MEDICAL LEGAL advice needed: Possible paradoxical reaction - Effexor XR w/ Lithium

[Katie in FL]

Basic Patient Information: Female, Age 34, with significant childhood traumas. Condition: Severe depression and PTSD.

1999: Patient presented with depression and was treated with 50 mg of Zoloft. Within a short time, patient began having paradoxical reaction, and stopped taking the medication.

2006: Patient began taking antidepressants again.

2007: Patient began seeing a psychiatrist to try to find the right combination of antidepressants for her treatment.
- October 11, 2007: Patient was on 112.5 mg of Effexor XR. Doctor wanted to rule out possible bi-polar diagnosis and prescribed lowest dosage of Lithium.
- November 1, 2007: Patient became significantly depressed (also in correspondence with ovulation). No mood improvement.
- November 8, 2007: Patient expressed suicidal ideation, but no plan.
- November 13, 2007: Patient was going to attempt suicide, but stopped the intended actions and contacted a counselor as well as the prescribing doctor for help and treatment.

2008: Patient remains on Effexor XR, no Lithium, and no additional suicidality noted or reported.

QUESTION:
- Medically it seems possible that the patient was experiencing another paradoxical reaction, similar to the 1999 occurrence, with the new combination of the Lithium and Effexor XR. What medical documentation or examples are available as proof to validate this concern, for the patient's medical and legal records?

Thank you!

 

[TheGeekess]

Legal records for what? I see nothing that screams any kind of legal issues at all.

 

[xylene]

You need to add

"History of medication non-compliance" to you mini medical record.

"Lowest dosage of lithium"

What the heck does that mean?

Lithium is dosed by patient weight and blood work review of clearance rates.

Why are you being assessed for Bi-Polar if the diagnosis is 'confirmed'?

 

[seniorjudge]

...
QUESTION:
- Medically it seems possible that the patient was experiencing another paradoxical reaction, similar to the 1999 occurrence, with the new combination of the Lithium and Effexor XR. What medical documentation or examples are available as proof to validate this concern, for the patient's medical and legal records?
...

What on earth are you talking about?

 

[TheGeekess]

You need to add

"History of medication non-compliance" to you mini medical record.

"Lowest dosage of lithium"

What the heck does that mean?

Lithium is dosed by patient weight and blood work review of clearance rates.

Why are you being assessed for Bi-Polar if the diagnosis is 'confirmed'?

I've have personal knowledge of a psychiatrist prescribing lithium in order to stabilize mood (in a patient with a similiar diagnosis).

However, if OP will read the package insert that came with the Effexor (and for that matter, any other anti-depressant on the market), they all state that it may take a couple of weeks for the drugs to start working. And in that time, suicidal ideations may occur, simply because a severely depressed patient may finally have the energy to actually consider suicide.

 

[Katie in FL]

Answers To The Questions

There IS a legal case that contains a lot of private info. I was uncertain of what details to give, so I gave the info that I felt was pertinent. It has nothing to do with suing a doctor nor the medicine company - that's all the details I feel comfortable in giving at this time. i apologize for being quite limited. Please let me know what additional details you feel you do need however.

Paradoxical reaction --> the medication was supposed to alleviate the depression. It actually led to suicidal ideation and almost an attempt -- therefore that makes it paradoxical. What more do you need to know about that question/phrase?

Effexor XR was started LONG before the lithium. And patient is still on the Effexor XR to date.

RE: "History of medication non-compliance" to you mini medical record.
---> What does that mean please??

RE: Lithium dosage
-- Uncertain of the dosage amount at this time - it was quite low. Doctor advised it was the lowest dosage available.

Bi-Polar was RULED OUT upon later extensive medical evaluation.


WHAT IS NEEDED FOR THE LEGAL CASE: Medical documentation, research, or examples where similar paradoxical reaction occurred.

 

[lealea1005]

Lithium can also be used in conjunction with anti-depressants for cases of severe depression. Lithium is not used to "rule out" manic-depression. Extensive testing is used to make the diagnosis.

Are you taking medications for any other medical conditions (blood pressure, thyoid, etc)? If so, does your Psychiatrist know about them?

 

[xylene]

RE: "History of medication non-compliance" to you mini medical record.
---> What does that mean please??

You stated in your first post that you decided to stop taking your medication after experiencing a side effect.

There followed a 7 year gap in treatment.

RE: Lithium dosage
-- Uncertain of the dosage amount at this time - it was quite low. Doctor advised it was the lowest dosage available.

Lithium is only effective as an anti-manic at a very narrow range of blood serum concentrations. That is the amount of lithium in the blood.

Too little and their is no effect.

Too much and toxicity occurs.

Dosage is commenced based on a formula of patient height and weight. Blood tests are then done to determine the patients precise clearance rate, and the dose adjusted to maintain the therapeutic serum concentration.

Bi-Polar was RULED OUT upon later extensive medical evaluation.

Who are you trying to sue? Spare us the 'its not relevant' routine. It is.

 

[TheGeekess]

Paradoxical reaction --> the medication was supposed to alleviate the depression. It actually led to suicidal ideation and almost an attempt -- therefore that makes it paradoxical. What more do you need to know about that question/phrase?

No it doesn't. It is almost an expected thing in a severely depressed patient. As I said in a previous post in this thread:
"However, if OP will read the package insert that came with the Effexor (and for that matter, any other anti-depressant on the market), they all state that it may take a couple of weeks for the drugs to start working. And in that time, suicidal ideations may occur, simply because a severely depressed patient may finally have the energy to actually consider suicide."

Don't believe me?

From the FDA website:
"Suicidal thoughts or actions: Persons taking Effexor may be more likely to think about killing themselves or actually try to do so, especially when Effexor is first started or the dose is changed. People close to persons taking Effexor can help by paying attention to changes in user’s moods or actions. Contact your healthcare professional right away if someone using Effexor talks about or shows signs of killing him or herself. If you are taking Effexor yourself and you start thinking about killing yourself, tell your healthcare professional about this side effect right away."
http://www.fda.gov/CDER/drug/InfoSheets/patient/venlafaxinePIS.htm

From the NIH website:
"You should know that your mental health may change in unexpected ways when you take venlafaxine or other antidepressants even if you are an adult over age 24. You may become suicidal, especially at the beginning of your treatment and any time that your dose is increased or decreased. You, your family, or your caregiver should call your doctor right away if you experience any of the following symptoms: new or worsening depression; thinking about harming or killing yourself, or planning or trying to do so; extreme worry; agitation; panic attacks; difficulty falling asleep or staying asleep; aggressive behavior; irritability; acting without thinking; severe restlessness; and frenzied abnormal excitement. Be sure that your family or caregiver knows which symptoms may be serious so they can call the doctor when you are unable to seek treatment on your own."
http://www.nlm.nih.gov/medlineplus/druginfo/medmaster/a694020.html

This is not a 'paradoxical' reaction.

 

[xylene]

Also

Anti-depressants can trigger manic episodes.

Manic episodes alone, and painful mixed states are times of profound suicidal thought. And action.

You do not need to feel glum to want to kill yourself.

 

[ecmst12]

I see no mention of DAMAGES here, either. Suicidal crisis was dealt with and has not recurred.

 

[Katie in FL]

Not trying to sue. Trying to advocate for patient & child

Wow... didn't know the mass of questions I would be facing with this question.

Okay...

1999 - - Medication was prescribed by a gynecologist. Not a family doctor nor psychiatrist. Medication stopped after the paradoxical reaction occurred. Advice was given on how to stop the medication. Patient dealt with the depression on her own, without medication until 2006. 1999 occurrence did not involve suicidal thoughts or actions.

More info: The patient had, along with a plan for suicide, a plan to include their school-aged child in the plan. The patient had not had any type of thoughts like this in the years since the child was born. And as mentioned before, there has been no reoccurring thoughts or actions.

There was no known manic phase noted in any of the doctors' notes. No other medical conditions (no thyroid or blood pressure problems - thyroid was tested prior to starting lithium, blood pressure was checked and was okay too.)

The patient advised that she knew she had to report the problem to get help for herself and the child, and knew that Dept of Children & Family Services would be contacted. The patient was unaware of the longevity of the process since she was being quite compliant and the suicidality was no longer occurring. In addition to those factors, there has been significant added stress factors in association with the process through DFACS, as well as her knowledge of the long-term issues that her child will face due to the involvement of DFACS. (This moves the case out of the medical field thread however... the part I'm trying to address is the medical portion, that could help prove that the patient has the ability to reunite with the child, since it was a one-time occurrence.)

The patient did not receive the extensive medical evaluation prior to being prescribed the lithium (cost is approximately $800-$1000, out of pocket.) Patient has had no medical insurance and was already paying for the high cost of psychiatry bills. Apparently the psychiatrist had information from the patient's history which warranted them in trying the lithium. Granted, that made the patient a guinea-pig of sorts, but the doctor felt it could not hurt the patient, and could not have foreseen the possible outcome.

With those additional facts, would you be able provide the sought-after information, please?

 

[xylene]

The fact that child and family services intervened in a family murder / suicide scenario is not damages.

The high cost of medical treatment is not damages either.

Prescribing lithium to a mood disordered patient (who you suggest has a family history as well) is not medical malpractice.

Suicidal ideation is a common occurrence and a known side effect of anti-depressants, especially upon initiation from a drug naive state.

The response of the health care providers offer proof the patient was being monitored for this effects.

Bottom line-

No damages.

No malpractice

No case.

The DCAFS issues that arise from a para-suicidal gesture along with 'involving the children' are not going to be resolved quickly or easily. There is just too much at risk.

 

[ecmst12]

If you concede that the doctor could not have forseen the possible outcome, then there is no POSSIBLE way there could have been malpractice. Malpractice requires negligence - a breech in the standard of care, which a reasonable medical professional would have known would result in damages.

 

[Katie in FL]

What COULD help reunite child with parent?

Patient has been 100% compliant with all requests made by DFACS and medical personnel treating her, has also taken initiatives to go above and beyond the requests of DFACS. Patient has been fully honest and forthcoming about everything to everyone involved in the case, which has also been noted to her benefit by both DFACS and medical personnel. However the psychiatrist who prescribed the medication is still advising that a "watch and wait" time of 6-12 months is necessary to avoid being responsible *just in case* there is some sort of reoccurrence.

What facts, regarding the possibility of problems stemming from the changes in medication, could be used to reunite the child with the parent, in this case please?

WHAT IS NEEDED: Facts and info that *COULD* help reunite child with parent. Medical research and/or case examples would likely provide sufficient evidence. If this was your case, and you were advocating for the patient - - what information would you provide to assist in earlier reunification.

Seeking reunification for the child and patient - - NOT seeking malpractice.