Standardized clinical treatment guidelines recommend that individuals with psychosis be treated with antipsychotic medication in the acute phase as well as throughout the protracted phases of maintenance and recovery (APA, 2006; NICE, 2014). Antipsychotic medication has unequivocally proven effective in acute and short-term treatment (Bola, Kao, & Soydan, 2012; Lally et al., 2017; Leucht et al., 2017; Mackin & Thomas, 2011). Over the longer term, there are significant challenges related to this type of treatment.
First, a sizable share of those remitting after a first episode psychosis may be able to achieve a good long-term outcome with a very low dose or without antipsychotic drugs at all. Robust predictors for the early identification of these patients are still lacking, which may result in excessive use of antipsychotic medicine (Harrow, Jobe, Faull, & Yang, 2017; Moilanen et al., 2013; Murray et al., 2016; Wunderink, Nieboer, Wiersma, Sytema, & Nienhuis, 2013).
Second, severe side effects, particularly associated with long-term use, include grey matter volume decrease and lateral ventricular volume increase (Fusar-Poli et al., 2013; Moncrieff& Leo, 2010), diabetes (Rajkumar et al., 2017), metabolic syndrome (Vancampfort et al., 2015), and reduced subjective quality of life and functioning (Wunderink et al., 2013; Wykes et al., 2017).
Third, shared decision-making has become a stated priority in medical treatment in an attempt to reduce the use of compulsory treatment and increase subjective empowerment and adherence to treatments that are actively chosen (Leng, Clark, Brian, & Partridge, 2017). Hence, shared decision-making is a central part of the recovery paradigm (Alguera-Lara, Dowsey, Ride, Kinder, & Castle, 2017).
This perspective has emerged resulting from a growing body of evidence showing a gap between the realities of those who use, refuse, or are forced to take antipsychotic medication and professionals and researchers (Faulkner, 2015; Moncrieff, 2013). Nevertheless, and despite non-adherence to treatment recommendations continuing to be considered a sizeable public health problem (Kane, Kishimoto, & Correll, 2013), few studies have investigated the effects of shared decision-making in mental healthcare settings (Boychuk, Lysaght, & Stuart, 2018; Schauer, Everett, del Vecchio, & Anderson, 2007; Slade, 2017; Stovell, Morrison, Panayiotou, & Hutton, 2016).
Large scale, prospective long-term, double-blind, controlled studies using clearly defined samples in terms of illness type, severity, and duration evaluating treatment effect are lacking (Sohler et al., 2016). These types of studies are essential to reveal how antipsychotic treatment affects critical functioning throughout the course of illness (Rhee, Mohamed, & Rosenheck, 2018; Zipursky & Agid, 2015). Also, meta-analyses of qualitative studies are needed to systematically describe and summarize the growing empirical qualitative knowledge base on service users’ subjective perspectives on using antipsychotic drugs. Such studies are essential to inform large-scale trials with clinically relevant hypotheses, as well as to illuminate clinical implications for different sub-groups of individuals.
Source: Journal of Mental HealthRead More
For over 2 decades, there have been debates, sometimes contentious, about the efficacy and safety of antidepressants. Growing awareness of the difficulty some patients have when discontinuing these medications has intensified these debates. Recently, Cipriani and colleagues published the largest meta-analysis to date that assessed the efficacy and tolerability of antidepressants. They concluded that all were more efficacious than placebo, and they also synthesized the trial results from head-to-head studies in an effort to guide pharmacologic treatment for major depressive disorder in adults. Although the researchers acknowledged many limitations in their analysis, including the fact that effect sizes were modest at best, the media overstated the results of the study. Both the meta-analysis and the news stories reinvigorated the debates about whether or not antidepressants “work.” Unfortunately, however, the key question—how can this meta-analysis help physicians in assisting their patients with a difficult decision about depression treatment options?—was lost in the controversy. In this commentary, we identify the questions and challenges that were not addressed in the current debate and offer specific suggestions for enhancing shared decision making for physicians working in primary care settings.Read More
(FiercePharma) – Johnson & Johnson has an FDA green light for its next big drug launch, and it’s a drug sure to command attention as the rollout progresses: Spravato, a tweaked form of ketamine, which is used legally in anesthesia, but illegally as a street drug.
Also known as esketamine, Spravato won agency approval Tuesday, ushering in the first new treatment mechanism for major depressive disorder in decades. The nasal-spray drug is OK’d as an add-on to oral antidepressants in patients who have tried at least two antidepressants without success.
The drug won’t come cheap. For the first month of therapy, when it’s administered more frequently, Spravato’s list price runs to $6,785 for the higher dose, before rebates and discounts. After that, depending on dose and frequency, the list price adds up to $3,450 max.Read More
(RxISK.org) – Maybe you heard the exciting news last month about a game-changing new treatment for depression. It offered new hope to millions who were not helped by existing drugs, the headlines said – the first real breakthrough in depression treatment since Prozac, some thirty years ago.
The product was Janssen’s esketamine nasal inhaler, described as a new variation on an old generic drug. Ketamine is an anesthetic, given by injection (IV) for invasive or unpleasant medical procedures that don’t require a complete knock-out. It’s known to cause feelings of “dissociation” (a sense of being outside one’s body or personal identity) and, occasionally, hallucinations. Some people like this effect, which has led to an illicit market in ketamine or “Special K” for recreational users. (Esketamine is simply one of the two forms of the ketamine molecule. It’s not a new drug, exactly, but Janssen can patent it as one, for an obvious economic advantage.)
For at least a decade, both studies and case reports have described severely depressed people getting rapid and robust relief within hours of a ketamine injection. Now Janssen (a subsidiary of Johnson & Johnson) claimed to have turned this old and rather scary-sounding drug into a new, safe and effective treatment which it dubbed “Spravato.”Read More
(MadInAmerica.com) – On December 18, 2018, U. S. Surgeon General Jerome Adams issued a public health advisory urging parents, teachers, and health professionals to address an epidemic of childhood e-cigarette use. The advisory emphasized repeatedly that the nicotine in e-cigarettes was addictive; was harmful to the developing brain; affected learning, memory, and attention; and exposed the lungs to harmful chemicals. In a press release, one federal health official claimed that “we have never seen use of any substance by America’s young people [to] rise as rapidly…” To address this crisis, the surgeon general’s office proposed local bans on indoor vaping and recommended retail restrictions to reduce the purchase of e-cigarettes among youth.
While the government chose to single out the rise of e-cigarette use, it has been ignoring the astronomical spread of another type of dangerous drug taken by children and youth: psychiatric medications.Read More
(RxISK.org) – A few years ago, a friend, Alan Baumeister, embarked on an interesting journey. Alan had been Head of Psychology in Louisiana State University. He has been actively involved in the history of the mental health field and psychological inputs to it for a long time.
Louisiana is the state that hosted Robert Heath in Tulane University in the 1970s who it could be argued was the father of Deep Brain Stimulation (DBS). His story is told in a wonderful book by Lone Frank ‘The Pleasure Shock’.
Alan now having a little more time on his hands had turned to a topic that had interested him for a while – a suspicion that chronic use of stimulants could trigger Parkinson’s disease – a prospect more likely with increased rates of supposed Adult ADHD.
He emailed me a copy of an article that he had written asking for my thoughts. It was an excellent article. The idea that stimulants might trigger problems like this was new to me but the case he outlined made sense. It seemed a good idea to put the hypothesis on the radar so that if there was a problem someone might actually look for the data to see how big the problem might be.
I was expecting that Alan might have some difficulties getting his paper published but not that he would have quite the difficulties he had. It took several years before he could find a journal happy to take it. Several journals that he approached refused even to review it. His paper came back by return of email. This is not the way science is supposed to happen.
Finally nearly two years ago the paper was published – see here.
Since then a further paper by another group has appeared – see here.
This appears to show that exactly what Alan figures is right – people with a history of ADHD it seems are at increased risk of Parkinson’s disease, dementia and other cognitive disorders. The authors don’t say these problems are caused by the stimulants – they leave open the option that the illness has caused the illness but this is stimulant caused until proven otherwise.
The question is whether cognitive problems are something specific to the effect of stimulants on the dopamine system which is also involved in Parkinson’s disease, some poisoning of the dopamine system, or whether it’s a more general issue of whether the more drugs that people take for longer periods of time the more likely they are to suffer brain failure – to dement. People with ADHD of course end up taking cocktails of drugs.
In one of those coincidences, in the course of a week, two weeks back, several women (its rarely men) got in touch about problems members of their family were having or had. One drew my attention to a very common effect on SSRIs that I and most doctors have learned to dismiss – low sodium.
This was something some of us might have noticed when SSRIs turned up first and some people ended up with drastically low sodium levels. When you see it first as a doctor, you wonder should I get this person to Intensive Care. But nothing much seemed to happen and the problem seemed more often than not to auto-correct.
Another mentioned Osmotic Demyelination Syndrome (ODS). I’d never heard of this.
Turns out in the small print of details very enthusiastic nerdy trainee docs or docs in training might have noticed when revising for exams decades back was a condition called Central Pontine Myelinolysis (CPM). Neurologists know about this the rest of us don’t. Described decades back, no-one knew what caused it but it was thought it might be a toxin. Myelinolysis was an invented word because no-one wanted to use demyelination. It was thought the Pons of the brain was somehow uniquely susceptible to injury by something.
Some neurologists have moved on, many haven’t and few other docs know anything about ODS.
Basically myelinolysis is demyelination. It can happen anywhere in the brain. Its most commonly triggered by drugs. Its particularly common when in the course of trying to restore a person’s sodium levels to normal they are either rehydrated too quickly or too slowly or just at the right speed but the patient still ends up the myelin sheaths of some of their nerves being destroyed.
This has been a lightbulb moment for me. I’ve seen many cases over the past decade – usually of women who have had clear cognitive problems following antidepressant intake linked to an atypical neurological picture such as Parkinson’s like syndrome, supranuclear palsy or atypical motor neurone disorder. Whether caused by their antidepressant or not, these have come on after antidepressant intake. They are all consistent with ODS.
Right from the very start of the SSRI era, there has been a handful of people who have taken an SSRI and had an encephalopathic response to it – they claim something has gone so badly wrong and remained wrong after stopping what might have just been a few days of treatment, they figure they must have brain damage. In some instances it’s happened on the first course of treatment in other instances it’s happened on re-exposure. Some have been young people. Others have been older women.
Another thing that has been very clear for over a decade is that a strikingly large proportion of those attending dementia services or memory clinics linked to dementia services are on SSRIs and related drugs. The problem has been trying to work out if the anxiety states or nervousness that led to their SSRI were the first sign of dementia or whether the drug has caused memory and cognitive problems.
There have been several articles lately pointing to increased rates of dementia in people taking antidepressants, especially SSRIs. The problems are unlikely to be confined to SSRIs in that most anticonvulsants have significant effects on sodium levels and sodium channels also.
Dementia used to be Alzheimer type or multi-infarct – stemming from a series of minor strokes. Multi-infarct dementia was linked to smoking and with the drop in smoking data suggests it is happening less frequently – perhaps though soon to be replaced by multi-demyelination dementia.
Given that even people with considerable expertise on SSRIs or even in brain demyelination syndromes know little or nothing about these issues, and people with no background in healthcare have told me more than I knew up to this week, it looks like a concerted effort by a wider than usual group of people is needed to try and assemble a picture of what might be going on and what people should know about and might do about the situation.
(The little white spot in the image above shows something happening in the Pons).Read More
(Unthinkable.cc) – Like so many, I’ve lost loved ones to suicide. The most obvious question that always comes up is why? What was it that led this individual…to that tragedy?
Although there will always be some uncertainty involved in this heartbreak, thousands of studies documenting various risk factors for suicide make it clear that no single cause is responsible, as much as hundreds of overlapping contributors.
As suicides keep rising, the same basic question comes up in another form: Why have the numbers been rising?Read More
(MadInAmerica.com) – A study recently published in World Psychiatry reviewed meta-analyses of pharmacological and non-pharmacological interventions for improving physical health outcomes for people diagnosed with schizophrenia. The study authors found that non-pharmacological interventions were more effective than pharmacological interventions for weight reduction and overall health, with individual lifestyle counseling as the most effective.
“People with schizophrenia have substantially poorer physical health than the general population, which is often attributed to an interaction between social circumstances, lifestyle factors and treatment effects,” the authors write.Read More
(CBC News) – Hundreds of nursing home residents in New Brunswick have been weaned off anti-psychotic drugs that were found to be ineffective and the cause of increased health risks.
“We’re doing it for improved dementia care,” said Julie Weir, assistant director responsible for clinical care and innovation with the New Brunswick Association of Nursing Homes.
In the last two years, nursing homes across the province have been trying to use anti-psychotic drugs more judiciously.
“We saw residents wake up and be more interactive with family members,” said Weir.
“We saw residents more participatory in their care — feeding themselves, helping in transfers from bed to chair or chair to bed.”Read More