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.
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Naming Your Feelings

In everyday society, I have learned that when most people ask, “How are you feeling today?,” they don’t really want to know the truth (or at least the full truth) so “I’m fine, how are you?” is our automatic response, which is often a lie and deflects the question away from ourselves and onto the other person. I am guilty of this and find it problematic for a number of reasons, mainly that I feel “fake” when I don’t answer truthfully/fully and that I think that this action doesn’t support good emotional health.

I don’t think that I need to explain why the response leaves me feeling fake when I use it, so I’ll dive right into the emotional health bit. If you have ever been to talk therapy, you know that the first question that is asked of you every time you visit is, “How are you feeling today?” In this situation, the therapist wants an honest answer from you and “I’m okay,” “Fine, thank you,” “Not good,” and other vague replies usually don’t cut it. For instance, I tend to say “I’m feeling okay,” at which point my therapist asks me “What does that mean? What feelings do you identify with right now?” The first time that a therapist asked me this and wouldn’t give up, I must have looked lost because I have a hard time putting a name on my feelings. Luckily, this particular therapist was quite resourceful. She dug around in her file cabinet for a few minutes, found a handout, and made me a copy of something very similar to this:

How Do You Feel
Image credit: https://s-media-cache-ak0.pinimg.com/564x/07/76/24/0776245ef14968c0b0f6074553ca3000.jpg

As I sat across from my therapist, I felt bad about myself because I had a difficult time naming my feelings even with the help of this handout. The official word for this condition is alexithymia, and this is what Wikipedia teaches us about it:

…a personality construct characterized by the subclinical inability to identify and describe emotions in the self. The core characteristics of alexithymia are marked dysfunction in emotional awareness, social attachment, and interpersonal relating. Furthermore, alexithymics have difficulty in distinguishing and appreciating the emotions of others, which is thought to lead to unempathic and ineffective emotional responding. Alexithymia occurs in approximately 10% of the population and can occur with a number of psychiatric conditions.

While my therapist and other mental health professionals never offered me this label, which I find morbidly ironic, she had me bring my “How Do You Feel Today?” handout to every session. I would look at each face at the beginning of our meeting and try to decide if that was how I felt. There were at least a handful of faces/words on my list like demure, loaded, purlish, and surly that I simply couldn’t relate to and my personal list of feelings was extremely limited (happy, sad, angry, bored, disappointed, frustrated, lonely, overwhelmed, scared, hopeful, proud, tired, and worried). Eavesdropping was also on the list, which really confused me. Isn’t that an action, not a feeling? I mean, you can feel like eavesdropping on someone, but that’s an urge to take action. I digress. My original handout, with my added list of feelings:

How Do You Feel Today?

A Facebook friend posted something today that made me start thinking about all of this:

Emoticons
Emoticons explained. Credit: Shira Dotnet.

Lightbulb moment! I have been frustrated with myself because I always use the same boring emoticons: 🙂 & <3. I realized today that it’s probably because I have a hard time matching the expression to the feeling! I saved Shira’s post. I don’t really care if I use emoticons on my personal accounts, but I have a small business and I want to use them more in those posts.

Almost a decade later, I choose not to attend therapy regularly anymore but I continue to try to get more in touch with my feelings in terms of putting a name on them. I just found the term, alexithymia, today and I am 100% certain that I have it, as I have issues with social attachment, interpersonal relating, and emotional responding too. I plan to learn more about it. After reading a little, I found out that it is not considered to be a mental disorder in the DSM-IV, but rather a personality trait that can influence mental health. The cause is unknown. Also from Wikipedia:

A person’s alexithymia score can be measured with questionnaires such as the Toronto Alexithymia Scale (TAS-20), the Bermond-Vorst Alexithymia Questionnaire (BVAQ), the Online Alexithymia Questionnaire (OAQ-G2) or the Observer Alexithymia Scale (OAS).

Do you struggle with identifying feelings? How do you cope? Do you have any tips for becoming more aware of your feelings? Please share!

Le Chat Domestique
The Domestic Cat and His Character. I purchased this poster while strolling along the Seine River in Paris in 2005.

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.

Mental Health Month 2017

Did you know that May is Mental Health Awareness Month? I forget every year but according to Wikipedia, it has been observed in the United States since 1949. I decided to post a fact about mental health once per day on one of my social media accounts and I thought I’d share all of them here in case anyone is inspired to do the same. All of these facts are quoted either from the National Alliance on Mental Illness or the World Health Organization. With regards to mental health in America:

  1. 1 in 5 Americans live with a mental health condition.
  2. Nearly 1 in 25 adults (10 million) in America live with a serious mental illness.
  3. A mental illness is a condition that affects a person’s thinking, feeling or mood. Such conditions may affect someone’s ability to relate to others and function each day.
  4. 20% of youth ages 13-18 live a with mental health condition. Of these, 8% have an anxiety disorder, 10% have a behavior or conduct disorder, and 11% have a mood disorder.
  5. Even though most people can be successfully treated, less than half of the adults in the U.S. who need services and treatment get the help they need.
  6. Half of all chronic mental illness begins by age 14; three-quarters by age 24. Despite effective treatment, there are long delays—sometimes decades—between the first appearance of symptoms and when people get help.
  7. The average delay between the onset of symptoms and intervention is 8-10 years.
  8. Mental and substance use disorders are the leading cause of disability worldwide.
  9. Serious mental illness costs America $193.2 billion in lost earnings per year.
  10. Approximately 26% of homeless adults staying in shelters live with serious mental illness.
  11. Approximately 24% of state prisoners have “a recent history of a mental health condition.
  12. 70% of youth in state and local juvenile justice systems have a mental illness.
  13. Individuals living with serious mental illness face an increased risk of having chronic medical conditions. Adults in the U.S. living with serious mental illness die on average 25 years earlier than others, largely due to treatable medical conditions.
  14. Over one-third of students with a mental health condition age 14­–21 and older who are served by special education drop out—the highest dropout rate of any disability group.
  15. Mood disorders, including major depression, dysthymic disorder and bipolar disorder, are the third most common cause of hospitalization in the U.S. for both youth and adults aged 18–44.
  16. Suicide is the 10th leading cause of death in the U.S., the 3rd leading cause of death for people aged 10–24 and the 2nd leading cause of death for people aged 15–24.
  17. 1.1% of adults in the U.S. (1 in 100) live with schizophrenia.
  18. 2.6% of adults in the U.S. live with bipolar disorder.
  19. 6.9% of adults in the U.S. had at least one major depressive episode in the past year.
  20. 18.1% of adults in the U.S. experienced an anxiety disorder such as posttraumatic stress disorder, obsessive-compulsive disorder and specific phobias.
  21. Of the 20.2 million adults living with addiction disorders, just over half have co-occuring mental health disorders as well.
  22. African Americans and Hispanic Americans used mental health services at about one-half the rate of Caucasian Americans in the past year and Asian Americans at about one-third the rate.
  23. More than 90% of children who die by suicide have a mental health condition.
  24. Lesbian, gay, bisexual, transgender and questioning (LGBTQ) youth are 2 to 3 times more likely to attempt suicide than straight youth.
  25. Each day an estimated 18-22 veterans die by suicide.
  26. The prevalence of mental illness (diagnosed American adults) by race: 13.9% Asian, 16.3% Hispanic, 18.6% Black, 19.3% White, 28.3% American Indian/Alaskan Native.
  27. LGBTQ individuals are 2 or more times more likely as straight individuals to have a mental health condition.
  28. Some critical issues faced by minority communities include decreased access to treatment, language barriers, higher levels of stigma, culturally insensitive health care system,  lower rates of health insurance, poorer quality of care, and racism, bias, homophobia or discrimination in treatment settings.
  29. War and disasters have a large impact on mental health and psychosocial well-being. Rates of mental disorder tend to double after emergencies.
  30. Human rights violations of people with mental and psychosocial disability are routinely reported in most countries. These include physical restraint, seclusion and denial of basic needs and privacy. Few countries have a legal framework that adequately protects the rights of people with mental disorders.
  31. Globally, there is huge inequity in the distribution of skilled human resources for mental health. Shortages of psychiatrists, psychiatric nurses, psychologists and social workers are among the main barriers to providing treatment and care in low- and middle-income countries. Low-income countries have 0.05 psychiatrists and 0.42 nurses per 100 000 people. The rate of psychiatrists in high income countries is 170 times greater and for nurses is 70 times greater.

If you’re looking for citations, they are here, here, here, here, and here. Happy Mental Health Awareness Month!!!

Mental Health First Aid

Thanks to Kalamazoo County Community Mental Health & Substance Abuse Services (KCMHSAS) for providing me with a full scholarship to attend this training, I went to an 8-hour Adult Mental Health First Aid course yesterday afternoon. According to their website, this course “teaches you how to identify, understand and respond to signs of mental illnesses and substance use disorders. The training gives you the skills you need to reach out and provide initial help and support to someone who may be developing a mental health or substance use problem or experiencing a crisis.”

The program was initially developed in Australia and has since been adapted for use in over 20 countries, including the United States. The main goal is to equip people with the tools they need to start a dialogue about mental health so that individuals who are in crisis can get the help that they need.

“Most of us would know how to help if we saw someone having a heart attack—we’d start CPR, or at the very least, call 9-1-1. But too few of us would know how to respond if we saw someone having a panic attack or if we were concerned that a friend or co-worker might be showing signs of alcoholism.

Mental Health First Aid takes the fear and hesitation out of starting conversations about mental health and substance use problems by improving understanding and providing an action plan that teaches people to safely and responsibly identify and address a potential mental illness or substance use disorder.” The Mental Health Action Plan utilizes the following acronym: ALGEE (pronounced like the word, “algae”)

  • Action A: Assess for risk of suicide or harm
  • Action L: Listen nonjudgmentally
  • Action G: Give reassurance and information
  • Action E: Encourage appropriate professional help
  • Action E: Encourage self-help and other support strategies

In the course, we learned the signs and symptoms of depression, anxiety disorders, suicidal behavior, non-suicidal self-harm, psychosis, and substance use disorders. We did a lot of group work, where we were given hypothetical situations and asked to use the Mental Health Action Plan to determine how to help the individuals in our case studies. We learned that the action plan is non-linear, meaning that you don’t necessarily complete all of the steps in order and you don’t have to complete all of the steps in each situation.

There were a dozen individuals in the class with me and the majority of them are social workers, but there were a few people who work outside of the mental health/substance abuse field, including business professionals, a college student and so on. I think that everyone found the course to be helpful. Much of the material seemed like common sense to me, but that may be because I have lived a lot of it. I found it interesting listening to people talk about the signs and symptoms. For example, we did an activity related to hearing voices (psychosis) in which we broke into groups of three and two people had a conversation with each other while the third person whispered into one of the other people’s ears. Everyone was shocked at how distracting this is but I have experienced auditory hallucinations, so I was not very surprised. I’m glad that it helped them to better understand what an individual that is hearing voices might be experiencing.

I think that the most important activity of the day was breaking into groups of two for role playing, having a conversation with a friend that we think might be suicidal, and asking them directly, “Are you having thoughts of suicide?” or “Are you thinking about killing yourself?” This activity is required in the course because how can we help someone who is suicidal if we can’t even ask them if we are? I had never said those words out loud and it was hard but we all did it and now I know that I can. I guess I just assumed that I would be able to do it before. We learned not to ask vague questions such as, “Are you thinking about harming yourself?” or “You’re not planning on doing anything crazy, are you?” because the individual may not see suicide as harmful or crazy. We need to be very direct. If the person says “yes,” there are four follow-up questions to ask:

  1. Do you have a plan?
  2. Have you decided when you would do it?
  3. Have you collected the things you need to carry out your plan?
  4. Do you have another plan?

I’m going to share two crisis resources here.

  • The National Suicide Prevention Lifeline is 1-800-273-TALK (8255). It is “a national network of local crisis centers that provides free and confidential emotional support to people in suicidal crisis or emotional distress 24 hours a day, 7 days a week.”
  • The Crisis Text Line is a 24/7 anonymous service for anyone experiencing any kind of crisis. Text 741741 or message them on Facebook and you will be connected to a trained counselor. If your cell phone plan is with AT&T, T-Mobile, Sprint, or Verizon, texts to 741741 are free of charge. If you have a plan with a different carrier, standard text message rates apply.

We covered a lot of material throughout the day, but we didn’t have to try to memorize everything because we were given a copy of the book, “Mental Health First Aid USA” to keep. It’s full of information about mental health conditions, plus statistics and vetted resources. KCMHSAS also provided us with a detailed resource list specific to our county.

If you’re able to attend a Mental Health First Aid training, I highly recommend it. Did you know that 19.6% of American adults (1 in 5) have a mental disorder in a given year? This is equivalent to 45.6 million people. These types of disorders can have a huge impact on their education, work, relationships, and health. Early intervention can greatly reduce the impact and first aiders can make a big difference by helping individuals that are in crisis to have their needs met. Can you imagine what the world would be like if we had as many people trained in Mental Health First Aid as we do in First Aid and CPR?