At times, psychotropic decision making can feel more like an art form than science. Decision trees based on various trials inform the prescriber, but often are based on having the correct diagnosis in the first place. Lamotrigine is increasingly prescribed in when the primary diagnosis is “Emerging Borderline Traits” or Borderline Personality disorder (BPD). Compared to alternative mood stabilizers, especially the atypical antipsychotic class, it appears to have a more tolerable side effect profile with potential for benefit. While lamotrigine is just one of many medications used off label in treating symptoms of BPD, it warrants investigation.
 
In 2018 the UK National Health Service (NHS) attempted to clarify this very point with the “

• …test whether or not prescribing lamotrigine in addition to usual treatment reduces symptoms of this condition, improves social functioning and quality of life, reduces the incidence of suicidal behavior, reduces the level of alcohol and substance misuse and lowers the amount of antipsychotic and other psychotropic medication that people are prescribed. 

 
LABILE resulted in over 270 patients with BPD separated into a lamotrigine arm and placebo arm. Each arm received normal treatment as well. Review of the study demonstrate reliable and valid results. Patients were recruited from NHS treatment centers and demonstrated severity across the spectrum of the condition.
 
To put it simply, in as real world a study as possible, with the largest number of patients yet, lamotrigine did not hold up the initial suggestion of benefit from earlier research. Results between placebo and lamotrigine treatment were equivocal. Levels of depression, the likelihood of self-harming or suicidal behavior and likelihood of problem drug or alcohol use were all comparable across the groups at follow-up. Social functioning was also equivalent across groups. 
 
Additionally, medication compliance was poor for all patients after 12 weeks, with only thirty three percent demonstrating consistency. In a medication where inconsistent/rapid titration can be life-threatening this can be especially concerning. The indication is that lamotrigine, similar to all other medications, does not treat or alleviate BPD symptoms. It adds cost and risk. 
 
A notable risk of lamotrigine is that of Steven’s Johnson Syndrome, a serious and life threatening blistering rash of mucosa and skin. When the medication is titrated too quickly, the risk increases markedly. After a two days of missed medication the 2 week titration schedule for lamotrigine must be started again. Poor compliance with
this medication certainly places patient at greater risk.
 
On the other hand, there is some reason to conclude hopefully regarding BPD. The interaction with the physician was stabilizing. The indication of having a legitimate treatable condition was validating. However the lamotrigine did not add to this benefit any better than an inert placebo.  
 
BPD warrants treatment. Patients with the disorder have a completed suicide rate greater than fifty times the general population. They utilize emergency and clinic resources to an extensive degree. Anti-depressants fair worse than placebo. Benefits of atypical anti-psychotics match placebo. Sadly, lamotrigine, much like many medications before it, once scrutinized does not meet the hope of its initial small studies and open label trials.
 
Therefore do not fall into the trap of avoiding the valid and successful treatment of Dialectical Behavior Therapy and Mentalization Based Therapy.
 
Crawford MJ, Sanatinia R, Barrett B, et al. Lamotrigine for people with borderline personality disorder: a RCT. Southampton (UK): NIHR Journals Library; 2018 Apr. (Health Technology Assessment, No. 22.17.) Available from: https://www.ncbi.nlm.nih.gov/books/NBK493476/

The rites of passage that often define childhood — summer camp, prom, tossing a mortarboard into the air at graduation — will look very different this year, if they happen at all. And that can have a profound impact on the mental health of young people. It's not just the loss of fun activities. They're missing out on experiences meant to “conclude one chapter in our life and start the next chapter,” said Dr. Joshua Stein. Read full article here
- by PAL Psychiatrist, Dr. Stein

PAL psychiatrist, Dr. Joshua Stein, joined Twin Cities Live this last week with ways to recognize anxiety and how families can manage symptoms during this pandemic.
 
How to recognize different levels of anxiety for you and your family

• Children may present with body concerns, stomachaches, diarrhea, headaches, outbursts, meltdowns, challenging behaviors
• Monitor levels of irritability
• Excess alcohol consumption, changes with food consumption (eating more or eating less)
• sleep issues

 
How do you know if it’s time to be concerned and seek professional help?

• Warning signs: changes to sleep, decline in hygiene, profound irritability, “giving up”
• Thoughts of self-harm or
• Any suicidal thoughts of any kind
• New sever conflict in a partner/spousal relationship

**If you are asking yourself this question let a professional help determine this
**The recent changes to telehealth allow rapid in home access
 
How do you stay informed without getting overwhelmed?

• Choose a reputable news source
• Set limits for consuming information (e.g., only read/watch newsources for 30 minutes 2x a day)
• Focus on what you can control; i.e meals, exercise, next book
• It is easy to slip into catastrophic ideas. This will happen. If it is interfering with parenting, please reach out

 
What kind of toll can it take on you to “be strong” for your family and how can that be managed?

• Take time at the end of the day to “Emote/Sound Off” with another adult. i.e. partner/friend/coworker
• Commonly we end the day at the TV; Instead make time to share struggle/grief/loss/laugh
• Know that it is healthy and important for your kids to see you experiencing normal emotions sometimes

 
Is there anything you can do right now to help – unplugging from the news, taking a walk, etc.

• Connectedness is important
• Don’t’ just text. Facetime or call family, your children’s friends, teachers, coworkers
• Let your child be the expert and teach you; learn about “Sound Cloud”, “fortnite”; “Roblox”; Learn a “Tik Tok” dance
• Dance to “Koo Koo Kangaroo”, “Go Noodle” with your children. Have them share their favorite video
• Create! Art, dominoes, a positive yard sign, school pride, face paint
• It’s ok to relax rules. Many parents feel guilt about children and excess screen time. Let yourself off the hook
• Get outside: Use your firepit; create a scavenger hunt, Build a Scooter Ramp; Use those Amazon boxes to build a fort
• Cuddle
• Take 5 minute mini-breaks to pause, breathe and focus upon gratitude

 
If you are a patient or family member or friend in need of immediate assistance:

• Disaster Distress Helpline
• Call 1-800-985-5990 or text TalkWithUs to 66746
• National Suicide Prevention Lifeline
• Call 800-273-8255 or Chat with Lifeline
• Crisis Textline
• Text TALK to 741741

Written by Joshua Stein, MD

A common difficulty in the outpatient office is determining the steps needed to ensure the safety of a patient once they identify that they are suicidal. There are two known methods to ensure safety; mental health treatment at the appropriate level of care and means reduction. The need to determine level of care will be examined in a future post. The significant importance of the removal of means to suicide, or Means Reduction, is the focus of this article.

A common myth is that a suicidal person, who has identified a source for completion, will substitute an alternative method if his/her original method is taken away. This belief in almost all settings represents a fallacy. The lethal means, whether overdose, a firearm, a one car crash etc, will not be substituted for another. 

Given the opportunity, the removal of chosen lethal means, especially firearms, will greatly reduce the How people attempt: leading to time to determine the Why, and introduce treatment.

​Per NAMI, there are numerous examples from history where the removal of a lethal means has decreased the death rate. In 1960, lethal oven gas ingestion was the leading cause suicides in the UK. By 1970, the country had substituted non-poisonous gas, resulting in a one third decrease in the suicide rate. The entirety of the drop stemmed from the change in gas, and non-gas related suicides had only increased slightly. The entirety of the change stemmed from means reduction to lethal gas.

The Israeli Defense Force (IDF) struggled significantly with suicides off base on vacations and weekends. In 2006 soldiers were no longer allowed to carry firearms off base for breaks. The suicide rate dropped approximately 40 % with no change in the rate of suicides during the week. The entirety of the change appeared to be related to the means reduction to firearms off base.
Numerous studies demonstrate that the acute action phase towards suicide is commonly brief. By removing the means to attempt, people often reach a plateau of safety when support can be introduced. The most common method of suicide attempt is by intentional overdose. The most likely lethal attempt is by firearm. Practical steps are outlined below:

1. If a means is shared, it must be removed (substitutions are not likely)
2. Additional means to suicide should also be removed to improve safety
3. Remove all firearms
4. Lockup medications, including OTC (carry in car if needed)
5. Remove car keys
6. Remove Sharp objects/knives
7. Remove cords and ropes
8. Remove alcohol
9. Identify a family member or friend who can remove the means before a patient returns home
10. Have the person who is removing the means alert the treatment team by phone call that this has been completed
11. Document this step

At times, resistance to removing the means may occur from a friend/family member. A common desire to increase the difficulty of the attempt often is a practical point to reach agreement. As these are common objects in the home and firearms carry significant value, there is a time at which reintroduction should occur. Similar to the safety assessment in the medical office that led to removal of means, a safety assessment can take place to approve returning these objects to the home.

​In conclusion, removal of the means works in significantly improving safety. If a patient is deemed appropriate to return home, whether from a hospitalization or an outpatient appointment, steps towards means reduction need to take place. Finally, when a patient identifies a means, action should be taken, the fallacy to believe an alternative means will be substituted is incorrect.

SOURCES:

• NAMI MEANS REDUCTION LECTURE
• Shaffer D, Pfeffer CR, & the Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with suicidal behavior. JAACAP. 2001;40(7 Supplement):24S-51S.
• Shain BN. Suicide and suicide attempts in adolescents. Pediatrics. 2007;120(3):669-675.
• American Association of Suicidology. Youth Suicide Fact Sheet. January 28, 2008. Available at: http://suicidology.org/c/document_library/get_file?folderId=232&name=DLFE-24.pdf. Accessed April 19, 2009.
• American Psychiatric Association. Let’s Talk Facts About Teen Suicide. Available at: http://healthyminds.org/factsheets/LTF-TeenSuicide.pdf. Accessed April 19, 2009.