Those Lying Psychiatrists

In the comment section of some of our blog posts, there have been comments about psychiatrists who lie.  While I haven't kept a tally of these remarks,  I think the most common assertion is that psychiatrists lie by telling patients they have to remain on medication for the rest of their lives.


My understanding of the term verb "to lie" is that it requires the person who utters a communication to know that it is not true, and it often is accompanied by a deceptive motive.  So, for example, if a patient has a UTI that can be treated with a cheap antibiotic taken for three days and the doctor knows this, but he is getting a kickback from the pharmaceutical agency and he's having trouble filling his schedule, so he prescribes the expensive antibiotic and tells the patient "You must remain on this for life, and you should come in for weekly visits or you will most certainly die," then this is a lie.


In medicine, we know very little for sure.  Every now and then we do know something absolute, like that if you do nothing about a specific condition, you will die.  What doesn't get said is that even if you do something about it, you may still die, and that no matter what, eventually you will die.


Doctors seldom know that you must do anything, when they say you must, or you should, or you need to, they are making a suggestion or recommendation based on the evidence that is available.  It's rare that evidence is complete.  You need to remain on this psychiatric medication for life is not any different in my book then You need to remain on a statin for life, or a blood pressure medication, or aspirin.  Maybe you have risk factors for coronary artery disease but it's possible you could live out your life without a statin without having cardiovascular disease, in which case you didn't "need" the statin.  Was your primary care doctor lying?  Of course, in the meantime, the statin could give you muscle problems, cause diabetes, or increase your risk of death by other means.  Oh, and while we're here, you "need a pap smear every year."  Oh, except now it's every 2 or 3 years, and not after 65.  Does every woman over 40 "need a mammogram?" Maybe it's 50?  Depends which agency you ask.  And don't start me on calcium, vitamin D supplements, yearly PSA measurements,  hormone replacement therapy, biphosphonates and all the other things we're told we "need" until it turns out they kill us. (Please note, there is nothing that currently indicates that vitamin D kills you and calcium only gives you increased risk for kidney stones, it doesn't kill you, and biphosphonates don't kill you unless perhaps they give you esophageal cancer).


When a patient is told they "need" a psychiatric medication for life, it's because the doctor believes the risk is high that the psychiatric disorder will recur without it.  Sometimes, it seems like a fair bet or that the risks are too high to chance NOT staying on a medicine.  Seven episodes of disabling major depression that caused the patient to lose their jobs, spouse, and have 4 hospitalizations and 3 serious suicide attempts?  Might not be a bad idea to stay on those meds, and you might not need such an extreme example to get there (I like to stay away from the lines).  


Sometimes, we're wrong -- after all, the recommendations are based on studies and statistics from groups of people with symptoms or illnesses, not on individuals.  The truth is that for most of these things, you don't know for sure until you try stopping them and see how you do without them.  But to call the doctor a Liar?  Isn't that going a bit far? Might be better to consult a fortune teller rather than a physician.

Whether or not they work, they're getting cheaper.

Over on Thought Broadcast, Steve Balt has a nice, disillusioned post about whether clinical psychopharmacology is a pseudoscience.    By the end of the post, I was ready to take down my shingle and go home.  I liked Steve's graphic so much (the little pill bottle guy juggling those mood stabilizers) that I stole it.


On another pharm note,  there are several popular medications that have recently gone off-patent or will soon go off-patent, allowing for more competitive pricing as generics become available.  Among them, several big-buck psychiatric medications, including Lexapro, Seroquel, Zyprexa, and Concerta. 

The Ten Percent Solution

Duane and others have mentioned this "10% rule," which essentially suggests making small changes in medication doses over extended periods of time (~1 year). A 10% decrease in dose every 4-6 weeks is often quoted. It's a rule that makes a lot of sense.

In response to a change in the brain's biophysicochemical stew (meds, trauma, chronic stress, etc), it generally takes neurons a couple weeks to fully generate new or recycle old protein machinery -- to adapt to changes. This duration can be shorter for some proteins, longer for others. Thus, small changes would be expected to minimize the shock to the system. This just makes good homeostatic sense.

There are problems with this as dogma, however. There is not useful research, at least that I am currently aware of, to demonstrate whether the "best" interval percentage change is 10% or 5% or 25%. We also don't know if the "best" interval is one week, two, four or eight. Or which medications and their affected pathways are best tapered at what intervals and amounts. Please share original source (ie, PubMed) links to peer-reviewed research below if you have relevant references.

Prescribing Psychotherapy: Today's Grand Rounds at Johns Hopkins

Today, I heard Dr. Meg Chisholm give Grand Rounds at Johns Hopkins Hospital on "Prescribing Psychotherapy." Coming at it from an obviously pro-psychiatrist-as-psychotherapist bias, Dr. Chisholm discussed the financial forces that encourage psychiatrists to have "med check only" practices. She mentioned Daniel Carlat's book, Unhinged, and even showed a picture of it --she gave it a thumbs up. Meg quoted someone as saying that psychiatrists are a precious resource and should only be doing time-efficient psychopharmacology and presumably cranking through those patients as fast as possible. She showed bar graphs that illustrate how fewer shrinks are doing psychotherapy and fewer patients are getting it. In terms of cost, it's not clear that split therapy is cheaper, and psychiatrist-for-meds/psychologist-for-therapy is actually more expensive than one-stop shrinking. She made the excellent point that while we know that a combination of therapy and meds works best for some conditions, we don't know if people do better if they have therapy with a psychiatrist or split therapy with two mental health professionals, and we really need outcome studies. Finally, she talked about what role, if any, psychotherapy training should have in the education of psychiatrists during residency.

There was a portrait of one of our mentors, the late Dr. Jerome Frank, a pioneer in psychotherapy researcher at Hopkins. Meg showed a photo from his younger days, but I chose one of Dr. Frank as I remember him (see above). There was the requisite cartoon of a psychoanalyst, and a picture of the fictional Dr. Paul Weston (Gabriel Byrne) over his In Treatment couch. Ah, but Meg has it wrong--- she's never watched the show yet her research revealed that Paul is a psychiatrist who prescribes medicine, but Paul is a psychologist with training in psychoanalysis. No prescription pad and we never see him actually practice psychoanalysis.

A psychologist in the audience made the point that the experience of doing split therapy is very different when done with different psychiatrists, and that it's a totally different event with a primary care doctor.

My thoughts? I had a few.

-- I don't like the implication that psychiatrists "should" practice a certain uniform way. "Should" every psychiatrist have to do psychotherapy even if they hate listening to the same patients? "Should" every psychiatrist see four patients per hour even if they would much rather practice psychotherapy? Doctors should do what they do best and like best, and it's fine if some docs do psychotherapy and some docs don't. Would we dictate that doctors in shortage fields shouldn't be allowed to hold administrative positions, do research that could be done by Ph.D's, take maternity leave, pursue hobbies, or have blogs?

--There's more to psychotherapy than just psychotherapy. Seeing patients often and for in-depth sessions allows for a more careful use of medications. In clinic settings where patients are seen infrequently and everyone's expectations are for 20 minute visits every 90 days, it's very difficult to address the question of whether a stable patient might do better on a different medication regimen. The risk of stopping a medication is often riskier than just continuing with the status quo. The question "Are you the best you can be?" doesn't get addressed and major changes in medications usually happen during periods of crisis or hospitalization.

--Psychotherapy continues to be an integral part of psychiatric treatment and residents should be required to learn to do psychotherapy even if they never plan to do it again. Without seeing patients through the process, a psychiatrist can't really appreciate the benefits or limitations, and the while we might like to think that psychotherapy is something one "prescribes" just like bactrim or synthroid or insulin, we all know that some people feel more helped by therapy than others and the importance of the interpersonal rapport is not something one can generically dictate.
----------------
Really good Grand Rounds.

Related Post: The Psychiatrist as Therapist

Serotonin du Jour

Scicurious writes in the Neurotopia blog everything you wanted to know about serotonin (*but were too anxious to ask).

This is a very well-done post on this topic. Go there. Read it. Tattoo optional.

"Serotonin is a pretty wild molecule for many reasons. First of all, it is formed form the amino acid L-tryptophan, which is one of the 20 standard amino acids required for life as we know it. Interestingly, tryptophan is also one of the few "essential" amino acids for humans, meaning that we don't make it ourselves, and have to get it from the diet. But don't worry, you've usually got plenty. The only way anyone could really suffer "tryptophan depletion" is if you're in a lab and they give you tons of other amino acids, or if you're starving. And if you're starving, you've obviously got bigger problems.

To make serotonin, start out with some L-tryptophan. This gets broken down in cells by an enzyme known as tryptophan hydroxylase to 5-hydroxytryptophan, this then gets broken down using the enzyme amino acid decarboxylase to 5-hydroxytryptamine, or 5-HT. Then the 5-HT is ready to be stored in vesicles in preparation for..."

Go to Neurotopia for more.

Pharmakon: Fantasizing about family secrets

This fictional novel, Pharmakon, is written by Dirk Wittenborn, the son of a 1950's era psychiatrist. Sounds interesting, and a little uncomfortable to be reminded of the more primitive roots of modern psychiatry. We still have a ways to go. From The Independent.ie.

"On Sunday, October 8 1950, my parents and their three young children were in the yard planting tulips when a stranger who seemed lost appeared in the street. My mother was just about to ask if he needed help when my father whispered urgently, "Don't look up and don't say a word." My mother thought he was kidding until he told her that the stranger was a deeply troubled former Yale student he had once treated. My father didn't know his former patient had a loaded revolver in his pocket, but he had good reason to be frightened -- the young man had recently composed a 'death list' of those he blamed for his unhappiness, and Dr JR Wittenborn was at the top.

For reasons that remain a mystery to this day, this mentally unbalanced angel of death passed my family by and walked up the road. Number two on his death list was a Yale psychiatrist who had also treated him, and lived in the neighbourhood. My father tried to warn his colleague, but in the pre-answering machine 50s there was no way to leave a message. A few hours later, gunshots rang out. The psychiatrist was murdered and his wife shot and severely beaten."

[Author on YouTube]

Have any of you read this?  What did you think?

Programmed Prescriptions

Today a computer told me that I couldn't use Prozac. More specifically, it said that the use of Prozac was contraindicated in people diagnosed with bipolar disorder. This experience led me to conclude that the only thing worse than having an insurance company tell you how to treat your patient is having a computer tell you how to treat him.

I'm required to use an electronic medical record. I don't generally mind this. The constant typing and the amount of time required for data entry is a pain in the rear, but I know it's the best way to ensure continuity of care between prisons. The problem is that the system also has preprogrammed treatment algorithms. I have no idea where they came from, who decided them and what data they're based on, but they exist. Episodically the computer tries to tell me how to practice.

The computer algorithm has also told me not to use lithium with people who are also on certain blood pressure medications and serotonergic reuptake inhibitors with people who have hepatitis. The computer doesn't say "be careful about this combination because it can cause X, Y or Z problems" or "be sure to watch drug levels more closely with this combination". It says, "Use of this drug is contraindicated in these conditions". Then, in order to continue entering the prescription, you have to click an "acknowledge" button to document that You Have Been Warned.

Truly, this is annoying on so many levels.

It's a CYA maneuver so the nameless Company can say it warned you if anything goes wrong. It's unnecessarily alarmist. It confuses the medication nurses who occasionally check to make sure the meds are OK to dispense. But more importantly, it's just bad information. These medication combinations are still effective, and they can be used safely, you just have to monitor them more closely. The geek who designed the system doesn't know this, he or she just programmed in the information he was told to put in. It probably seemed like a good idea.

And it will be someday, once computers are granted prescribing privileges.

*****************

And now I want an opinion from our readers. It's got nothing to do with psychiatry.

If you make hot cocoa from cocoa powder and other ingredients, instead of using hot water and a bag of cocoa mix, is that considered 'homemade'? Dinah says it's all one and the same. I say it's making cocoa 'from scratch' just like baking a cake without using a boxed mix.

What is your definition of 'from scratch'? And what's your favorite hot chocolate recipe? I'm looking for suggestions.

Tell Your Doctor If You Experience Any Of The Following...

A reader writes in:

I might suggest that in some cases, the more outre side effects of SSRIs are not reported because the person taking the drug is afraid of being thought insane. I had unbelievable rage while I was taking Effexor, and never told anyone about it because I was afraid of not being believed, and also afraid that there was something else seriously wrong with me.

I am a highly intelligent and naturally moral person, and never hurt anyone despite my desire to do so, though I did put my fist through a wall at one point. But I had extremely disturbing violent impulses while on the drug, including a desire to maim or kill my beloved cats, and a strong desire to physically assault the woman I was dating at the time. All of this vanished completely when I decided to voluntarily go off the drugs, which I had been told I would need for the rest of my life. As it happened, the psycho-emotional disorder I had was consistently missed by therapists and clinicians, and SSRI drugs were not an appropriate treatment.

This may or may not account for the peculiar side effects, but at any rate -- my thought is that possibly these things go unreported due to shame and fear on the part of the patient.

So we don't give medical advise here on Shrink Rap. I borrowed this comment, however, because I'm struck with how often patients withhold critical information. If a patient tells me that since we started a medication, he's had a new symptom, if that symptom is intolerable to him, or in any way worrisome, I don't sit there thinking they are crazy. I stop the medicine. If the side effect sounds like it's a little uncomfortable but the overall quality of someone's life is better with the medication, I simply restate the facts and my thoughts about whether the good outweighs the bad, I let the patient chime in with their thoughts (I'm not in their body), and I consider the circumstances before the medication was started as well as the response to the medicine. If someone was suicidally depressed and unable to function , then maybe it's worth tolerating a dry mouth in exchange for the ability to return to work and not be sad or suicidal?

It's not just medications-- it's anything major going on in someone's life. If something huge is going on in a patient's life, the doctor needs to know. "I'm more depressed lately," has one meaning in the context of a medication change and another meaning in the setting of a recent loss.

What psychiatrists can't do is know what someone is experiencing without being told. We don't have crystal balls, we don't have ESP, we aren't mind readers, we don't "know" what you're thinking, feeling, worrying about, distressed by, unless a patient tells us in fairly precise terms.

It's Not Supposed To Work This Way

Okay, so pick your psychiatric diagnosis-- only don't pick Adjustment Disorder, or Major Depression, single episode. Pick a psychiatric diagnosis where we Know that it recurs and where long-term treatment is indicated. Let's say schizophrenia, or bipolar disorder, or recurrent major depression with a bunch of episodes. Let's say the episodes are bad and the patient gets lots of symptoms and life gets ugly.

So pick your medicine to treat Illness X. The patient takes the medicine and most of the symptoms get much better, the patient feels better, everyone takes a deep breath, the side effects are minimal or non-existent. Life is good, though the patient still has some problems (ah, don't we all....) and lives a bit on the edge in a way that leaves us wondering-- is there a personality disorder here? A developmental issue? A social issue? Or are there perhaps some residual symptoms? Maybe this is just one of those people who will never fit neatly into a boxed corporate-climbing life, or for whom meds and therapy won't be complete answers.

We're moving along okay, nothing scary is happening, the patient is mostly well, the medicine is tolerated, life is looking up. And then an episode hits---this is not "supposed" to happen. But we all know that the medicines decrease the likelihood of a recurrence of illness, while they are no guarantee.

So we take our ill patient and we do what one might do: raise the dose, assess symptoms, increase the frequency of sessions, get thee to a lab: check levels, look for other things that could account for the sudden symptom exacerbation, think about drug interactions and what's that thyroid doing anyway?

The patient returns. Ah, much better, the symptoms have abated, the patient feels better than ever. The obvious signs of illness are gone. For the sake of clarification, in psychiatry "signs" are thinks we can see-- psychomotor slowing or activation, abnormal movements, changes in the rate of speech, disordered thoughts, conversations with non-existent people...fill in the blanks. The patient is eating and sleeping better, functioning better, less irritable, less chaotic.

One little thing, Doctor: "I stopped the medicine."

Oy. So the patient stopped taking the medicine that treats the illness and gets much better. Maybe the problem wasn't a breakthrough of symptoms, maybe it was that the patient was having unrecognized side effects from the medicine and feels better without it? Nope, the symptoms were classic illness symptoms, not side effects. Why would they get "better" from the psychiatric symptoms when the med stops? I have no idea. And yes, I promise you, the patient had the symptoms before any psychotropic medication was ever started-- this isn't simply an adverse reaction to the medication. The best I can do is that the episode was self-limited and happened to end as the medication stopped, but that feels a little lame even to me.

So now what? The patient had numerous episodes of the illness before getting diagnosed and treated. But, really, you can't say to a patient: This is the gold standard of treatment for your illness, take the medicine even though you feel much better since you stopped it. Oh, I guess you could say it, but no patient will listen.

It's hard to prophylax well patients. We could try another medication on the theory that it may protect against future episodes, but if someone is feeling well, there is very little immediate up-side to prophylaxis: You feel well now and you may get side effects (oh, and you'll have to get labs and EKGs and maybe the new medicine will give you lovely adverse effects). We could do nothing and wait: it's pretty clear that it's just a matter of time and the "well" patient is a time bomb.

It's not supposed to work this way.

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]

An Ounce Of Prevention

In medicine, therapeutic interventions tend to fall into one of three classes. Tertiary prevention means doing something to reduce the impact of symptoms in a disease that already exists. Secondary prevention is when you try to catch the disease at an earlier stage, either before symptoms develop or before they become severe. Routine blood pressure checks are an example of secondary prevention because blood pressure measurement catches hypertension (hopefully) before complications like stroke or heart disease develop. Finally, primary prevention is when you do something to keep the disease from starting to begin with. Routine pap smears are a primary preventive measure for cervical cancer---the idea is to catch abnormal cells before they transform into cancer.

So how does this all apply to psychiatry?

It's relevant because, unfortunately, in our specialty right now almost all interventions are tertiary interventions. We see patients after a disease has developed, when they are bothered enough by their symptoms (or their families or employers are bothered enough) to make them seek treatment. By the time they come to treatment they have often already experienced some type of morbidity, either in the form of time lost from work or impaired social functioning, or even impaired physical recovery as in the case of hospitalized medical patients with untreated depression.

There have been some secondary prevention efforts. Every October there is a national depression screening day, when health fairs offer evaluations for clinical depression in addition to other general medical assessments. Internists, family practitioners and other primary care providers are starting to include screening for mental disorders as part of routine health care.

The area where psychiatry is still grossly lacking, mainly because of our still-meager understanding of the basic causes of mental illness, is in primary prevention. Simply put, we just aren't very good yet at preventing psychiatric illness.

We do our best primary prevention when the psychiatric disorder is the result of an identifiable physical cause. We can prevent cognitive impairment and lowered IQ by checking babies for hypothyroidism and children for lead poisoning. You can prevent HIV psychosis by preventing the spread of HIV and keeping the disease under control to delay or prevent dementia. General paresis, or dementia due to advanced untreated syphillis, is pretty much gone now due to the invention of penicillin.

Unfortunately, we still don't know how to prevent schizophrenia or bipolar disorder. We may be about to find a way to prevent clinical depression, at least in some patients. The Associated Press today summarized the findings of an article in this week's issue of JAMA regarding the prophylactic use of an antidepressant in post-stroke patients. One hundred twenty-seven stroke patients were divided into three groups: one treated with escitalopram, one given therapy and one group given a placebo. The escitalopram group was significantly less likely to develop clinical depression over the course of the year following stroke than either of the two control groups.

Now I'm waiting for a study to see if prophylactic antidepressants are useful in other at-risk groups, like heart attack patients, who are also prone to clinical depression in the months following the attack.

It's only one study, but it's a start.
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And now : an intrusion from Dinah. I've decided I like putting my comments on the front of the post.

So here's the problem with preventative psychiatry in it's infancy. In the studies above, the issue is one of Risk. I don't know that I'd want to take a medication (with all the risks, side effects, possible adverse reactions, and the question of the unknown longterm or short term effects) for a condition that one is at Risk for. Invariably, some people will be exposed to medications who would never develop the targeted illness. It's a hard sell for me, unless the risk is 100 per cent.

I think we like to think maybe if an illness is caught early in it's course, then it won't get as bad, or at least the symptoms can be treated earlier. This is one rationale for on-going psychotherapy in people who want to be seen between episodes: that therapy may prevent future episodes, may give people tools to prevent relapse, and that the subtle signs of illness may be caught sooner before they become full blown episodes.

Thank you for letting me join in here.

Sidebar Poll on MAOIs

Something's slowing the loading time for Shrink Rap. One reader thought it was the latest podcast. Clink thinks it's the sidebar polls. So I'm posting the results and taking them down. I was surprised that we have so many readers who've taken MAOI's... and thanks for the comments on our post below.

Have You Ever Taken An MAOI?

Yes	26 (27%)
No	70 (72%)

Vote on this poll

Votes so far: 96

Did It Work?

Yes	14 (56%)
No	9 (36%)
Not Sure	2 (8%)

Votes so far: 25

Did You Have Any Adverse Reactions?

yes	16 (61%)
no	10 (38%)

Vote on this poll
Votes so far: 26
Days left to vote: 2

Why This Shrink Doesn't Prescribe MAOI's

Graham wrote in a question:

OK, so since it was a pretty generic post, I'm going to ask a question of you three that's pretty far off topic. Why do you think MAO inhibitors are so infrequently used in psychiatric practice today? Besides dietary/drug interactions, their safety profile is good. There are masses of studies showing efficacy. Why switch patients from one SSRI/TCA to another to another instead of trying a MAO inhibitor. Do you think MAOI's have a place as second line agents in certain circumstances?

What a great question, I've been thinking about this one for a bit and this is what I've come to. I don't use Monoamine Oxidase Inhibitors (MAOI's) to treat depression or anxiety, though from time to time, I think about it. Why not? It's a really good question, they are really good medications, sometimes helpful when other meds don't work, and lore has it that they are helpful with "rejection sensitivity" in patients with borderline personality disorder.

So Why Don't I use them?

1) They are dangerous in combination with a bunch of foods-- aged cheeses, certain red wines, fava beans, and I'd have to look up the rest of the list. It includes medications, even some over-the-counter medicines. Accidental or purposeful ingestion of these substances in combo with MAOI's can lead to hypertensive crises-- think stroke and death. This makes me a little wary.

2) Pure gut bad association-- at the hospital where I went to medical school, the young daughter of a New York Times editor died-- the combination of MAOI's and prescribed Demerol were thought to play a role in her death.

3) I don't like to give patients medicines that they can easily fatally overdose on.

4) My own naivete. By the time I started residency training in psychiatry, SSRIs were hot. Many patients were on TCA's (tricyclic antidepressants, and you can OD on these, too). I saw two patients in my residency on MAOIs. I've worked in 3 different clinics, each with an active caseload of about 1,000 patients. There was one patient in the first clinic I worked in (1992) on an MAOI. I've never seen the chart of any other patient treated at any of these clinics with an MAOI. Okay, I haven't seen any patient's chart, but the point here is that I'm just not familiar with them, so they aren't my first/second/third/fourth choices for treatment. Should they be?

5) Once you've used an SSRI, you have to wait weeks to use an MAOI, not always an easy prospect for a depressed patient.

Thanks Graham, I'm running my next sidebar poll in your honor!

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.

---

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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And Now a Word or Two about Mood Stabilizers

I came to talk about mood stabilizers and figured I'd start by summarizing our sidebar poll "What is Your Favorite Mood Stabilizer?" Only every time I come on, the poll has gotten more votes, so I guess I'm waiting for the mood stabilizer poll to stabilize.

Here's where we're at so far:

What's Your Favorite Mood Stabilizer?

Lithium	32 (22%)
Depakote (Valproate)	27 (19%)
Zyprexa (Olanzapine)/ other atypical anti-psychotics	29 (20%)
Carbamazepine (Tegretol)	1 (0%)
Gabapentin (Neurontin)	9 (6%)
Lamotrigine (Lamictal)	44 (30%)

143 votes, Lamictal has been consistently in the lead since the beginning. Both surprising and not surprising.

I talked about How A Shrink Chooses an Antidepressant. I have less to say about how a Shrink Chooses a Mood Stabilizer. In fact, I'm not really sure. I'll tell you how This shrink chooses a mood stabilizer. It's not that much different, so click on the that post for more details.

• History of Past Response.
• Family History of Response
• Patient Preference. This is a big one with mood stabilizers. The gold standard is Lithium and some patients just won't hear of it. They think taking lithium means they're really far gone, that it's heavy duty stuff, that it means they're crazy.
• Medical issues: lots of them with mood stabilizers.... lithium can effect the thyroid and kidneys, it interacts with lots of other meds, depakote can effect the liver, so can tegretol, lots to think about, lots to monitor.
• How strongly I'm convinced that the patient has had a full blown manic episode. Plenty of people say "I'm Bipolar" but the history doesn't reveal a story for episodic, syndromic co-occurance of the hallmark symptoms of mania: elevation in mood or irritability, increased energy/ decreased need for sleep, quickening of thoughts or speech, impulsivity with regard to spending, sexuality, religion, hallucinations, grandiose delusions, inflated sense of worth or well-being. None of these symptoms alone are enough to diagnose mania, ya gotta have a few and they have to occur at the same time as the other symptoms. Lots of people shop impulsively to cheer themselves up, lots of people have periods where they feel more energetic and productive, lots of people get happy when they win the lottery. It's sometimes hard to get a history for a syndromic diversion from a baseline (or pre-morbid) personality.
• If I think someone definitely has bipolar disorder, and there isn't a reason not to use it, I start with Lithium. It's a good mood stabilizer. It's cheap. I'm familiar with how to use it. It's also a good anti-depressant augmenter. Despite all the hype about the awful side effects (weight gain, nausea, tremor, cognitive slowing, renal and thyroid impairment), I've seen lots of people have good responses and not have any side effects, so I start with that assumption and I use low doses. If the patient gets better, I don't push the level, even if it's really low. If the patient has intolerable side effects, I try another preparation of lithium (eskalith, lithobid), and if that doesn't work, I stop it and try another med. Why do I like lithium? I think because I've heard enough people put up resistance, then try it and come in saying "I feel normal for the first time." The down side is that you have to do bloodwork every 3-4 months even if the patient is well and has no symptoms.
• If I'm not so sure about the manic component as a real, syndromic entity, and the primary complaint is depression, I start with Lamictal. The upside-- it's well tolerated, people like it, there's no routine labwork and there's no stigma. The down side-- slow going to build up from a dose of 25mg to the therapeutic range of around 400mg. Another down side-- that fatal rash risk. And the final down side-- I've heard a couple of anecdotes of patients who have ended up in the ICU with rashes, liver zorkout, life-threatening problems. Not a lot, but it only takes one such story to make you hold your breath when you write a prescription and I have a friend who says "I'll never be able to prescribe Lamictal again." It's not science. I actually tell patients this story-from-hell when I prescribe it, and they'll still take it over lithium. Mostly, it's a good medication, it's well tolerated, and it helps.
• If a patient doesn't want Lithium, I prescribe depakote. It's associates with it's own issues, including weight gain, needs lab monitoring, and if the patient doesn't have insurance, it's expensive and hard to get samples of.
• I haven't prescribed tegretol in ages and I wondered if the reason it's so unpopular on our sidebar is because it isn't used so much.
• I prescribe anti-psychotic medications to people who are agitated, acutely suffering, not sleeping, in need of something quicker than lithium/depakote/ or lamictal. These medications work, they're well-tolerated, patients like them. And I worry about the metabolic effects and wish there was some free ride.
  
• Sometimes I use one of the older anti-psychotic-- navane may be my favorite
  
• If there is no history of substance abuse (---hmmm, that's rare in people with bipolar disorder), I may prescribe some ativan or klonopin for the short term.
• I haven't used Trileptal, I don't know why. I have a patient or two on Neurontin, I stopped prescribing it when studies showed it didn't help with mood stabilization. Perhaps I was wrong. And I haven't seen very many people tolerate Topamax, though I have seen it work wonders for migraines.
  
• Lithium is my favorite.

Okay-- I know there are lots of people out there who've had bad experiences with lithium. I'm not advocating that anyone re-try a medication they didn't tolerate. I'm just suggesting that everyone responds differently and before the medication is prescribed, your doc doesn't have any way of knowing if you will have problems or be one of those people who has a wonderful response and no side effects.

And to one of our anonymous commenters who wrote in:

Anonymous said...

I hope you have a really great reason for purposely for gathering useless data.

Yes, anonymous, I had a really great reason: I was curious, wondered if I'd learn something (and I did) and I thought I'd use the information for a blog post. Rest assured, I have indeed gathered completely useless and out of context data. It still makes me happy when my useless information is quoted by the Wall Street Journal.

How to Select an Antidepressant: Part 2

Dinah posted about How Psychiatrists Select Antidepressants, which was a very thoughtful and concise description of the factors we take into consideration. Supremacy Claus commented on Dinah's pragmatic, plain-speaking distillation (talk about plain-speaking pragmatism, check out this legal eagle's excellent blog). Dr Smak (another great blog... she and Dinah should go shoe-shopping together) was surprised to find no mysterious revelations, and "The" Shrink (a great new psychiatrist blog... welcome!) felt doctor preference was a missing element.

I started a comment, but it got so long and non-plain-speaking (sorry, S. Claus) that I moved it here.

Shrink, not so sure about the physician preference part (or maybe I am atypical... ha). I don't have a "favorite" or fall back antidepressant, as I find that when I apply Dinah's list (which is quite comprehensive and a good list), I am usually left with one or a couple drugs, and can still find a reason to pick one over the other (eg, cost). I feel I am quite familiar with the zillions (ok, maybe it's only 15 or 20) and ready to pick whichever seems best.

I do think Dinah's #4, 5, and 6 should be expanded on, and #4 should be split into 2 separate sections (I'm a splitter)... #4a being Other Medical Issues (eg, Seizure -x-> Wellbutrin; Psoriasis -x-> Lithium; Hypertension -x-> Effexor; etc) and #4b being Drug Interactions.

Drug Interactions is a whole 'nother post, and is a BIG factor for me when prescribing. Many of my pts are on multiple meds, so it becomes really important to think about this. Prozac and Paxil, for example, are famous for 2D6 interactions, so I avoid it when folks are on drugs which are solely metabolized by that enzyme. Luvox is a great hs antidepressant, but will muck with 1A2-metabolized drugs. Serzone and 3A4 drugs (though, haven't seen Serzone in years now... too bad, was a great drug to have around, esp if you knew how to use it... great for blocking SSRI-induced sexual side effects).

#5: Target Sx - When I think thru these, I think in terms of receptors (may be a tomato-tomahto thing here). I hear "no appetite" and think "I want histamine antagonism"; I hear "can't concentrate" and think "dopamine agonism"; I hear "no energy" and think "norepinephrine".

#6: Side Effect Profile - This is the one I spend the most time on with a pt. For any given side effect that is either desireable (sleepy, energizing, stimulates appetite, reduces appetite, etc) or undesireable (weight gain, wt loss, sexual, rash, seizure, nausea, etc), I have a pecking order in my head of drugs and their propensity to cause -- or not cause -- the particular side effect (other term is "adverse reaction", though they are only "adverse" when undesireable). The above 3 sections are where a better understanding of psychopharmacogenetics would come in handy.

The above may be where Dr Smak noted the perceived "secret way" in which shrinks pick 'em. What may be different in the way in which psychiatrists and PCPs select antidepressants is just in the way these thought processes get all merged together, or maybe thought about in an explicit way (my receptor-tomahto approach) or an implicit or nonverbal way (Dinah's best guess-tomato approach).

This "gut feeling" about which drug to use is merely the end result of a massive probability calculation which is automatically performed in the brain, based on all the above input about which side effects or target symptoms should take precedence for that specific pt, which drugs are more or less likely to deliver them based on receptor and metabolic profiles and based on literature and personal experience, in addition to the other factors like likelihood for compliance and affordability, all boiled down to a single "I think you should try Effexor". Much of that calculation is not conscious, and I think Dinah belies the complexity under the surface by simply (but honestly) stating "my best guess".

My Patient, Myself

I saw this abstract and wanted to post it. Entitled Psychiatrist Attitudes toward Self-Treatment of Their Own Depression, it's a survey conducted of Michigan psychiatrists regarding their opinions toward self-prescribing. A survey of more than 500 Michigan psychiatrists showed that more than 40% would medicate themselves for mild to moderate depression and that 15% had actually done so in the past. Seven percent of psychiatrists said they would treat themselves for severe depression or depression involving suicidal ideation.

The AMA code of medical ethics states: "Physicians generally should not treat themselves or members of their immediate families...It would not always be inappropriate to undertake self-treatment or treatment of immediate family members. In emergency settings or isolated settings where there is no other qualified physician available, physicians should not hesitate to treat themselves or family members until another physician becomes available. In addition, while physicians should not serve as a primary or regular care provider for immediate family members, there are situations in which routine care is acceptable for short-term, minor problems."

So why or when would a doctor consider treating himself? I don't know Michigan well, but I'd guess they probably have the same shortage of psychiatrists that other Midwestern states have. If you're a depressed psychiatrist you may be the only game in town. Maybe he'd be concerned about privacy and information-sharing among colleagues.

Or maybe the AMA would consider mild clinical depression to be a "short-term, minor problem" for which the self-treatment exception would apply. There are probably hundreds of physicians who at one time or another have written antibiotic prescriptions for themselves or for family members. I wonder if this also applies to prescribing for family pets? Should a psychiatrist prescribe Prozac for his obsessional cat? Thorazine for the nervous dog? A recent survey of neurologists showed that more than 90% agree that it would be appropriate to self-prescribe for acute minor illnesses. Another survey of young Norwegian physicians found that 90% had self-prescribed in the past year.

Don't ask me what Michigan surgeons would do...

My Three Shrinks Podcast 16: Encyclopedia of the Weird

[15] . . . [16] . . . [17] . . . [All]

---

ClinkShrink here. I volunteered to help Roy by editing one of our podcasts--heaven help me, I did the best I could. Be patient, I'm using Windows. This is podcast number 16 which was actually podcast number 14 taped about a month ago and taken out of order for no particular reason.

---

April 17, 2007
Topics include:

• First up are the Top 25 Crimes of the Century, a topic that could only be mine. It's a Time article that lists some of the most infamous or unusual crimes, but I have a couple bones to pick about their choices. Roy and Dinah just think I'm weird for even knowing this stuff. [Listen in to find out Clink's favorite crime. -Roy]
• Next we answer a question from Driving Miss Molly regarding how much and what kind of preparations psychiatrists do before their patients' appointments.
• Finally we do the Shrink Rap blog rollcall, where Shiny Happy Person deals with medical training in the UK and under the NHS, Roy flirts with the Girl with the Blue Steth, and Intueri talks about bipolar disorder in kids.

Find show notes with links at: http://mythreeshrinks.com. This podcast is available on iTunes (feel free to post a review) or as an RSS feed. You can also listen to or download the .mp3 or the MPEG-4 file from mythreeshrinks.com.

Thank you for listening.

Medicines: The Good, The Bad, & The Ugly

So we started this line with Why I Still Prescribe Seroquel (see post below with it's 58 heated comments), ClinkShrink continued it with her Max & Me post which drew in my dog, and it got me thinking about a discussion on medications in general. I started with Life Is Full of Risks as the set up for this, so if you're still along for the ride, thanks for listening. And if you've seen Roy...it seems he Quit his Day Job then disappeared. I'm hoping I don't have to have those floor boards pulled up again.

I work in Free Society -- a term I learned from ClinkShrink who works in the jails. My patients are all adults and with few exceptions, they seek my help of their own accord. Often they come with a request for medications, sometimes a request for a specific medication--something that's helped them in the past, something that's helped a friend.

So humor me while I talk a little about medicines.

The Good
Medications are prescribed by doctors to target symptoms, to target abnormal laboratory or radiologic findings, or to prevent the development of disease in at-risk populations. Symptoms are things like pain, insomnia, hallucinations, cough, angina, heartburn. The goal of medication is to relieve the symptoms. Abnormal laboratory values are things like elevated glucose levels in diabetics, low red blood cell counts (anemia), elevated cholesterol. Examples of medication given to healthy people might include aspirin to prevent heart attacks, or the ill-fated Hormone Replacement Therapies that were given to women in the hopes of preventing heart disease and
osteoporosis, Lithium for bipolar disorder that is continued between symptomatic episodes. I didn't get it all-- fit chemotherapy for cancers, anti-hypertensives, and a slew of other medications where you will. At any rate, the point of the medicine is to get rid of something bad or to prevent something worse from happening, or both: anti-hypertensives normalize blood pressure and prevent end-organ damage --end organs for high blood pressure are the retina, the kidneys, the coronary arteries, and the cerebral arteries-- so the goal of them medicines is to normalize the numbers and prevent strokes, blindness, and renal failure.

So the good: medications sometimes work. In some people, some of the time, they make the bad things go away and they allow people to live healthier lives longer.

The Bad:
The bad thing about some medications is that they have Side Effects. Side Effects are results of the medications that are nearly always unwanted, kind of the weeds in the garden. Symptoms in their own right, they happen, with some regularity, and sometimes we even use medications for their side effects rather than their primary purpose. So trazodone is an antidepressant, but it makes a lot of people sleepy, so it's used in sub-therapeutic (for depression) doses to help with insomnia. Mostly, though, side effects are bad-- they are uncomfortable for the patient and are often a reason people will stop medications. It's great if that medicine strengthens my bones so I won't break them later, but not if it gives me intolerable Side Effect X now. Side Effects are uncomfortable, they aren't fatal, and they are reversible, they go away when the medication is stopped, and for certain medications, certain side effects are fairly common-- if Ibuprofen upsets your stomach, you're not alone.

What's interesting about side effects is that few of them happen to everyone. So a lot of people will have sexual side effects from SSRI's, but certainly not everyone. Some people will have a tremor from lithium, some will get tired on thorazine. Certain cancer chemo therapies cause everyone to lose their hair, and dry mouth on therapeutic doses of tricyclic antidepressants (at least in my personal observation) seems to be par for the course, but many side effects seem to be fairly random. Many psychotropic medications are known to cause weight gain, and that has been a topic of concern in the comments on Shrink Rap, but I've certainly seen plenty of people take medications that are associated with weight gain who never gain weight. We don't know who will have side effects, kind of like we don't know who any given medication will work for, and because of this, it really becomes impossible to tell patients anything more than a list of the more frequent side effects with this implicit understanding that other side effects may also occur. Pharmacies provide lists, but it's hard to be comprehensive. From the doctor standpoint, there is no guarenteed free ride: when you swallow a pill the possibility of a side effects are there and largely unknown. For the patient who is struggling with a condition that's impeding his life, as many psychiatric patients are, it may be worth taking the risk of any given side effect because that side effect may simply not happen. Since weight gain is a hot topic, I will say that I've seen patients have good responses to Lithium, Clozapine, and Zyprexa (all notorious for causing weight gain) who've not gained an ounce. Other's have inflated like balloons-- the only good news here is that the weight goes on a pound at a time and the medicine can be stopped if the weight starts going on. The problem, of course, is what to do when the patient has a good response to the medicine but also has side effects: unfortunately this scenario leaves the patient with difficult choices.

The Ugly:
Side effects are unpleasant, but often anticipated, and reversible. Many medications have really rare and really ugly effects-- these aren't side effects but Adverse Reactions. They can be awful, and they can be fatal and they can be irreversible. So Stevens-Johnson Syndrome, fulminate liver failure, and agranulocytosis are not side effects, they are life-threatening adverse reactions. Tardive Dyskinesia is an Adverse Reaction, though one that takes time to develop. Adverse reactions are the stuff of Black Box Warnings. The usual response to the Ugly is to stop the medication ASAP.

So what do I tell patients?
Mostly, I tell patients the more common side effects and of any black box warnings. I don't know, off hand, every side effect of every medication. If a patient asks in more detail, I open a PDR and read from the list of side effects. I offer reassurance that the medication can be stopped if side effects develop. I can offer no real guarantees about the possibility of catastrophic reactions-- though generally these are less then the risk of getting into one's car and usually I'm left to say "I've never seen that." A friend recently had a patient experience a life-threatening really rare reaction to a medication (one not listed in the PDR) and for a while after I told any patient I started on that medication about this patient's reaction--- no one refused the medication even after hearing the story. My friend says she will never again be able to prescribe that medication. Rational? No, but our own experiences are sometimes more powerful than statistics. In the case of side effects, ultimately the patient is left to decide if the cure is worse than the disease. In the case of an adverse reaction, I stop the medication and don't restart it.

Sometimes, in some patients, the medications simply relieve the symptoms without any ill effects. It's nice when that happens.

Life is Full of Risks

The next time you step into your car, stop and think for a moment about the risks. The following things might happen. You could have a fender bender or bump into an inanimate object, causing damage to your car, someone else's car, or some one's property. It will be expensive to repair, your car insurance rates might rise and if it happens repeatedly you may become uninsurable. You could have an accident in which you are injured--perhaps with broken bones that will take months to heal, internal bleeding which may require emergency surgery and cause organ damage, or anatomically unnoticeably muscle or nerve injuries which could cause you years of chronic pain and disability. You could have injuries which leave you scarred and disfigured, you could become paralyzed and never walk again, never have use of your arms, require a respirator to breathe. You could die. And even if you're a very safe driver, there is no guarantee that someone else on the road isn't intoxicated or simply careless. And maybe you're not a great driver, and in a moment's distraction while you fiddle with the radio or respond to a child's request, you are at fault in an accident that disables another human being. You may be sued. You may have to live with a lifetime of guilt for the distress you've caused others in a moment too short to contain an ounce of bad of intent.

And while the likelihood of something bad happening is low for any given trip to the store, in the course of driver-lifetime, it is not an unlikely thing. Nearly everyone has had a fender bender; many many people have been in car accidents resulting in some form of injury to someone, thousands of people die in motor vehicle accidents in a given year-- nothing about the risk is anything but in your face.

And still, you will get in your car, just as I will soon get into my car. It's important to get to work, we all need to pay the mortgage. And we're out of chocolate sauce, what is ice cream without the topping? The kid really should learn to play guitar, gotta get him to those lessons. We take the risk because we do it so much, we've extinguished our anxiety about a very real danger. We take the risk because we've decided the quality of our lives is better if we do. And there are a whole host of reasons why every car doesn't simply have the very best safety rating and why someone would purchase any car that isn't the absolute safest one available.

This was a long way of saying, when you take a medication, there are risks. The prescribing doctor should tell you those risks, even if the patient is also a doctor, even if the patient really needs the medication but won't take it if he's told of the one in a million shot of death. The risks may be immediate, they may be long-term, they may be unknown, especially for the medium and long term. Each doctor decides what risks to tell patients, and honestly, these decisions are colored by some very non-scientific things. If the doctor took the drug and it didn't work for him or he had an unpleasant side effect, if he just saw a patient who had a dramatic bad effect even if it's known to be rare, if the last seven people walked in thrilled with how much better Drug X has made them feel, all with words of praise for the wonderful prescriber. No doctor tells a patient every possible side effect-- we simply can't remember them all, time doesn't allow for such lengthy discussions, many patients don't want to hear it. And while a patient should be warned of the more common side effects, will be told of any potentially life-threatening possibilities as deemed by the fated Black Boxes, many are coming for treatment because they are in pain or anguish, physical or mental-- they want the distress to go away and it's obvious that there is risk involved-- they're willing to accept at least some risk in exchange for the possibility of relief.

Stayed tuned for the next post: The Good, The Bad, & The Ugly -- more about medication. But first, I need to run to the store.