Are Antidepressants Over- or Underprescribed?

March 4th, 2011 by gelenberg No comments »

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 by gelenberg No comments »
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 by gelenberg No comments »

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

Aging

February 18th, 2011 by gelenberg No comments »

In college I majored in psychology. Back then, B. F. Skinner ruled. I remember reading an essay he wrote about coping with aging. In his characteristic practical, methodical manner, Skinner dealt with memory lapses by writing himself a lot of notes and being very organized.

The first of the Baby Boomers have begun to turn 65. I’m a tad ahead of the Boomers, and many of the patients I see are in their 60s, 70s, and 80s. What advice can we give them—and ourselves—about steps to improve health and function and lower risks as the years take their toll?

Skinner used paper and pencil to augment his memory. We can do likewise, but we also have many electronic options from which to choose—and they can beep or chime at designated moments.

Modern technology can assist in many ways. For those who can afford them, new cars feature a growing number of active and passive safety features, helping to avoid and survive accidents. Trouble hearing? Technologic advances have made modern hearing aids vastly more effective than their predecessors—and easier to conceal.

There is nothing like a fall to make us feel old all of a sudden. Lowering the risk of falls as we age takes thought and planning. The greatest risk zone is one’s own home. Check it out. Look for and correct obvious hazards. Consider night lighting. Assess surfaces that are slippery when wet: e.g., bathroom and kitchen floors and entrance halls. When staying overnight in an unfamiliar setting, evaluate the path between bed and bathroom for hazards in low light. For our patients and ourselves, be mindful of postural hypotension and when dizziness may strike. Attention to sidewalks and proper footgear is important in winter.

Strength and aerobic training can lower the risk of falls. Balance exercises are particularly valuable as we age.

I love pets. Over the decades, I have bonded with and delighted in a number of horses, dogs, and cats. But for all they offer us, pets presents risks as we get older. The dangers from horses are obvious: you can fall off, get stomped on, kicked, etc. Smaller animals can trip their owners. Collars that jingle will warn of a running approach. It is good to routinely grip a handrail when descending stairs. Walking a dog on a leash idea demands constant awareness and precautions.

Doctors are always preaching the gospel of diet and exercise—and we should. Maintaining a healthy weight, body mass, flexibility, mobility, and cardiovascular tone help us age with grace, better function, and greater ease. Growing old may not be fun, but as the old cliché puts it, it beats the alternative.

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

A Life Worth Living

February 11th, 2011 by gelenberg No comments »

Psychiatry is a medical specialty. Appropriately, we tend to focus on pathology: symptoms, dysfunction. But before I complete an assessment of a patient, I try to remember to elicit what the person is about, what makes him or her “tick.” What are the assets, the passions? Should I neglect to elicit those “positives,” even if I prescribe an ideal treatment, the patient may not follow my advice—because we would not have “connected.”

Similarly, clinicians routinely inquire about what is demoralizing, what makes a person consider suicide. The “flip side” too is important. What is re-moralizing? What keeps the person grounded, attached to life?

I’ve run into several patients lately who turn to mental-health professionals for passports to meaning and happiness, for antidotes to ennui. I was struck by how these folks had reached adulthood without learning those things that make life meaningful, fun, worthwhile, things that make us happy to awake in the morning. Those things seem pretty elementary: passions; contributing to causes outside ourselves; play with others, a sense of mastery and productivity; feelings of goodness and efficacy; attachments to people we care about; and love. When I meet someone like that in a clinical encounter, I do share those observations. But typically the patient is disappointed. It seems life has yet again brought them to a god with feet of clay.

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

Comfort and Hygiene

February 4th, 2011 by gelenberg No comments »

I can’t recall when I first heard the term “comfort food,” but I connected with it instantly. When we’re lonely or blue, most of us prefer to eat something familiar, simple, and old-fashioned—like chicken soup. I was well into mid-life when I gave thought to the need for self comfort at selected times—like during or after a stressful event or following a loss or disappointment. Foods can be comforting, and even an occasional calorie splurge will be blessed by the health overseers—so long as it’s modest and occasional. (The four hours of comfort that alcohol affords can be more problematic.)

“Sleep hygiene” is by now old hat. It’s certainly not “high tech.” And it’s obvious on its face. But in young adulthood I was so busy charging ahead on my career that I missed out on the comforts of a gradual wind-down before bed. So did my patients, because I never counseled them about it.

Back then if I had an intense evening—a late meeting, working on a grant application—I’d finish up quickly, change into my PJs, and dive for the pillow. The extra minutes in bed that my haste bought me typically was at the expense of a restful night. But it took me years to figure that out.

Of course, some people are fortunate enough to be able to weather a stressful evening, hit the sack, and sleep like proverbial babies. They are lucky and don’t need this sermon.

But the rest of us need permission, discipline, and structure to dial down the stressors and dial up some comfort at day’s end—especially after a stressful or painful day. The last dose of caffeine should be many, many hours before bed. Baths are good; showers are bad. Stretching, breathing exercises, and yoga are good. Vigorous exercise is bad. Comfort reading and TV are good. News, work, and stimulating reading or viewing are bad. A pre-bed check of email might bring comfort, but since it also may bring stress it is best avoided. When I typed “sleep hygiene” into an internet search engine, it spewed out reams of advice—much more than I can offer. But in today’s complex, stressful, high-tech, multi-tasking, multi-media world, there’s a place for the simple, the obvious, and the comforting.

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

Xanax

January 28th, 2011 by gelenberg No comments »

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 by gelenberg No comments »

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 Shooting in Tucson

January 13th, 2011 by gelenberg No comments »

Like virtually everyone else in the U.S., I was stunned to learn of last Saturday’s violence and murders. It touched me personally, as I had spent 18 years in Tucson, where my wife had been a TV anchor. My wife and I know Congresswoman Giffords and several shooting victims. In 2006, my wife ran against Gabby Giffords for the Democratic nomination to the House seat, which Gabby ultimately won—now three times. I was also intimately involved in mental health services in Tucson and Arizona, so the nature of the crime and presumed mental illness of the alleged shooter struck home.

What can we learn from this horrible, seemingly senseless tragedy? Probably, laws should make it easier to detain someone for a psychiatric examination if they are suspected of being mentally ill. And it should be easier to force a mentally ill person to undergo prescribed treatment. But even though Arizona’s mental health funding is anemic and decreasing, Arizona’s laws in this regard are exemplary. In fact, I will advocate for changing Pennsylvania’s statutes along similar lines. Apparently and sadly, the system in Tucson failed to intervene in time in this case. Better resources and greater public awareness of when and how to intervene when a young man appears so disturbed might make a difference in the future.

I was appalled by the rancorous and violent tone of the 2009 debates on health care reform. The vitriol has continued, increased, and extended to matters of budget, immigration, and much more. Vigorous debate and exchange of ideas is a healthy part of democracy. But thinly veiled threats and incitement to violence feed the fires of those with aggressive impulses and poor self control—including people with psychosis. As a society, we must find a dividing line between censorship and fostering harm.

Finally, there is the matter of gun control—the “third rail” of politics. A psychotic, homicidal person can hurt, maim, and kill with a blunt instrument or knife—but not as many people as quickly as with an automatic or semi-automatic firearm. A Glock pistol with an enlarged magazine can wreak havoc, killing a little girl and creating instant widows and widowers. I pray for Congresswoman Gifford’s recovery and for all the victims and their loved ones. It is so very, very sad.

- 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 by gelenberg No comments »
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