Archive for the ‘BTP’ category

In The Moment

May 20th, 2011

I just attended the APA meeting in Honolulu. One day I got in a little pool time. Sitting in an idyllic Hawaiian setting, on a perfect day, I glanced around and noticed about half the people at the pool were talking on cell phones. I pass people on the street walking with their children but gossiping with friends on the phone. Pet owners often miss out on the joy of play with their furry companion in favor of seemingly trivial chatter. Climbing Diamondhead outside of Honolulu, I reached the top, marveled at the site (and caught my breath), and had to step around distracted people on their cell phones. Let’s not even touch the subject of distracted driving.

I love many of the advances modern technology has brought us—including the ability to keep in touch across miles, to reach out to loved ones through satellite communications and so many electronic formats. But moments of intimacy, awe, play, solitude, and quiet are vital to our souls. Let’s not drown them out with noise.

-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

 

 

 

 

 

 

What Do You Know?

April 27th, 2011

As a physician I’ve long been struck by the observation that the best doctors are not those with the largest scope of knowledge or skills. Rather, the finest clinicians are the ones who know what they don’t know. Being comfortable with our vast areas of ignorance makes us safe for patients. We can learn the answers to clinically important questions. These days, most facts are as close as the smart phones we carry in purse or pocket. Or we can refer a patient to a colleague. Over the course of my career, acknowledging that I don’t know something has become easier as I’ve grown more self confident.

And what I’ve learned as a practitioner—knowing my limits—carries over to my role as an administrator. I am no expert in many of the areas of management: e.g., human resources, finance, accounting, legal, and more. But I have grown comfortable in saying “I don’t know” and asking others. In a world of growing complexity, it’s reassuring to be part of a team.

- 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

 

 

 

Therapy Is A Journey

April 15th, 2011

If a patient has taken medicines, I always get as much detail as possible: dose, duration, response. If a patient has been involved in psychotherapy, I try to learn what in the patient’s life has changed and through what means. People who demean and disparage the whole concept of psychotherapy claim it’s simply rent-a-friend. It can be, but ideally it should be much more.

Our goal as parents is to render ourselves obsolete. That’s also what I aim for when I’m a therapist: helping patients achieve the competence and confidence to kick off their “training wheels.” Even supportive psychotherapy should have an “end game.” Patients who seem to require the regular advice and encouragement of a professional can be coached on other sources of support: friends, interest groups, religious organizations. Symptom-based treatments or therapies designed to achieve behavior change should move progressively toward specific goals. Progress should be measurable. Endless therapy should be the exception.

When I take a patient’s history, and the patient has been in therapy, I hope to learn that therapy has provided a vehicle, that the patient and therapist have been on a journey—toward a destination. If therapy has just been a place to go and talk, if there has been no obvious progress, I raise questions.

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


 

Psychiatrists Don’t Do Therapy?

April 1st, 2011

A recent front-page New York Times article described how most psychiatrists have abandoned psychotherapy. It featured a Pennsylvania psychiatrist who, assisted by his wife as office manager, worked a very large and efficient volume practice of medication prescribing. The doctor, in his mid-60s, had been trained in dynamic psychotherapy and felt regret at not getting to know his patients nowadays. But what else could he do? The new short-visit, medication-focused practice style was the only way he could protect the lifestyle to which he and his wife had grown accustomed.

When I have the opportunity, I counsel medical students and residents to start out in practice by keeping their “expense base,” i.e., their lifestyles, modest. Am I advocating asceticism? No, freedom. If a couple becomes accustomed to a lavish way of living—big house, expensive cars, clothes, jewelry, and the trimmings—it is extremely hard to go down. Therefore, when insurers or, increasingly, employers demand more productivity or decreased income, the choice is forced. The penalty for many colleagues is conscience pangs and perceived stress. They “cannot” practice the medicine they wish to and would feel good about. I have witnessed many physicians pay the price in stress-induced medical and psychiatric symptoms and disorders.

I make no moral judgment, but it is, in fact, a choice. And there are consequences in either direction. And few who follow the rancorous debates concerning healthcare reform think physician compensation won’t take a “hit” over the coming decade and beyond.

So, can psychiatrists still practice patient-centered care, taking sufficient time to carefully evaluate patients, to get to know them? And can we still practice psychotherapy? Of course we can. It’s a question of money. We can accept lower rates of reimbursement per hour from insurers—for at least a percentage of our time. We can do some “pro bono” work. Or we can return to the days of yesteryear and ask patients to pay “out of pocket.” There are choices. There are options.

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

Dandelions and Orchids

March 11th, 2011

Dandelions are hardy. Give them a crack on a city sidewalk, and they will thrive. The beautiful orchid, by contrast, is much more delicate. To thrive it needs conditions like those in Costa Rica: warm, sunny, and moist.

Increasingly, research on the human genome suggests that important gene-environment interactions may lead to psychiatric syndromes. An example is that two short alleles on the serotonin-transporter (5-HTT) gene may heighten vulnerability to depression under adverse circumstances.

Why would such vulnerability genes survive? Shouldn’t people who inherit them be adversely selected, so their genes would decrease and die out over generations? Or, might such genetic patterns give evolutionary advantage in selected environments—something like sickle-cell trait making people more resistant to malaria?

Emerging evidence, including data from studies by Penn State scientists, suggests that some genetic patterns, such as two short 5-HTT alleles, might confer behavioral advantages in an optimal environment. People with two short alleles who grow up in nurturing, intact families, with educational and economic privilege, may actually show greater resilience and creativity, while others with the same genetic pattern, who come from poverty and dysfunction, may do worse than average. If this theory is correct, the people with two short 5-HTT alleles are “orchids,” doing beautifully in ideal environments, but worse than average in bad environments. The majority of people, who have either a short and a long or two long alleles, are “dandelions,” doing moderately well in a broad range of environments.

As I write periodically in BTP, we stand on the threshold of dramatic and exciting breakthroughs in understanding the brain. In time, these discoveries should help people who suffer from psychiatric syndromes—including autism, ADHD, depression, and PTSD

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