Archive for the ‘Treatments’ category

The Best Laid Plans

April 8th, 2011

During the decades I have spent in academic medicine and psychiatry, I have read countless inspired theories and hypotheses concerning diseases and their treatments. Unfortunately, few have panned out. Scientists were going to cure schizophrenia with renal dialysis. Personally, I was going to alleviate tardive dyskinesia and depression with the dietary neurotransmitter precursors lecithin and tyrosine.

Fortunately, medical science is not a religious faith. The nature of empiricism allows for hypotheses to be proved—or more commonly, disproved. That’s been the story of my career and, sadly, most psychiatric science of the last century. But in our healing arts, it’s better to face the truth.

Doesn’t it stand to reason that if we inhibit both the norepinephrine and serotonin reuptake pumps, we should heal more depressed people than if we block only the serotonin transporter? A study called PREVENT showed that not to be the case.

And if we administer long-acting injectable antipsychotic medicines to patients with schizophrenia, shouldn’t we lower the relapse rate more than if we depend on their taking oral tablets? Again, no. An upcoming article in Biological Therapies in Psychiatry—“Does LAIR Beat Oral Antipsychotics?”—bursts this very logical bubble.

Someday, we’ll reach “personalized medicine” in psychiatry. Someday, more good theories will prove true than not. We’re not there yet.

-Alan J. Gelenberg, M.D.
Editor, Biological Therapies in Psychiatry
Shively/Tan Professor and Chair, Psychiatry, Penn State University
Editor-in-Chief, Journal of Clinical Psychiatry


 

Flip The Incentives

March 25th, 2011

In the dysfunctional world of today’s U.S. healthcare, there are reverse incentives to care for people with chronic illnesses. Why control blood sugar in patients with diabetes, lower blood pressure in those with hypertension, or control high lipids? Doctors and hospitals make our “margins” on the strokes, MIs, limb amputations, and renal dialysis and transplants that result from poor care. And health insurance companies have little interest in long-term care, knowing that people move from one insurer to another frequently. In fact, if you get sick, your insurer is highly motivated to move you on.

Someday our healthcare system, with costs rising hugely, will figure this out. When it does, the incentives will reverse. The low-cost interventions that can enhance care for people with chronic illnesses—self-management techniques, removal of barriers, etc.—will make good economic and human sense. For a psychiatrist this brings great hope—as a citizen and an administrator, for sure. But also because the low-cost interventions are largely behavioral. Getting people to live healthier lives, take care of themselves, promote safety, and care for chronic illnesses can be achieved with easy behavioral techniques—many deliverable electronically. Even more, reversing the current perverse incentives will open opportunities for treating comorbidities—e.g., patients with diabetes mellitus who are also depressed can be identified and treated for both, and the results will be enhanced care of physical and mental health—with improved quality of life and economic productivity. Someday—perhaps soon.

- Alan J. Gelenberg, M.D.
Editor,
Biological Therapies in Psychiatry
Professor and Chair, Psychiatry, Penn State University
Editor-in-Chief,
Journal of Clinical Psychiatry

Do You Believe In Magic?

March 18th, 2011

Psychiatrists often treat patients who have magical thinking. But I’ve also observed magical thinking in psychiatrists and other physicians.

I recently spoke at a conference about treating depression. I presented data from several large recent studies (STAR*D, REVAMP, PREVENT), all of which refuted hypotheses about how to tailor depression treatment to individual cases. I spoke of what Gary Sachs calls a “menu of reasonable options.” I endorsed algorithm- and measurement-based care, recommending TMAP as a reasonable and easily accessed algorithm. I cited numerous articles I’ve reviewed in the pages of BTP.

When it was time for questions, someone asked if I could please provide guidance on how to choose the right antidepressant for a given patient. For example, the questioner went on, could the agitated/retarded dimension be used to select the optimal drug? I could give an answer, I responded, but it would be free of science or evidence—since there is none. There have been many theories on this, going back to the 1950s—using behavioral symptoms, urinary metabolites, and more. But they’ve all come a cropper.

I’ve heard speakers endorse hypotheses as if they were facts. Some “experts” were well compensated by companies, who hoped their products would gain competitive market advantage from doctors believing groundless theories. Other speakers promoting magical solutions to unanswered questions appeared simply to relish the celebrity status pseudoscience provided.

I do not like to be ignorant. I yearn for the day when personalized medicine will be a reality in all specialties, psychiatry included. But for our patients, it is better to be candid, to acknowledge the boundaries of medical knowledge. Today the best treatment for a patient is the one the patient will adhere to. And the best doctor is the one who knows what he or she does not know.

- Alan J. Gelenberg, M.D.
Editor,
Biological Therapies in Psychiatry
Professor and Chair, Psychiatry, Penn State University
Editor-in-Chief,
Journal of Clinical Psychiatry

Are Antidepressants Over- or Underprescribed?

March 4th, 2011

To begin at the conclusion, my answer to my own question is: yes.

Those of us who conduct mood disorder research typically emphasize the underprescribing. Research I became aware of in the early 1980s found that only 20% to 25% of patients with MDD received minimally adequate treatment. NIMH and advocacy groups ramped up public awareness campaigns. Did they work? Many independent studies through at least last year have sadly come to the same conclusion found 30 years ago: Only a minority of MDD patients receive minimally adequate treatment—biological or psycho-social. Nothing has changed.

What’s with the overprescribed then? An article in press at the Journal of Clinical Psychiatry, which I edit, from Pagura et al, reports that in 2005 about 27 million Americans took antidepressants. But only 26.3% of them met diagnostic criteria for any psychiatric diagnosis at any time during their lives. This computes to roughly 5% of the citizenry taking an antidepressant without an obvious justification. Most likely, some are appropriately receiving prescriptions from primary care providers for pain and other reasonable indications. But others are probably getting their “scripts” from a harried clinician in lieu of a time-consuming assessment and possibly therapy or counseling. As a society, we should do better.

- Alan J. Gelenberg, M.D.
Editor,
Biological Therapies in Psychiatry
Professor and Chair, Psychiatry, Penn State University
Editor-in-Chief,
Journal of Clinical Psychiatry

Unintended Consequences

March 1st, 2011
I read in the New York Times recently about the NIH establishing a National Center forAdvancing Translational Sciences, whose purpose is to foster the development of newmedicines. The raison d’etre of the new center is that the pharmaceutical industry is slowingdown the entry of new molecules into therapeutics. The cost of bringing a new drug to marketnow stands north of $1 billion. One of the areas of greatest concern is psychiatric therapeutics.

There are many valid explanations for this worrisome slowdown in drug development:changing business models, shifting subject populations in clinical trials, an evolving regulatoryenvironment, worldwide concerns about escalating healthcare costs, etc.


But a recent development that troubles me is the growing rift between talented experts inbiomedical research and the development process.


In the last few years, there have been legitimate and shocking stories about conflicts of interestamong some researchers and academics. As a result of This has led to intense media focus andscrutiny in the U.S. Senate., As a result, the NIH, the FDA, journals, professional societies, anduniversities rapidly constructed elaborate and often cumbersome mechanisms to avoid theslightest hint of taint. It’s now very difficult for the most knowledgeable experts to advise theNIH, the FDA, or the pharmaceutical industry, or to work on treatment guidelines and the like.Because of restrictions on research, paperwork, and fear of embarrassment if they consult withindustry, many experts stay home and focus on their science. And so we get less of the healthydynamic—the flow of knowledge and perspective—that enhances new-product development.


Pendulums swing. I worry about the unintended consequences of how far this one has swung.This challenge for our society is vaguely analogous to the need to strike a balance between civilliberties and public safety. How can our regulatory systems reasonably leverage the power ofacademic knowledge and expertise while, at the same time, safeguarding all of us against therogue scientist who would put personal gain above the welfare of fellow citizens?

- Alan J. Gelenberg, M.D.
Editor,
Biological Therapies in Psychiatry
Professor and Chair, Psychiatry, Penn State University
Editor-in-Chief,
Journal of Clinical Psychiatry

Unintended Consequences

February 25th, 2011

I read in the New York Times recently about the NIH establishing a National Center for Advancing Translational Sciences, whose purpose is to foster the development of new medicines. The raison d’etre of the new enter is that the pharmaceutical industry is slowing down the entry of new molecules into therapeutics. The cost of bringing a new drug to market now stands north of $1 billion. One of the areas of greatest concern is psychiatric therapeutics.

There are many valid explanations for this worrisome slowdown in drug development: changing business models, shifting subject populations in clinical trials, an evolving regulatory environment, worldwide concerns about escalating healthcare costs, etc.

But a recent development that troubles me is the growing rift between talented experts in biomedical research and the process.

In the last few years, there have been legitimate and shocking stories about conflicts of interest among some researchers and academics. This has led to intense media focus and scrutiny in the U.S. Senate. As a result, the NIH, FDA, journals, professional societies, and universities rapidly constructed elaborate and often cumbersome mechanisms to avoid the slightest hint of taint. It’s now very difficult for the most knowledgeable experts to advise the the or the pharmaceutical industry, or to work on treatment guidelines and the like. And so we get less of the healthy dynamic — the flow of knowledge and perspective — that enhances new-product development.

Pendulums swing. I worry about the unintended consequences of how far this one has swung. This challenge for our society is vaguely analogous to the need to strike a balance between civil liberties and public safety. How can our regulatory systems reasonably leverage the power of academic knowledge and expertise while, at the same time, safeguarding all of us against the rogue scientist who would put personal gain above the welfare of fellow citizens

Xanax

January 28th, 2011

n my humble opinion, benzodiazepines are not evil. Nor are they magical. They’re just drugs—with the potential to do good or ill, depending on dose, administration, the patient, etc., etc. They do many things well, help many people, and when prescribed by a knowledgeable physician and taken by a responsible patient, they can alleviate suffering. When the New York Times Magazine lambasted “Valiumania” decades ago, I thought that unfair.

But the triazolobenzodiazepines triazolam (Halcion and others) and alprazolam (Xanax and others) have always given me pause. Patients, friends, and colleagues have forgotten whole mornings’ activities after a bedtime dose of triazolam due to its powerful anterograde amnesia. It was withdrawn from the market in several countries because of these cognitive disturbances.

All benzodiazepines can, of course, be abused. But alprazolam gives more of a “buzz” than I’ve seen with other benzos. Its withdrawal effects are intense and dangerous. Patients taking maintenance doses of alprazolam watch the clock, eagerly awaiting their next dose. And boy, is it hard to get many patients to stop that medicine.

Some of the properties of triazolam and alprazolam may be due to their pharmacodynamic properties and receptor effects. Others likely reflect their pharmacokinetics—namely, their brief half-lives. I try to avoid prescribing them, favoring other members of the class when a benzo makes sense.

Given these opinions, I was dismayed to read in November’s Psychiatric Times that, of more than 250 million prescriptions for psychiatric drugs written in the U.S., alprazolam was far and away #1! Almost 50 million prescriptions were written last year for brand-name Xanax or generic forms.

I suspect most of the prescriptions are written by primary care practitioners, rather than psychiatrists. It’s a disappointing pattern.

- Alan J. Gelenberg, M.D.
Editor,
Biological Therapies in Psychiatry
Professor and Chair, Psychiatry, Penn State University
Editor-in-Chief,
Journal of Clinical Psychiatry

The Age Variable

January 21st, 2011

Several articles I’ve been working on for my monthly newsletter, Biological Therapies in Psychiatry, made me think of aging as a key variable in therapeutics. Commonly prescribed psychotropic medications adversely affect bone health and may increase the risk of falls—a double whammy for fractures. Some psychiatric medicines increase the risk of bleeding, others the risk of venous thromboembolism. All of these hazards are even greater in the elderly—particularly in patients with medical illnesses and taking multiple medications.

The population is growing older. I am seeing more patients in their 60s, 70s, 80s, and 90s. And, miracle of miracles, I’m getting older! (Who knew?!) We can’t reverse the calendar. But we can factor a patient’s age, comorbid conditions, and other treatments into our therapeutic algorithms. Some of the approaches are decidedly low-tech.

Can my patient read the name and directions on a medicine bottle? (The print can be really teeny.) Does the bottle have a child-proof cap that’s hard for someone with frail hands or arthritis to open? Does the patient understand the nuances of how and when to take the tablets? Especially when there are multiple medications, advise about inexpensive pill containers, with the days of the week embossed in large characters on easy-to-open boxes. They come in many shapes and sizes and can be filled weekly by a patient or family member. Calendars and electronic devices also can provide mnemonic assistance.

Ask patients and family members about driving competence and safety. There are increasing numbers of electronic and mechanical devices in newer cars, which can enhance the safety of older drivers (and their passengers and others). And there comes a time to discuss relinquishing a driver’s license.

I think and ask about barriers, obstacles, and other tripping risks in the home—especially for paths likely to be trod after dark (like the route from bed to bathroom). What about risks for slipping in bathrooms?

Practitioners know to ask about other medicines a patient is taking. I cannot possibly be conversant with all current medications, but answers about their indications, adverse effects, mechanisms, and potential interactions are as near as my computer or smart phone. And I try to remember to ask about over-the-counter preparations, including dietary supplements—many of which can interact with prescribed medications.

We can’t turn back time. But we can remain aware of its effects and open practical conversations with patients and their friends and families.

- Alan J. Gelenberg, M.D.
Editor,
Biological Therapies in Psychiatry
Professor and Chair, Psychiatry, Penn State University
Editor-in-Chief,
Journal of Clinical Psychiatry

The Person Within

January 10th, 2011
Gerry Klerman, my mentor, referred to the Washington University approach to psychiatric diagnosis (and the DSM-III that it spawned) as a “Chinese-menu:” one from column A, 2 two from column B. We have lived with this descriptive focus for several decades, and truly, psychiatrists must be competent in reliable diagnosis. But there’s undoubtedly more to our art and science.
A few days ago I admitted a 50-something gentleman to our in-patient hospital. He came with a long-standing diagnosis of schizophrenia. I always bring a critical eye to psychiatric diagnoses of patients I am newly meeting. But in his case, the diagnosis fit well. The history was totally consistent, and with his blunted affect and ongoing paranoid and odd delusions, the diagnosis of schizophrenia was pretty well established.
I completed our interview, then explained to the patient that I was going to spend a few minutes entering his information into a computer terminal. (It was my first experience with our new electronic medical record.) While I was busily typing away, he leaned over to read my ID badge. “Alan,” he said. I was surprised to hear my first name and looked up. “You’re a snappy dresser.” My face broke into a broad, spontaneous grin. “Thanks,” I responded. “I really appreciate your saying that.”
I do my best to teach our students and residents what I struggle to remember myself. There’s the Axis-I diagnosis. Sometimes it’s a severe one, like schizophrenia—which robs people of much of their human ability to connect with others. But beyond the multiple axes of DSM-IV, there are human strengths, talents, likes and dislikes. And as this man showed me, the ability to reach out and relate at a person-to-person level often persists.

- Alan J. Gelenberg, M.D.
Editor,
Biological Therapies in Psychiatry
Professor and Chair, Psychiatry, Penn State University
Editor-in-Chief,
Journal of Clinical Psychiatry

BAL

January 3rd, 2011

When I was in medical school and during my medical internship, it was axiomatic that we treated patients—not laboratory values. That axiom remains valid in today’s high-tech medicine.

I find that sometimes my non-psychiatric colleagues fail to appreciate the gravity of alcohol and sedative-hypnotic withdrawal, a syndrome that carries a high mortality risk. And sometimes a patient can come into an ER with alcohol on his breath and a high blood alcohol level (BAL) and still be in impending delirium tremens (DTs).

A woman walked into our ER. (Yes, she really walked.) She spoke coherently but was agitated. Her BAL was the highest I’ve ever seen: 455! Within an hour she had a seizure and was in florid DTs. She had no other neurological abnormalities on physical exam or scan. So with a BAL that high, she was actually in alcohol withdrawal. She must have been routinely consuming a huge quantity of alcohol, with a high level of dependence.

We treat patients—not lab values.

- Alan J. Gelenberg, M.D.
Editor,
Biological Therapies in Psychiatry
Professor and Chair, Psychiatry, Penn State University
Editor-in-Chief,
Journal of Clinical Psychiatry