Friday, October 23, 2015

What I'm Learning at the MGH Pscyhopharm Conference (Part 0.5)

Greetings from Boston!

I am here, with 750 or so psychiatrists, at the Massachusetts General Hospital's 39th annual psychopharmacology conference.   I wanted to update my medication knowledge, and the meeting runs through the weekend.  The day has been stuffed with useful information, and really good lectures -- much too much to blog about and there are still 2 hours left tonight.  Let me just give you a sample from each lecture:

Dr. Nierenberg on Bipolar Depression:
He suggested checking out
"Bipolar depression is really hard to treat; so many people don't get all the way better."
~People can be depressed, manic, anxious and irritable all at the same time.
~Antipsychotics and a  mood stabilizer aren't much better than antipsychotics alone.
~There are 4 FDA approved treatments for bipolar depression: olanzapine/fluoxetine combo, quietipine (Seroquel), Lurasidone (Latuda), and Lamotrigine (Lamictal)
~Seroquel's response rate is the same for 300mg as for 600mg
~Latuda's response rate is the same for 20-60mg as for 80-120mg
~Lamotrigine is not approved for the acute treatment of bipolar depression, but for prevention.  It is well tolerated.
~Lithium + Lamictal are more effective to prevent depression than mania.
~Some people use antidepressants alway, some never : the experts can't agree.
~Low dose Abilify has been disappointing in bipolar depression.
~Single dosing at night may prevent renal complications.

Dr. Perlis on Long-term management of Bipolar Disorder
You only know if someone has bipolar depression after they've had an episode of mania; family history or early age of onset don't make the diagnosis if the patient is depressed.
~Effective antimanic agents: lithium, valproate, carbamazepine, any antipsychotic.
~Lamictal, gabapentin, and toprimate have not been shown to be effective for mania
~Lithium decreases the risk of suicide.
~Aim for a level of at least 0.6, but risk of renal damage increases with time (decades) and levels (>0.8)
~Lithium and valproate are better than valproate alone
~This guy likes lithium.

Dr. Fava on Treatment-resistant depression
Strategies: increase dose, change medications, augment, combine.
~Buspirone is a safe agent to use for augmentation
~Mirapex (pramippexole) --can go gradually up to 1.5mg bid
~There is some way to get a compounding pharmacy to make intranasal ketamine, but this needs to be monitored.
~Lots of stuff has been tried.

More later --  


Unknown said...

Currently on a behavioral health rotation for my DNP degree and working on a power point for class on bipolar... sooo... thanks for sharing!

George Dawson, MD, DFAPA said...

I have used buspirone augmentation since Star*D and agree that it is generally effective. There are rare but significant problems with serotonin syndrome and early serotonin syndrome. If I had to guess based on my experience and review of the literature I would suggest it is less likely to cause serotonin syndrome than MAOIs + antidepressants or gram quantities of tryptophan + antidepressants but it can happen. Vital signs and symptoms of serotonin toxicity need to be closely followed.

Another mistake is that many people prescribe the same doses used for buspirone monotherapy and that is generally too high when used with antidepressants.

Joel Hassman, MD said...

from the above 1st lecturer:

"~People can be depressed, manic, anxious and irritable all at the same time."

yeah, it's also called axis 2 disorder features as much if not more than any legitimate bipolar disorder.

Oh, and I am just dying to know what medS routine the lecturer recommends, what, at least 4 meds?

One of the first rules I think patients have the right to enact is simply this: ask the prescriber if he/she would be willing to take 3 or more psychotropic meds, and prescribed at the same time as starting dosages.

Watch the squirming and throat clearing before your eyes, or, just the simple denial or deflection. Incredible what passes as "responsible" psychopharmacology these days, hmm???

And all based on a generic diagnosis...

Dinah said...

Lisa -- I'm happy to help! Good luck.
George -- he suggested 15mg/d (5 tid, I believe). They've noted that a true serotonin syndrome is quite rare, though serotonergic side effects can be seen.
Joel -- I'm not sure I agree that having a variety of symptoms that don't fit neatly into the boxes DSM created means that the symptoms aren't valid or legitimate, and much as I think no one asks for a either a mood or a personality disorder, I worry that chalking symptoms up to "axis II" is a way of blaming the patient and not trying to help. Bipolar disorder can be very hard to treat with all it's co-morbidities.

Joel Hassman, MD said...


So you are going to agree that we, who have been practicing for more than 20 years, were underdiagnosing Bipolar Disorder by what, 300-400% of the time once antipsychotics got the alleged indication to be used as "mood stabilizers"?

Sorry, I do not agree with that failed premise, and mood lability does NOT equal Bipolar Disorder as much as colleagues just reflexively conclude and then put patients on three or more psychotropics within the first 2-3 visits at most.

Treatment resistant illness is based on several tenets, and the first is not just automatically the patient is on the wrong meds. Umm, did I go to the wrong program when I was advised rethink the diagnosis if typical and reliable meds have NO impact whatsoever on the symptoms?

And I am letting readers know my opinion about the worst offenders who sold the biochemical model was the basis to psychiatry back in the early 1990s: Stanford, Harvard, and Hopkins were, what I call, the Unholy Three who had the largest and loudest KOLs selling drugs were the ticket.

When I applied to residency programs in 1990, Hopkins told me I would not get any training in psychotherapy. That application was dumped in the trash after that revelation. And where are you getting your CMEs this weekend?

Ivy League school, nah, to me a Poison Ivy league...

Sorry, how much degradation of your profession can you endure before finally realizing you are mad as hell and not going to take it anymore..............

Unknown said...

Thanks, Dinah, for passing on what you are learning.

Unknown said...

Thanks for sharing the tidbits...psychiatry really is both an art and a science....I'm not a doctor or a doctoral candidate, but i am a patient and a nurse...and thoughtful psychopharm has given me a chance to remake my life..."cookbook" psychopharm of following a protocol without really attending to the individual person nearly led me to give up on all meds.
Sounds like a very intense weekend! Clairesmum

Jen said...

Can you give more info about compounding pharmacies and intranasal ketamine? We are using ketamine for severe, treatment resistant depression, but it's financially impossible to maintain on a government employee's salary. Any info would be helpful. Thanks.