The Best Laid Plans

April 8th, 2011 by gelenberg No comments »

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 by gelenberg No comments »

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 by gelenberg No comments »

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 by gelenberg No comments »

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 by gelenberg No comments »

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 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