From public relations to art counterfeiting, male hustling, and aimless travel, Andy Behrman's tale of living with bipolar disorder is also frank and honest.

Andy Behrman wrote Electroboy: A Memoir of Mania while convalescing from four months of electroconvulsive therapy (ECT) that effectively ended 20 years of undiagnosed, out-of-control bipolar disorder. His book reads at times like a chronicle of loss for that old life of sleepless nights fueled by drugs, anonymous sex, aimless travel, and midnight pastrami binges followed by tofu and tuna diets and male hustling. And yes, he admits, one of the secrets of manic depression is the pleasure it brings. "It's an emotional state similar to Oz," he writes, "full of excitement, color, noise, and speed—-an overload of sensory stimulation—whereas the sane state of Kansas is plain and simple, black and white, boring and flat."

But in 1992, his life fell completely apart. A successful public relations consultant in New York, Behrman had gotten drawn into an art counterfeiting scheme ("the most exciting proposition I'd heard in years"), was tried, found guilty and sentenced to five months in federal prison. It was around that time that he was finally diagnosed with bipolar disorder— after seeing eight different psychiatrists over a 12-year period.

His 2002 memoir has been optioned as a movie and is currently in pre-production— with Tobey ("Spider-Man") Maguire set to play Behrman on the big screen. The book, while raunchy and likely to be distasteful to some readers, is often funny and always honest. At his most psychotic, Behrman imagines himself chewing on sidewalks and swallowing sunlight. He squirrels away his nest egg— a tidy sum of $85,000, earned in the counterfeiting scheme— in a shoe box, and his "strudel money"— some 25,000 German deutsche marks (about $10,000)— in the freezer, neatly stacked between a bag of chicken breasts and a pint of ice cream.

In the book, Behrman describes his New Jersey childhood as happy, yet he was never comfortable in his own skin. A precocious boy, he always felt "different"; he had a compulsive need to wash his hands a dozen times a day and lay awake nights counting cars go by. Yet his family never guessed that anything was the matter. In fact, it was he— at the age of 18, right before heading off to college— who asked to see the first of what would grow into a parade of therapists.

Today, 37 different medications and 19 electroconvulsive therapies later, the 43-year-old Behrman is stable, married, and living in a Los Angeles suburb, where he and his wife just had their first child. He is a strong advocate for medication, and no longer considers it a challenge staying on his. He regularly addresses patient support groups, doctors, and mental health conferences, and is a featured speaker at the three upcoming conferences of the Depression and Bipolar Support Alliance (DBSA).

Here, in an interview with bp Magazine, Behrman insists on dispelling the perceived glamour of mental illness. If he still feels any ambivalence, he doesn't let on in our conversation.

Why did you write Electroboy?

Behrman: I had read a few books about bipolar disorder but I never identified with any of them, because my story didn't sound like their story. I thought maybe my case is some kind of special case. I even thought for a while that maybe my diagnosis was wrong. And it was only after Electroboy came out that I heard from other people who said their story was just like mine. They, too, thought their stories were too graphic, too dramatic, too something to fit into the category of the illness. Their responses made me feel like my brand of bipolar disorder was more the norm than anyone else had ever represented, because there is a lot of high drama, a lot of craziness, a lot of risktaking, and a lot of destructive behavior.

How did your parents react?

Behrman: I gave them an advanced copy of the book and I don't think they knew how to react. I think they were just shocked. Pun intended. They were flabbergasted that I had led this life that they knew nothing about. They stopped talking to me for a while.

Then they wanted to sit down with a therapist. The general concern was that I was completely exposing myself, that it was a confessional. I think they were also concerned for themselves. We talked at length about bipolar, really for the first time. Before, I had just been seeing psychiatrists on my own and reporting back to my parents.

And they came to the realization that this was something they had ignored. I think they felt guilty that they had been oblivious to it, as well as guilty that they had passed it on to me.

Is there a family history of bipolar disorder?

Behrman: Yes. Probably my paternal grandfather. Nobody talks about him very much, but he was an attorney who kept very odd hours. We know he had mood swings, but he wasn't diagnosed with anything. My father is somewhat obsessive-compulsive and my mother is very driven, as is my sister. We're all related and similar in personalities, though I'm the only one diagnosed.

When did you realize that things had gotten out of hand?

Behrman: Probably when I became involved with the art-counterfeiting scandal. I was aware of the danger, but I thought I was being rational. I was aware of the dangers, but not frightened by them. It became a crisis only when everything broke down and my plan was discovered and there was this fear of what was going to happen to me. That's when I really sought help.

I can imagine the prosecution sighing, and saying, yeah, right, the bipolar defense: "My mania made me do it."

Behrman: The issue of my bipolar disorder never came up at my trial, which was in 1993. The issue only came up at my sentencing. That was 11 years ago and I had never heard of bipolar disorder. I had never heard of the term manic-depressive, which [is how] it was referred to back then. I didn't know anyone with bipolar and I was pretty aware.

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When you were first diagnosed, you thought it was a terminal illness.

Behrman: I thought I wouldn't make it to my next birthday. The only treatment back then was lithium. I saw eight psychiatrists before I got my diagnosis and was misdiagnosed almost always with depression. Bipolar patients are misdiagnosed on average eight to 10 times before they see a doctor who diagnoses them correctly. Back then, I thought they were all right. And it's understandable, because I only went to those doctors when I was in my down periods, feeling terrible. I didn't go when I was feeling elated or manic. And that's still a problem today: people who are bipolar are not so willing to give up their mania.

You devote a lot more space in your book to the manic episodes than the depressive ones.

Behrman: The manic behavior is easier to remember. My lows seemed a lot different than the lows that a unipolar depressive feels. I wasn't blue. My lows were filled with rage, anger, and irritability. I was dysfunctional and agitated, really miserable with life, and desperately trying to get back to where I had been the day before.

And, honestly, in Electroboy, you make the mania sound almost glamorous.

Behrman: I'm always surprised when people say Electroboy is so glamorous. If that's glamour, I can live without it. I think people make the assumption that because you're traveling from New York to Tokyo and Paris, you're living a glamorous life. But if you're not in control and you can't stop what you're doing ... if, when you're in Paris, and you think, why not Johannesburg? Like I got to the Berlin Wall [in 1989], and I thought, no big deal; it's just some people chopping off little blocks of cement. Let's go back to Paris.

Depressives say, oh you're so lucky to be manic-depressive, you don't know how horrible it is not to be able to get out of bed. I completely understand. But at the same time, bipolar is so frightening. When you're flying high, you don't know where it's taking you. If you're driving, you don't know if you're going to crash; if you're flying, you don't know where your plane is taking you.

Given all that, do you ever miss it?

Behrman: Not at all.

Perhaps there was a period when I did, but now if you see where my life is compared to where it was ... God, it's been 12 years. There was a period after I left, well, I was asked to leave, my art consulting job, when I didn't work for eight years.

What is your life like now?

Behrman: I've been stable since 1999. I've left New York and I'm living in LA. I was married in November 2003, and my wife and I just had our first child, Kate Elizabeth, on April 27. So I'm stable, married, living in the suburbs, and working full time writing two books [a sequel to Electroboy, and a self-help book for bipolar disorder], doing my speaking engagements, and working on a film version of Electroboy.

How do you think living in Manhattan influenced your behavior?

Behrman: Manhattan is a very convenient place to be bipolar; it's the city that never sleeps. And a bipolar is a person who never sleeps. If you feel like going out for a snack at 4 a.m., you can find a diner that's never closed; you can go to the corner and buy magazines; you can go to a club.

LA is hardly a land of peace and quiet.

Behrman: LA might not be the land of peace but try finding a hamburger at 10 o'clock at night. The potential for getting into trouble is much greater in Manhattan.

Do you think bipolar disorder is being overdiagnosed?

Behrman: I don't think it's overdiagnosed, but I do think it's overglamorized in the media. People say, "Oh he must just have bipolar." It seems to be the glamorous diagnosis of the moment. I could never understand that because it's the least glamorous one I can think of. I used to tell my psychiatrists, "Just take a limb off. I'm sick of this illness that I can't get under control."

For six or seven years, I was on 37 different medications and I also underwent electroconvulsive therapy because the medications didn't work for me. There was nothing that would break my manic cycle. I was walking around on drugs that were sedating me and not allowing me to function, literally being in my apartment for five years and just watching television. And at the same time, cycling back and forth from mania to depression. It was a really uncomfortable, pretty horrible time of my life.

What made you decide to try electroconvulsive therapy?

Behrman: At that critical part of my life, I was just begging for help. My psychiatrist was initially opposed to it. She said, "You're so sensitive to medications, I don't think it's a good idea." But she referred me to another doctor who said I was a great candidate. Without being too cynical about it, I think doctors who treat patients with ECT... well, it should be a last resort, and he didn't know me too long.

How long?

Behrman: About 15 minutes.

And when was your first treatment?

Behrman: The next day. It was the only thing left to treat acute mania, but I have to tell you I was so unwell at the time it didn't even frighten me. The doctor didn't give me a lot of information: "Just trust me, you're going to feel better". he told me.

And you trusted him.

Behrman: My initial reaction was: this is really glamorous; this will be another adventure. I also thought that if I undergo this barbaric treatment then I won't feel guilty. I can tell my family and friends that I've tried everything. I can't be held accountable ....

So what was it like?

Behrman: After my first electric shock treatment, I felt like everything had been recalibrated, my thinking was a lot clearer. [That's] not to say that I didn't experience the side effects: the memory loss and the achiness. I needed to be rubbed and massaged. I was in tremendous pain, and barely recognized my sister when she came to the hospital. I knew I knew her, I just didn't know how.

You've become a new voice for the bipolar consumer. Are you comfortable in that role?

Behrman: I have a Web site, something that my publisher didn't really think was important to do, but after my book came out I started getting tons of mail—-up to 600 emails a week from people thanking me for the book and telling me their own stories. I responded to every email and every response led me to other people and groups of people who asked me to come and speak, and so I would go, and I didn't question it because the idea was to tell my story and listen to other stories.

This whole bipolar world is so connected on the Internet that basically I could do this sitting behind a computer. But people want to see you in person, and somehow when you speak in person your story is more meaningful. I never get tired of it. My wife asks, "Why does your speech change every time?" It's never the same. Even at book readings, I never read from the book, I just start talking.

next: Years Later, a Quieter Mind
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Report on American Psychiatric Association 2004 Annual Meeting

At a scientific meeting such as the annual meeting of the American Psychiatric Association (APA), often some of the most interesting and exciting things presented are found in poster sessions. For the uninitiated, these are sessions in which there are aisles of bulletin boards containing posters describing research projects, and investigators stand in front of them, answering questions and explaining their work, if asked. While the sessions can be quite overwhelming with the sheer amount of data and projects available, they can also be considerably more leisurely and relaxing; viewers can walk down the aisles and look at the research at their own pace, skipping over things they may not be particularly interested in, and lingering over ones that they are, even talking to the investigator standing right there. The downside is that many, if not all, of the studies are not major research projects with huge numbers of subjects or data, but are usually preliminary studies that may lead to larger pieces of work in the future, perhaps ending up as journal articles. Thus, one will not see the best science in a poster session, but one may see future research directions for great science in our field.

At the poster session devoted to biological psychiatry and psychopharmacology at the APA 2004 Annual Meeting, there were a number of things to stop and linger over. One study[1] showed increased synaptic efficiency and plasticity in the hippocampus of rats exposed to lithium (Lithium Carbonate), providing further evidence that therapies for mood disorders in general often have similar effects in this area of the brain. Another study[2] took a different spin on the relationship between diabetes and psychotropic medication by looking at the effect on bipolar patients of different classes of medications on hemoglobin A1C levels, considered to be a sensitive indicator of hyperglycemia. This work showed that A1C levels went significantly down with lithium, anticonvulsant mood stabilizers, and antidepressants, but up slightly with antipsychotics.

Not surprisingly, there were many posters in this session looking at genetic markers. Some of these demonstrated genotypes that may be protective of psychiatric disorders, other showed genotypes that may be predictors of medication response or nonresponse, and still others looked at the genetics that may predict whether patients will get certain side effects from their medication. While some of the studies may be more positive with more robust data than others, it is truly remarkable to see the depth and breadth of psychogenetics. This may be the place where a poster session truly predicts where our future lies.

The pharmaceutical industry is quite present at the annual meeting, and the poster sessions are no exception. There are multiple posters that deal directly with marketing agendas of particular agents. For example, one poster showed that ziprasidone (Geodon) does not prolong QTC intervals significantly,[3] another dealt with making rashes from lamotrigine (Lamictal) particularly unlikely,[4] another compared aripiprazole (Abilify) favorably with olanzapine (Zyprexa) in the incidence of metabolic syndrome,[5] and another showed that extended-release divalproex sodium (depakote) works well.[6] Industry support on these kinds of studies is reasonably well documented, and they can be interesting, but it is not unusual to see a poster that is telling you what sales reps have been telling you for months.

One intriguing poster made an argument that has become particularly unpopular in the current literature. A study from the University of Pennsylvania[7] showed that antidepressant monotherapy in the treatment of bipolar II major depression may be safe and effective with a very low manic switch rate. This study was funded by a grant from the National Institute of Mental Health and contradicts much current literature. Another intriguing poster[8] showed that psychiatric inpatients who had a history of using cannabis required longer admissions, more intensive treatment in the hospital, and higher doses of medication.

Not surprisingly, there were multiple posters on polypharmacy and, in particular, on innovative combinations of psychotropic agents. Among the more intriguing were one on the combined use of lamotrigine and lithium in bipolar disorder[9] and the combined use of donepezil and divalproex in Alzheimer's disease.[10] Other posters looked at somewhat better-known combinations, such as using mirtazapine with other relatively new antidepressants,[11] and showed that venlafaxine may be the best medication to combine with mirtazapine. Some preliminary data were shown[12] about adjunctive modafinil with selective serotonin reuptake inhibitors. No discussion of drug combinations would be complete without looking at the issue of drug-to-drug interactions, and one poster[13] showed data about how remarkably likely it was for a clinically significant drug interaction to take place.

Arguably, the most interesting posters are about those agents or applications that are new. These can be a novel way to use a well-known agent, such as a study using mirtazapine intravenously in medically ill patients.[14] They can also be a completely new use for a well-known drug such as the use of mifepristone, known as a controversial oral abortion medication (RU-486), as a successful and extremely well-tolerated treatment for psychotic major depression.[15] There can also be intriguing work about relatively new medications and new ways to use them. A relatively new anticonvulsant, levetiracetam, was shown in a number of posters to have potential efficacy for aggressive disorders,[16] bipolar disorder[17,18] and hypomania.[19] There were many posters that showed new uses for well-established psychotropics, such as the use of anticonvulsants including lamotrigine[20] and divalproex[21] as adjunctive treatment for schizophrenia. There were also posters about the use of paroxetine in the treatment of fibromyalgia[22] and irritable bowel syndrome.[23]

Finally, there are the brand-new agents, the ones that are not available for general clinical use but show some promise. Some of these are imminent for launch into the marketplace, like pregabalin for anxiety disorders.[24,25] Others are so new that they do not have names yet, just a number assigned to investigational drugs. One intriguing example of this is DOV 216303, which is a triple reuptake inhibitor -- it blocks the reuptake of serotonin, norepinephrine, and dopamine. The poster presented[26] described a study where the medication was given only to healthy volunteers, but it was found to be quite safe with a very low incidence of adverse events. Given the new interest in medications blocking the reuptake of multiple neurotransmitters, it will be interesting to see what the addition of dopamine reuptake blockade will do for efficacy.

This description of a poster session is by no means intended to be a comprehensive review of all of the information and ideas presented. There were many more posters at the session that went unmentioned. It will hopefully, however, describe the themes and the highlights and give the reader a sense both of what the room was like and where the research community is looking.

next:

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References

1. Shim S, Russell R. Exposure to lithium enhances synaptic plasticity in the hippocampus. Program and abstracts of the American Psychiatric Association 2004 Annual Meeting; May 1-6, 2004; New York, NY. Abstract NR316.
2. Castilla-Puentes R, Coleman B, Russo L, et al. Effects of psychotropics on HbA1c in a cohort of bipolar patients. Program and abstracts of the American Psychiatric Association 2004 Annual Meeting; May 1-6, 2004; New York, NY. Abstract NR317.
3. Haverkamp W, Naber D, Maier W, et al. QTc interval during ziprasidone treatment of patients with schizophrenia. Program and abstracts of the American Psychiatric Association 2004 Annual Meeting; May 1-6, 2004; New York, NY. Abstract NR335.
4. Wang PW, Chandler RA, Alarcon AM, et al. Low incidence of lamotrigine treatment-emergent rash with dermatology precautions. Program and abstracts of the American Psychiatric Association 2004 Annual Meeting; May 1-6, 2004; New York, NY. Abstract NR348.
5. Casey D, L'Italien GJ, Cislo P. Incidence of metabolic syndrome in olanzapine and aripiprazole patients. Program and abstracts of the American Psychiatric Association 2004 Annual Meeting; May 1-6, 2004; New York, NY. Abstract NR338.
6. Jackson RS, Venkataraman S, Owens M, et al. Tolerability and efficacy of divalproex extended release in psychiatric patients. Program and abstracts of the American Psychiatric Association 2004 Annual Meeting; May 1-6, 2004; New York, NY. Abstract NR346.
7. Amsterdam J, Shults J. Antidepressant monotherapy of bipolar patients type II major depressive episode. Program and abstracts of the American Psychiatric Association 2004 Annual Meeting; May 1-6, 2004; New York, NY. Abstract NR336.
8. Issac M, Issac MT. Metabolic and Clinical Implications of cannabis use in psychiatric intensive care. Program and abstracts of the American Psychiatric Association 2004 Annual Meeting; May 1-6, 2004; New York, NY. Abstract NR341.
9. Goodwin FK, Bowden CL, Calabrese JR, et al. Concomitant use of lamotrigine and lithium in bipolar I disorder. Program and abstracts of the American Psychiatric Association 2004 Annual Meeting; May 1-6, 2004; New York, NY. Abstract NR340.
10. Aupperle PM, Sohynle S, Coleman J, et al. Divalproex sodium extended release augmentation of donepezil. Program and abstracts of the American Psychiatric Association 2004 Annual Meeting; May 1-6, 2004; New York, NY. Abstract NR345.
11. Blier P, Ward H, Jacobs W, et al. Combining two antidepressants from treatment start: a preliminary analysis. Program and abstracts of the American Psychiatric Association 2004 Annual Meeting; May 1-6, 2004; New York, NY. Abstract NR357.
12. Schwartz TL, Cole K, Hopkins GM, et al. Adjunct modafinil reduces SSRI-induced sedation in patients with MDD. Program and abstracts of the American Psychiatric Association 2004 Annual Meeting; May 1-6, 2004; New York, NY. Abstract NR367.
13. Preskorn S, Shah R, Silkey S, et al. The potential for clinically significant drug-drug interactions in patients. Program and abstracts of the American Psychiatric Association 2004 Annual Meeting; May 1-6, 2004; New York, NY. Abstract NR368.
14. Morlet A, Tamiriz G. First report of intravenous mirtazapine in medically ill patients with depression in Mexico. Program and abstracts of the American Psychiatric Association 2004 Annual Meeting; May 1-6, 2004; New York, NY. Abstract NR344.
15. Schatzberg, AF, Solvson HB, Keller J, et al. Mifepristone in psychotic major depression. Program and abstracts of the American Psychiatric Association 2004 Annual Meeting; May 1-6, 2004; New York, NY. Abstract NR397.
16. Jones J, Deutchman D, Chalekian JS, et al. Levetiracetam: efficacy, tolerability, and safety in aggressive disorders in 100 patients. Program and abstracts of the American Psychiatric Association 2004 Annual Meeting; May 1-6, 2004; New York, NY. Abstract NR372.
17. Deutchman DA, Deutchman D, Chalekian JS. Levetiracetam: efficacy, tolerability and safety in bipolar disorder in 200 patients. Program and abstracts of the American Psychiatric Association 2004 Annual Meeting; May 1-6, 2004; New York, NY. Abstract NR373.
18. Ahmadi A, Ekhtiari S. Levetiracetam as an add-on in adults and children with bipolar disorder. Program and abstracts of the American Psychiatric Association 2004 Annual Meeting; May 1-6, 2004; New York, NY. Abstract NR404.
19. Goldberg JF, Burdick KE. Preliminary experience with levetiracetam in bipolar hypomania. Program and abstracts of the American Psychiatric Association 2004 Annual Meeting; May 1-6, 2004; New York, NY. Abstract NR408.
20. Vass A, Kremer I, Gurelik I, et al. Pilot-controlled trial of lamotrigine adjuvant treatment in schizophrenia. Program and abstracts of the American Psychiatric Association 2004 Annual Meeting; May 1-6, 2004; New York, NY. Abstract NR395.
21. Citrome LL, Jaffe AB, Levine J, et al. Mood stabilizer use in schizophrenia 1994-2002. Program and abstracts of the American Psychiatric Association 2004 Annual Meeting; May 1-6, 2004; New York, NY. Abstract NR350.
22. Purcell C, Patkar A, Masand P, et al. Predictors of response to placebo-controlled, double-blind trial of paroxetine controlled release in fibromyalgia. Program and abstracts of the American Psychiatric Association 2004 Annual Meeting; May 1-6, 2004; New York, NY. Abstract NR361.
23. Masand P, Patkar A, Dube E, et al. Paroxetine controlled-release treatment of irritable bowel syndrome. Program and abstracts of the American Psychiatric Association 2004 Annual Meeting; May 1-6, 2004; New York, NY. Abstract NR370.
24. Khan A, Simon NM, Tobias KJ, et al. Pregabalin in GAD: does it also improve core depressive symptoms? Program and abstracts of the American Psychiatric Association 2004 Annual Meeting; May 1-6, 2004; New York, NY. Abstract NR364.
25. Bockbrader HN, Wesche D. Pharmacokinetic profile of pregabalin: results of a series of studies. Program and abstracts of the American Psychiatric Association 2004 Annual Meeting; May 1-6, 2004; New York, NY. Abstract NR378.
26. Lippa A, Beer B, Stark J, et al. DOV 216303, a triple reuptake inhibitor: first human studies. Program and abstracts of the American Psychiatric Association 2004 Annual Meeting; May 1-6, 2004; New York, NY. Abstract NR393

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People from different cultures express symptoms of depression in various ways. In addition to changes in their mood, Hispanics tend to experience depression as bodily aches and pains (like stomachaches, backaches or headaches) that persist despite medical treatment. Depression is often described by Hispanics as feeling nervous or tired. Other symptoms of depression include changes in sleeping or eating patterns, restlessness or irritability, and difficulty concentrating or remembering.

Use of Mental Health Services

Among Hispanic Americans with a mental disorder, fewer than 1 in 11 contact mental health specialists, while fewer than 1 in 5 contact general health care providers. Among Hispanic immigrants with mental disorders, fewer than 1 in 20 use services from mental health specialists, while fewer than 1 in 10 use services from general health care providers.

One national study found that only 24% of Hispanics with depression and anxiety received appropriate care, compared to 34% of whites. Another study found that Latinos who visited a general medical doctor were less than half as likely as whites to receive either a diagnosis of depression or antidepressant medicine.

Precise estimates of the use of complementary therapies by Hispanic Americans do not exist. One study found that only 4% of its Mexican American sample consulted a curandero, herbalista, or other folk medicine practitioner within the past year, while percentages from other studies have ranged from 7 to 44%. The use of folk remedies is more common than consultation with a folk healer, and these remedies are generally used to complement mainstream care.

Availability of Mental Health Services

In 1990, about 40% of Hispanics either did not speak English at all or did not speak it well. While the percentage of Spanish-speaking mental health professionals is not known, only about 1% of licensed psychologists who are also members of the American Psychological Association identify themselves as Hispanic. Moreover, there are only 29 Hispanic mental health professionals for every 100,000 Hispanics in the United States, compared to 173 non-Hispanic white providers per 100,000.

Another big problem is access to professional help. Nationally, 37 percent of Hispanics are uninsured, compared to 16% for all Americans. This high number is driven mostly by Hispanics' lack of employer-based coverage - only 43% compared to 73% for non-Hispanic whites. Medicaid and other public coverage reaches 18% of Hispanics.

Need for Mental Health Care

Generally speaking, the rate of mental disorders among Hispanic Americans living in the community is similar to that of non-Hispanic white Americans. However,

• Adult Mexican immigrants have lower rates of mental disorders than Mexican Americans born in the United States, and adult Puerto Ricans living on the island tend to have lower rates of depressions than Puerto Ricans living on the mainland.

• Studies have found that Latino youth experience proportionately more anxiety-related and delinquency problem behaviors, depression, and drug use than do non-Hispanic white youth.

• Regarding older Hispanic Americans, one study found over 26% of its sample were depressed, but depression was related to physical health; only 5.5% of those without physical health problems said they were depressed.

• Culture-bound syndromes seen in Hispanic Americans include susto (fright), nervios (nerves), mal de ojo (evil eye), and ataque de nervios. Symptoms of an ataque may include screaming uncontrollably, crying, trembling, verbal or physical aggression, dissociative experiences, seizure-like or fainting episodes, and suicidal gestures.

• In 1997, Latinos had a suicide rate of about 6% compared to 13% for non-Hispanic whites. However, in a national survey of high school students, Hispanic adolescents reported more suicidal ideation and attempts proportionally than non-Hispanic whites and blacks.

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High-Need Populations

Hispanics are relatively under-represented among people who are homeless or children in foster care. However, they are present in high numbers in other high-need populations.

• People who are incarcerated. 9% of Hispanic Americans, compared to 3% of non-Hispanic white Americans, are incarcerated. Latino men are nearly four times as likely as white men to be imprisoned at some point during their lifetimes.

• Vietnam War Veterans. Latinos who served in Vietnam were at higher risk for war-related post-traumatic stress disorder than were black and non-Hispanic white veterans.

• Refugees. Many refugees from Central America experienced considerable civil war-related trauma in their homelands. Studies have found rates of post-traumatic stress disorder among Central America refugee patients ranging from 33 to 60%.

• Individuals with Alcohol and Drug Problems. In general, Hispanic Americans have rates of alcohol use similar to non-Hispanic whites. However, Hispanic women/Latinas have unusually low rates of alcohol and other drug use, while Latino men have relatively high rates. Rates of substance abuse are higher among U.S.-born Mexican Americans compared to Mexican-born immigrants. Specifically, substance abuse rates are twice as high for U.S.- born Mexican American men than for Mexican-born men, but seven times higher for U.S.-born Mexican American women than for Mexican-born women.

Appropriateness and Outcomes of Mental Health Services

Few studies on the response of Latinos to mental health care are available. Several studies have found that bilingual patients are evaluated differently when interviewed in English as opposed to Spanish. One small study found that Hispanic Americans with bipolar disorder are more likely to be misdiagnosed with schizophrenia than are non-Hispanic white Americans.

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A malady that mimics depression

The patient couldn't tell me what was wrong, and neither could his 80-year-old mother. He had been lying on the sofa for weeks, she said, and he wouldn't get up.

Sloth was a sin, but was it a reason to be admitted to the hospital?

They lived in a house in East St. Louis, Ill. He was 56 and single, working odd jobs until recently, when he parked himself on the couch, watching television. He was sleepy most of the time, forgetting appointments and leaving chores unfinished. When confronted, he became irritable and withdrawn.

His mother suspected drugs, but he never left the house long enough to buy any. She begged him to see a doctor, but he wouldn't. When the situation became intolerable, she called 911.

It was my first hospital rotation in medical school, but even to my novice eye this wasn't the usual midsummer lethargy.

The man moved slowly and slurred his words. He denied using drugs and said he had had no previous medical problems. Though he vaguely recalled taking a medication, he couldn't remember what it was.

His body was cool and dry. His heartbeat was slow but otherwise normal.

I asked him a few standard questions. He knew where he was and the year, but not the month or the president. I asked him to count backward from 100 by 7's, but he stopped at 93.

He wasn't intoxicated or hypoglycemic. A brain scan revealed no stroke, tumor or bleeding.

Of all the diagnostic possibilities, infections were probably the most serious. AIDS can cause premature dementia, but he didn't have the usual risk factors. Lyme disease was unlikely; the tick carriers are not endemic to the area.

What about meningitis or, worse, syphilis? Untreated syphilis can infect the spinal cord and brain, causing severe nerve damage and dementia. Syphilis is one of the great masqueraders, a disease with such varying symptoms that it can almost never be excluded with certainty. In urban areas then, the incidence of syphilis was rising. The best way to rule it out was a spinal tap.

With my resident's help, I scrubbed the man's lower back with an antiseptic soap and then injected local anesthetic into the tissue between the third and fourth vertebrae. It was my first spinal tap, and luckily the needle went right into his spinal column, returning a clear fluid. We sent the fluid off to the laboratory.

That evening, test results started coming back. Blood tests for kidney and liver disease were negative. The spinal fluid was clean, ruling out an infection. But when the level of thyroid-stimulating hormone came back, it was off the scale. The patient had the worst case of hypothyroidism the doctors had ever seen.

I ran into an E.R. resident later that night and told him we had made a diagnosis. "Let me guess," he said. "Hypothyroidism."

"How did you know?" I asked in disbelief.

"I tapped on his knee," he replied.

Later I tried it, eliciting the slow reflex that is a classic sign of the disease. Physical examination is always easier when you know the answer.

We immediately gave him thyroid medication, and after a couple of days his heartbeat sped up, his thoughts became clearer and his body temperature rose to normal. Lying in his hospital bed, he apologized to his mother for all the trouble.

Hypothyroidism can mimic many symptoms of major depression, including forgetfulness, low energy and the inability to concentrate. In 1888, the Clinical Society of London published the first major report on the disorder, calling it myxedema and comparing it to childhood cretinism. Its most severe form brings on a reduced level of consciousness and even paranoia and hallucinations.

The next day his mother brought in a brown bag. In it was an empty bottle of thyroid hormone. He had been taking the drug but had stopped six months earlier after it ran out, slowly sinking into an amnesiac delirium that made him forget he needed it, a lapse that almost cost him his life.

Hypothyroid coma has a 20 percent mortality rate even if recognized and treated appropriately.

Every day in emergency rooms, patients get inappropriate treatments because they don't carry lists of their medications. When someone rolls in unconscious, the medication list can be the most valuable piece of diagnostic information.

"Remember to write this down," I told his mother.

After what they had been through, she agreed it was a sensible plan.

next: Depression May Originate in Our Genes
~ depression library articles
~ all articles on depression

Conference transcripts featuring authoritative guests detailing management and treatment of bipolar disorder in adults and children and related issues.

1. Bipolar Medication Non-Compliance, Dual Diagnosis, Dealing Effectively With Manic Episodes
   Guest: Dr. Eric Bellman

2. Bipolar Medications
   Guest: Dr. Carol Watkins

3. Coping With Feelings and Thoughts of Suicide
   Guest: Dr. Alan Lewis

4. Dealing with Depression Naturally
   Guest: Syd Baumel

5. Depression Treatments
   Guest: Dr. Louis Cady

6. Diagnosis and Treatment of Bipolar Disorder - Manic Depression
   Guest: Dr. Ronald Fieve

7. Electroconvulsive Therapy Experiences
   Guests: Sasha and Julaine

8. Experiences of Living with Bipolar Disorder
   Guest: Paul Jones

9. Food and Your Moods
   Guest: Dr. Kathleen DesMaisons

10. How to Better Cope with Bipolar
    Guest: Madeleine Kelly

11. Living with Bipolar Disorder
    Guests: David and Jean

12. Living Without Depression and Manic Depression: A Guide To Maintaining Mood Stability
    Guest: Mary Ellen Copeland

13. Mood Disorders in Children
    Guest: Trudy Carlson

14. Parenting Bipolar Children
    Guest: George Lynn

15. Parenting Difficult Children
    Guest: Howard Glasser

16. Recovery Issues in Bipolar Disorder
    Guest: Dr. Emanuel Severus

17. Self-Help Stuff That Works
    Guest: Adam Khan

18. Successfully Managing Bipolar Disorder
    Guest Julie Fast

19. Treating Self-Injury
    Guest: Michelle Seliner

Dr. Lenard Adler

Dr. Lenard Adler, our guest, is the author of the book Scattered Minds: Hope and Help for Adults with Attention Deficit Hyperactivity Disorder. The transcript covers the diagnosis and treatment of Adult ADHD. Natalie is the HealthyPlace.com moderator. The people in blue are audience members.

Conference Transcript

Natalie: Good evening. I'm Natalie, your moderator for tonight's ADHD chat conference. I want to welcome everyone to the HealthyPlace.com website. Our social network is fairly new in the Internet, but already we have several thousand people who have signed up. A social network is a place for people with mental health conditions as well as their family members and friends to meet each other, maintain blogs and provide and get support, and it's free to join.

Tonight, we are going to discuss the diagnosis of Adult ADHD first because, without an accurate and proper diagnosis, one can't get the right treatment.

Our guest is Dr. Lenard Adler, director of the Adult ADHD Program at New York University Medical Center and author of Scattered Minds: Hope and Help for Adults with Attention Deficit Hyperactivity Disorder.

Good Evening, Dr. Adler, and thank you for joining us tonight.

Dr. Adler: I'm happy to be joining you.

Natalie: I am constantly seeing news stories and studies about "undiagnosed ADHD in adults." I think most parents today are familiar with ADHD in children. Is it different for adult ADHD?

Dr. Adler: ADHD used to be thought of as a disorder primarily affecting children; we now know that about 2/3 children with ADHD go on to be adults with ADHD. This means that about 4.4% of the US adult population or 8 million individuals have ADHD.

Natalie: For adults with ADHD, do the first symptoms usually appear during childhood or is this something that can pop up during adulthood?

Dr. Adler: There must be a childhood onset of symptoms, but you don't need to meet full criteria or be diagnosed in childhood. There can be an adult presentation of ADHD, but to meet full criteria, not adult onset.

Natalie: Are the symptoms of ADHD in adults different from those in children?

Dr. Adler: The symptoms are similar, but individuals must be aware of how symptoms change from childhood to adulthood. The inattentive symptoms of trouble with distraction, trouble paying attention, trouble completing tasks, etc. are more prominent for adults than the hyperactive-impulsive symptoms. Also, adults tend to try to cope with their symptoms and this needs to be kept in mind.

Natalie: Here's a link to symptoms of ADHD in adults. But in your book "Scattered Minds," you mention some "hidden warning signs of adult ADHD". Could you please go over those?

Dr. Adler: There are a number of warning signs- which are some of the impairments from the condition- underperformance on the job, multiple motor vehicle accidents, higher rates of divorce, smoking cigarettes and if the ADHD is not treated, substance use.

Natalie: Accurate diagnosis of childhood ADHD is a problem because some of the symptoms cross over several disorders, like bipolar disorder or conduct disorder. Does the same hold true for diagnosing adults with ADHD? Or is it because they are adults, the symptoms and the ability of the patient to accurately communicate the symptoms, makes diagnosis easier?

Dr. Adler: These co-occurring conditions are important for adults too- adults with ADHD have higher rates of co-occurring bipolar disorder, depression and anxiety disorders. The ability for adults to present a longitudinal history is critical as ADHD symptoms tend to persist, while the symptoms of mood disorders are often episodic.

Natalie: If I think I have adult ADHD, which type of professional is the best for me to see about diagnosis issues? And what about ADHD treatment?

Dr. Adler: Although there is a screening test (self-administered) to identify individuals at risk for ADHD, the diagnostic evaluation requires sitting down with a health care professional and taking a history. 4 criteria need to be met to make the diagnosis: symptoms, impairments, childhood onset and being certain that the symptoms are from ADHD and not another mental health disorder. The diagnosis is a clinical one and there is not a blood test or brain scan that can make the diagnosis. The diagnosis is usually made by a psychiatrist, psychologist, neurologist or primary care physician.

Natalie: Do you think a family doctor, in general, can do a good job of diagnosing adult ADHD?

Dr. Adler: It depends on whether the PCP is adequately trained or not.

Natalie: Sometimes people go to see a doctor or therapist and say "I can't concentrate, always feel fidgety, and I've felt this way for a long time." After that sentence, the doctor is writing a prescription for an ADHD medication. So when I see a professional for an ADHD diagnosis, what kind of diagnostic tests/interviews should I expect so I know this person is doing a thorough and competent job?

Dr. Adler: There is no substitute for taking a comprehensive history, which reviews life long symptoms and impairments. Again to make the diagnosis of ADHD the above 4 criteria need to be met. Rating scales, be they diagnostic or symptom assessment, can often be quite helpful in establishing the symptom onset, chronicity, and impairments.

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Natalie: Here's an audience question Dr. Adler.

missyred: How often is ADHD misdiagnosed in adults? What is it mistaken for instead?

Dr. Adler: ADHD can be misdiagnosed or not diagnosed in adults. A recent community-based survey (the National Comorbidity Survey) found that only 10% of the adults with ADHD had seen and received treatment for their ADHD in the last year. Estimates are that only about 1/4 adults with ADHD are treated. Sometimes the co-occurring conditions- bipolar disorder, major depression, anxiety disorders or substance use disorders are identified, but the ADHD is missed.

Natalie: Let's start with some treatment issues, then we'll get to more audience questions in a few minutes.

So, let's say I have been diagnosed with ADHD. How is it determined what treatment is best for me?

Dr. Adler: The treatment plan should be established in partnership with your physician. Since we know that ADHD is a neurobiological disorder, medications, be they stimulant or non-stimulant medications play primary roles. Cognitive behavioral therapy or coaching can also be quite helpful.

Natalie: The treatments for adult ADHD available today consist of medications (stimulants like Ritalin, Adderall, Concerta and non-stimulant ADHD drug, Strattera) along with therapy. For major depression, medications PLUS therapy is the gold standard of treatment. Is that true for treating adult ADHD?

Dr. Adler: Medications are used to treat the symptoms and cognitive behavioral therapy (CBT) is used to make change. This is an evolving area in terms of research, but data from Mass General Hospital seem to indicate that CBT is most helpful as an adjunct to Rx.

Natalie: A lot of people don't want to take medication. How does a doctor determine that a person needs medication for ADHD?

Dr. Adler: It is a personal decision to take medication. As ADHD is a lifetime disorder it is often difficult to treat without medication. Some individuals will decide to pursue this course of action and medication could be introduced at a later time if desired.

Natalie: What is the best one can hope for from their ADHD medication? And what would be a reasonable expectation?

Dr. Adler: About 70% of children and adults will respond to the first medication they take and only about 15% of individuals are non-responsive to medications. The medications are not cures, but they do provide significant symptom relief. It is important to set reasonable expectations about what medication can and cannot provide. Also, for non-stimulant medication, it is important to wait for the medication effect.

Natalie: And so "reasonable expectations" for the performance of the medication would be what?

Dr. Adler: Improvement in clinical trials means at least a 30% reduction in ADHD symptoms. However, one might expect a more significant reduction in their own treatment. It is not only the improvement of symptoms, but the reduction of impairment that is important.

Natalie: I know that for antidepressants and antipsychotics, patients typically have to try several, and maybe even try a combination of medications, before they get desirable results. Does the same hold true for ADHD medications?

Dr. Adler: It is always important to start with one ADHD medication. Sometimes a combination of ADHD medications, be it long and short-acting stimulants or stimulants and non-stimulants are used. You should start with one medication though and try to optimize the dose to maximize response.

Natalie: And are there some adults with ADHD who are treatment-resistant; meaning currently existing medications just won't work for them?

Dr. Adler: Only a small percentage of ADHD adults are medication non-responsive, about 15%. There are good treatments available and my message is to keep trying. Sometimes it requires a combination of medications or adjusting the dose and time of administration.

Natalie: Let's get to some audience questions, Dr. Adler. Here's the first one:

missyred: I would imagine hobbies and crafts that are detailed in the making would be hard for anyone with ADHD, what other activities could be helpful?

Dr. Adler: It is important to have structure to your day. Regular exercise can be helpful. Things that tend to help deal with anxiety can also help, like yoga if you can do it.

missyred: At what age in adulthood would this become noticeable, or does it just follow from childhood into adulthood with frustrations and inabilities to complete tasks and projects.

Dr. Adler: The age of presentation in adulthood varies. In our program, the average age of people presenting for evaluations is in the mid-30s. One key point is that some significant symptoms have been present from childhood. A variety of things can bring an individual in for an evaluation. One of the most common is that since ADHD tends to run in families, that a parent has had a child recently diagnosed with ADHD.

Natalie: Here are a few audience comments. Then we'll get to the next question.

danielle7263: I've had ADHD since I was very young.

Phylo3839: Adults? I was diagnosed as a senior!

annieandall: You mentioned coaching as treatment, what is that?

Dr. Adler: ADHD coaching is a form of behavioral therapy which involves a life coach, who helps provide advice regarding organization and planning. There is a professional coaches association or the support group CHADD can help provide information about local coaches.

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beki: I had a child that was diagnosed with ADHD and he seems to have outgrown it. Is it possible that they outgrow it?

Dr. Adler: Yes, it is possible to have the symptoms remit, but this happens in about only 1/3 children.

LoveJoLu: What about the patch for adults?

Dr. Adler: A methylphenidate (which is the chemical name for Ritalin) patch recently became available. It is marketed as Daytrana. It can provide treatment throughout the day and it is important to take the patch off several hours before bedtime.

Natalie: I know the ADHD patch is used for kids. Does it work for ADHD adults too?

Dr. Adler: The patch is marketed for children with ADHD. There is not currently any data in adults so the use in adults would be off-label.

Natalie: Meaning some doctors are prescribing it for adults. The patch is just not FDA approved for adults at this time.

I realize you're a medical doctor and medical doctors typically turn to recognized therapies like prescription medication, but what are your thoughts about "alternative remedies" for ADHD like herbs or nutritional supplements?

Dr. Adler: Alternative therapies have been investigated for ADHD and I do review some of them in Scattered Minds. When pursuing nutritional supplements, it is important to realize that these treatments have not undergone research with scientific rigor as the medications have. If you are planning to take supplements to treat your ADHD, please review this with your physician.

Natalie: Does changing your diet in some way help relieve ADHD symptoms?

Dr. Adler: A balanced healthy diet is important, but restrictive diets have not been shown to help ADHD symptoms. Also, the concept of sugar intake making ADHD worse has also been debunked.

Natalie: Here's another audience question:

Notavailable(akaGG): I have adult ADHD but the hypo disorder, I can't seem to find information on that type. Can you tell me anything about that?

Dr. Adler: Do you mean that you have the primarily hyperactive-impulsive type, without inattentive symptoms?

Notavailable(akaGG): Yes.

Dr. Adler: This type of ADHD in adults is actually not all that common- probably only about 5% of adults have this type. The good news is that the type of symptoms (inattentive or hyperactive-impulsive) has generally not been shown to influence medication response.

Natalie: When it comes to treating adult ADHD, it sounds like you have to be in it for the long-haul. As director of the Adult ADHD Program at New York University Medical Center and a physician who specializes in adult ADHD who has seen probably hundreds of patients, how difficult is it for a patient to stick with treatment over the long-term?

Dr. Adler: Well, that is a question that I am commonly asked. Treatment should be initiated for a period of time sufficient to be certain that significant symptom reduction occurs. Most people take medications over the long term as ADHD is often lifelong. Sticking with a treatment plan is critical. It is easier to take medications once or twice a day and the good news is that the newer longer-acting stimulants and non-stimulants fit that bill.

LoveJoLu: So adults will have to take meds the rest of their lives for ADHD symptoms?

Dr. Adler: Not necessarily, the rest of your life is a very long time. The decision as to how long, should be carefully discussed with your physician, but some individuals do take medications long term.

Natalie: If a patient quits treatment for ADHD, what have you found to be the usual reasons?

Dr. Adler: ADHD patients stop treatment for a variety of reasons, it could be wanting to take a break from the medication and inadvertently stopping it or it could just be a planning problem and they forget their appt or to get their prescription renewed.

Natalie: And do you have any helpful insights into "how to hang in there" through the treatment process for the long-term?

Dr. Adler: ADHD is a disorder that can and should get better. Establish a treatment plan with your doctor that works for you.

Natalie: Our time is up tonight. Thank you, Dr. Adler, for being our guest, for sharing all this great ADHD information and for answering audience questions. His book is Scattered Minds: Hope and Help for Adults with Attention Deficit Hyperactivity Disorder. We appreciate you being here.

Dr. Adler: You are most welcome. Good luck to you all.

Natalie: Thank you, everybody, for coming. I hope you found the chat interesting and helpful.

Good night everyone.

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Disclaimer: We are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.

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Julie Fast, author of: "Take Charge of Bipolar Disorder: A 4-Step Plan for You and Your Loved Ones to Manage the Illness and Create Lasting Stability" is our guest. She is joining us from her home in Oregon.

Natalie is the HealthyPlace.com moderator

The people in blue are audience members.

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Natalie: Good evening, everyone. I want to welcome everyone to the HealthyPlace.com website. Our guest is Julie Fast, author of: "Take Charge of Bipolar Disorder: A 4-Step Plan for You and Your Loved Ones to Manage the Illness and Create Lasting Stability"

Ms. Fast has written several books on bipolar disorder, including "Loving Someone with Bipolar Disorder" and she's a writer for Bipolar Magazine. She also developed the "Health Cards Treatment System" to treat her own Bipolar Disorder. 

Good evening, Julie and welcome to our site. Thank you for coming.

Julie Fast: Thank you. I am happy to be here.

Natalie: One thing that really caught my eye: you had experienced the symptoms of bipolar disorder for 15 years, starting at age 16, before being diagnosed. You had the classic signs wild mood swings from mania to depression, psychotic episodes. You even lived with and married a man whose bipolar symptoms were so bad at one point that he had to be hospitalized. Yet, you never recognized your symptoms as being indicative of bipolar disorder. And even if you didn't know the term "bipolar disorder," it's amazing to me that you didn't view yourself as being "ill" in some way. How is that?

Julie Fast: I have bipolar II which is one of the reasons it took me so long to get diagnosed. Bipolar I is depression with full-blown mania. Bipolar II is depression with hypomania - a milder form of mania. Bipolar I is very easy to diagnose as a person who is really manic is easy to see. Bipolar II can be very difficult to diagnose- especially before all of the attention paid to bipolar disorder in the media these days - simply because people with mild mania never go to the doctor- they feel too good. I never even knew that the summers I used to have where I went absolutely wild were a mood swing. I just thought they were the real, non-depressed me.

It's hard to believe that just 10-20 years ago, the ignorance surrounding bipolar disorder was enormous. When my partner went through his terrible manic/psychotic episode in 1994, I had never heard of bipolar disorder - so I had nothing to compare. All I knew is that I was much more depressed than he was and that I had never experienced full-blown mania. This explains why I never connected the illness with myself even though I am a 100% classic bipolar II diagnosis.

After he got out of the hospital, I could no longer explain away my terrible mood swings, nor could I run away from them anymore and I was diagnosed in just 20 minutes- after 15 years of being sick all of the time. It is depressing to think of what my life would have been like if things were as they are today.

Natalie: As I mentioned at the top, Julie Fast has written several books on bipolar disorder. Tonight we're discussing her new book, due out next week, "Take Charge of Bipolar Disorder: A 4-Step Plan for You and Your Loved Ones to Manage the Illness and Create Lasting Stability" Julie, what is the theme of this book?

Julie Fast: The main theme is that it takes a comprehensive plan to manage this illness. Medications are very important, but they are not enough. I thought that medications would be the answer to all of my problems- so I didn't have anything in place in case they didn't work.

Natalie: Managing the illness and creating lasting stability. For many people living with bipolar disorder, that sounds like a dream come true. How easy is that to accomplish?

Julie Fast: I want to be very honest here. There is no quick fix with bipolar disorder. I personally have to manage the illness all day, every day. By doing this I have created my own stability. It is better than anything I have experienced before. It's not easy in terms of the time and effort it takes, but it is a LOT easier than being so sick you can't work or you have to go to the hospital. For the five years after my bipolar diagnosis, I was really too sick to function. This is when I created my own management plan and that is what has made the difference. From the tens of thousands of people I have talked to regarding bipolar disorder, I know that many people struggle if they don't manage the illness daily. I liken it to diabetes. You don't eat well one day and then go have a cake the next without repercussions.

Lasting stability means diligent, daily management with a plan that works. It's unfair we have to work so hard at this, but we do. I often say that I would give anything to be normal, but I am not normal and I have to accept that and do what I can.

Natalie: And is it within most people's grasp or is it something you must dedicate years to before you see some real results?

Julie Fast: We all have different degrees of this illness - but I can guarantee that there are tips in this book that can show results in a few days. I know because that is how it was for me. For example, there is a chapter called "Bipolar Conversation". With the one skill learned in this chapter, people with the illness and the people around them can learn what to say and what not to say when a person is in a mood swing. This can change a relationship almost overnight.

There are many things that take years, such as my being able to work again. I am very limited in my work options in that I can't handle a 9-5 office setting, but at least I can do work from my home or on a part-time basis. I wasn't able to do this at all until I used the four steps in this book. Writing these books is very hard for me. I am sick in some way the entire time, but I use my skills and I keep going. This is one of the main ideas I want to get across in Take Charge. Few of us have a recovery where the illness is completely gone. Because of this, we have to find something that works for us or the illness will take over.

Natalie: What are the 4 steps to taking charge of bipolar disorder?

Julie Fast: 1. The first step is medications for bipolar. What many people might be surprised to know is that only about 20% of people respond quickly and effectively to bipolar medications. The rest of us have to try a variety of medication combinations in order to eventually find something that works. Unfortunately, this can take years and the side-effects are often terrible.

2. The next step is lifestyle changes. The good thing about these changes is that they are often free. The bad thing is that they are not simple to start. For example, drug and alcohol abuse are the number one reason for poor treatment outcome. And yet, simply stopping the behavior is difficult for many people. Caffeine is another trouble maker, especially for people with anxiety. Stopping caffeine can make a big difference and many people do this successfully.

3. The third step is behavioral changes. This step had a huge impact on my life as it is, where I finally realized that my odd, confusing and often very scary behavior is totally normal for bipolar disorder.

4. Finally, the fourth step is asking for help. This section is not simply going to a doctor or therapist, which are naturally helpful and important. Step four teaches people how to ask for help from the right person and then helps family members and friends.

Natalie: The step that deals with medications and supplements -- in your online autobiography, you state that you stopped taking medications because you were unhappy with the side-effects. And you promised your doctor at the time that if your condition got really bad you would restart them. Knowing that each person is different, I want to know specifically for YOU, was that a good thing?

Julie Fast: I really had no choice. I was given 23 medications within my first four years of treatment of bipolar disorder with little result. I also gained over 50 pounds and was physically miserable. This was simply not acceptable and I would not let doctors do this again. I believe that effective medication treatment should be done very carefully and individually. Simply throwing a medication at someone to see if it fits, is a disservice to those of us with the illness and for many people, especially those with rapid-cycling, because it makes the illness much worse.

Having said this, I very much believe in medications. I have gone on antidepressants out of necessity. Considering that antidepressants should not be used alone in the treatment of bipolar disorder unless under strict observation by a doctor or in conjunction with a mood stabilizer, I had immediate rapid-cycling between depression and mania almost daily towards the end. I was SO sad to stop the meds as they worked. Last year, due to some personal and work triggers, I once again was too ill to manage on my own and I started Lamictal. It has worked well for me and helps about 25% of the time. Sometimes I have real breakthrough and I know what it is like to have a quiet brain, but it is rare.

I think meds are lifesaving for most people, but there needs to be a lot more help for those of us who don't get much relief from medications. That is why I wrote Take Charge of Bipolar Disorder.

Natalie: Lifestyle changes, behavioral changes, asking for assistance from others all seem helpful. But I want to know how difficult is it to effectively manage the illness and create lasting stability without taking antipsychotic medications and mood stabilizers for bipolar disorder?

Julie Fast: It is VERY difficult! I try new antipsychotics all of the time. When Abilify came on the market I was so excited and yet I still had trouble. I now take it in emergencies. Mood stabilizers are essential but not all of us respond well to them. I say- try everything you can until you find something that works- but just do it slowly and with a good doctor

Natalie: The last step: "Asking for help from family members, friends, your doctors." A lot of people have trouble doing that. Why is that? And what suggestions do you have for dealing with that issue?

Julie Fast: First of all, it is very rare for someone to say, "I need help." That is so straightforward and if we were all like that a major part of the problem would be solved. The reality is that the person without the illness will often only get clues that a person needs help. So you will have to know the clues. It is hard to ask for help in the middle of a mood swing. I teach people to have something in place before they get sick so that others know what to do without the person with bipolar disorder having to talk so much about what they need. It's all about talking when you are well so you can get help when you are sick.

When I am sick now, my family and friends know that I will be either depressed, psychotic or anxious and they know what to do. It took years for this to finally work- but it works!

Natalie: The second part of that is: if you are a family member or loved one and someone comes to you and says "I need help" - one of the biggest problems or frustrations is that most of us don't know what that means and what to do. What suggestions do you have in that regard?

Julie Fast: How could you know what do to unless someone teaches you? I really don't know one person who innately knows how to help someone in a mood swing. They have to be taught. A book like Take Charge definitely teaches you many of the skills you need, but the real teacher is the person with the illness. Ask them what they need and what helps during specific mood swings. Each person is different, for example, when I am psychotic, I can't stand to be touched, but when I'm depressed I need touch. There is no way a family member or friend can just know this by osmosis. We have to talk about it. There seems to be this big separation between those of us with the illness and those who want to help.

"Here is what I say and do when I am depressed and here is how you can help". You can do this with every mood swing. It takes time to get people to work together, but they can.

Natalie: One last thing I'd like to address and then we'll get to some audience questions: You have written several excellent books on bipolar disorder. You write regularly for Bipolar Magazine. So I know you've met and interviewed a lot of people living with bipolar disorder. What common characteristics or traits do those people who are successful at managing the symptoms of bipolar disorder have versus those who aren't so good at it?

Julie Fast: Here is something interesting. Over the past four years, I have received and read over 30,000 emails from people who have bipolar disorder or who love someone who does. And out of all of those letters, and I am not kidding, not one of them said something new about this illness. We all get sick in the same way. I have had letters from Saudi Arabia, Thailand, Australia, Finland, etc. and they all have the same questions and stories. This shows me that this is not an individual illness with an individual cure.

This means that a set management plan that is specific in what needs to be done, will work for everyone. Oh, I would say that the people with a management plan that they use every single day, are the ones who are successful- they take the meds they can take and always keep trying to find new ones that work more successfully, they watch their sleep, they accept that partying or working at a stressful job will probably make them ill, they surround themselves with supportive people and teach those people how to help them, they keep going no matter how sick they are or how much they want to die and they know the first signs of mania so they can get help before it goes too far. And most of all, they know and believe that this is a serious and often life-threatening illness - they have done nothing wrong- the behaviors can be embarrassing and scary at times, but the person with bipolar disorder is not flawed in any way.

I would say that the people in this chat room are those who are doing what they can to get better. This illness can take everything from you. You have to be ready to fight it in any way you can. People who manage it successfully keep going even when they feel too sick to function.

Natalie: Julie, here's our first audience question:

alice101: I have a question: Julie, you said that you went through several doctors before you found a good psychiatrist. how does one go about finding a good doctor?

Julie Fast: I had three docs before I found the right one. One of the problems, of course, is insurance but here are some suggestions: You have the right to interview your doctor just as you would any employee. We forget they work for us: we pay them!

My doctor is amazing, and has been good to me (he is the coauthor of my books) but you have to be selective. You will know when you have the right one because he or she will look in your eyes and really ask how you are and then in a really short period of time, make you feel that things are going to get better. So shop around!

rleet: How do I remove my own frustration and focus on helping? I am a caregiver.

Julie Fast: Well, that is certainly the most important question. First of all, anyone who has to help a person with bipolar disorder is going to get very frustrated. You never know who you are going to talk to! Will they be depressed today? Or yell at me?

Here are some tips: Remember it is an illness, and the better it is managed, the less frustration you will have at their behavior so management is the first step. Second, set limits! You have the right to your own life. Let the person with the illness know you care, but that you need them to help themselves while you help them this is such a huge topic- Take Charge of Bipolar Disorder covers the question in more detail.

Rainycloud: What do you do when you live with someone who denies your illness?

Julie Fast: I have a friend who just had a major manic episode. Her father simply refuses to believe that what she did, had anything to do with an illness. He doesn't understand Bipolar.

You have a few choices: Ask them to read my first book Loving Someone with Bipolar Disorder. At least they could see that the illness is real! Next, do what you can to get better and find someone who does believe you and wants to help. Sometimes the answers to these difficult questions can seem harsh.

Also, you can gently ask for help from this person, but you can't change them. It's tough.

Robin: How do you feel about the Bipolar diagnosis for young children, around 11? Do you think if you had been diagnosed earlier, your life with bipolar would've been different?

Julie Fast: That is a good question. I actually believe that bipolar disorder in children is quite different than the adult diagnosis. Children have more behavioral problems as well as acting out problems. I did not have the signs of bipolar at age 11, so I think that bipolar is being used as a bit of a grab bag for kids and needs to be watched carefully. I definitely would have benefited if I had been diagnosed at 16 when mine started

Natalie: Here's an audience comment, then we'll go to the next question:

merril: Juvenile Bipolar is often like oppositional defiant disorder... with a bit of ADD. The most challenging part is to find medications for someone whose biochemistry is changing by the month or more often!

Julie Fast: I totally agree- in fact- I have read that the ODD, OCD, Anxiety and Bipolar symptoms are now all lumped into a Bipolar diagnosis.

Candra: Hi Julie! I have ultra-rapid cycling bipolar II, and I was wondering: when do you personally know you are having a psychotic episode? What symptoms do you exhibit, and what can you do to prevent it from going any further?

Julie Fast: Psychotic symptoms include intrusive thoughts: I want to die, I wish I could be hit by a car, I suck, I am a failure; hallucinations, seeing yourself get killed, seeing animals scurry around chairs, hearing things or smelling things that are not there; suicidal thoughts - active and passive; paranoid thoughts such as - someone is following me- or people are talking about me at work; and finally delusions where you think something such as a billboard has special meaning for you. It's very uncomfortable and I have lived with these symptoms all of my adult life.

clance13: My daughter is having problems with keeping a relationship, going and finding a guy. What should I tell her?

Julie Fast: Ah... the problem most of us have. Keeping a relationship is difficult for anyone but when you have Bipolar, there is so much more stress added.

I suggest that she works on the illness first- get my books- or any book she can find and work on reducing symptoms so that she is less of a burden to a person. We are clingy and needy or so manic we are irritated and hard to be around. Then I would suggest working on communication skills- such as being a good partner by taking care of yourself first.

I have done all of this myself and it has worked- though romantic relationships are hard.

tuttifrutti: My daughter often begs me to kill her and I just don't know what to do. I have been asking for help for years and unfortunately I have been seen as a crazy mum.

Julie Fast: She begs you to kill her because bipolar disorder is making her say and feel these things. It is beyond scary to hear someone you love talk this way, but I am not shocked. I have often wished someone would kill me. Wanting to die is really wanting to end pain.

You can talk to her this way: "you have an illness that makes you suicidal. It is painful and horrible. Many people have this illness and they hurt like you do. Let's work together on getting help for the illness and focus on that first. What can I do right now is to help you focus on what is causing this instead of what you are feeling."

I am often suicidal as I am often stressed and my family now knows to say this to me. And finally, she needs to talk to her doctor about medications, especially an antipsychotic medication.

These are all such important questions and I know it is frustrating to get such short answers! I do cover all of this in the books in more detail

stredoa: I am 21, bi-polar, engaged and am getting married next year. I am often clingy with my fiance and sometimes he says I am too clingy. How can I work on this without feeling hurt, because I want to hug him or be near him when I know I need to give him space?

Julie Fast: Take care of yourself first. I have a chart in my book called the Chain of Neediness. It goes like this: When I am sick I can ask for help in this order: professional, therapist, support group, friend who understands bipolar disorder, partner, family, others.

If you put your partner first in your health care, you will scare him into thinking you need him too much. Remember, the illness may make you this way and the better you manage the illness, the less needy you will be. When you need that hug, consciously ask what is going on and what you really need.

carolm: It is possible to completely recover from bipolar disorder? My daughter had classic symptoms for several years, then began getting better. She is totally off all medications and has been for many months and doing great. Should we expect it to come back?

Julie Fast: This is definitely possible, but very, very rare. I assume she has bipolar I? people with bipolar one can have long periods of stability between mood swings, or only have one severe episode and never have one again

carolm: They never classified her as I or II.

Julie Fast: Wow, that is just amazing, isn't it? I assume it is I, as II is much more chronic in terms of depression. So, yes, this is possible and wonderful! Just watch very carefully for triggers such as getting laid off from work, having a baby, etc. It can come back.

doug: How do I talk to my kids about my bipolar?

Julie Fast: It depends on the age. I have a four-year-old nephew and he knows all about it. I say "I am sick today" and he knows I am depressed and that I cannot love him as much that day. I may just have to sit with him.

Older kids can definitely help and be part of the treatment plan. Believe me, they know what is going on, so they should be involved.

Maturity matters as does fear. Are they scared? That is one thing you will need to address- it may be more important to make them feel safe than to involve them in a treatment plan. My policy is to be honest with everyone, including the children in my family- it is just a matter of degrees.

Natalie: How do you deal with someone who is diagnosed Bipolar but doesn't want to believe it? I'm sure in the beginning, it's difficult. But we get lots of letters from parents, spouses, etc. with this question.

Julie Fast: Over 50% of people diagnosed with Bipolar disorder refuse to believe they have the illness. Those are pretty discouraging numbers! The main problem is that one of the symptoms of Bipolar is to think you don't have bipolar. This is common in schizophrenia as well. I suggest that you work on yourself, set limits, learn how to talk to them when they are in a mood swing, remind yourself it is an illness and they really are not doing this to you personally, they are sick. Sometimes, if you change and learn to respond to them instead of reacting you may get some results. I wish I had a more definitive answer for this one.

Natalie: Here's an audience comment:

binoman: I can answer that Natalie. I've had this problem over and over again. You keep on talking until they get it. It's a difficult situation, but you eventually get used to knowing that you are not going to be well received with anything you say.

Julie Fast: I agree with the comment- you can keep trying, but when doing that you can keep changing yourself and learn more about the illness in order to help yourself.

Natalie: Our time is up tonight. We have been talking to Julie Fast, the author of "Take Charge of Bipolar Disorder: A 4-Step Plan for You and Your Loved Ones to Manage the Illness and Create Lasting Stability" and "Loving Someone with Bipolar Disorder: Understanding and Helping Your ". You can purchase them by clicking on the links.

Thank you, Julie, for being our guest. You were an interesting guest with very helpful information and we appreciate you being here.

Julie Fast: Good night everyone.

Natalie: I encourage everyone to sign up for our mailing list. It's free and we'll notify you of other events happening on the HealthyPlace.com website. I also invite you to sign up for the first and only social network for people with mental health conditions as well as their family members and friends.

Thank you, everybody, for coming. I hope you found the chat interesting and helpful.

Good night everyone.

Disclaimer: That we are not recommending or endorsing any of the suggestions of our guest. In fact, we strongly encourage you to talk over any therapies, remedies or suggestions with your doctor BEFORE you implement them or make any changes in your treatment.

A Mexican man who at 1,200 lbs. is possibly the heaviest person in the world hopes to travel to Italy for a life-saving operation to shed weight.

Manuel Uribe, sitting on his bed at home in Monterrey, Mexico, is possibly the heaviest person in the world.

Manuel Uribe, bedridden for the past five years, cannot stand on his own and will need a special flight to take him from Monterrey, Mexico to Modena, where a surgical team has offered to perform an intestinal bypass free of charge.

"I can't walk. I'm can't leave my bed," the 40-year-old Uribe, who weighs the same as five baby elephants, said in a recent telephone interview.

"I'm trying to reduce my weight a bit right now so I can be in the right condition for the operation."

Uribe made an impassioned plea for help earlier this year on Mexican television, saying he weighed a more normal 290 lbs. until aged 22 and did not know what happened to him.

The broadcast drew the attention of doctor Giancarlo De Bernardinis, who visited Mexico with a medical team to examine Uribe in March.

Bernardinis, whose biggest patient to date weighed 770 lbs., told Reuters he plans a gall bladder, intestinal bypass procedure that will allow Uribe to pass food more quickly without so many calories being absorbed.

Bernardinis planned to perform the surgery in Modena as early as this month, although a Mexican health official doubted Uribe would be ready for a trip to Europe that quickly.

Medical mystery Uribe's case puzzles doctors since his cholesterol and blood-sugar levels are normal, despite his extreme obesity.

"His heart works very well. He has some respiratory difficulty because of his obesity, but in strict terms, he's well," said Marco Anibal Rodriguez Vargas, the director of hospitals in the Mexican state of Nuevo Leon.

Rodriguez Vargas said Mexican hospitals still hoped to treat Uribe themselves, but added Uribe would ultimately decide what to do.

Uribe said it was just a matter of time before he went to Italy: "Are we going? Yes. We're going. But the doctors will decide when."

The operation would last four to five hours and would likely require Uribe to spend one month in Italy.

"He will always be heavier than normal but certainly not like he is now ... We would be satisfied even if he weighed 330 lbs. after two years," Bernardinis said.

No one has managed to find suitable scales for Uribe in years and estimates of his weight are made partly by tape-measure. Guinness World Records 2006 only said it was aware of living people weighing over 1,120 lbs.

The record for the heaviest man ever is held by Jon Brower Minnoch, who died in Seattle in 1983 after reaching a record 1,400 lbs. He was in his early 40s.

Uribe hopes to avoid that fate. His wife, horrified by his increasing size, feared the worst and abandoned him more than a decade ago.

"She left me because she must have thought I was dying," Uribe said.

"Thank God, I'm still alive and hopefully will be able to take care of this problem."

Source: Reuter

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Brand name: Tolinase
Generic name: Tolazamide

Tolinase, tolazamide full prescribing information

What is is Tolinase and what is it prescribed for?

Tolinase is an oral antidiabetic drug available in tablet form. It lowers the blood sugar level by stimulating the pancreas to release insulin. Tolinase may be given as a supplement to diet therapy to help control type 2 (non-insulin-dependent) diabetes.

There are two type of diabetes: type 1 (insulin-dependent) and type 2 (non-insulin-dependent). Type 1 diabetes usually requires insulin injection for life; type 2 can usually be controlled by dietary changes, exercise, and oral diabetes medications. Occasionally—during stressful periods or times of illness, or if oral medications fail to work—a type 2 diabetic may need insulin injections.

Most important fact about Tolinase

Always remember that Tolinase is an aid to, not a substitute for, good diet and exercise. Failure to follow a sound diet and exercise plan can lead to serious complications, such as dangerously low blood sugar levels. Remember, too, that Tolinase is not an oral form of insulin, and cannot be used in place of insulin.

How should you take Tolinase?

Remember that if you are diligent about diet and exercise, you may need Tolinase for only a short period of time. Take it exactly as prescribed.

While you are taking Tolinase, your blood and urine glucose levels should be monitored regularly. Your doctor may also want you to have a periodic glycosylated hemoglobin blood test, which will show how well you have kept your blood sugar down during the weeks preceding the test.

• If you miss a dose...

Take it as soon as you remember. If it is almost time for the next dose, skip the one you missed and go back to your regular schedule. Do not take 2 doses at the same time.

• Storage instructions...

Store at room temperature.

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What side effects may occur with Tolinase?

Side effects cannot be anticipated. If any appear or change in intensity, inform your doctor as soon as possible. Only your doctor can determine if it is safe for you to continue taking Tolinase. The most frequently encountered side effects from Tolinase—nausea, a full, bloated feeling, and heartburn—may disappear if the dosage is reduced.

Hives, itching, and rash may appear initially and then disappear as you continue to take the drug. If a skin reaction persists, you should stop taking Tolinase.

Why should Tolinase not be prescribed?

Do not take Tolinase if you are sensitive to it or have ever had an allergic reaction to it; if you are suffering from diabetic ketoacidosis (a chemical imbalance leading to nausea, vomiting, confusion, and coma); or if you have type 1 (insulin-dependent) diabetes and are not taking insulin.

Special warnings about Tolinase

It's possible that drugs such as Tolinase may lead to more heart problems than diet treatment alone, or diet plus insulin. If you have a heart condition, you may want to discuss this with your doctor.

Like other oral antidiabetic drugs, Tolinase may produce severe low blood sugar (hypoglycemia) if the dosing is wrong. While taking Tolinase, you are particularly susceptible to episodes of low blood sugar if:

• You suffer from a kidney or liver problem;
• You have a lack of adrenal or pituitary hormones; or
• You are older, run-down, or malnourished.
• You are at increased risk for a low blood sugar episode if you are hungry, exercising heavily, drinking alcohol, or using more than one glucose-lowering drug.

Note that an episode of low blood sugar may be difficult to recognize if you are an older person or if you are taking a beta-blocker drug (Inderal, Lopressor, Tenormin, and others).

If switching to Tolinase from chlorpropamide (Diabinese), you should take special care to avoid an episode of low blood sugar.

Stress such as fever, trauma, infection, or surgery may increase blood sugar to the point that you require insulin injections.

Possible food and drug interactions when taking Tolinase

If Tolinase is taken with certain other drugs, the effects of either could be increased, decreased, or altered. It is especially important to check with your doctor before combining Tolinase with the following:

• Airway-opening drugs such as Sudafed and Ventolin
• Alcohol
• Aspirin or related drugs
• Beta-blocking blood pressure medications such as Inderal and Lopressor
• Blood-thinning drugs such as Coumadin
• Calcium channel blockers such as Calan and Isoptin
• Chloramphenicol (Chloromycetin)
• Corticosteroids such as Cortef, Decadron, and Medrol
• Diuretics such as Esidrix and Diuril
• Estrogens such as Premarin and Estraderm
• Isoniazid (Nydrazid)
• MAO inhibitors (antidepressants such as Nardil and Parnate)
• Miconazole (Monistat)
• Nicotinic acid
• Nonsteroidal anti-inflammatory drugs such as Motrin and Naprosyn
• Oral contraceptives
• Phenothiazines (antipsychotic drugs such as Mellaril)
• Phenytoin (Dilantin)
• Probenecid
• Rifampin (Rifadin)
• Sulfa drugs such as Bactrim and Gantrisin
• Thyroid drugs such as Synthroid

Special information if you are pregnant or breastfeeding

If you are pregnant or plan to become pregnant, inform your doctor immediately. Tolinase is not recommended for use during pregnancy, and should not be prescribed if you might become pregnant while taking it.

Control of diabetes during pregnancy is very important, but in most cases it should be accomplished with insulin injections rather than oral antidiabetic drugs.

Tolinase should not be used during breastfeeding because of possible harmful effects on the baby. If you are a new mother, you may need to choose between taking Tolinase and breastfeeding your baby.

Recommended dosage for Tolinase

Your doctor will determine the dosage level based on your needs.

Adults

The usual starting dose of Tolinase tablets for the mild to moderately severe type 2 diabetic is 100 to 150 milligrams daily taken with breakfast or the first main meal.

Older Adults

If you are malnourished, underweight, an older person, or not eating properly, the initial dose is usually 100 milligrams once a day. Failure to follow an appropriate dosage regimen may precipitate hypoglycemia (low blood sugar). If you do not stick to your prescribed dietary regimen, you are more likely to have an unsatisfactory response to Tolinase.

Overdosage

An overdose of Tolinase can cause an episode of low blood sugar. Mild low blood sugar without loss of consciousness should be treated with oral glucose, an adjusted meal pattern, and possibly a reduction in the Tolinase dosage. Severe low blood sugar, which may cause coma or seizures, is a medical emergency and must be treated in a hospital. If you suspect an overdose of Tolinase, seek medical attention immediately.

last updated: 04/2006

Tolinase, tolazamide full prescribing information

Detailed Info on Signs, Symptoms, Causes, Treatments of Diabetes

back to: Browse all Medications for Diabetes

Brand name: Tolinase
Generic Name: Tolazamide

Contents:

Description
Clinical Pharmacology
Indications and Usage
Contraindications
Special Warning
Precautions
Adverse Reactions
Overdosage
Dosage and Administration
How is Supplied

Tolazamide patient information (in plain English)

Description

Tolinase Tablets contain tolazamide, an oral blood glucose lowering drug of the sulfonylurea class. Tolazamide is a white or creamy-white powder with a melting point of 165° to 173° C. The solubility of tolazamide at pH 6.0 (mean urinary pH) is 27.8 mg per 100 mL.

The chemical names for tolazamide are (1) Benzenesulfonamide, N-[[(hexahydro-1H-azepin-1-yl) amino] carbonyl]-4-methyl-; (2) 1-(Hexahydro-1H-azepin-1-yl)-3-(p-tolylsulfonyl)urea and its molecular weight is 311.40. The structural formula is represented below:

Tolinase Tablets for oral administration are available as scored, white tablets containing 100 mg, 250 mg or 500 mg tolazamide. Inactive ingredients: calcium sulfate, docusate sodium, magnesium stearate, methylcellulose, sodium alginate.

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Clinical Pharmacology

Actions

Tolazamide appears to lower the blood glucose acutely by stimulating the release of insulin from the pancreas, an effect dependent upon functioning beta cells in the pancreatic islets. The mechanism by which tolazamide lowers blood glucose during long-term administration has not been clearly established. With chronic administration in Type II diabetic patients, the blood glucose lowering effect persists despite a gradual decline in the insulin secretory response to the drug. Extrapancreatic effects may be involved in the mechanism of action of oral sulfonylurea hypoglycemic drugs.

Some patients who are initially responsive to oral hypoglycemic drugs, including Tolinase Tablets, may become unresponsive or poorly responsive over time. Alternatively, Tolinase Tablets may be effective in some patients who have become unresponsive to one or more other sulfonylurea drugs.

In addition to its blood glucose lowering actions, tolazamide produces a mild diuresis by enhancement of renal free water clearance.

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Pharmacokinetics

Tolazamide is rapidly and well absorbed from the gastrointestinal tract. Peak serum concentrations occur at three to four hours following a single oral dose of the drug. The average biological half-life of the drug is seven hours. The drug does not continue to accumulate in the blood after the first four to six doses are administered. A steady or equilibrium state is reached during which the peak and nadir values do not change from day to day after the fourth to sixth doses.

Tolazamide is metabolized to five major metabolites ranging in hypoglycemic activity from 0-70%. They are excreted principally in the urine. Following a single oral dose of tritiated tolazamide, 85% of the dose was excreted in the urine and 7% in the feces over a five-day period. Most of the urinary excretion of the drug occurred within the first 24 hours post administration.

When normal fasting nondiabetic subjects are given a single 500 mg dose of tolazamide orally, a hypoglycemic effect can be noted within 20 minutes after ingestion with a peak hypoglycemic effect occurring in two to four hours. Following a single oral dose of 500 mg tolazamide, a statistically significant hypoglycemic effect was demonstrated in fasted nondiabetic subjects 20 hours after administration. With fasting diabetic patients, the peak hypoglycemic effect occurs at four to six hours. The duration of maximal hypoglycemic effect in fed diabetic patients is about ten hours, with the onset occurring at four to six hours and with the blood glucose levels beginning to rise at 14 to 16 hours. Single dose potency of tolazamide in normal subjects has been shown to be 6.7 times that of tolbutamide on a milligram basis. Clinical experience in diabetic patients has demonstrated tolazamide to be approximately five times more potent than tolbutamide on a milligram basis, and approximately equivalent in milligram potency to chlorpropamide.

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Indications and Usage

Tolinase Tablets are indicated as an adjunct to diet to lower the blood glucose in patients with noninsulin dependent diabetes mellitus (Type II) whose hyperglycemia cannot be satisfactorily controlled by diet alone.

In initiating treatment for noninsulin-dependent diabetes, diet should be emphasized as the primary form of treatment. Caloric restriction and weight loss are essential in the obese diabetic patient. Proper dietary management alone may be effective in controlling the blood glucose and symptoms of hyperglycemia. The importance of regular physical activity should also be stressed and cardiovascular risk factors should be identified and corrective measures taken where possible.

If this treatment program fails to reduce symptoms and/or blood glucose, the use of an oral sulfonylurea or insulin should be considered. Use of Tolinase must be viewed by both the physician and patient as a treatment in addition to diet and not as a substitute for diet or as a convenient mechanism for avoiding dietary restraint. Furthermore, loss of blood glucose control on diet alone may be transient thus requiring only short-term administration of Tolinase.

During maintenance programs, Tolinase should be discontinued if satisfactory lowering of blood glucose is no longer achieved. Judgments should be based on regular clinical and laboratory evaluations.

In considering the use of Tolinase in asymptomatic patients, it should be recognized that controlling the blood glucose in noninsulin-dependent diabetes has not been definitely established to be effective in preventing the long-term cardiovascular or neural complications of diabetes.

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Contraindications

Tolinase Tablets are contraindicated in patients with: 1) known hypersensitivity or allergy to Tolinase; 2) diabetic ketoacidosis, with or without coma. This condition should be treated with insulin; 3) Type I diabetes, as sole therapy.

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SPECIAL WARNING ON INCREASED RISK OF CARDIOVASCULAR MORTALITY

The administration of oral hypoglycemic drugs has been reported to be associated with increased cardiovascular mortality as compared to treatment with diet alone or diet plus insulin. This warning is based on the study conducted by the University Group Diabetes Program (UGDP), a long-term prospective clinical trial designed to evaluate the effectiveness of glucose-lowering drugs in preventing or delaying vascular complications in patients with noninsulin-dependent diabetes. The study involved 823 patients who were randomly assigned to one of four treatment groups (DIABETES, 19 (supp. 2):747-830, 1970.)

UGDP reported that patients treated for five to eight years with diet plus a fixed dose of tolbutamide (1.5 grams per day) had a rate of cardiovascular mortality approximately 2 ½ times that of patients with diet alone. A significant increase in total mortality was not observed, but the use of tolbutamide was discontinued based on the increase in cardiovascular mortality, thus limiting the opportunity for the study to show an increase in overall mortality. Despite controversy regarding the interpretation of these results, the findings of the UGDP study provide an adequate basis for this warning. The patient should be informed of the potential risks and advantages of Tolinase and of alternative modes of therapy.

Although only one drug in the sulfonylurea class (tolbutamide) was included in this study, it is prudent from a safety standpoint to consider that this warning may also apply to other oral hypoglycemic drugs in this class, in view of their close similarities in mode of action and chemical structure.

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Precautions

General

Hypoglycemia

All sulfonylurea drugs are capable of producing severe hypoglycemia. Proper patient selection and dosage and instructions are important to avoid hypoglycemic episodes. Renal or hepatic insufficiency may cause elevated blood levels of tolazamide and the latter may also diminish gluconeogenic capacity, both of which increase the risk of serious hypoglycemic reactions. Elderly, debilitated, or malnourished patients and those with adrenal or pituitary insufficiency are particularly susceptible to the hypoglycemic action of glucose lowering drugs. Hypoglycemia may be difficult to recognize in the elderly and in people who are taking beta-adrenergic blocking drugs. Hypoglycemia is more likely to occur when caloric intake is deficient, after severe or prolonged exercise, when alcohol is ingested, or when more than one glucose-lowering drug is used.

Loss of Control of Blood Glucose

When a patient stabilized on any diabetic regimen is exposed to stress such as fever, trauma, infection, or surgery, loss of control of blood glucose may occur. At such times it may be necessary to discontinue Tolinase Tablets and administer insulin.

The effectiveness of any hypoglycemic drug, including Tolinase, in lowering blood glucose to a desired level decreases in many patients over a period of time, which may be due to progression of the severity of the diabetes or to diminished responsiveness to the drug. This phenomenon is known as secondary failure to distinguish it from primary failure in which the drug is ineffective in an individual patient when first given. Adequate adjustment of dose and adherence to diet should be assessed before classifying a patient as a secondary failure.

Information for Patients

Patients should be informed of the potential risks and advantages of Tolinase and of alternative modes of therapy. They should also be informed about the importance of adherence to dietary instructions, of a regular exercise program, and of regular testing of urine and/or blood glucose.

The risks of hypoglycemia, its symptoms and treatment, and conditions that predispose to its development should be explained to patients and responsible family members. Primary and secondary failure should also be explained.

Laboratory Tests

Blood and urine glucose should be monitored periodically. Measurement of glycosylated hemoglobin may be useful in some patients.

Drug Interactions

The hypoglycemic action of sulfonylureas may be potentiated by certain drugs including nonsteroidal anti-inflammatory agents and other drugs that are highly protein bound, salicylates, sulfonamides, chloramphenicol, probenecid, coumarins, monoamine oxidase inhibitors, and beta-adrenergic blocking agents. When such drugs are administered to a patient receiving Tolinase, the patient should be closely observed for hypoglycemia. When such drugs are withdrawn from a patient receiving Tolinase, the patient should be observed closely for loss of control.

Certain drugs tend to produce hyperglycemia and may lead to loss of control. These drugs include the thiazides and other diuretics, corticosteroids, phenothiazines, thyroid products, estrogens, oral contraceptives, phenytoin, nicotinic acid, sympathomimetics, calcium channel blocking drugs, and isoniazid. When such drugs are administered to a patient receiving Tolinase, the patient should be closely observed for loss of control. When such drugs are withdrawn from a patient receiving Tolinase, the patient should be observed closely for hypoglycemia.

A potential interaction between oral miconazole and oral hypoglycemic agents leading to severe hypoglycemia has been reported. Whether this interaction also occurs with the intravenous, topical or vaginal preparations of miconazole is not known.

Carcinogenicity

In a bioassay for carcinogenicity, rats and mice of both sexes were treated with tolazamide for 103 weeks at low and high doses. No evidence of carcinogenicity was found.

Pregnancy

Teratogenic Effects

Pregnancy Category C

Tolinase, administered to pregnant rats at ten times the human dose, decreased litter size but did not produce teratogenic effects in the offspring. In rats treated at a daily dose of 14 mg/kg no reproductive aberrations or drug related fetal anomalies were noted. At an elevated dose of 100 mg/kg per day there was a reduction in the number of pups born and an increased perinatal mortality. There are, however, no adequate and well-controlled studies in pregnant women. Because animal reproduction studies are not always predictive of human response, Tolinase is not recommended for the treatment of the pregnant diabetic patient. Serious consideration should also be given to the possible hazards of the use of Tolinase in women of child bearing age and in those who might become pregnant while using the drug.

Because recent information suggests that abnormal blood glucose levels during pregnancy are associated with a higher incidence of congenital abnormalities, many experts recommend that insulin be used during pregnancy to maintain blood glucose levels as close to normal as possible.

Nonteratogenic Effects

Prolonged severe hypoglycemia (four to ten days) has been reported in neonates born to mothers who were receiving a sulfonylurea drug at the time of delivery. This has been reported more frequently with the use of agents with prolonged half-lives. If Tolinase is used during pregnancy, it should be discontinued at least two weeks before the expected delivery date.

Nursing Mothers

Although it is not known whether tolazamide is excreted in human milk, some sulfonylurea drugs are known to be excreted in human milk. Because the potential for hypoglycemia in nursing infants may exist, a decision should be made whether to discontinue nursing or to discontinue the drug, taking into account the importance of the drug to the mother. If the drug is discontinued and if diet alone is inadequate for controlling blood glucose, insulin therapy should be considered.

Pediatric Use

Safety and effectiveness in children have not been established.

Geriatric Use

Elderly patients are particularly susceptible to the hypoglycemic action of glucose lowering drugs. Hypoglycemia may be difficult to recognize in the elderly (see PRECAUTIONS). The initial and maintenance dosing should be conservative to avoid hypoglycemic reactions (see DOSAGE AND ADMINISTRATION).

Elderly patients are prone to develop renal insufficiency,which may put them at risk of hypoglycemia. Dose selection should include assessment of renal function.

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Adverse Reactions

Tolinase Tablets have generally been well tolerated. In clinical studies in which more than 1,784 diabetic patients were specifically evaluated for incidence of side effects, only 2.1% were discontinued from therapy because of side effects.

Hypoglycemia

See PRECAUTIONS and OVERDOSAGE sections.

Gastrointestinal Reactions

Cholestatic jaundice may occur rarely; Tolinase Tablets should be discontinued if this occurs. Gastrointestinal disturbances, eg, nausea, epigastric fullness, and heartburn, are the most common reactions and occurred in 1% of patients treated during clinical trials. They tend to be dose-related and may disappear when dosage is reduced.

Dermatologic Reactions

Allergic skin reactions, eg, pruritus, erythema, urticaria, and morbilliform or maculopapular eruptions, occurred in 0.4% of patients treated during clinical trials. These may be transient and may disappear despite continued use of Tolinase; if skin reactions persist, the drug should be discontinued.

Porphyria cutanea tarda and photosensitivity reactions have been reported with sulfonylureas.

Hematologic Reactions

Leukopenia, agranulocytosis, thrombocytopenia, hemolytic anemia, aplastic anemia, and pancytopenia have been reported with sulfonylureas.

Metabolic Reactions

Hepatic porphyria and disulfiram-like reactions have been reported with sulfonylureas; however, disulfiram-like reactions with Tolinase have been reported very rarely.

Cases of hyponatremia have been reported with tolazamide and all other sulfonylureas, most often in patients who are on other medications or have medical conditions known to cause hyponatremia or increase release of antidiuretic hormone. The syndrome of inappropriate antidiuretic hormone (SIADH) secretion has been reported with certain other sulfonylureas, and it has been suggested that these sulfonylureas may augment the peripheral (antidiuretic) action of ADH and/or increase release of ADH.

Miscellaneous

Weakness, fatigue, dizziness, vertigo, malaise and headache were reported infrequently in patients treated during clinical trials. The relationship to therapy with Tolinase is difficult to assess.

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Overdosage

Overdosage of sulfonylureas, including Tolinase Tablets, can produce hypoglycemia.

Mild hypoglycemic symptoms without loss of consciousness or neurologic findings should be treated aggressively with oral glucose and adjustment in drug dosage and/or meal patterns. Close monitoring should continue until the physician is assured the patient is out of danger. Severe hypoglycemic reactions with coma, seizure, or other neurological impairment occur infrequently, but constitute medical emergencies requiring immediate hospitalization. If hypoglycemic coma is suspected or diagnosed, the patient should be given a rapid intravenous injection of concentrated (50%) glucose solution. This should be followed by a continuous infusion of a more dilute (10%) glucose solution at a rate which will maintain the blood glucose at a level above 100 mg/dl. Patients should be closely monitored for a minimum of 24 to 48 hours since hypoglycemia may recur after apparent clinical recovery.

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Dosage and Administration

There is no fixed dosage regimen for the management of diabetes mellitus with Tolinase Tablets or any other hypoglycemic agent. In addition to the usual monitoring of urinary glucose, the patient's blood glucose must also be monitored periodically to determine the minimum effective dose for the patient; to detect primary failure, ie, inadequate lowering of blood glucose at the maximum recommended dose of medication; and to detect secondary failure, ie, loss of adequate blood glucose response after an initial period of effectiveness. Glycosylated hemoglobin levels may also be of value in monitoring the patient's response to therapy.

Short-term administration of Tolinase may be sufficient during periods of transient loss of control in patients usually controlled well on diet.

Usual Starting Dose

The usual starting dose of Tolinase Tablets for the mild to moderately severe Type II diabetic patient is 100-250 mg daily administered with breakfast or the first main meal. Generally, if the fasting blood glucose is less than 200 mg/dl, the starting dose is 100 mg/day as a single daily dose. If the fasting blood glucose value is greater than 200 mg/dl, the starting dose is 250 mg/day as a single dose. If the patient is malnourished, underweight, elderly, or not eating properly, the initial therapy should be 100 mg once a day. Failure to follow an appropriate dosage regimen may precipitate hypoglycemia. Patients who do not adhere to their prescribed dietary regimen are more prone to exhibit unsatisfactory response to drug therapy.

Transfer From Other Hypoglycemic Therapy

Patients Receiving Other Oral Antidiabetic Therapy

Transfer of patients from other oral antidiabetes regimens to Tolinase should be done conservatively. When transferring patients from oral hypoglycemic agents other than chlorpropamide to Tolinase, no transition period or initial or priming dose is necessary. When transferring from chlorpropamide, particular care should be exercised to avoid hypoglycemia.

Tolbutamide

If receiving less than 1 gm/day, begin at 100 mg of tolazamide per day. If receiving 1 gm or more per day, initiate at 250 mg of tolazamide per day as a single dose.

Chlorpropamide

250 mg of chlorpropamide may be considered to provide approximately the same degree of blood glucose control as 250 mg of tolazamide. The patient should be observed carefully for hypoglycemia during the transition period from chlorpropamide to Tolinase (one to two weeks) due to the prolonged retention of chlorpropamide in the body and the possibility of a subsequent overlapping drug effect.

Acetohexamide

100 mg of tolazamide may be considered to provide approximately the same degree of blood glucose control as 250 mg of acetohexamide.

Patients Receiving Insulin

Some Type II diabetic patients who have been treated only with insulin may respond satisfactorily to therapy with Tolinase. If the patient's previous insulin dosage has been less than 20 units, substitution of 100 mg of tolazamide per day as a single daily dose may be tried. If the previous insulin dosage was less than 40 units, but more than 20 units, the patient should be placed directly on 250 mg of tolazamide per day as a single dose. If the previous insulin dosage was greater than 40 units, the insulin dosage should be decreased by 50% and 250 mg of tolazamide per day started. The dosage of Tolinase should be adjusted weekly (or more often in the group previously requiring more than 40 units of insulin).

During this conversion period when both insulin and Tolinase are being used, hypoglycemia may rarely occur. During insulin withdrawal, patients should test their urine for glucose and acetone at least three times daily and report results to their physician. The appearance of persistent acetonuria with glycosuria indicates that the patient is a Type I diabetic who requires insulin therapy.

Maximum Dose

Daily doses of greater than 1000 mg are not recommended. Patients will generally have no further response to doses larger than this.

Usual Maintenance Dose

The usual maintenance dose is in the range of 100-1000 mg/day with the average maintenance dose being 250-500 mg/day. Following initiation of therapy, dosage adjustment is made in increments of 100 mg to 250 mg at weekly intervals based on the patient's blood glucose response.

Dosage Interval

Once a day therapy is usually satisfactory. Doses up to 500 mg/day should be given as a single dose in the morning. 500 mg once daily is as effective as 250 mg twice daily. When a dose of more than 500 mg/day is required, the dose may be divided and given twice daily.

In elderly patients, debilitated or malnourished patients, and patients with impaired renal or hepatic function, the initial and maintenance dosing should be conservative to avoid hypoglycemic reactions (see PRECAUTIONS section).

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How is Supplied

Tolinase Tablets are available in the following strengths and package sizes:

100 mg (white, round, scored, imprinted Tolinase 100)

Unit-of-Use Bottles of 100 NDC 0009-0070-02

250 mg (white, round, scored, imprinted Tolinase 250)

Bottles of 200 NDC 0009-0114-04

Bottles of 1000 NDC 0009-0114-02

Unit-of-Use Bottles of 100 NDC 0009-0114-05

500 mg (white, round, scored, imprinted Tolinase 500)

Unit-of-Use Bottles of 100 NDC 0009-0477-06

Store at controlled room temperature 20° to 25°C (68° to 77°F) [see USP].

Rx only

Tolazamide patient information (in plain English)

Detailed Info on Signs, Symptoms, Causes, Treatments of Diabetes

last updated: 04/2006

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The information in this monograph is not intended to cover all possible uses, directions, precautions, drug interactions or adverse effects. This information is generalized and is not intended as specific medical advice. If you have questions about the medicines you are taking or would like more information, check with your doctor, pharmacist, or nurse.

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