Archive for the ‘Treatments’ category

A suicidal vet – and what I recommended

August 19th, 2010

Our residents and students just presented a patient to me at an inpatient case conference. The man was a veteran in his mid-50s, admitted after a very serious suicide attempt. This was the latest in a series of high-lethality attempts, which have left him seriously scarred. He became psychotic in his early 20s during military service, and over the decades since has had marginal function. He carries the diagnosis of schizoaffective disorder, which his history and my interview supported.

He has taken a raft of antipsychotic medicines—almost all available. He has also taken a host of antidepressants. Conspicuous by its absence was clozapine, which I recommended. Clozapine is unquestionably the best among antipsychotics, and evidence suggests it can attenuate suicidal impulses better than any other in the class. It’s a classic “double-edged sword,” with serious adverse effects and toxicity. But his risks from those is proportionally much less than the very high likelihood he will end his life in the near future.

The importance of negative trials

August 12th, 2010

An op-ed in the 23 July, 2010 Washington Post points out that doctors can learn a great deal from negative clinical trials. They teach us what doesn’t work.

I recall theories and preliminary clinical impressions in the 1970s that dialysis could cure schizophrenia. The NIMH sponsored studies. Dialysis didn’t work. Great. That saved patients discomfort and risks, families disappointment, and everybody a lot of money.

Some psychiatrists thought gabapentin could treat mania. It couldn’t. Negative studies are important.

I have edited the Journal of Clinical Psychiatry for 23 years. If a negative study is rigorous, well conducted, and with sufficient statistical power, we’ll publish it. Let’s learn what works. And what doesn’t—so we won’t waste resources and subject patients to potential harm unnecessarily.

A reader suggestion: Eye Drops Sublingually

August 5th, 2010

In your March, 2010 issue of BTP, I wrote an article on clozapine induced hypersalivation. In it I mentioned oral anticholinergics or alphaadrenergics as potential remedies.

Reader Dr. Jaymie Shanker writes of her solution for this problem: 1% Atropine eye drops sublingually. Dr. Shanker shares:
“I start with one drop SL before bed. For some people, that is all they need. Other people need 24 drop SL qhs; some, in addition to their one drop SL qhs, put one drop into a small amount of water next to the bed, so if they wake at night drooling, they can drink that water and control the drooling for the remainder of the night. Most people don’t need it during the day, but some do use one or a few drops SL in the morning as well. The only side effect is dry mouth, if too much is used. No systemic side effects! People love it! They feel so much better getting off their oral, systemic anticholingic…Of course, it ALWAYS prompts a call from the pharmacy before the first Rx is filled, because giving an eye drop sublingually is pretty unusual.”
I thank Dr. Shanker for sharing her experience.

Mood Disorders: Intervention works

July 29th, 2010

Bob Post just gave our weekly grand rounds at Penn State. Speaking from his long, productive (over 900 publications!), and illustrious career in studying mood disorders, Bob addressed the long-term course of unipolar and bipolar disorders. He speaks with the passion he feels for the topic and compassion for those who suffer from the ravages of these brain diseases.

Most probably people inherit a genetic vulnerability to mood disorders. It will be a long, long time before doctors can correct DNA anomalies. But stresses and abuse, especially in childhood but even long after, also contribute to the risk of episodes of depression. Current science suggests these environmental variables adversely affect brain structure and function, perhaps via epigenetic effects, which control how genes express coded proteins. More mood episodes are bad. They hurt, carry mortality and morbidity risks, and adversely affect function. Beyond that, they make future episodes even more likely, compromise long-term function and disease course, add medical and substance-abuse co-morbidity, and worsen treatment response.

The good news is that intervention works—decreasing the risk of future episodes, improving outcome, and saving lives. The broad array of treatments for bipolar disorder and recurrent depression—including medicines, stimulation techniques, psychotherapy, rehabilitation approaches, and perhaps even diet and exercise—protect the brain. Many increase levels of brain-derived neurotrophic factor (BDNF), which appears to attenuate the effects of bad life events.

Dr. Post emphasized the importance of early intervention in patients with mood disorders. (The typical lag from onset of bipolar disorder to first clinical attention is typically on the order of 10 to 15 years!) He also stressed the benefits of life-long treatment. In addition to warning patients about side effects, Bob suggests we tell patients about the positive benefits of psychiatric treatments for their brains.

Stun Guns: A place in psychiatric care?

July 22nd, 2010

Here’s a stunner for many of us in a profession based on the tenet “first do no harm.”  It seems some hospital security personnel are now using stun guns to subdue unruly patients. According to a report in the Washington Post, it’s not just police using Tasers and similar “non-lethal” weapons.

My reaction is strong and mixed. Under my department at Penn State, I’m responsible for the medical care of 74 in-patients. We also have four out-patient clinics. The threat of violence from psychiatric patients is always on our minds, as it is everywhere.

This technology is relatively new, but the dilemma isn’t.  We want to keep patients—and staff—safe.  If a patient becomes excited, agitated, angry, and potentially assaultive, we try verbal and behavioral interventions to de-escalate the situation.  When needed, we administer medications and, as infrequently as possible, resort to seclusion and/or physical restraint.

Is there a role for stun guns? Honestly, I’m unsure. It will require thoughtful investigation and discussion of the pros and cons, risks and potential benefits, and an ultimate local decision of where—if at all—these devices fit into an algorithm for patient and staff safety.

Mental Illness: Nature vs. Nurture

July 16th, 2010

Nature versus nurture. Teasing apart these two contributions to behavior and mental illness has preoccupied philosophers and practitioners since antiquity. The confluence of these factors came home to me when I saw a woman who suffered from Bipolar disorder and PTSD.

My patient had recently separated from an abusive, alcohol-dependent husband. Not surprisingly, her father had had the same behaviors. Her father also suffered from Bipolar disorder. When manic, he drank. When drunk, he abused his daughter—physically and sexually. Her own Bipolar disorder was complicated by PTSD from her childhood, exacerbated by the stresses of   her marriage repeating elements of her childhood.

So, presumably her dad had passed on to her the genetic vulnerability to develop Bipolar disorder, and via his comorbid alcoholism (well over half of patients with Bipolar disorder succumb to substance abuse) and resulting behavior, he abused her.

Treating a patient like this requires all of the art and science of our field. A therapeutic relationship is crucial. Therapy is essential—to help her with the symptoms of PTSD, as well as Bipolar disorder, and to help prevent her from repeating the pattern of destructive relationships. And all patients who have an unequivocal diagnosis of Bipolar disorder require maintenance medication. Needless to say, the medicine will only work if it is taken, again underscoring the importance of the therapeutic dyad.

MDD Guidelines

June 15th, 2010

Whew. This wasn’t easy. But it was necessary. And I hope useful for years to come.

A work group of the American Psychiatric Association just finished a 4-year gargantuan effort to revise and update the Major Depressive Disorder Treatment Guideline. And the APA has now formally approved the document.

I chaired the work group, made up of esteemed scholars, scientists and clinicians who gave generously of their time and talents.  Together we considered how much had changed since the second version of the guideline came out in 2000.

  • New medications have been studied in short- and long-term trials.
  • Drugs have been approved as adjuncts.
  • New forms of psychotherapy have been created and studied.
  • Nutritional supplements and exercise have been proposed and studied.
  • New stimulation interventions are available.

The work group looked carefully at each, and debated the pros and cons on their scientific merits. Some of the new treatments met the test for recommendation by this work group, and subsequently by the APA.

While there are many effective treatments, both new and old, as a whole, available options leave much to be desired.  Even after repeated treatments with a variety of medications and methodology, as many as one third of patients will remain symptomatic. There remains a tremendous need.

Given our current limitations, however, I am confident the new guidelines will help clinicians choose among a wide variety of approved treatments, from diet and exercise to brain stimulation. And our work must continue.