Posts Tagged ‘antipsychotics’

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


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.

Summer heat and a caution about fluids

July 9th, 2010
More thoughts triggered by summer’s heat. Hydration is good—usually. A couple of exceptions, however, apply to folks with chronic mental illness.
Occasional people who have chronic psychosis drink enough water to drop their serum sodium and risk seizures, coma, and death. Most likely, the mental illness itself somehow manages to impair the usual feedback loop that turns down antidiuretic hormone and maintains proper fluid balance. Antipsychotics also may contribute. The resulting syndrome of inappropriate antidiuretic hormone (SIADH) often is diagnosed following a seizure and usually requires assessment of medications and restriction of fluid intake.
More common in people with mental illness is consumption of calorie-laden beverages, with resultant weight gain and sometimes dental caries and gum disease. As I wrote in another recent blog, encourage the chronically ill to stay well hydrated—especially in hot weather. But the best fluid is plain water, sometimes made more appealing with a slice of fruit or cucumber. Sugared beverages should be discouraged, as they can lead to weight gain and its many long-term consequences, like diabetes mellitus. Diet soft drinks have been found to spur increased desire for sweets, thus paradoxically leading to weight gain. Water and seltzer are far better for
long-term health than sodas and even juices.