Diving with OCD/Anxiety + taking lexapro?

[pearl21]

Hi all, I am a long-time diver (15 years). Recently, my brother has shown an interest in learning to dive. There are some anxiety and OCD issues that run in our family.

I have a little of it myself and have dealt with panic attacks and such in the past but have known what they were for a long time and that they can't hurt me, so they don't really bother me anymore.

Anyway, my brother takes 15mg of Lexapro daily for OCD and some anxiety that results from his OCD. He had some rough times several years back with the OCD but has improved steadily over the last several years. He has been on lexapro and has taken cognitive behavioral therapy for about 3 years. I won't say he's free from OCD because I don't think there is such a thing for someone who has it, but he is a stable person now. I don't have concerns about him "freaking out" while diving or anything like that any more than the next person. However, I do have concerns about Lexapro and diving. I don't know anything about it so I don't know if the effects of it would be amplified at depth or not. From what I understand, the drug is not a sedating drug. It does not have warnings about operating machinery or driving while taking it, etc.

Can anyone tell me if diving while taking this drug is safe?

[H2Andy]

well, Lexapro is an SSRI, and i am not aware of any counter-indications for diving with SSRI's, though you need to be aware that high doses of SSRI's have been linked to seizures ... of course, no one really knows what effect (if any) higher pressures can have on this effect

i take 60 mg of Celexa (also an SSRI) and can dive ok, never had a problem. never had a problem topside either. maybe that's as good a sign as you are going to get of how your brother will react under water.

of more concern to me (not a doctor, etc.) would be getting a panic attack while diving, related to a possible anxiety disorder. i don't think OCD will be an issue under water, personally.

here's a good article:

http://scuba-doc.com/alertdiver2.html

[fisherdvm]

Not speaking as a medical person, but more from personal experience. Mental disorder runs strong in my family, and I was married to a woman with OCD.

I took an SSRI (Paxil) after my ex-wife left me with my son during residency. It had a dramatic effect on my thinking and response. So I am very impressed with how these drugs worked. I was worried that it would affect my decision making ability - but it did not. I still finished my residency and passed the board exam. However, it caused severe insomnia that lasted for the several years I took it, and the day I stopped, I slept like a baby for a full 8 hours.

I agree with Andy, my fear would be getting an anxiety or panic attack while diving. People with OCD might make excellent divers from the standpoint of being meticulous about predive, dive, and post dive checks. But some are affected by excessive anxiety. It might not take much stress or information overload to paralize such a person.

I would be careful to label anyone as having OCD. In my opinion, patients with true OCD tends to be very limitted in task loading. In my opinion, people with OCD can not multitask - which is absolutely required in diving - being aware of multiple skills and issues at the same time.

Whereas, obsessive compulsive trait is invaluable in many professions, trades, etc.... and does not make a person showing such trait as having OCD.

[mstevens]

I've got a patient with *treated* OCD with whom I'd dive in a second (if he were someone else's patient. I'm more worried about panic disorder unless it's really well-controlled, and even then would not be very comfortable diving with someone using benzodiazepines. However, when it comes to SSRI's such as Lexapro themselves (apart from the conditions for which they may be prescribed) I have absolutely no concerns whatsoever when it comes to diving. As a caveat, as a psychopharmacologist I'm probably abnormally comfortable with medications in general.

I couldn't agree more with fisherdvm about the differences between OCD and OC traits, and about untreated OCD being a serious problem for diving while OC traits might perhaps be advantageous. Apart from difficulties multitasking, OCD can cause severe problems with simply quitting something or switching tasks. Sometimes it's critically important to stop doing one thing and start doing another right away.

[fisherdvm]

I think the british scuba organization have issued warnings concerning certain SSRI and seizure threshold lowering.

My guess, not based on any studies, is that the whole class of SSRI's might lower seizure thresholds, and divers who take such drugs should be careful not to push their oxygen toxicity limit, and not to push the NDL either.

[DocVikingo]

Hi pearl21,

No reason to wonder what the British Sub-aqua Club (BSAC) (UK Sports Diving Medical Committee (UKSDMC) actually wrote it) has promulgated regarding SSRIs. It's right here:

"SSRI's and diving

As mentioned in the last newsletter there are more divers than ever using antidepressants, particularly the selective serotonin reuptake inhibitors such as fluoxetine (Prozac). This is thought to be dangerous when diving because of the risks of the medication, and the underlying condition. Some individuals require SSRI’s for anxiety or stress symptoms rather than clinical depression but these patterns of behaviour are not ideal personality traits for any diver who may have to cope with very dramatic events underwater.

The SSRI’s are less sedative than other antidepressants such as the tricyclics, although the recognised side effects still include drowsiness, dizziness and rarely convulsions or mania. Their effect in humans at hyperbaric pressure is largely unknown and there are no published studies in a peer reviewed journal examining this issue. Given the lack of information it is not possible to advise divers on the actual risks involved. It certainly would be possible to perform an anonymous retrospective survey of divers to assess anecdotal experience with SSRI’s but the scientific value of this is limited. There are biases inherent in this technique particularly since enthusiasts are more likely to reply to the survey, rather than those no longer involved in diving because of drug related problems. The solution may lie in performing a prospective safety audit, similar to the diabetes and diving database asking divers on SSRI’s to detail their diving pattern. An additional study would be to examine volunteers established on SSRI’s by psychometric testing at hyperbaric pressure although this would provide limited information on the effects of such drugs in the real world when diving in the cold, sometimes murky water around the UK.

It is reasonable to continue the ban on diving with other classes of psychiatric medication because of the more prevalent side effects likely to interfere with diving. The paternalistic and protectionist approach in assessing fitness to dive is often criticised but sport diving is unusual in that divers are not simply responsible for their own safety, but have to be able to provide help for their buddy in an emergency. The diver can certainly be asked to give informed consent to diving while taking SSRI’s but the buddy should also be asked to consent to their involvement. This raises confidentiality issues which are difficult to resolve.

There are two conflicting approaches to the problem. The first is to assume that SSRI’s and sport diving are incompatible and that the current ban should continue. This would be a safe approach but there would be no supporting evidence and such a policy could lead to the unnecessary exclusion of divers. The second is to assume that SSRI’s are unlikely to cause problems when diving if the individual has no examination abnormalities, has no reported side effects from their medication, and assuming that the underlying condition is well controlled and not a recognised contraindication to diving.

The committee currently recommends that any individual taking SSRI’s should be advised against diving. Exceptional cases should be referred for consensus assessment and if approved then these divers will be followed as a prospective cohort. Scientific studies are already being designed to assess the effects of SSRI’s at pressure."


Before making a decision, I strongly suggest that you read the following article I wrote for DAN's Alert Diver magazine:

Depression & Diving: Part II
Making the Call on Recreational Diving
http://www.awoosh.com/Doc%20Vikingo%27s%20Resource%20Page/Depression_&_Diving.htm

While its focus is depression, there is considerable discussion of SSRIs and application to diving with any mental disorder. Also, the concluding section, which examines approaches to making the call on diving with a mental disorder, may assist you in the decision making process.

Feel free to ask any questions that may arise from that reading.

Regards,

DocVikingo

[pearl21]

Doc (and others),

Great information, thank you.

Do you have any idea if the percent of people taking SSRIs in the general population is the same percentage as in certified divers?

Also, do you know what percent of diving fatailties are attributed by DAN to convulsions/seizures? Does DAN try to get toxicology reports from fatal cases to see what medications were in the victim's blood?

[H2Andy]

Also, do you know what percent of diving fatailties are attributed by DAN to convulsions/seizures? Does DAN try to get toxicology reports from fatal cases to see what medications were in the victim's blood?

unfortunately, no

accident analysis (as to cause of death and other details) is extremely difficult to do in scuba diving

all coroner's reports basically say "died from drowning"

no kidding

[fisherdvm]

Seizures are hard to diagnose, even if the patient is alive, and you saw it happening. You can not tell in every case if a loss of consciousness event, falling, or twitching is due to seizure, fainting, heart arrhythmia, or drug reaction.

That is why frequently - you will need a cardiologist input, and a neurologist input - before you can diagnose seizure.

An eeg done soon after the event (on a living patient), and a tilt table test done by a cardiologist might be needed to confirm a case of seizure.

Naturally, you can not do either on a drown victim - they have no brain wave and no blood pressure.

[DocVikingo]

Hi pearl21,

My pleasure.

1. (Q) "Do you have any idea if the percent of people taking SSRIs in the general population is the same percentage as in certified divers?"

(A) This has not been directly studied. However, based on studies of the number of active divers with affective and anxiety-mediated disorders, the percentages might be expected to be somewhat similar.

2. (Q) "Also, do you know what percent of diving fatalities are attributed by DAN to convulsions/seizures? Does DAN try to get toxicology reports from fatal cases to see what medications were in the victim's blood?"

(A) DAN receives this info only if it is reported as part of existing incident/treatment records. It does not make any special efforts to develop this data.

Regards,

DocVikingo

[mstevens]

Does DAN try to get toxicology reports from fatal cases to see what medications were in the victim's blood?

Back when I was an autopsy tech, the pathologists would request toxicology screens and levels of therapeutic drugs the patient was known or suspected to have been taking. The screens were quite general, and were limited to common drugs of abuse (some of which were also therapeutic drugs such as barbiturates or benzodiazepines). Sometimes, heavy metal panels or insecticide screens were requested.

Too many drugs exist for it to be practical to screen for every possibility at autopsy or clinically, so a tox report will only ever let you know if specific drugs that were looked for actually showed up, not a "real" answer to the question of what drugs were in the system.

You might also be surprised at how very few autopsies are performed. Many "ME cases" aren't even necessarily autopsied.

[pearl21]

Hi pearl21,

My pleasure.

1. (Q) "Do you have any idea if the percent of people taking SSRIs in the general population is the same percentage as in certified divers?"

(A) This has not been directly studied. However, based on studies of the number of active divers with affective and anxiety-mediated disorders, the percentages might be expected to be somewhat similar.



Doc,

If the percentages are similar, and given that those percentages are not trivial, wouldn't it be reasonable to assume that SSRIs and diving mix pretty well? If they did not you'd probably hear of a lot of problems/accidents. Would you agree that's a reasonable assumption?

If not, why?

Thanks

[H2Andy]

If they did not you'd probably hear of a lot of problems/accidents.

only if someone were tabulating whether the injured or dead divers were on any sort of anti-depressant

that is not done, so no one really knows

[pearl21]

only if someone were tabulating whether the injured or dead divers were on any sort of anti-depressant

that is not done, so no one really knows

The 2006 DAN report shows 88 (reported) diving fatalities involving US/Canadian citizens. 88 is a very small percentage of US/Canadian certified divers, whereas the percent of all US/Canadian certified divers taking SSRIs is most likely not a small percentage. If there was a serious SSRI problem, you'd expect to see a lot more deaths.

Comments on that logic?

[H2Andy]

i agree with your logic

i'm just saying, there's no real way of knowing

[fisherdvm]

An anology of this is the suicide rate in patients who used accutane. It is so low, that it is not statistically significant. But to the average dermatologist, like myself, you do see patients who flip the switch and act abnormally.

Because of the low incidence of diver death, and the poor collection of data - it is only reasonable for physicians and diving organizations to make conservative recommendations.

There are medicines that doctors tell their patients not to use while they are pregnant, but the same doctors willl use these medicines on themselves during pregnancy. The risks might be so small and theoretical, but with litigation a major issue, I don't think you'll get any professionals to tell you what you want to hear - ie. that they think SSRI is safe to mix with diving.

Based on what DocVikingo posted, I would say, SSRI is not safe to mix with diving. But what I do myself if I were taking SSRI is my own personal decision.

[DocVikingo]

Hi pearl21,

IMHO, both fisherdvm & H2Andy make excellent points.

The numbers are incredibly small and would be beyond the reach of any clinically meaningful statistics even if we did know the number of divers on SSRIs who were harmed while on scuba, which we don't. Then, there is the issue of whether the injury or death was the result of an SSRI, another concurrently administered psychotropic (combination drug therapy is common), the mental disorder itself, some combination of the aforementioned, or an unrelated cause. It will be a long while before this specific question is answered.

In the meantime, I again refer to the concluding section of my article which examines approaches to making the call on diving with a mental disorder, and in particular:

"3. Assume that depression (or anxiety-mediated disorder) and the drugs used to ameliorate it do not preclude diving provided that: (a) mental status examination demonstrates the condition to be well controlled; (b) the diver on medication has been on for an extended period and side effects dangerous to scuba are neither reported nor observed upon careful examination; (c) there are no other contraindications in the clinical picture; and, (d) the diver feels he is up to it and fully comprehends the remaining risks."

This perspective should be examined with the diver's psychiatrist and medical clearance for scuba discussed.

Given medical clearance, and that the diver is upfront with dive ops and buddies, it largely boils down to the degree of risk the individual is willing to assume.

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.

Regards,

DocVikingo

[Spratman]

As with the others, I take several different medications for my depression/bipolar 2 disorder. (Zoloft, Trazadone and Trileptal) I have been diving for three years in several different environments without any problems. Sometimes the issue of diving with depression does not get clearly defined. Diving with depression untreated is a no brainer. BAD!

I've read Doc V's articles and agree with fisherdvm and H2Andy as well. If anyone should want start a project regarding testing on divers with depression, I'd gladly volunteer. I think garnering some actual data on this matter would be useful to all.

Having said that, it's got to be a doctor/patient discussion and a diver/dive doctor discussion as well. I'm quite comfortable with underwater training and responding to emergency situations. I believe that it goes on a individual basis. Your buddies need to be aware of it and comfortable with diving with you as a buddy. The guys I dive with believe that I'm a safe and stable diver, and would dive with me anytime.