group. Neurology. 1997;48:182–8.
  6. Shailesh J. Valproate-induced hair loss: What to tell patients. Current Psychiatry. 2011 November;10(11):62-62.
  7. (2017, March 01). Divalproex Sodium (Oral Route). Retrieved from http://www.mayoclinic.org/drugs-supplements/divalproex-sodium-oral-route/description/drg-20072886 on 2017 July 21.

My Psychiatric Drug List

It’s important to keep track of your own psychiatric history drug because you will be asked about it in the future and it is much easier when you have everything written down. I wasn’t smart enough to do this from the beginning, but I requested copies of my medical records later when I was applying for Social Security Disability. This is a running list that I will update as needed.

Antianxiety

  • Ativan 1mg BID (10/07-11/08? check BHR records)
  • Celexa
  • Klonopin 0.25mg, 0.5mg, 1mg PRN (7/05-

Antidepressant

  • Effexor XR 75mg, 150mg (12/03-8/04)
  • Lexapro 10mg, 15mg, 20mg (8/05-11/08? check BHR records)
  • Pamelor HCL 10mg
  • Remeron 15mg
  • Trazodone HCL 50mg
  • Wellbutrin 150mg, 200mg, 300mg (8/04-11/08? check BHR records)
  • Zoloft 100mg (3/03-12/03)

Antimanic

  • Depakote ER 1500mg, 2000mg
  • Lithium ER 300mg (am) + 450mg (pm), 400mg BID, 450mg BID, 1200mg (10/07-11/08? check BHR records)

Atypical Antipsychotic

  • Abilify 5mg, 10mg, 15mg, 20mg (2/06-4/06, 6/06-8/07, 2/08-11/08? check BHR records)
  • Latuda 20mg
  • Geodon 20mg
  • Seroquel XR 150mg, 200mg, 300mg

Mood Stabilizer

  • Lamictal 25mg (2/06-2/06)
  • Topomax 25mg, 50mg, 100mg, 150mg, 200mg, 50mg (am) + 150mg (pm) (3/06-

Eugeroic (Wakefulness-Promoting)

  • Provigil 100mg, 200mg (10/06-4/07)

Central Nervous System Stimulant

  • Ritalin 5mg (6/07-
  • Concerta 18mg (5/07-

Sedative

  • Ambien 10mg, 12.5mg (5/05-7/05, 6/06-7/06, 12/06-2/07, 5/07-)

Herbal & Over The Counter

  • Melatonin
  • Vitamin D3 2000 IUs

 

bold = possible personal gene-drug interaction (based on my GeneSight test results)

Psychiatric Drugs That Impair Memory

I scored a copy of Martha Stewart’s book Living the Good Life: A Practical Guide to Caring for Yourself and Others for fifty cents at Salvation Army last month and I just sat down to read it. Part 1 features a section on brain health and there’s a big list of medications that have been shown to affect memory. There are over 15 classes of drugs listed, from analgesics (pain killers) to steroids. I would like to share the relevant psychiatric drugs here in the name of informed consent.

Antianxiety Drugs

  • alprazolam (Xanax)
  • diazepam (Valium)
  • lorazepam (Ativan)
  • oxazepam (Serax)
  • temazepam (Restoril)
  • triazolam (Halcion)

Antidepressant Drugs

  • amitriptyline (Elavil)
  • imipramine (Tofranil)

Antipsychotic Drugs

  • chlorpromazine (Thorazine)
  • haloperidol (Haldol)
  • thioridazine (Mellaril)

Hormones

  • levothyroxine sodium (Synthroid)

Seizure Drugs

  • carbamazepine (Tegretol)
  • gabapentin (Neurontin)
  • valporic acid (Depakote)

Sleep Drugs

  • zolpidem (Ambien)

I have personally taken a number of these drugs as well as several of the antibiotics, antihistamines, decongestants, anti-nausea drugs, steroids, pain drugs, and hormones and I am certain that long-term use of the psychiatric drugs has caused memory problems. I did not have memory issues until college, which is when my prescriber put me on a bunch of different psych meds. I am 34 years old now and I have significant memory issues. What about you? Have psychiatric drugs impaired your memory? Did you know about this side effect before you agreed to take the drug? How does this make you feel? I am mad (to say the least). I intend to research when it was determined that each of the drugs that I took caused memory problems and, if I was not properly warned before taking the drug, file claims against the makers of the drugs.

My Experience with Geodon

Ziprasidone (the generic form of the antipsychotic drug Geodon) was prescribed to me in the spring of this year because I was experiencing a long-lasting bout of moderate to severe bipolar depression with episodes of rapid cycling bipolar and intrusive suicidal thoughts. Ziprasidone is used to treat acute manic or mixed episodes associated with bipolar disorder and to treat symptoms of schizophrenia. It is also used as a maintenance treatment of bipolar disorder when added to lithium or valproate (Depakote). I took the medication as prescribed (1 20mg capsule by mouth at bedtime with food) along with my other meds (depakote extended release, trazodone, metformin) for four days before I had to stop. Geodon caused me to wake up in the middle of the night every night and have strange thoughts. More specifically, I wanted to go outside and run as fast as I could through the woods behind our house. My sleep was disturbed despite taking trazodone at night for sleep. Complete prescribing information can be found here. FDA (U.S. Food & Drug Administration) can be found here.

Shameless

I started watching Shameless on Netflix about a month ago and I am halfway through season 5 already. I like it for several reasons, one of which is the excellent portrayal of bipolar disorder in both Monica and Ian Gallagher. Spoiler alert: if you haven’t watched through season 5 episode 8, you may want to skip this post for now.

I didn’t “get” Monica until the Thanksgiving dinner episode, at which time I knew as soon as she stood up from the table that she was going to do something terrible. In terms of “highs” and “lows,” I spend most of my time depressed and I tend to get suicidal. Unfortunately, I also get impulsive. As Monica and Ian show us, depressed + suicidal + impulsive = danger.

When Ian was acting strange after going MIA from the army, I wasn’t sure if it was drugs or mania but when he wouldn’t get out of bed for days, I knew.

The one thing that I would say is that my experience in psych wards was slightly different from what Monica and Ian experienced. I have been in three different wards. Two things:

  1. Psych wards have nightly “checks,” in which hospital staff look into your room at night to make sure that you are in bed, okay, and that you’re not getting into trouble. So, Monica’s nighttime sexytime with the other patient is something that isn’t likely to happen.
  2. The guard at the hospital got rough with Ian. I have never experienced or witnessed unnecessary force in a psych ward. I’m sure that it happens, but I don’t think it is common.

I’m up to the point where Ian says that he flushed his meds because they make him feel awful. If you have never taken medicine for a mental illness, you can’t possibly understand what it’s like. And you can’t understand what it’s like to live with a mental illness if you don’t have one, but this show can help you to get a feeling for it. It’s refreshing to see bipolar accurately portrayed in a show. I tried watching Homeland, a series in which Claire Danes plays a CIA agent with bipolar disorder. I thought that show did okay, but Shameless does much better. Consider watching it.

GeneSight Test: Part 3 (Results)

Welcome to part 3 of my GeneSight series! I have submitted my spit and received my results! Did you miss my intro and/or procedure posts? You’ll want to read those first. This is the longest and most complex of all of them. I hope that you will find it as interesting as I do.

I received my reports within 2 weeks from my healthcare provider and was eager to see what they said. The GeneSight Psychotropic test report is 9 pages long and my GeneSight MTHFR test report is one page. Are you ready to hear about how my genetic makeup affects the way drugs work in my body?

The reports are pretty easy to read. My provider showed me an example of a report that he receives, which is color coded. Green means “Use as directed.” These are the medications that your body doesn’t have any issues responding to. Yellow means “Use with caution.” These have a moderate gene-drug interaction, so they might not work well for you. Finally, red means “Use with increased caution and more frequent monitoring.” These have a significant gene-drug interaction. Pages 1-4 of my report feature the green/yellow/red gene-drug interaction results.

The psychotropic test analyzed my gene-drug interaction with 22 antidepressants, 12 anxiolytics and hypnotics, antipsychotics, and mood stabilizers. Most of the drugs fell in the green category (note: my report printout is in black and white, but it is still very easy to interpret). I have moderate gene-drug reactions with 2 antidepressants: doxepin (Sinequan) and fluoxetine (Prozac) and one antipsychotic: asenapine (Saphris). I have never tried any of those medications. I have significant gene-drug interaction with one antipsychotic: olanzapine (Zyprexa) and two mood stabilizers: carbamazepine (Tegretol) and lamotrigine (Lamictal). I have tried the mood stabilizers and experienced side-effects that led me to see my prescriber and change meds. Note that the mood stabilizers Neurontin, Eskalith, and Topamax do not have proven genetic markers, so I have no results for those.

If a drug has a gene interaction, the reason is notated. For example, both of the antidepressants that are in the yellow zone might require lower doses because of high serum levels.

The next two pages of the report are more complicated to read and understand. These pages list “patient genotypes and phenotypes,” with pharmacodynamic genes on page 5 and pharmacokinetic genes on page 6. Some definitions:

  • Genotype: genetic makeup
  • Phenotype: observable characteristics (based on genotype/environment interaction)
  • pharmacodynamic: drug effects and how they work
    pharmacokinetic: movement of drugs within the body

These reports seem to be mostly full of “normals” for me, which is good (I think). There are a couple that are not normal, which leads us to the next section: a 2-page table with all of the drugs listed on the left side, all of the genotypes listed across the top, and a key at the bottom that has the following two options:

  1. A solid black circle = “Variation was found in patient genotype that may impact medication response.”
  2. An empty circle = “This gene is associated with medication response, but patient genotype is normal.”

I have 18 drugs that have solid black circles under one or more genotypes: (Wellbutrin, Remeron, Zoloft, Effexor, Trintellix, Valium, Lunesta, Restoril, Ambien, Clozaril, Prolixin, Haldol, Depakote, Sinequan, Prozac, Saphris, Zyprexa, and Lamictal). I have been on 10 of these drugs and I currently take high doses of Depakote. It would have been cool to have these results 16 years ago, when I first sought treatment for my issues!

Page 9 is the last page of my psychotropic report. It lists all of the details about the test (specimen collection details, a list of scientific procedures performed on the sample, etc.), a statement that the test hasn’t been approved by the FDA, a disclaimer of liability, customer service information, and a signature from the doctor that verified the report.

The last page of my document is a 1-page report on my folic acid conversion test. The MTHFR results are reported in a very simple and straightforward manner. A check mark is located in one of three categories: “Normal folic acid conversion,” “Reduced folic acid conversion,” or “Significantly reduced folic acid conversion.” I have reduced folic acid conversion. Just like the psychotropic test report, this report also has a short genotype/phenotype section. Based on my genotype, it is expected that I have reduced folic acid metabolism, moderately decreased serum folate levels, and moderately increased homocysteine levels. The report states that my serum levels may be too low and folate supplementation or higher daily intake of folic acid may be required. I will discuss this with my prescriber in April. Again, test information, disclaimers, and so forth are listed and the document is signed by someone who verified it.

This is getting to be a ridiculously long post, so I think I will stop here and say “to be continued” until after my follow-up appointment.

GeneSight Test: Part 2 (Procedure)

Welcome to part 2 in my GeneSight series! If you missed part 1, click here to read it really quick before proceeding. Part 1 gives an overview of what the test is, why it is used, why I had it done, and a list of other tests available from this specific company.

After my Nurse Practitioner and I decided that I would get tested, a Medical Assistant walked me you through the DNA sample collection process. The process that I experienced:

  1. I signed a form authorizing Assurex Health, Inc. to bill my medical insurance for the tests. I was told that the GeneSight Financial Assistance Program is available to help make GeneSight affordable for those who qualify. My provider told me that the test is expensive (several thousand dollars), but Assurex is very good at getting insurance companies to pay, and individuals usually end up paying no more than $300 out-of-pocket. I was told that I will receive a bill if my insurance doesn’t cover everything, at which time I can appeal and/or apply for assistance.
  2. The Medical Assistant gathered the testing supplies and I completed two short identical forms (one for each test) that were submitted with my samples. I was told that my samples and results would be kept confidential and comply with HIPAA (Health Insurance Portability and Accountability Act) and GINA (Genetic Information Nondiscrimination Act) that ensure the security of personal and genetic information.
  3. I was given two large cotton swabs and asked to rub them inside my cheek until they were soaked with spit. This was quick and painless. She had me drop the swabs into a plastic pouch, which she sealed and packaged for shipment.
  4. That’s it! The office mailed my samples (pre-paid FedEx) to Assurex. I was told that my results would be available to my healthcare provider within 36 hours after the lab received my samples, and that I would receive a copy of the results from my healthcare provider. I received a copy of my report in the mail just under 2 weeks after submitting my spit/cells. I have an appointment with my Nurse Practitioner in April to discuss the report.

Check back soon for part 3: the results!