Meds or Therapy?

It's this funny thing, people talk about the rise in the use of medications like it's a bad thing (and perhaps it is) and the decline of psychotherapy by psychiatrists as also being a bad thing (and perhaps it is).  It's almost like a see-saw, and there is the thought by some that using medicine is a quick-fix, a way of avoiding looking at the more difficult issues that we as humans face in the natural course of human suffering.  It's funny -- as I started by saying -- because it seems like the combination of medications together with psychotherapy  may work best.

Let me address the quick fix thing.  First off, most psych meds take a while to work, they aren't quick fixes.  Second, we've all read that medication helps depression only 30% of the time, or the same rate as placebo, and this  because in clinical psychiatry it often takes a few tries to help someone -- switching medicines, augmenting one medicine with another, or trying some unconventional or creative cocktails. The study looked at a single trial of one medicine versus a sugar pill, not real life psychiatry.  And then we've got that *#$&~ DSM issue which boxes one in, says people have to "meet criteria" as though it's a totally real entity any more than diabetes is (-- see Psych Practice's post on just how scientific the diabetes diagnosis actually is) and there is the implicit criticism that if you take a pill for psychic pain that doesn't 'meet criteria' then it's just WRONG.  Can you imagine if you had a headache and wanted to take an aspirin to stop the pain, but you were told that since there wasn't an anatomical reason for the pain, taking that aspirin makes you a weak pill-popper?     

There are those who feel we should rely more heavily on psychotherapy, as though it's one or the other.  As though we know in advance who therapy will help heal of their mental  illness (we don't), or who therapy will help comfort during a painful journey.  I believe therapy is helpful to many people for many reasons: one is that for some people it provides tremendous insight and relief, though the two are not necessarily connected.  Another, is that by scheduling patient for hour-long sessions, it's so much easier to evaluate and understand them, to know the quirks of their personality and the patterns of their distress in relation to the nuances of their lives, and not just as a checklist of symptoms and side effects taken as independent variables apart from their environment and their perceptions of that environment.  You help them see their patterns, whether it's how they relate to authority figures or how they always feel worse (or better!)  when they stop their medicines.  Finally, when you're on a journey that may be long and painful, it's so nice to feel heard and cared about and like you're a human being whose emotions are important, and not like a person at the deli counter-- #16 today, "I'll have a script for Zoloft  please."    But as a cure, therapy doesn't always work, and we don't have a prescription for how long and how much therapy one needs, or of what type, before we can tell if a trial is adequate.  For medications, there are often some guidelines with regard to dose and time; for therapy there is not.  If you come for treatment of depression, how much therapy is enough to say we've given it a fair chance before adding medications?  Twice a week, 50 minute sessions, for two months or two years?  And what if the patient can't afford the cost of that and wants to try the $4 generic from Wal-Mart?  

So that you know where I stand: if it helps, go for it.  Meds (if the benefit outweighs the risk-- and yes that's important: sometimes the benefit does not outweigh the risk), therapy, light boxes, exercise, ECT, TMS, DBS, acupuncture, yoga, chocolate... I'm all for the reduction of discomfort for those who are seeking it, and I'm all for letting people heal as they will without the judgement of others telling them how to do it right. 

Hmm, I'm not sure what got into me today....

Things I'm Thinking About This Holiday Weekend

Happy Presidents' Day.  I probably have 50 blog posts floating around in my head, but I thought I'd share with you some of the stuff I've been reading on line lately.  


The New York Times Op Ed editor doesn't seem to like stimulants these days.   A few weeks back there was an article talking about a study showing that long-term stimulants aren't helpful, and today there is a piece by a writer who finds distraction helpful...told with some contempt towards his friend's son whom he calls Ritalin Boy.  Steve over on Thought Broadcast has his own take on ADD meds.   
 What do you think: are stimulants helpful or not?  I'll stand aside for this one. 


Then there was the article about the business/computer whiz who put hundreds of thousands of dollars of his own money (and all his time) into a kidney transplant matchmaking service.  If you need an uplifting story, this is an interesting one. 


Over on KevinMD,  Dr. George Lundberg is a bit skeptical of SAMHSA's new defining features for the Recovery Movement.  I more or less agree, it feels like it's more about semantics (what does it mean to say recovery is "person-driven"? as opposed to?) than substance, and a lot of it seems to boil down to the idea that patients should be treated with respect and people with mental illnesses should work towards achieving their full potential.  Those things I agree with, for everyone. 


And finally, for the writers among us, Pete Earley has a Before You Quit Your Day Job post up on his blog.  I'm still pondering the $80,000 advance.  The Shrink Rappers need an agent, oh, but we do love our friends over at Johns Hopkins University Press.  


And finally, for my friend ClinkShrink the Introvert,  who wrote a review of a Quiet: The Power of Introverts in a World that Can't stop Talking (---huh, stop looking at me), here is an article called The Brainstorming Myth by Jonah Lehrer in The New Yorker. 


Okay, lots of links.  This is what I've been thinking about.  Aside from that, I made a quick trip to NYC and had my photo taken with Cookie Monster in Times Square, and I loved Jersey Boys.

The Psychotropic Media Wars

 Just in case you haven't had enough of people ranting about the efficacy (or not) of psychotopic medications in the popular media, I thought I'd refer you over to an article by Dr. Harold Koplewicz on The Huffington Post.  Here's a quote:

Good studies for psychiatric treatments are desperately needed. In the meantime, we have patients, in our case children and adolescents, who desperately need help. These children may be out of control, overwhelmed by anxiety, dangerously aggressive, disorganized in their communication, floundering in school. We need to help them. Medications, often along with behavioral therapy, can have a transformative effect. If they don't help, we are not forced to continue using them. We would like to see objective research catch up with the clinical realities but can't wait until that happens. Furthermore, falling back on pure non-pharmacological treatment is not the better alternative, since these treatments have rarely undergone objective evaluation.

As to the issue of psychoactive drugs actually harming patients by altering their brain chemistry over the long term, which Angell posits, here too data is lacking. It makes no sense to forego present benefit because of undemonstrated future harms. We try to weigh the risks of psychoactive drug treatment against the risks of forgoing treatment. That risk often includes academic failure, dropping out of school, substance abuse and even suicide. Unfortunately, the risks of avoiding demonstrated useful treatments are not something critics, like Angell, consider.

Psych Meds are THE Problem: A Post for Duane Sherry

Shrink Rap prides itself on being a take-all-comers place for open dialogue about the issues and controversies in psychiatry.  Five plus years, and the feel of our blog has gone through many evolutions.  In the last 6-8 weeks, things have gotten very heated around the topics of involuntary hospitalizations and the question of whether medications cause illness or treat illness.  

I see patients who walk in the door in distress.  The only people who walk in feeling well are those who have been treated by someone else and are coming to continue treatment, either because their shrink moved, they moved, something changed.

Once in a while, someone comes in and they are in distress and they are already on psych meds and I look at the regimen and say "No wonder you feel badly, you're on way too much medicine" and I stop things.  Mostly though, I start new medicines and I see people who were sick get better.  Some people have problems with medicines, but not like I hear people talk about in our comments section.  Here at Shrink Rap, people hate anti-psychotics. Very few patients tell me  that very low dose anti-psychotics bother them.  Medicines need to be added carefully, at low doses, and increased gradually.  The patient is supposed to get better: it they don't, the medicine should be stopped.  Sometimes people end up on a zillion medications, no better, and it's not clear why they are on them.  See: Medications: The Good, Bad & Ugly, and  You're Supposed to Get Better.  These are some of my views on treatment and medications.

It's not unusual that patients come in and casually mention in the course of a therapy session, "oh, I stopped taking the meds."  I ask why.  Side effects?  Felt they were no longer necessary?  I ask if they feel better without them (some do, some don't).  I'm here to help, and since I work in a totally voluntary setting, I may spout statistics, especially to someone with a high risk of relapse who was having no side effects and no problems with the meds and feels no differently off them-- but hey, you don't want to take medicines-- it's fine with me, and I'll hang out with you in therapy anyway. 

Duane Sherry has been visiting us for a while now in the comment sections and he feels strongly that medications are the problem, not the answer, and that people who think they are better are wrong.  He and I are seeing different before & after shots.  He asks if I give informed consent (funny, I do) and thinks people should explore different options such as orthomolecular therapies.  He's posted many links, and something gets troubling about the repetitive nature of it (at least to me) and something gets troubling about the accusatory tone, though he has really toned down the blatant --you're an idiot-- comments. Thank you, Duane, this has meant a lot to me.

So let me give Duane a moment here to get out his message of Meds are Harmful / Psychiatry Sucks here on the main page of Shrink Rap.  Duane, you're still welcome to comment, but please stop with the repetitive links, and please keep the tone respectful.  You might want to consider getting your own blog where like minded people can have a forum.

Duane says:

The drugs numb.
They provide temporary relief.
And that's all they do.

The greatest injury happens in their long-term use... They are addictive, because they meet the medical definition of physiological addiction in two vital areas:

a) Increased tolerance
b) Measurable effects during withdrawal

Have your patients look at the "side effects" more closely... Really look at what the drugs do.

Then see how many want to be placed on them.

Here is Duane's website...funny, no place for comments:
http://discoverandrecover.wordpress.com/wellness

Here are some links Duane likes:

http://www.foodforthebrain.org/content.asp?id_Content=1635
http://www.vitamindcouncil.org/health-conditions/mental-health-and-learning-disorders/depression/
http://www.townsendletter.com/Nov2009/hoffer1109.html
http://www.youtube.com/watch?v=aBjIvnRFja4&feature=channel_video_title
http://www.madinamerica.com/madinamerica.com/Timeline.html
http://breggin.com/index.php?option=com_content&task=view&id=40&Itemid=52
 http://recoveryfromschizophrenia.org/therapists-guide-to-reducing-medications/

Duane, Please put any other links you'd like in the comment section of this post: your personal space on Shrink Rap.  If you'd like, in future comments you can say "I'm putting links up in my space on Shrink Rap" and link back to this post and put them in the comment section here.
 
For the most part, we need to agree to disagree.  I don't believe I am going to sell Duane on the idea that medications sometimes help people live better lives.  And I don't think he's going to sell me on the idea that they should never be used. 

To my co-bloggers: please forgive me. 

Transfering Care and Do You Have to Meet All Criteria for a Disorder to get Meds?

A college student wrote in and asked the following questions:
1. Do you ever transfer care and how do you decide when to transfer care? If a patient is stable do you transfer care and prescribing over to a general/family/primary care doc? I know that most depression, anxiety, adhd, etc is diagnosed and treated in primary care these days anyways, under what situation is diagnosis and treatment management by a psychiatrist recommended over a general practitioner or conversely when is treatment management by a general practitioner recommended over a psychiatrist? Do you ever feel like your patient's level of need/functioning/distress doesn’t warrant your care, such as when they are improving with treatment, if so do ever you suggest that they should reduce their visits or seek care elsewhere?

2. Does a patient have to be diagnosed with a disorder in order to be prescribed medications? For example, do they have to fit the clinical criteria in the DSM for depression before you will feel comfortable prescribing antidepressants to them, or is just complaining of feeling sad and hopeless enough? Is complaining of being inattentive and failing classes enough to warrant adhd medications? I know it gets dicey with controlled substances and insurance coverage/reimbursement, but in general I am curious regarding the indications for medication prescriptions? If a patient doesn’t fit the exact DSM criteria for a disorder but they feel they will benefit from medications, do you give it to them?
-------------
Wow, that is a lot! The student began by telling us she sees a psychiatrist for 7 minutes every three months to get stimulants.

Do I transfer care? Not usually. Maybe the better answer is really rarely. I get patients from primary care docs who feel the patient needed more. I figure people come to me because they want a psychiatrist, they like having someone to talk to (I do Not do 7 minute sessions, but I certainly do see people a few times a year), and they like knowing they have a psychiatrist if something should go wrong. If someone who is stable for a while on a set dose of medicines were to ask, "Can I just get this from my primary care doctor?" I would say "Sure." I really have only been the one to suggest it when the patient makes it clear that scheduling with me is a burden, and I don't think I'm adding to the mix in any meaningful way. When this has happened, I've said, why not just have your primary care doc prescribe it and if you have any problems, I'm happy to see you again. This hasn't happened much. What happens more often is that people drift out of treatment, and I imagine they either stop their medicines, or get them from their internist. Sometimes they come back when they have a problem, and that's fine with me.

Regarding questions about whether meeting DSM criteria is a necessity for medications, that really depends on the doctor. I don't keep a DSM in my office and I never sit there with a check list of symptoms to say "Yup, you got it," "Nope, you don't." Why is that? Because the book was written by consensus-- a bunch of guys in a room agreed these are the symptoms you need to have Panic Disorder, not by a blood test or some thing that clearly correlates with prognosis. Precise diagnoses are really good for insuring that everyone in a research protocol has the same condition, and I don't do research. So maybe the patient doesn't quiet have enough symptoms for a diagnosis of depression, or perhaps they haven't gone on quite long enough, but perhaps the symptoms that are there are intense, incapacitating, or dangerous, and the patient is requesting medications. I'm not likely to send them out saying "You need one more symptom and 2 more days before your suicidal misery meets criteria, so come back when you have another symptom."

ADD may be it's own issue because of the controlled substance/addictive substance question, and the fact that some clinicians feel the diagnosis is over-made. People can be inattentive for many reasons: depression, pretty girl outside the room, boring instructor, cell phone texts keep coming in, worried about not being invited to big party tonight, upset about cat's cancer diagnosis...and the list marches on. Failing tests may be due to lower than needed IQ, partying too much, misunderstanding about what would be on the test, instructor with lower than needed IQ, girl in next seat vomiting, poor preparation, bad night's sleep, substitution of decaf for caffeinated coffee (Clink's version of Hell). Lots of people with ADD do just fine without meds. Being smart helps in the way of compensation. Lots of people with ADD seem to have disabilities beyond what one might expect with some distraction. I don't treat a lot of ADD, and my guess is that it depends on who you go to for this: the people who have large practices and do a lot of this work seem to have somewhat lower thresholds for aggressive prescribing, and a greater comfort level with the problem and the cure.

I hope I answered the questions okay.

I Might As Well Go Home Now.

Psychiatry's getting blasted this week: we don't know what we're doing, our diagnoses are not valid or reliable, our treatments no better than placebo and we maxed out in the 1960's with imipramine. Yesterday's NYTimes Magazine article on The Upside of Depression (see my post) implies that we're derailing evolution by treating what may be an adaptive condition, and The Wall Street Journal says Psychiatry Needs Therapy ! Edwarder Shorter writes:
Psychiatry seems to have lost its way in a forest of poorly verified diagnoses and ineffectual medications. Patients who seek psychiatric help today for mood disorders stand a good chance of being diagnosed with a disease that doesn't exist and treated with a medication little more effective than a placebo.

What's a shrink to do with this? Perhaps the diagnoses we make are wrong and the meds we use are ineffective, but at the end of the day, the patients seem to get better. Maybe it's my charm (hmmm, there's a thought) or the concurrent psychotherapy, or some other non-specific factor...maybe the cognitive dissonance that you have to believe that anything you're paying a small fortune for has to be working.

So do read Shorter's article and tell us what you think.

Do Generics Work as Well as Name Brands?

It's my first night of vacation! I saw my last patient today and then started pulling the pictures off the walls in anticipation of my move. I ran over to see the new place, and it still needs insulation (it's on the floor), paint, and carpet. And doorknobs might be nice.

So we're expecting quite the snowstorm here. I'll let you know how it goes tomorrow, but the current forecast is for up to 20 inches. It didn't take me long to float from the weather to the health section of the New York Times, and here's an article by Leslie Alderman about generics versus name brands.

Are generics as good as name brands? I don't have any studies, I'm purely running on anecdotes, but this is my thinking: Usually. When I was resident, I learned that 15% of the time (and this isn't science, I don't think, I believe it's someone else's anecdote) generic nortryptiline doesn't work when name brand Pamelor does. So I've always asked patients to start with Pamelor....I don't use it much anymore....because who wants to spend 6-8 weeks on a medication trial and have someone not respond only to realize they were in that small group of patients who are sensitive to the brand.

Other meds: I've had a handful of people complain about generic Prozac-- fluoxetine. It's not as effective for them, or they have more side effects. Alderman's article talks about Wellbutrin XL and I didn't even realize that the XL form now has a generic. Sometimes people want the name brand.

So what do I do when a patient specifically requests the name brand? I give it to them: if they are right, then they are right. And if they simply believe that they won't respond to the generic, because there are people who say "Generics don't work on me," well, then there's power to such beliefs, and I just want my patients to get better.

What do you think?

You May Go Now.

I've learned something important from....reading the comments posted to our blog, listening to people talk, being a person who talks....No one likes to feel their concerns are being dismissed (myself included).

It's a recurrent theme in the comments that are sent to us, especially with regard to medications: a reader has a concern about a medication, feels it isn't working or that the side effects are too severe, and either their doctor does not address their concerns in a way that feels validating or the reader perceives that the doctor does not understand....since I'm not there, I can't say which is happening, but the feeling on the part of our readers is clear.

And just so you know, I've been on both ends of the discussion. I once lowered the dose of a medication, found it to be just as effective at a very low dose, and was told this was a "homeopathic dose." I didn't really know what that meant. In my terms, I had a headache that felt very real to me, and after taking a very low dose of a painkiller, my headache was gone. I wanted the least possible medication, so I stuck with the low dose. I'm not sure what was meant by the comment, but I heard it as the dose I was taking was so low it couldn't really be helping and I must have been imagining it's efficacy. This was my interpretation; the doctor may well have said it was simply to comment on how low the dose of medication was and not as a statement related to either the realness of my symptom or the realness of my response. I suppose I would have preferred to have heard that I must be rather sensitive to the effects of the medication, the "homeopathic dose" comment rubbed me the wrong way.

I've learned there a patients who have unpredictable and unexpected responses to medications. Some people tolerate huge doses of medications, others don't tolerate even small doses. Sometimes people have weird responses, and we don't really know what to make of it. My favorite example of this happened many years ago-- a patient told me he saw "trails" of light when he turned his head which he attributed to the Serzone I prescribed. Okay, that's weird, I'd never heard of that type of side effect from ANY medication. I didn't know what to make of it. The next week, I saw a case report in a journal of three cases of "visual trails" induced by Serzone. Go figure.

So why don't doctors just take patients' word when they say they are having a specific symptom: be it from an illness or from a medication? Why don't doctors hear when patients say they are very sensitive or not and need very high or very low doses of medications? More and more, I think we do.

Why not always?
Here are some reasons:
--Sometimes doctors are dumb.
--Sometimes doctors are egotistical.
--Sometimes doctors are frustrated. Especially if a medication helps an illness but causes awful side effects. And it's not just doctors. Family members will want patients to stay on their medications because they are less irritable, more functional, easier to get along with...even though the medicines cause side effects.
--Sometimes patients lie. This is especially true when controlled substances are involved: So a patient says that he's anxious and absolutely the only thing that helps is 6 mg a day of Xanax and he feels slighted that the doctor doesn't just take it at face value and prescribe it. Or believe that he's dropped the pills down the sink? Or never gotten them from his 90 day mail order company
--Some people are very suggestible and develop many side effects that they've read about. I really do wish there was a way of saying this without the word "suggestible" having a pejorative feel. Can't it just be? In medical school, I once heard someone say you can tell if a patient is simply saying "yes" to everything if they said their hair hurts when they pee (hair can't feel).
--Sometimes patients complain of things we've just never heard of .happening before. I don't think these problems should be dismissed, and I've taken to telling patients that I'm not in their body/head and they really need to be the one to determine if the benefit from the medication outweighs the side effects. This can be a difficult decision in the time while they are waiting to see if the medication is going to be effective.
--Sometimes patients misinterpret their doctor's comments. I'm often told I think such-and-such when in fact I don't think that at all. My doc might be surprised to hear I took the "homeopathic" comment to mean any thing other than 'my, what a low dose you responded to."

Finally, I've learned that patients can have very high expectations of their doctors. People often write in angry that their docs didn't warn them about specific side effects, and they'll mention a side effect to a medication I've never even heard of. It doesn't mean I don't think it happened, it just means it's not the usual for a psychiatrist to warn a patient, hey MedX could make your nose turn green and swell.

I think in psychiatry, we're all still just finding ourselves. So many of these medications are so new, and they efficacy and side effects varies so very much from person to person. Why does one patient get better with no side effects at all from the very first medication, while someone else is on maximum doses of 5 medicines at once, and still another patient has intolerable side effects to a tiny dose of anything?

Attention Everyone!

.

In yesterday's New York Times Magazine, Walter Kirn wrote about his own personal, and highly ambivalent relationship with Adderall, a medication he used to help him focus his attention. It wasn't clear from the article if Mr. Kirn actually had Attention Deficit Disorder, if he was simply struggling with a difficult time, or if he wanted an edge.

In A Phamocological Education, Kirn writes:

Adderall, I discovered during the courtship phase of what became our deeply tortured relationship, offers a kind of assistance to the brain that feels just right, at first, for the age of multitasking. The drug might as well have been invented by Microsoft and embedded in the Windows toolbar. It seemed to allow me to do three things at once and not completely fail at two of them. Far more important, however, it helped me do one thing at once and focus on it. If I was toiling at my computer, it sharpened the clicking sensations of the keyboard while lowering the volume of the phone whose ringing might have broken my work trance. It also, for me at least, suppressed emotion, freeing me from the claims of other people (my children primarily, because I work at home) who wanted a piece of my precious, deskbound time.

Antidepressants and the Efficacy of Tamoxifen in Preventing Breast Cancer Recurrence

Yesterday's new included an article on how certain ssri's decrease the efficacy of tamoxifen in preventing recurrence of breast cancer.

Lisa Rapaport writes:

Tumors were more than twice as likely to return after two years in women taking the antidepressants while on the cancer drug, compared with those taking tamoxifen alone, the study showed. The research, by Medco Health Solutions Inc., was presented today at a meeting of the American Society of Clinical Oncology in Orlando.

Doctors began treating hot flashes with antidepressants, an unapproved use, after a U.S. study seven years ago linked the former standard remedy, hormone replacement therapy, to an increased risk of breast cancer and heart attacks. Other types of antidepressants, such as Wyeth’s Effexor, may be safer for women on tamoxifen than Paxil or Prozac, said Powel Brown, director of cancer prevention at the Lester and Sue Smith Breast Cancer Center at Baylor College of Medicine in Houston.

-------

The question has been around for a while: This 2005 paper talks about whether women with CYP2D6 alleles might metabolize tamoxifen differently in the presence of certain ssri's and thereby decrease it's efficacy (I hope I said that right: I feel like Roy talking about genes):

In a study of 80 tamoxifen patients, the research team found that women homozygous or heterozygous for CYP2D6 variant alleles had a statistically significant decrease in plasma levels of tamoxifen and its active metabolites after four months of treatment, as compared to women homozygous for CYP2D6 wild-type alleles.

---------

I'm left with more questions then answers. I looked for the Medco study on-line, but didn't find it.

My Sister Says...

So when I give a medication recommendation I talk about why I think the medication would help, I talk about what it treats, what the side effects are and what the risks of taking the medication are. That's a lot of information to absorb all at once so I ask my patients if they have any questions about what I've said. Most of the time they decide to take medication, sometimes they don't. When they decide not to take it they've got good reasons, most of the time.

The only bad reason I've heard is: "I talked to my mother and she heard bad things about it, so I'm not going to take it."

Every inmate has a sister, a girlfriend, an aunt or a mother somewhere with some health care training. All of these family medical advisors know more about psychotropics and are more reliable sources of information than I am, apparently.

I try to be generous and remember that maybe there are idiosyncratic issues here, like maybe the patient did have a weird reaction to some medication that he doesn't remember but his mother does, or maybe there are multiple family members who all had the same problem with a certain medication so he might too.

But usually it's just a matter of trust. The inmate's LPN sister has taken care of him all of his life, has rescued him and given him shelter and sent him money when he needed it, so what she says about medication goes.

It reminds me of a story I heard when I was an intern. My attending went to visit his mother, who was in the hospital for elective surgery. He offered her some advice about her anesthesia, and she responded: "I'll talk to my doctor about that." Her doctor was an intern. My attending was the chairman of the anesthesia department at a major academic institution.

So I guess it goes both ways when it comes to being the family medical advisor. Are you the family medical advisor? Do you want to be? And if so, do they listen?

Paxil, anyone?

I ran a poll, not long ago, after reading Peter Kramer's blog post on the relative efficacy of the different SSRI's. Here's what we found:

Which SSRI is the most Effective?

Prozac 15% (22 votes)
Zoloft 14% (21 votes)
Luvox 0% (0 votes)

Paxil 5% (8 votes)
Celexa 7% (10 votes)

Lexapro 19% (28 votes)

Cymbalta (SNRI) 13% (20 votes)

Effexor (SNRI) 18% (27 votes)
Wellbutrin (neither, but it's here anyway) 9% (14 votes)

Total Votes: 150

Which Medicine Causes the Most Side Effects

Prozac 13% (17 votes)
Zoloft 7% (10 votes)
Luvox 5% (7 votes)
Paxil 31% (41 votes)
Celexa 1% (1 votes)

Lexapro 4% (6 votes)
Cymbalta 7% (10 votes)
Effexor 25% (33 votes)

Wellbutrin 7% (9 votes)

Total Votes: 134

Okay, so let's start by talking about how this 'poll' is meaningless. We don't know who took it-- patients, docs, random plumbers surfing through. We don't know what experience these people have had with antidepressants-- so the question has different meaning if it's asked to a doc who has only ever prescribed Prozac and Zoloft, then if it's asked to a patient who has been on a long trial of every medication. There's no real head-to-head here, no measures of efficacy, no controls. And I didn't even specify what the efficacy was for: Depression? Anxiety? OCD? Panic? Halitosis? Slipping behind your ear to hold your glasses in place?

Still, we had a clear loser, and I was surprised: Paxil. Few people voted for it's efficacy, many for it's side effects.

I don't start people on Paxil so much anymore: the lore is that it causes more weight gain then the others, and when I do prescribe it, I tell people to get weighed. It may cause weight gain, as an overall risk to populations, but all I care about is if it causes weight gain to my particular patient, and clearly, some people do not gain weight on it. The more concerning thing about Paxil has been the withdrawal syndrome that some people experience and so far I've found that it's manageable, especially if people come off very slowly. Still, all things being equal, these days I may start with something else.

So why was I surprised: I guess I haven't heard a lot of patients complain about side effects, and I have patients who've been on this medicine for some time. It seems to work particularly well, at least that's my impression, for Anxiety, and it seems to be well tolerated, the 'polls' would say otherwise. And for the uninsured, the generic is on Walmart's $4 list (as is Celexa).
Just my thoughts.

And to those who've read yesterday's post about does Facebook wreck your brain: If you read either the original article or the comments to our post, you'll note that the original piece is simply theories that all this computer time may re-wire people; there were no studies, no proof. And as some of our readers pointed out, On-line interactions may well be a segway into the world of Real Life encounters for people who might otherwise hesitate. I often wonder if my college experience would have been broadened by the world of the internet---

To the Max--- Life With a Little Help

I'm back from my White Christmas, back to muddy Maryland. I'm trying to find something stimulating to blog about with my brain on psychiatric vacation. Judith Warner of the New York Times has been kind enough to help with her op-ed piece "Living the Off-Label Life." She talks about a Shrink Rap favorite topic: the line between distress and illness, the use of medication (or in this case, non-meds such as coffee ...Clink....diet, etc) to help people reach some idealized potential. Ms. Warner writes:

------
What if you could just take a pill and all of a sudden remember to pay your bills on time? What if, thanks to modern neuroscience, you could, simultaneously, make New Year’s Eve plans, pay the mortgage, call the pediatrician, consolidate credit card debt and do your job — well — without forgetting dentist appointments or neglecting to pick up your children at school?

She goes on to discuss an article in Nature:

That’s why when Henry Greely, director of Stanford Law School’s Center for Law and the Biosciences, published an article, with a host of co-authors, in the science journal Nature earlier this month suggesting that we ought to rethink our gut reactions and “accept the benefits of enhancement,” he was deluged with irate responses from readers.

“There were three kinds of e-mail reactions,” he told me in a phone interview last week. “ ‘How much crack are you smoking? How much money did your friends in pharma give you? How much crack did you get from your friends in pharma?’

But Greely and his Nature co-authors suggest that such arguments are outdated and intellectually dishonest. We enhance our brain function all the time, they say — by drinking coffee, by eating nutritious food, by getting an education, even by getting a good night’s sleep. Taking brain-enhancing drugs should be viewed as just another step along that continuum, one that’s “morally equivalent” to such “other, more familiar, enhancements,” they write.
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Seems like something we struggle with over and over....

Quote of the Day

I've had a long day and it felt like every one was pretty troubled. I'm trying to decide who to give credit to for the 'quote of the day.' I started by thinking it might go to the person who informed me that I looked good (always nice to hear) and then added that usually I look sick and I've gained some weight. Okay, I'm not sure what to do with that one.

I've decided, instead, that I liked the remark posted by blogging psychiatrist Doug Bremmer in the comment section of my post Tell Your Doctor if You Experience Any of the Following....

He writes:

Doug Bremner (MD) said...

As a "blogging doctor" I am struck by how much anger there is out there about side effects of antidepressant medications, and how much psychiatrists are felt to be to blame for that. Perhaps there has been over-promotion of prescription medications. But there are side effects that we don't know about and only learn about with longer experience. We are not magicians or mind readers.

I do often feel when I read our comments from readers who've had bad experiences with medications or hospitalizations or psychiatrists who say insensitive things, that people feel there is something purposeful about it. It's hard when someone comes in and describes something as a side effect of the medication and I recall that the symptom was there before the medication was even started. With time, we've learned that this can be the case-- if a patient starting an SSRI now says "this medication is making me feel more suicidal," Docs listen. It's still hard when someone says a medicine causes a side effect never described and I don't know what to do with it. Sometimes I try to talk people into staying on their medication if, for example, they complain that a newly added anti-depressant is making them more depressed-- the medicines take time to work, weeks in fact. If a patient continues to complain, eventually I'm left to conclude that this medication either doesn't work or isn't tolerated in this person. Sometimes people complain bitterly about side effects while at the same time they say they feel the medication helps, and then I say: It's up to you. It gets trying when this means that every visit consists of stopping a medication that hasn't been given a fair chance only to begin another medication-- the arsenal of medications available can be run through pretty quickly with this strategy and it doesn't make sense. Okay, I'm rambling.

I Have A Friend....

ClinkShrink is looking for something to climb. Roy is collecting links to Mental Health Blogs: Thanks for all your contributions and if you'd like to add another mental health blog to the list, please visit Roy's post and comment.

I titled this post "I have a friend..." because it's not an unusual way for someone to start a conversation with a psychiatrist about a mental health problem in a social setting-- maybe it's about a friend, maybe it's about themselves, I never ask, I take it at face value. Sometimes I later hear, "actually it's my problem."

So I have a friend (--really) ....

We're together in a public place, there are people around that we know, probably not within earshot, but who knows? The friend is, well, more of an acquaintance-- we don't know each other so well.

"I know you don't like Xanax, but it's the only thing that helps when my thoughts race."

I'm caught off guard. It was a statement, not a question, and I should have listened.
I mumble something. Whatever it was, it was probably the wrong thing to say.

"Why don't you like Xanax?" Friend asks.

Oy: if you haven't read Roy's post on Why Docs Don't Like Xanax (some of us), then by all means, CLICK HERE.

Issues with addiction, I say.

"I don't take it every day, just when I can't sleep and my thoughts are racing. What else could I take?"

Okay, at this point I retrospectively cringe at my response. What was I thinking? Roy and ClinkShrink would crawl under a rock and pretend they don't know me. I mumble something about Ativan and Valium being less addictive. I mumbled something about perhaps the Xanax wasn't a problem. Oh, I recommend these medications rarely, really rarely, and only to patients I've carefully evaluated. What was I thinking to suggest the names of other meds? Or what wasn't I thinking?

The subject changed, we didn't discuss it any farther, but I was left obsessing about the weirdness of my response, the irresponsibility of it, the cavalierness of even hinting that certain medications (addictive ones at that) might be better than something already prescribed for a condition I didn't explore, by another physician, for a person I didn't know terribly well.

So this post will now have two themes:
1) When personal friends asks a psychiatrist (this psychiatrist in particular) for advice.
2) What I did wrong, which is basically everything.

Friends ask me for suggestions from time to time. ClinkShrink and Roy might (I'm not sure, I'm surmising this) say one shouldn't give any suggestions and that by listening, engaging, offering advice, that one essentially establishes a doctor-patient relationship and becomes responsible for them and becomes open to all the obligations inherent in any doctor-patient relationship, including the right to be sued for malpractice. Again, I'm putting words in their mouths, so Clink and Roy: do feel free to add to the bottom of this post.

I don't tend to worry about being sued. And when a friend wants to talk about a problem, knowing I am a psychiatrist, I listen and I don't usually immediately say, "Ask your Doctor" --because, well, it feels dismissive and I feel like the voice-over in one of the pharmaceutical commercials. I usually listen, answer what's asked to the extent that I can, and if the situation warrants, I gently suggest it might be worthwhile to have at least a one-time psychiatric evaluation. I never, ever, tell my friends they need long-term intensive psychotherapy or specific meds: that would be the job of the evaluating psychiatrist and I like having friends! I will refer friends to shrinks I think they'd like, if they want, though, hey, it's my best guess as to interpersonal/professional chemistry. I try to figure out an appropriate boundary -- somewhere that's caring but not opening myself up to to hearing all sorts of overly personal details-- and I try not to upset my friends or leave them feeling uncomfortable. Finally, I try to be of help.


Here's what I did wrong with my Xanax-for-racing-thoughts friend:

• I didn't listen to the issue. Was there even a question or was it just a request that I hear that Xanax is helpful to this particular person? I never found that out.

• If there was a question as to the appropriateness of this particular medication for this particular person, I really was in no position to comment or second-guess the doc who prescribed the med.

• I jumped to a conclusion that, in the moment, I didn't even realize I was jumping to: The friend mentioned that Xanax helped with racing thoughts. I know this friend has trouble sleeping when there is a lot going on. "Racing thoughts" are a symptom of Bipolar Disorder-- it's a term used to describe the symptom of having one's thoughts go so fast that the patient can't keep up with them. They don't generally happen with conditions other than mania, and I assumed the friend wasn't really having "racing thoughts" but anxious ruminations associated with insomnia-- in other words, dwelling on daytime events and worrying which were interfering with sleep. I don't know any details, it was a quick assumption. It wouldn't have been appropriate ( nor would I have wanted) to ask all that I'd need to ask to figure out the precise phenomena, diagnosis, or if Xanax or something else was the appropriate treatment. I also assumed this friend doesn't have a substance abuse history and I'd have no way of knowing that....perhaps any addictive drug, be it Xanax, Valium, Ativan...might be the wrong choice. I should have kept quiet.
  

The subject changed, it took me a little bit to process what I'd said and what I hadn't said, and somewhere in there, we followed it up with a second, briefer conversation in which I said much of what I've said here.

Hoping my friend is now sleeping better....

Street Value of Psychiatric Medications

StevebMD asked: "Is there a way to find out the "street value" of various psych meds in different cities? We know that benzos and opioids are highly valued, but I'm curious about other things like antipsychotics and sleep meds."

So I did some googling and did not find much. I even went on erowid.com, but couldn't find much there, either. So, I thought I'd set up a little database for people to enter what they know about the street value of, say, a 100mg pill of Seroquel.


Now, I am NOT trying to encourage these sorts of illicit transactions (you do know that it is a federal offense to sell a controlled prescription drug, right?). Indeed, the more we become aware of the potential for diversion of the drugs we prescribe, the more we can guard against it.


So, please complete the following form for any medications you may have knowledge of (either from asking your patients or from your own personal knowledge). Include your zip code so that I can set up a Google Map of all the entries. Once we have a number of datapoints, I will add the map to this post.

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[View Database]

Online Access to Prescription Medication History

I saw a headline this morning that the California attorney general is moving to provide instant access to a patient's prescription history for doctors and pharmacists (regulatory boards and law enforcement organizations currently have ready access to this info).  

State Atty. Gen. Jerry Brown unveiled a plan Wednesday to provide doctors and pharmacists with almost instant Internet

 access to patient prescription drug histories to help prevent so-called doctor shopping and other abuses of pharmaceuticals.

Brown told a Los Angeles news conference that the state's prescription monitoring is a "horse-and-buggy" system that needs significant improvements because it now can take healthcare professionals weeks to obtain information on drug use by patients. That delay can allow some patients to get large quantities of drugs from multiple doctors for personal use or sale.

"If California puts this on real-time access, it will give doctors and pharmacies the technology they need to fight prescription drug abuse, which is burdening our healthcare system," Brown said.

The database, known as the Controlled Substance Utilization Review and Evaluation System, contains 86 million entries for prescription drugs dispensed in California.

I have mixed feelings about this issue.  Maryland passed a similar bill this past session to study such a program.  There is a very serious problem with abuse and diversion of controlled medications, such as Percocet, OxyContin, Lortab, and Xanax.  It is indeed very easy to get scripts from duped physicians and nurse practitioners and PAs, get it filled, and then sell it on the street for a 1000-5000% profit.  We need methods to control this.

The flip side is the risk of privacy violation.  Patients could have their privacy breached.  So, how much are we as a society willing to give up to combat this problem?

My suggestion:  Build in banking-level protections, provide patients access to their own histories, provide patients the ability to permit or deny access on an individual basis (so that they have control over access), and permit patients to see who has accessed their records.  Also, provide protections to prescribers and pharmacists which allow them to not prescribe or fill a medication if the patient refuses access to their history.

This provides a greater amount of control over access to personal info, while still providing the ability of prescribers and pharmacists to exercise careful judgment about the medications they write or fill.

I'm not totally sold on this solution, but it does seem to be a better compromise than the big brother approach.  I'd like to hear your thoughts on this difficult problem.  Please add your comment below.

Sober Thoughts

[I'd like to thank Clinking By Proxy for helping me post while my Comcast was down. I owe you chocolate. And yes, Dinah, I'll babysit Max. He's adorable.]

I used to think that I wouldn't write about substance abuse because I wasn't an "official" substance abuse expert, at least not on paper. I didn't do an addictions fellowship and addiction per se was not usually the primary focus of treatment in my outpatient clinic. Then came my Dose Dependent post and the Benzo Wars podcast and all the subsequent comments, positive and negative, about the issue. I discovered I had a lot to say, mainly as a result of several years of direct practical experience.

Many doctors, as a rule, do not like patients with substance abuse problems. They fill up the emergency room, they suck down psychiatric resources, they fill up the psychiatric inpatient beds looking for detox or housing, they fill up the inpatient medical wards with conditions resulting from their lifestyles. They take a lot of time and work and they're not always nice people to deal with.

Those are the folks with the severe addictions, the ones that result in arrest and incarceration or homelessness and poverty. There are lots of other addicts out there whom I never see, the middle-class non-criminal addicts whose addiction touches the lives of their families and loved ones but never quite sinks to the level of the streets. These addictions are no less serious. I think I get vocal about these folks (and about things like prescription controlled substances) because I can see where things are headed. I know how bad they can get and the human wreckage that will be left along the way. I can tell you story after story about people who have never done a thing wrong in their lives until that on-the-job accident and the first opiate prescription, or that first hit of cocaine (or the first benzo prescription) and the next thing you know the wife is gone, the job is gone, the house is gone, and they're in prison. It does happen, more often than you think.

Doctors can't always tell who is or isn't an addict among these nice, educated, relatively well-heeled genteel non-criminal folks. Addiction is a hidden disease, a disease of denial, a thing that's carried in secret and buried away even from the addict. Addicts can hide their problems even from people living in the same household. Shame is a powerful motivation for secrecy. Doctors aren't soothsayers or mind readers, and taking a good history or talking to relatives won't always turn up the problem prior to writing a prescription. We want to care for people and relieve distress and a prescription is one way to do that. Unfortunately, it is also possible to create a new addiction in a person who never had one before and we have no way of knowing ahead of time which patient this will happen to. Giving a warning about addiction potential or cautions about continuous use is one way of approaching this problem, thus leaving the responsibility for the addiction back with the patient ("I warned you this could happen, I have it documented in the informed consent section of my progress note.") but this would be little comfort to me when I see these folks in prison.

When I read comments from people who say they're reluctant to take more of their prescribed controlled substance, I say: "Respect your gut." If you think it may be a problem for you, it could be. If your loved ones or doctor is encouraging you to take more and you're not comfortable with that, say so. Repeatedly if necessary. You're the one carrying both the symptoms and the addiction risk. As one of our anonymous commenters said:

"We didn't wake up one day addicted. It was one or more of your colleagues with an MD after their name who started all of this for the vast majority of us so as someone else said, why don't you take it up with them at your conferences or in professional writings or wherever it is that you all gather to talk down about us and the problem your crew created?"

That's exactly why we're blogging and podcasting about this. Thank you.

The 4H Club

When I took a medical history from one of my patients he told me, "I belong to the 4H club: hepatitis, HIV, herpes and hemorrhoids."

In medicine you see the term "comorbidity" used quite a bit. It basically just means that a patient has more than one medical problem happening all at once. It isn't specific to any particular combination of illnesses. In forensic psychiatry it usually means mental illness combined with substance abuse, combined with personality disorders. In the correctional world you can add a few extra layers of pathology by throwing in the medical diseases: hepatitis, HIV, head trauma, diabetes and other stuff, like the 4H list given to me today by one of my patients. (On the positive side, he had no history of closed head trauma.)

Practically speaking, what this means for treatment is that everything is going to be a little more complicated. You have to think about how the personality disorder will color the patient's reaction to your care, how the head trauma will affect his ability to understand what you say to him, and what the co-existing medical conditions will do to your choice of psychopharmacology. That can be a challenge. (OK, so the hemorrhoids in today's patient didn't really complicate the pharmacology. At least not until they invent rectal psychotropics.)

Working in a correctional environment actually helps when you're dealing with some of these multiply co-morbid cases. The structured environment gives some predictability and stability to their lives. It takes away some degree of stress in that they don't have to think about where their next meal is coming from. The clear rules and expectations set boundaries for containing the maladaptive behaviors. And while drugs and alcohol certainly do exist in jails and prisons, there's a lower likelihood that the patient will be using inside the walls than in free society. Finally, the patient has access to medical care that he might not otherwise have in the streets so the co-existing medical conditions are less likely to hinder treatment. My job would be much harder if I were treating these folks in free society.

Then again, in free society I'd have a desk and a telephone. And modern ventilation. And office supplies. And an office. Clerical support. A fax machine. Ample parking space. Unlocked restrooms. A vermin-free place to eat. And...

Oh, never mind.

Fluoxoperidonacaine: How drugs get their name

Ladyk73 (aka LadyAK47) asked a while back about how drugs get their names.

Hello there! I have a question!!!!!!
(I can imagine Roy crawling into the dungeons of some long-lost medical library somewhere to find the answer to this)

Anyways, this is really bothering me.

When I was a C-/D+ pharmacy student, one of the few things I learned was that there was some sort of nomenclature that was used to name drugs. The generic/chemical name, not those fancy drug pushers name....

Why does Trazodone have an -one suffix? As in a whole lot of corticosteriods end in -one.
What does the -one in trazadone stand for? Or does any of the name can be explained by nomenclature ways?

Great question!  Glad you asked...

The drug names are all decided by Tony, Bill, David, Peter, and Darin.

These are the most recent members of the USAN, the United States Adopted Name Council.  This is a 5-member organization consisting of representatives from the AMA, APhA, USP, FDA, and a member-at-large.  USAN works with the World Health Organization to come up with rules for naming drugs, and agrees on new drug names after the manufacturer applies for a new name (usually after submitting the drug to the FDA as an IND (Investigational New Drug).

There is a list of rules for naming drugs, typically based on their chemical structure, their therapeutic indication, or their mechanism of action.  Examples:

a.  The name for the active moiety of a drug should be a single word, preferably with no more than four syllables.
b.  The name for the active moiety may be modified by a single term, preferably with no more than four syllables, to show a chemical modification, such as salt or ester formation.  Examples can include cortisone acetate from cortisone, cefamandole sodium from cefamandole or erythromycin acistrate from erythromycin.
c.  Only under compelling circumstances is a name with more than one modifying term acceptable.  Compelling circumstances may pertain to such examples as pharmaceuticals containing radioactive isotopes or the different classes of interferons.
d.  Acronyms, initials and condensed words may be acceptable in otherwise appropriate terminology.

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To see the entire list of rules, go to this .pdf, the USAN Stem List.  Examples:

CHEMICAL SUFFIX	TYPE OF MEDICATION	EXAMPLES
-anserin	serotonin 5-HT2 receptor antagonists	altanserin, tropanserin, adatanserin
-azepam	antianxiety agents (diazepam type)	lorazepam
-peridol	antipsychotics (haloperidol type)	haloperidol
-peridone	antipsychotics (risperidone type)	risperidone, iloperidone
-perone	antianxiety agents/neuroleptics	duoperone
-pezil	acetylcholinesterase inhibitors used in the treatment of Alzheimer’s disease	donepezil , icopezil
-pidem	hypnotics/sedatives (zolpidem type)	zolpidem alpidem
-pirdine	cognition enhancers	linopirdine, besipirdine, sibopirdine

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