A new article published in the International Journal of Qualitative Studies on Health and Well-being addresses the utility of the ADHD diagnosis and provides alternatives to the controversial medicalized treatment for common behaviors of children.
Attention-deficit hyperactivity disorder (ADHD) has received intense critical attention in the research literature recently, as has been reported on here at Mad in America. Researchers suggest that overdiagnosis and overmedication are the order of the day for children whose behaviors are challenging for adults—such as teachers and parents—to control.Read More
This story was co-published with The Atlantic.
Everything happened so fast as I walked out of the doctor’s exam room. I was tucking in my shirt and wondering if I’d asked all my questions about my injured shoulder when one of the doctor’s assistants handed me two small boxes of pills.
“These will hold you over until your prescription arrives in the mail,” she said, pointing to the drug samples.
Strange, I thought to myself, the doctor didn’t mention giving me any drugs.
I must have looked puzzled because she tried to reassure me.Read More
JEFFERSON CITY, MO. (AP) – Child advocates filed a federal lawsuit against the Missouri Department of Social Services on Monday over allegations of inappropriately providing psychotropic drugs to foster care children and systemic lack of oversight of the medications.
Attorneys for Children’s Rights, the National Center for Youth Law and Saint Louis University School of Law Legal Clinics say the lawsuit is the first of its kind nationwide that focuses only on psychotropic drugs given to foster children.Read More
A new study, published open-access in the latest issue of PLOS One, surveys German physicians concerning their understandings of the well-documented placebo and nocebo effects of antidepressant drugs. The study finds that most doctors endorse the effectiveness of antidepressants while acknowledging that placebo effects may account for a significant share – around 40% – of symptom improvement.
“Overall, the findings suggest that the majority of physicians is generally aware of placebo and nocebo effects in antidepressants caused by psychological factors such as expectation and experience from patient and–to a lower degree–physician,” the authors write. “However, these effects are given a subsidiary role when compared to pure pharmacological effects.”
In recent years, researchers have paid increased attention to placebo and nocebo effects in medical research. Placebo refers to the positive effects a drug has that are not directly related to its pharmacological properties. “Non-specific” factors, such as patient and doctor expectations, have been shown to have an important and measurable impact on different symptoms. These same factors can also have negative or nocebo effects on individuals, however, when expectations and contexts lead to unwanted side-effects.
Past studies have suggested that placebo accounts for up to 75% of antidepressant effects, but psychiatrists and other physicians attribute only 26% of their success to these nonspecific factors. It is perhaps telling, however, that in past surveys 38% of psychiatrists admitted to prescribing sub-therapeutic doses – or doses lower than believed necessary to have an effect – of antidepressants. The researchers suggest that the underlying aim in these instances would be to induce placebo effects.Read More
NEW YORK (Reuters Health) – Simultaneous benzodiazepine treatment doesn’t make newly prescribed antidepressants more effective, but a sizeable minority of patients showed signs of dependence in a large observational study.Read More
BOSTON — Sleep-disordered breathing (SDB) may play a role in persistent depressive symptoms and poor response to standard pharmacologic treatments in adolescents, new research suggests.
Screening adolescents with treatment-resistant depression (TRD) for SBD “may be clinically valuable, since SDB is readily treatable,” said Teena Chase, MD, PhD, Department of Psychiatry, University of Ottawa, Ontario, Canada, during her oral presentation here at SLEEP 2017: 31st Annual Meeting of the Associated Professional Sleep Societies.Read More
Recently, after morning rounds seeing patients admitted to his hospital through emergency, Dr. David Juurlink tweeted: “Can the next doctor wanting to prescribe Seroquel for sleep,” he said, “just not?”
Of the roughly 20 patients he saw that morning, four had been prescribed Seroquel, an antipsychotic, for insomnia.
Seroquel and its generics aren’t approved as sleeping pills. Quetiapine, the active ingredient, has been officially approved in Canada for schizophrenia, bipolar disorder and major depression only. Yet drug safety experts are growing increasingly alarmed by the drug’s use as a doctor-prescribed nightcap for insomnia, with a 10-fold increase in quetiapine prescriptions for sleep problems in Canada between 2005 and 2012 alone.Read More
A streamlined brief behavioral intervention for pediatric anxiety and depression delivered by pediatricians is superior to outpatient mental health care with follow-up, new research shows.
A randomized trial comparing the two approaches found that 56.8% of youth who received brief behavioral therapy (BBT) experienced improvement in anxiety and depression scores compared to 28.2% of those who were referred to mental health care with follow-up calls, an approach described as assisted referral to care (ARC).
In particular, Hispanic youth had markedly stronger responses to BBT than non-Hispanic patients, suggesting that the protocol “may be a useful tool in addressing ethnic disparities in care,” the investigators, led by V. Robin Weersing, PhD, associate professor at the Department of Psychology, San Diego State University, and director of the Child and Adolescent Anxiety and Mood Program, write.Read More
Eve was 12 when she first started thinking about suicide. By the time she was a senior in high school, she’d tried several times. Then one morning, alone at home, she downed a lethal dose of pills. The only reason Eve lived to graduation day was that her parents unexpectedly doubled back that morning. She wound up in the ICU and barely survived.Read More
“Deprescribing” is a relatively new term, first appearing in the literature in 2003. It concerns the overuse of medications, or use of certain ones for too long—in general, polypharmacy. Deprescribing is defined as the process of withdrawal of an inappropriate medication, supervised by a healthcare professional, with the goal of managing polypharmacy and improving outcomes.1
Polypharmacy and potentially inappropriate medications have been associated with many negative health outcomes, including reduced quality of life, adverse drug reactions, addiction, falls, nonadherence, hospitalizations, and mortality. Other considerations to support deprescribing include reduced cost and perhaps even improved patient adherence.
Currently, there are few available studies on polypharmacy, with most of those that exist focusing on reducing polypharmacy and the number of medications prescribed. Few studies have looked at actual clinical outcomes, such as improved morality and reduced hospital admissions. We do not really know that much about the outcomes of deprescribing just yet.
There are some data that have shown that patients actually want to take fewer medications, but in reality, we as physicians do not really know how to do it and do not do it as much as we perhaps should. Studies looking at physician barriers address such issues as lack of awareness, meaning our own insight into the appropriateness of our prescribing and deprescribing; inertia, the failure to act despite the awareness of the benefits of deprescribing; self-efficacy, having the skills, knowledge, attitudes, and the information to deprescribe; and, finally, the feasibility of it—having the time in practice to do it and the medical culture influences to support it.1
Deprescribing, for obvious reasons, should be a shared decision-making process. We can talk about dose reduction and switching to other safer medications, or we can talk about tapering and stopping the medication altogether.
How do we do it? The first step would be to collect a complete and comprehensive medication history that includes supplements and vitamins. We have to assess the patient’s adherence to the medications and the overall risks and benefits depending on individual patient factors. We want to talk about the patients’ and caregivers’ values and preferences, and the goals of care surrounding those medications and their continuation.
There are drug-related factors that need to be taken into account, including polypharmacy, the pill burden, the medication regimen, drug/drug interactions, and the use of specific high-risk drugs. Patient factors to consider are life expectancy, cognitive and functional factors, what kind of impairment the medications are causing (from fall risk to comorbidities), multiple prescribers, and palliative care.
When we begin the process of deprescribing, we need to figure out which medications are most important to the patient. We then have to identify the potentially inappropriate medications that they are on and consider medications that they are on without any specific indication—either the condition has resolved, or we do not know why they are taking it. Then we should note whether a medication has questionable efficacy or alters the risk in combination with other medications, at which point we should obviously talk about adverse drug reactions and potential for future harm.
There are specific tools that we can use for using explicit lists of medications that are inappropriate in older adults; these include the Beers criteria2 and the Screening Tool for Older Persons’ Prescriptions (STOPP) criteria.3
When we decide on the medication withdrawal, we need to prioritize what we want to start with first.
When is the appropriate time? Anytime, but we need to consider such questions as whether the medication is known to cause withdrawal symptoms. MedStopper.com is a really good resource for this. Are we talking about a slow dose reduction before an altogether discontinuation? We need to monitor for the benefits as well as the harms of medication withdrawal.
We need to plan the tapering or withdrawal process and monitor it with very specific documentation and communications to everybody involved: the patient, their caregivers, and perhaps other clinicians caring for the same patient. We then create a management plan, what symptoms to look for, what the action plan is, and what kind of monitoring is required by us, and then whom to contact should there be any side effects or withdrawal symptoms.4,5
There are several guidelines to hone this process. There are decision support tools and specific algorithms that are very useful for proton pump inhibitors, benzodiazepines, certain antipsychotics, and antihyperglycemics, which you can find at the website deprescribing.org.
At this point, there is some evidence supporting the benefits and safety of deprescribing. Although not very robust, the body of literature is growing as we speak. There are tools out there to help. We just need to be committed to the idea that deprescribing is a good process, and then help change the culture of medicine by doing it.
Reeve E, Thompson W, Farrell B. Deprescribing: a narrative review of the evidence and practical recommendations for recognizing opportunities and taking action. Eur J Intern Med. 2017; 38:3-11.
American Geriatric Society 2015 Beers Criteria Update Expert Panel. American Geriatrics Society 2015 updated Neers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015; 63:2227-2246. https://guideline.gov/summaries/summary/49933/American-Geriatrics-Society-2015-updated-Beers-Criteria-for-potentially-inappropriate-medication-use-in-older-adults
O’Mahony D, O’Sullivan D, Byrne S, O’Connor MN, Ryan C, Gallagher P. STOPP/START criteria for potentially inappropriate prescribing in older people: version 2. Age Ageing. 2015; 44:213-218. https://academic.oup.com/ageing/article/44/2/213/2812233/STOPP-START-criteria-for-potentially-inappropriate
Le Couteur D, Gnjidic D, McLachlan A. Deprescribing. Aust Prescr. 2011; 34: 182-185. https://www.nps.org.au/australian-prescriber/articles/deprescribing
Frank C, Weir E. Deprescribing for older patients. CMAJ. 2014; 186: 1369-1376. https://www.nps.org.au/australian-prescriber/articles/deprescribing