Tuesday morning I had my long-awaited appointment to get a second opinion on my psychiatric meds. It’s ironic that I by the time I got it, I am less depressed and anxious than I’ve felt for most of a year. But after all the work it took to get this consultation, I went anyway. I actually think my improvement is due to the leave I’m taking from work and excitement about my upcoming trip (more on that another time).

My normal prescriber is a psychiatric nurse practitioner. She’s all right but I wanted this consult because I’ve been on the same anti-depressant (venlafaxine, aka Effexor) for about two years, and it clearly didn’t keep me from the lows of this past year. We added bupropion (aka Wellbutrin) some time ago, which possibly gave me more energy but I didn’t notice a huge difference. I also take trazodone and clonazepam to sleep at night. I couldn’t help wondering if this was the best I do with meds.

I met with the Director of Adult Psychiatry at the medical university. The advantage: the guy keeps up with all the newest research on treatment for anxiety and depression. The disadvantage: it’s a teaching university, so I got a third-year med student doing his psychiatric rotation sitting in. I decided I’d give him something interesting to talk about with his fellow med students at the bar, and I went ahead and talked about the suicidal thoughts and self-harm of last spring and summer, the hopelessness, (undetailed) history of childhood sexual abuse, demanding professional job and poor concentration and exhaustion–all of it like no big deal, like I might talk about my sore foot at the podiatrist. I wonder if I made him more or less likely to choose psychiatry as his specialization?!?

But I digress. What I meant to write about was what I learned from the consult. Here are the 4 big take-home messages.

1. For a person who self-harms when the internal agitation gets unmanageable, he much prefers the use of Xanax to something like clonazepam, because it is much faster acting and therefore provides quick relief and reduces frequency of self-harm. I haven’t burned myself for months, but this is good to know for the future, just in case, you know.
2. He does not prescribe Effexor anymore because people have such a hard time coming off of it. He had two patients become psychotic and need hospitalization coming off it (and another friend of mine told me her psychiatrist calls it Side-Effexor). Plus I just went through one of my worst depressions and was taking it all the whole time. He thinks duloxetine (Cymbalta) might be better, and if so that I should taper onto it while slowly tapering off the Effexor. But..
3. I have taken lots of different meds over the years and never experienced long-lasting relief. He said if I wanted, I could have a DNA test that would provide us some useful information about serotonin re-uptake as well as metabolism of meds in the liver. This can help guide selection of meds as well as help determine dosages. For example, if your liver metabolizes a drug faster than typical rates, you could benefit from a higher-than-standard dose. I don’t know about you all, but I didn’t know this was possible. I think it’s encouraging that medicine is going in this direction and away from the let’s guess and see what happens approach. So I decided to go ahead and pay $400 out of pocket to have my cheek swabbed and my DNA sequenced. I hope it will be worth it.
4. He told me to check out the manufacturer of the generic drugs I’m taking (all 4 of them are generics). All generics are not alike, no matter what people tell you, he said. A lot of generics are made in India, and they all go through Central Drugs Standard Control Organization that tests and certifies that they meet FDA standards. Except that it turns out they only test new drugs and are woefully understaffed. Medications that are not newly developed don’t get tested. He also said you can go to FDA.gov and search by pharmaceutical company to see if there have been any warnings about a particular drug manufacturer. If so, I should think about switching to a pharmacy that uses a different manufacturer. Why should it be on us to track down this information? Can we really expect a depressed person who has trouble getting out of bed to do this online research and then call around to lots of local pharmacies to ask them all where their drugs come from? And what if you live in a small town with only one pharmacy?

In the end, all decisions are on hold until I get the results of the genetic testing, and even then, I won’t do anything about it until I get back from my travels. It was interesting though. It made me simultaneously hopeful that we are learning how to better match psych meds to individual need but frightened that people can’t be sure about the quality of the meds they take.