Returning to diving after antidepressants?

[terrylowe]

Perhaps you should list "muscle strain neck- resolved"

 

[drrich2]

How much risk you're facing can be hard to determine, and how much risk you consider acceptable is a highly individual decision. The 2 issues I recall discussed on antidepressants and diving fell into 2 main categories:

1.) The illness the med. was designed to treat - what if you are suicidally depressed & decide to spit out your reg. at depth or some such, have a panic attack, etc...

2.) Side-effect issues. If memory serves, seizures were a key concern raised, since underwater seizures can easily be fatal, given the nature of scuba diving.

Some years ago, I recall a discussion of Wellbutrin, which is reputed to lower the seizure threshold (making seizure more likely) more so than most antidepressants. The numbers I recall (and I don't know just how they were generated and in no way can I attest to accuracy on them) were:

1.) Antidepressants in general were associated with about a 2 in a 1,000 risk of seizure. I did not see a seizure risk statistic for the general population, so how that compares I don't know.

2.) Wellbutrin was thought to have a 4 in 1,000 or so risk. This risk increases with higher doses in a day, and higher single doses (for example, if you're on over 400 mg/day, your risk might be higher than 4 in 1,000).

3.) Delayed release Wellbutrin (e.g.: SR, and I presume XL) were thought to have a risk more like other antidepressants, but higher doses might be a potential concern there.

Perhaps there are newer numbers and more updated thinking. I'm just firing off what I found years ago and over the years.

Since nitrox diving carries some potential for oxygen toxicity, one of the effects of which can be seizure, people sometimes discourage use of other medications that even in theory might impact seizure risk (e.g.: Sudafed, which is an over-the-counter non-controlled substance sympathomimetic). Yet I believe many people dive nitrox while taking Sudafed.

So, is it acceptable for a diver on antidepressants to dive? I don't know of any consensus, and I'm not giving any professional advice on the subject. The only 100% safe dive is the one you don't make.

Richard.

 

[Scott L]

.....

 

[DocVikingo]

Hi oranget,

It isn't unusual for medications with antidepressant activity to be used in certain chronic pain disorders. Deanxit (flupentixol+ melitracen) & amitriptyline are good examples; Cymbalta (duloxetine) & Tofranil (imipramine) are others.

A very detailed article on diving WHILE ON antidepressants appears in several threads on this board and interested parties are urged to read it --> http://www.scubaboard.com/forums/diving-medicine/54067-depression-deep-diving.html (See post 3#).

In the case of return to diving AFTER DISCONTINUATION of such drugs, your doctor was correct in cautioning about anxiety during the recommended 14 day tapering off period for Deanxit. The same is true of amitriptyline. Known psychiatric adverse reactions of withdrawal of these meds, especially abrupt withdrawal, include irritability, restlessness, abnormal dreams & insomnia. There may be physical symptoms as well.

However, by 4 weeks (Deanix) & 2 weeks (amitriptyline) post-discontinuation, particularly from low doses, a history of use, in-and-of-itself, is a complete non-issue.

As TSandM has said, it would be prudent to make sure that any residual pain issues don't pose risks to safe scuba. I'd add to that that you also should be free of any analgesic medications of concern to scuba (e.g., narcotics).

Regards,

DocVikingo

This is educational only and does not constitute or imply a doctor-patient relationship. It is not medical advice to you or any other individual, and should not be construed as such.

---------- Post Merged at 07:19 AM ---------- Previous Post was at 05:51 AM ----------

Hi Richard,

I’m a bit lost:

1.) “The illness the med. was designed to treat - what if you are suicidally depressed & decide to spit out your reg. at depth or some such, have a panic attack, etc...”

The poster indicated that his meds were prescribed for ongoing neck pain, not a depression or anxiety-mediated disorder. How did we end up here?

2.) “Side-effect issues. If memory serves, seizures were a key concern raised, since underwater seizures can easily be fatal, given the nature of scuba diving.

b.) Wellbutrin was thought to have a 4 in 1,000 or so risk. This risk increases with higher doses in a day, and higher single doses (for example, if you're on over 400 mg/day, your risk might be higher than 4 in 1,000).

c.) Delayed release Wellbutrin (e.g.: SR, and I presume XL) were thought to have a risk more like other antidepressants, but higher doses might be a potential concern there.”

Wellbutrin (bupropion) is chemically unrelated to flupentixol, melitracen & amitriptyline, the drugs the poster was taking. How did we end up here?

“Nitrox diving carries some potential for oxygen toxicity, one of the effects of which can be seizure, people sometimes discourage use of other medications that even in theory might impact seizure risk (e.g.: Sudafed, which is an over-the-counter non-controlled substance sympathomimetic).”

There are over a dozen "Sudafeds” ( Sinus Pressure Pain and Cold Congestion Relief - SUDAFED® ); to which specific product are you referring?

RE: “I did not see a seizure risk statistic for the general population, so how that compares I don't know.”

Incidence estimates vary by source, and of course by age and classification. In the general adult population, the annual incidence of a first single unprovoked seizures is around 0.02%. Approximately 10% of the general population will have at least one seizure during their lifetime.

Regards,

DocVikingo

 

[drrich2]

DocVikingo:

The poster indicated that his meds were prescribed for ongoing neck pain, not a depression or anxiety-mediated disorder. How did we end up here?

I was addressing the antidepressant topic more generally, given that on a public forum others on such med.s may have different concerns, and such threads are sometimes used as reference. I was not implying the OP had a depressive or anxiety disorder.

Wellbutrin (bupropion) is chemically unrelated to flupentixol, melitracen & amitriptyline, the drugs the poster was taking. How did we end up here?

Again, in a more general discussion, Wellbutrin, which is an antidepressant, is reasonable to mention.

There are over a dozen "Sudafeds” ( Sinus Pressure Pain and Cold Congestion Relief - SUDAFED® ); to which specific product are you referring?

Pseudoephedrine.

Thanks for the info. on seizure incidence.

Richard.

 

[DocVikingo]

Hi Richard,

I see, I guess, although given the focused nature of the OP your treatment of the topic strikes me as ranging from the moot to the tangential.

In any event, if the intention is to use OP's more explicit question as a springboard for a ranging, general discussion of antidepressants and diving, a very detailed article on the topic appears in several threads on this board and interested parties are urged to read it --> Depression and deep diving (See post 3#).

Regards,

DocVikingo

---------- Post Merged at 04:01 AM ---------- Previous Post was at 03:44 AM ----------

....I know it is your body, your life and you can decide how to live and how to die, etc. However, some divers need to think about the effects (financial, emotional, psychological, even physical if there is a heroic attempt at rescue) on the dive operator and the impact of years of litigation the dead diver's family will bring against the dive op.

Well said and so true, so true, Terry.

Below is courtesy of the Jan '10 issue of Undercurrent & yours truly:

"The World Recreational Training Scuba Council (http://www.wrstc.com/main.php), of which PADI, SSI, SDI, IDEA, ACUC and DAN, amongst others, are members, is dedicated to the worldwide safety of the recreational diving public.It encourages members to use a standard medical statement before offering training or diving (http://www.wrstc.com/downloads/RSTCMedStatementGeneric.pdf).

"Lying About Your Health Could Be Lethal -- our medical expert tells you why you shouldn’t fib to dive shops

Last month, we published reader comments about how much, if any, health information you disclose on the dive shop medical questionnaire. A surprising number of you say you keep mum. I saw many of the reasons you gave for why as having merit. DocVikingo, a frequent Undercurrent contributor, is less inclined to accept such untruthfulness. Here’s his opinion:

Scuba diving, perceived by much of the non-diving public as risky if not outright dangerous, has avoided government meddling to an astonishing degree. Regulation by federal, state and local governments has been avoided largely because the dive industry polices itself. This includes common practices like asking divers to complete a medical history questionnaire before training or a taking a dive trip. This self-policing has benefited divers by giving them freedom to dive whenever, however and with whomever they choose. Much of this is obviously due to divers adhering to industry practices. But when it comes to being forthright in completing medical questionnaires, it’s sometimes a different story.

When Undercurrent asked readers about whether they disclose medical conditions to dive operators, a surprising number of you replied that you didn’t, for fear of an operator not permitting you to dive. But I’m with much of the dive industry and medical experts in believing it’s a mistake not to tell the truth about your health. It could cost you your life, and possibly the lives of the buddies and guides you’re diving with.

The risks are real. For example, Divers Alert Network’s annual report on dive-related accidents and deaths routinely indicates that cardiovascular events cause 20 to 30 percent of all fatalities. Moreover, medications like tranquilizers, antidepressants and narcotic pain relievers and certain cardiac and respiratory drugs that cause no problems topside may act differently at depth, and may combine with or increase nitrogen narcosis, resulting in significantly impaired thinking and behavioral control.

“The Diver’s Responsibility, not the Dive Center’s”

Consider this tale sent in by an Undercurrent reader about a Bahamas dive he did last June. One of his fellow divers was a 68-year-old woman who looked physically fit and at least a decade younger. However, during the first dive, one of the divemasters had approached her at 75 feet, motioning for her to ascend a bit but she kept descending. At 100 feet, the divemaster physically tried to force the woman to ascend but was pushed away. He partially inflated the woman’s BCD but she immediately dumped the air through her shoulder valve. Another divemaster then descended to 170 feet and could see the woman’s bubble line starting well below his depth. He used the backup tanks suspended below the boat to decompress from the extreme depth. The woman’s body was never found.

Our reader later learned through a mutual acquaintance that the woman had had a minor stroke the month before that Bahamas dive. “There has been considerable speculation about the cause of her actions and subsequent disappearance,” he wrote us. “While we may never know for certain, the leading theories are that she either got nitrogen narcosis at 70 feet, or suffered a stroke and became confused and disoriented. If she had a transient. ischemic attack, or TIA, (a ‘warning stroke’ or ‘mini-stroke’ that produces stroke-like symptoms but no lasting damage.) the month prior, my medical friends indicate it is dubious she would have received a physician’s clearance to dive. There are generally other underlying medical issues, and a greatly increased risk of suffering another stroke after a ‘minor’ TIA stroke.”

Out of curiosity, our reader e-mailed PADI and asked about its fitness-to-dive policy. The reply: “While dive students are required to complete a medical history questionnaire before participating in any PADI courses, PADI diving facilities are not required to medically screen all of their customers. Divers learn during their training that, after certification, they must always ensure that they are medically fit for diving before doing so. This is the diver’s responsibility rather than the dive center’s.”

Because so many of you readers admit that you are untruthful on the medical release, we wondered if dive medicine experts did the same, just to avoid the hassle of dealing with dive operators who have far less medical knowledge. Ern Campbell, M.D., a.k.a. ScubaDoc, said that even if he had a condition he feared may prevent a dive operation from taking him on board, he still “would disclose the condition to the operator and expect an appropriate explanation of any denial to dive.” Dr. Michael Bennett, president of the South Pacific Underwater Medicine Society, told us: “I believe the medical risks of diving are real and present a threat to my well-being. Therefore, I would not be selfish enough to cheat and put my fellow divers at risk when they might be called upon to save me!”

Drugs Work Differently Underwater

Common reader statements we received included, “I’m capable of monitoring my own medical problems” and “I don’t pose a danger.” In many cases, such assertions are not accurate. For example, common conditions like asthma, diabetes and seizures may appear well-managed but can unexpectedly and rapidly spiral out of control. When they do so underwater, the results can be deadly. The altered environment in diving (e.g., water that’s cooler than body temperature, exertion, increased partial pressures of gases) can precipitate relapses. The fact is the potential effects of such changes upon most medical conditions -- and the drugs used to control them -- are not known with certainty.

Other readers responded along the lines of, “What does the dive op know about the implications of my medical issues for scuba?” The answer is, “Probably very little.” This is why the shop can quite reasonably ask you to report your medical status, and may require a signed clearance to dive from a physician who does understand the implications. Remember, if a dive crew is unaware of your medical disorders, appropriate treatment could be substantially delayed.

In a related vein, some readers believed that a dive operator asking for such personal information was in violation of their right to medical privacy. Actually, it isn’t. The privacy provisions of the Health Insurance Portability and Accountability Act (HIPAA) are binding on healthcare insurers, providers and facilities, not dive operators and training agencies. You voluntarily waive your “right” to keep your medical information private when you contract for dive certification or a two-tank dive. It is the operator’s perfect right to ask the diver to be honest regarding medical conditions that could mean additional risks to the business, other customers and the diver himself. There is nothing illegal, unethical or inappropriate about this. From a liability standpoint, dive businesses would be insane not to.

You’re not the Only Diver on the Boat

Perhaps the lamest of the excuses was, “It’s my life and my choice to dive with a disease.” This might be arguable if you are an unemployed solo diver without family or friends. However, if you are diving with a dive operator and other customers, then your fitness to dive most assuredly is of concern to them.

When you are less than honest in revealing your medical status, not only could you as the diver be harmed, but so could your buddy, divemaster or others who risk their lives to save yours. Karl Huggins, program director of the University of Southern California’s Catalina Hyperbaric Chamber, says that if individuals “... knowingly conceal these conditions once they know what the risks are, it’s not just themselves they’re putting at risk but also those who may need to respond to them in an emergency situation.” He goes on to say, “Divers may rationalize that ‘It’s my life and I can assume any risk I want because the damage I do, I do to myself.’ But when they’re paralyzed and can’t do their job or function normally in their work and personal lives, is it just themselves they’re affecting?”

Not to mention that you could cause a dive trip to be aborted for everyone, possibly on an expensive liveaboard in a far-flung location, because the crew needs to rush you to medical care. Under these conditions, liveaboards make no refunds to any divers on the itinerary. If you’re lucky enough not to expire from your previously undisclosed medical condition, you might be thrashed to death by the other passengers.

If and when enough divers lie, incidents will occur and they eventually will catch the government’s eye. When that happens, laws will be passed, like requirements of medical exams before receiving dive training and mandatory completion of a medical history form in Australia, Malta and other locations. A number of preventable diver deaths due to medical reasons have occurred in Australia’s Queensland region over the past several years. Many were the result of divers being untruthful about their medical status and made news headlines. This resulted in the government considering even more rules and tighter enforcement. Do you want some random diver’s failure to disclose medical conditions that led to a dive accident or fatality to lead to tighter restrictions on your own dives?

You participate in recreational scuba on a voluntary basis. No one is forcing you to do it. It’s a recreational pastime, a fun thing to do. If you don’t like being asked to properly and truthfully complete a medical questionnaire, a practice intended to protect customers and the businesses that offer them scuba services, you don’t have to participate. You can find diversions with rules that better suit you and don’t require total disclosure of your medical history. Heaven knows there are dozens of them that don’t put you and others in such a potentially hazardous situation. - - DocVikingo"

Regards,

DocVikingo

 

[Mantra]

This is a very interesting thread. Thanks for the discussion, all.

I have an anxiety disorder - part genetics, part fallout from some work in combat zones etc. I don't take medication, and it has been a decade since I have experienced a panic attack. I only ever experienced a handfull of them, and once my doctor worked out what was going on, they rapidly resolved. I generally have a heightened sense of stress and anxiety these days, but not to the extent that it dictates my behaviour.

My gut feeling is that this doesn't hold much in the way of risk for me when diving. If anything, I'm pretty familiar with what stress/panic feels like and have solid practice in not letting it take me over. Panic is often a self-fueling thing, right, in that one panics because one is feeling paniced and out of control and a spiral happens? Besides, the stuff that triggers a sudden stress response from me (certain thought patterns, explosion-like noises, gunfire-like noises, a certain quality of light) aren't likely to be around underwater

Sould I trust this intuition, do you think? Are there any studies that show correlation between a pre-existing anxiety disorder and likelihood of panic underwater? For me, knowing what I know of my own experience with this, the opposite might almost hold true.

Hope I'm not hijacking. It just seems like a few people read anxiety disorder as being axiomatically problematic for diving, and this is something I should consider, my own intuition notwithstanding.

 

[DocVikingo]

Hi Mantra,

You ask: "Are there any studies that show correlation between a pre-existing anxiety disorder and likelihood of panic underwater?"

Yes, there are. Here are a couple of important studies:


1. “Int J Sports Med. 2004 May;25(4):314-22.

Trait anxiety predicts panic behavior in beginning scuba students

Morgan WP, Raglin JS, O'Connor PJ

SourceDepartment of Kinesiology, University of Wisconsin-Madison, Madison, WI 53706-1189, USA. wmorgan@education.wisc.edu

Abstract

Recreational scuba diving is associated with a significant number of fatalities and decompression illnesses each year, and there is evidence that permanent neuropsychological injury can occur in divers. There is also evidence that the principal cause of decompression illness and fatalities in divers is rapid ascent, and it appears that the primary stimulus for rapid ascent is panic. The primary purpose of this investigation was to evaluate the extent to which an objective measure of trait anxiety could be effective in predicting panic behavior in students undergoing scuba training. Trait anxiety was assessed at the outset of scuba instruction in 42 students, and the instructor recorded instances of panic behavior during the 4-month course. It was predicted that individuals scoring 39 or greater on the trait anxiety sub-scale of the State-Trait Anxiety Inventory would be more likely to experience panic behavior than individuals with scores below this cut-off. Predictions and actual recordings of panic behavior were performed independently using a blinded paradigm. Eleven of the students exhibited panic behavior on two or more occasions during the instruction, and 35 of 42 (83 %) predictions were accurate (p < 0.001). It is concluded that an objective measure of trait anxiety can be employed a priori for prediction of panic behavior in beginning scuba students.”


2. A Study of Panic in Recreational Scuba Divers à http://www.divepsych.com/UJ1Q03p040_044_qxd.pdf



Regards,

DocVikingo

 

[Lopez116]

Hi Mantra,

You ask: "Are there any studies that show correlation between a pre-existing anxiety disorder and likelihood of panic underwater?"

Yes, there are. Here are a couple of important studies:


1. &#8220;Int J Sports Med. 2004 May;25(4):314-22.

Trait anxiety predicts panic behavior in beginning scuba students

Morgan WP, Raglin JS, O'Connor PJ

SourceDepartment of Kinesiology, University of Wisconsin-Madison, Madison, WI 53706-1189, USA. wmorgan@education.wisc.edu

Abstract

Recreational scuba diving is associated with a significant number of fatalities and decompression illnesses each year, and there is evidence that permanent neuropsychological injury can occur in divers. There is also evidence that the principal cause of decompression illness and fatalities in divers is rapid ascent, and it appears that the primary stimulus for rapid ascent is panic. The primary purpose of this investigation was to evaluate the extent to which an objective measure of trait anxiety could be effective in predicting panic behavior in students undergoing scuba training. Trait anxiety was assessed at the outset of scuba instruction in 42 students, and the instructor recorded instances of panic behavior during the 4-month course. It was predicted that individuals scoring 39 or greater on the trait anxiety sub-scale of the State-Trait Anxiety Inventory would be more likely to experience panic behavior than individuals with scores below this cut-off. Predictions and actual recordings of panic behavior were performed independently using a blinded paradigm. Eleven of the students exhibited panic behavior on two or more occasions during the instruction, and 35 of 42 (83 %) predictions were accurate (p < 0.001). It is concluded that an objective measure of trait anxiety can be employed a priori for prediction of panic behavior in beginning scuba students.&#8221;


2. A Study of Panic in Recreational Scuba Divers à http://www.divepsych.com/UJ1Q03p040_044_qxd.pdf



Regards,

DocVikingo

I read that article once before and actually found it to be a pretty positive article. Here's the bottom line of that study:

"Females with a prediving history of panic were 1.4 to 2.0 times as likely as those without a prior history. Most divers who panicked during a dive reported they remembered their training in how to deal
with panic and used that training. Eightyfive percent of those who panicked while diving did not make a rapid or uncontrolled ascent. Even among the 15 percent who made a rapid or uncontrolled ascent,
only five percent of males and four percent of females reported suffering from symptoms of decompression illness."

IMHO I believe that Mantra's comment ("If anything, I'm pretty familiar with what stress/panic feels like and have solid practice in not letting it take me over.") is right on the money.

Also, whereas panic disorder used to be an absolute contraindication to scuba diving, since 2001, that has been changed. The caveat is now that people with an untreated history of panic disorder is a severe risk condition for diving. I think the more society learns about these conditions, the more people stop hiding these things, and the societal "stigma" (real or perceived) is removed, these conditions can be treated more efficiently and effectively until the "severe risk condition" can also be downgraded. Again just my humble opinion.

 

[Mantra]

Thanks, guys. I'm reading more too, and am worried that this might be a thread hijack, so have moved the discussion on anxiety disorders and diving to:

http://www.scubaboard.com/forums/divers-disabilities/432915-anxiety-disorders-diving.html