I’m sorry for the hiatus in posting; I have another blog (related to addiction) plus there always seems to be tons of paperwork this time of year– not to mention getting things together for the tax season.  With taxes in mind, perhaps it is appropriate to write a post that has to do with the FDA. 

I am going to share an e-mail exchange with a patient about a medication that is part of the changing landscape for treating depression.  Since the replacement of ‘tricyclic antidepressants’ like amitriptyline and desipramine by SSRIs (serotonin reuptake inhibitors), the general approach to medication for depression has been SSRI, second SSRI, SNRI, then augmenting the SNRI, then augment with something else, and finally consideration of ECT.  There are other treatment choices in the algorhythm such as psychotherapy, bupropion, or mirtazepine, but the general pattern of SSRI— second SSRI—- SNRI has been the backbone of treatment in the modern era of psychiatry.

At the same time there have been other medications that are thought of as ‘mood stabilizers,’ including a group of medications known as the atypical antipsychotics.  To use their trade names, the medications include Zyprexa, Risperdal, Seroquel, Geodon, and Abilify. Recently two of these medications have received FDA indication for uses other than for bipolar mania or for schizophrenia, and there are indications that the lines between medications thought of as ‘antidepressants’ and medications considered ‘mood stabilizers’ will become more blurred going forward.  This should be a good thing, as we are gaining additional options to treat mood disorders– a group of illnesses that cause considerable suffering in the country and world.  But the new medications have powerful effects, and so like most medications have potential side effects– in this case the risk of increasing blood glucose, cholesterol, and triglyceride levels, and increasing the risk of weight gain and diabetes. 

The e-mail exchange relates to the issue of medication side effects, and when should a person disregard the scary print at the bottom of the advertisement (or the ridiculously-fast-spoken list of side effects at the end of a TV commercial).  The patient has struggled with depressive symptoms for a number of years, and has been treating the symptoms with the ’safest’ medications– i.e. SSRIs– avoiding medications with greater risks and side effects.  I have been her psychiatrist for a short period of time, and we are not yet certain whether her symptoms are part of Major Depressive Disorder or are instead the depressive side of Bipolar Disorder.   I recently suggested to the patient that we look at the big picture– that the depression is taking a toll on her life, that the depression has affected her relationships and career path, and that the depression has even put her at risk for suicide.  I think I will let the exchange finish the point I tried to make.  She is a bright patient who reads up on whatever we discuss, something that sometimes makes my work easier, and other times makes my work more challenging– albeit in way that medicine SHOULD be challenging.

I suggested considering a more potent medication, such as Seroquel.  She sent a message that included the following comment:  

I looked up Seroquel…and get freaked out by things like this:  http://www.usatoday.com/news/health/2009-04-08-fda-seroquel_N.htm  I will let interested readers go to the link on their own, but the link is to an article questioning the wisdom of the FDA in giving Seroquel the new indications.  As I mentioned earlier, I think that more choices are a good thing– providing we have bright doctors who take the time to educate their patients, who take the time to learn enough about their patients, and who make reasoned decisions based on ‘risk to benefit ratios’– assumptions that may or may not be valid.  I have written about my disdain for psychiatric practices that do ‘7-minute med checks’, and I believe that those practices may serve their patients more safely by sticking to the SSRI’s!

My long-winded response to the patient:

I am not pushing Seroquel- only suggesting that when you look objectively, there may be a case for more aggressive treatment of your depression.  I want to point out a couple things in the USA Today article, an article that is clearly written by someone with certain preconceptions.

First, the article correctly reports that the FDA found that the risk/benefit ratio of Seroquel does not favor using the medication as a  first-line agent.  But it is important to note that after reviewing all of the data, the FDA DOES favor approving the use of the medication for treating depression in people who (like you) do not achieve remission of mood symptoms from first-line treatments like Prozac. 

There are a couple comments in the article that I find misleading; for example, the quote of lawyers who said ‘the company knew Seroquel caused diabetes.’  Seroquel doesn’t ‘cause diabetes’.    There is an increased risk of diabetes in people taking Seroquel, but the risk varies with dose and length of time taking the medication.  The drug is used at 600-800 mg for mania or schizophrenia but only 300 mg for depression, and people who take it for a short period of time at a lower dose are at lower risk.  The risk of diabetes in patients taking Seroquel goes from around 3% to around 6%.  For an individual, the risk of NOT getting diabetes goes from 97% to 94%.    The effect can be worded in a scary way—‘the risk of diabetes doubles’- but going from 97% to 94% odds of NO diabetes is less frightening—especially when the odds ratio takes into account the risk and pain of experiencing years of depression.  The risk if diabetes can be greatly reduced, by the way, by monitoring blood sugars and stopping the medication if glucose tolerance changes.

It is important to distinguish between the risk to an individual vs. the risk to a population.  The FDA looks at the latter, but the individual should look at the former.  For example, much has been made of the risk of suicidal ideation in children and adolescents taking antidepressants.  The result of the FDA black-box warning of this issue has been a significant drop in antidepressant prescriptions for children and adolescents, and at the same time (coincidentally?) a significant increase in suicides in the same age group.  The warning came because retrospective evaluation of pooled research data showed that ‘suicidal ideation and behavior almost doubled’ in depressed patients starting antidepressants compared to depressed patients starting placebo tablets.  A ‘doubling’ sounds bad… but there was no increase in actual suicides, and the data may reflect something benign.  For example, perhaps kids on antidepressants talk about their thoughts more.  Looking at the data beyond the ‘doubling’ headline, in the placebo group about 2% of the depressed patients had increased suicidal thoughts.  In the treatment group the number was around 4%.  This is in fact a ‘doubling’ of suicidal thoughts, but we can look at the exact same data in a different way.  In the placebo group, 98% of the patients did not report increased thoughts of self-harm, and in the treatment group 96% had no increased thoughts of self-harm.  This way of looking at the data is much less likely to scare a mother into dumping her child’s Prozac down the drain… but is also less likely to catch your eye in the check-out aisle where the papers are sold! 

I will again point out that no suicides were attributed to antidepressants.  But meanwhile, suicide IS one of the leading causes of death in that age group, and most of those suicides occur in adolescents with untreated depression.  There has been less dramatic reporting of similar increases in suicidal ideation in patients taking virtually any of the anti-seizure medications, and in similar effects from other medications—like Singulair, a medication for asthma. 

Government health agencies look at fractional risk multiplied times 200 million people.  A 5% risk of diabetes means an additional ONE MILLION people with diabetes!  But an individual still has a 95% chance of NOT having the illness.  I remember going through a similar calculation back in med school, when I contemplated giving up the bacon that I loved to lower my risk of heart disease.  For now, I am still eating bacon!

I want to leave this discussion making two primary points.  First, it is important that patients know the true balance of risk to benefit for any treatment or medication, and that they try to learn the truth behind the headlines.  This point is a perfect segue for a plug for my practice.  I see at most two patients per hour for follow-up visits, and find that even the 30 minutes that I set aside at minimum is a short period of time to adequately explain all that the patient should know– particularly when most of the appointment must be used to collect information from the patient, not the other way around.  I have no idea how people gain anything from the typical 7-minute appointment.  If you are a dissatisfied patient, give me a call through my telepsychiatry practice!

Second, at some point it may become time to treat a mood or anxiety disorder or some other psychiatric condition with more potent medication, including medication that has temporary side effects.  When a person develops gallstones, he/she usually ends up with either a number of small scars from laparoscopy or one big scar under the right ribcage from an open procedure.  In either case, the person experiences significant pain for a number of days.  I sometimes think about the different tolerances people have for the treatment of different conditions, from the financial perspective and from the perspective of tolerable side effects.  People think little of spending thousands of dollars for anything involving a scalpel or anesthesia… my teenage daughter’s broken arm took 10 minutes to cast and the orthopedist charge was almost $1000, but I will get nowhere asking an insurer to pay $140 for an hour of my time with a patient!  Likewise, mild nausea from Effexor will keep a patient from taking the medication, even when the illness is so severe that the person is home-bound from panic attacks. After several days of at most mild dysphoria, the medication has a good chance of eliminating the anxiety entirely! 

What are the reasons for the differences?  I have a few guesses, including the stigma of mental illness, the difficult nature of change, and the powerful effects of denial.  In all cases I don’t see significant changes in ‘how things are’ on the horizon… so noncompliance and unwillingness to accept proper treatment will likely remain an issue for psychiatrists to understand and to consider as part of the entire illness.

Thanks, as always, for reading this far.  I wish you all the best.

JJ

There are a number of web sites devoted to medicine, and it can be difficult to sort out the information that is accurate and unbiased from information that is placed more prominently after ‘donations’ to support the site. I try to ‘tell it like it is’ when it comes to mental health information, and if there are topics where I am expressing an opinion i try my best to point that fact– so that people know what is supported by data, what is supported by experience, and what is not ‘supported’ at all– but is conjecture based on background knowledge and opinion influenced by family issues and other personal life experiences.

Visit the growing medical database at Medpedia, and if you are an expert, add your knowledge as well.

I like the approach of Wikipedia and now Medpedia. The information is collected by the contributions of experts in the field, and if a person drifts into conjecture there are ways for others to step in and edit the information. That information is then edited by other readers. The result is a growing database of information that represents the best of human knowledge. Since contributors know that their comments are subject to edit, they are careful to get the facts right. And the very complex topics come together from the collective knowledge of the group.

I have contributed information about opiate dependence to Medpedia, and my two main blogs will be featured on their site. I invite readers to check out their information– which is growing daily. Please look for my blog while you are there, and say ‘hi’!

Here is another psychiatry radio show from the archive featuring myself, Jeffrey T Junig MD PhD, interviewed by Bob Hoffmaster of KFIZ radio.  I do tele-psychiatry by the way– if you are interested in a different type of psychiatry– the ‘old fashioned’ kind where you have time to talk. Check out my practice if you have the time; I am taking new patients, and I ‘see’ patients from across the country.  I avoid prescribing controlled substances, so if you require Xanax-type medications, I am not the right person.  But I can prescribe the typical psychiatric medications that are not controlled by the DEA– pretty much anything except for stimulants, ‘benzos’, or narcotics. Please read about my philosophy, which includes ‘seeing’ no more than 2 patients per hour. I don’t ‘belong’ to panels but I do submit insurance claims, and many people who have significant deductibles have no difference in payment for out of network docs– if the person never reaches the deductible, it doesn’t make any difference!

Another show from the archives.  I should mention that the other person on the show with me is Bob Hoffmaster, who does the morning show at KFIZ Fond du Lac every day.  As you can hear, he makes the show a breeze;  he has a curiosity about everything, and all I have to do is come in and chat with him.  It is always the high point of my week– too bad it has to happen on a Monday!!

Continuing my efforts to get all of the episodes on i-tunes, here is the show from 4.13.2009.  If you like it, send me a question and I’ll discuss it on the air next week!  Send it to radioshow@fdlpsychiatry.com.

Unpublished (until now) shows of  Shrink Zone Radio,  with Jeffrey T Junig MD PhD from Fond du Lac Psychiatry, and hosted by Bob Hoffmaster, KFIZ Radio, Fond du Lac Wisconsin.

Information about my psychiatric practice, click here;  for telepsychiatry offered across the entire country, click here.

I’ve fallen behind in publishing podcasts of my weekly radio show, so there will be a number of them posted over the next few weeks.  I tell you– the technology is maddening, trying to keep up!  I have a blog about addiction and a forum;  the forum was meant to be where I would spend much of my time, but I never seem to get there.  Then there is the social media–  Facebook, Linked In, even Classmates.com….  I never knew what to say to people back in high school, and despite having a radio show and giving lectures to a couple hundred med students at a time I STILL don’t know what to say!  And Twitter… I don’t have any idea what that is about.  Does anybody REALLY care what I am up to that often?  Like tonight– I watched a movie called ‘Felon’, that featured Val Kilmer (wow– how did HE get so old, while I stayed so young?)– does anyone find that interesting?!  Really?

I do want to put an idea out there just in case lightening strikes.  I have a book that I have written that is really special.  Really.  I have written a number of long essays, and a couple short e-books… and I have written some things that really are not that good.  But I have this book that is about 250 pages long that is about addiction, and I really thing I am on to something.  It is different, as it is written in the form of blog questions and personal responses, so it can be picked up and put down over a short period of time for those with short attention spans.  It is filled with multiple layers of drama, as people write to me about these very intense struggles that they are experiencing related to addiction.  And it is informative, but in a different way than most addiction books.  I talk about my own life experiences and then generalize them to how addiction affects everybody.  I apply psychodynamics to some topics, and explain why I am confused about some other topics.  I have had good feedback about the book– and no, not just from my mother!!

I want to get the book published, and I will go ahead and self-publish it if I have to.  I have purchased the ISBN numbers and am set to offer it on Amazon, but I would prefer, of course, to see it released and marketed by someone.  If anyone who reads this blog knows a good publisher or agent who deals with mental health and addiction topics, please send me a note at drj@fdlpsychiatry.com. I also have an e-book on the market about opiate dependence and treatment using buprenorphine, which can be purchased on Kindle or at a number of web sites including Bupe Guide.

In the meantime, enjoy my show.  I will try to release a new weekly episode every few days or so.  And above all, THANKS for listening!!

Jeff J

In the meantime,

I heard a report on the radio this morning about a study that was one of those ‘no brainers’—  results from a study about something that is already obvious, like ‘binge drinking associated with fighting,’ or ‘chronic illness linked to shorter life expectancy.’  But this report came over the radio just a I was driving past one of my community’s larger employers, a company that  is currently deciding whether to move operations to another state.

The study found that people who lose their jobs suffer as much emotionally as they do financially;  they have a high incidence of depression, anxiety, and sleep disorders.  This is no surprise when you think about the time we spend at work.  Many people find most of their friends through their work.  And after years of living a certain routine that includes going to a familiar place every day for the majority of our waking day, it is disorienting to suddenly drop out of the routine and spend the majority of the day at home.

If you find yourself in such a situation there are things that generally make a person feebetter and things that tend to make people worse.  In general, the person will favor the behaviors that ultimately make  them worse.  It feels good to ‘hole up’ at home, ignore the phone, and embrace isolation.  But such a course of action will surely cause one’s mood to suffer and reduce one’s self esteem.  All the the things that seem impossible are the ones that will likely make a person feel better;  spending some time with friends, opening the shades and windows, and getting some exercise.  The exercise in particularly will make a huge different on a persons’ mood.

I have a telepsychiatry practice that I use to ‘see’ patients from across the country.  As I have mentioned several times before I try to separate my practice from other practices by spending more time with people.  I see little value in the seven-minute follow-up appointment where you are tell how you are doing on the two-minute walk from the waiting room to the office, sit down for three minutes to describe your medication side effects, and then hear about the new drug on the 2-minute walk back out again.  I teach psychiatry residents about the practice options awaiting them, and my primary suggestion is to find a practice where they have TIME.  There is nothing more frustrating then seeing patients at a productivity based clinic (where you don’t have the option to slow down), and thinking ‘I could really help this person– if I had more time!’

What can we do for people who lose their jobs?  I’ve been considering holding group sessions once per week where people can get together and offer and receive support from each other.  Groups also help people realize that they are not alone, which can make a big difference in how people do after job loss.  If you are one of the many people who have lost a job, there are a couple things to consider that may help deal with the loss.  First, remember that it IS a loss;  people who lose jobs have many of the same feelings as those who lose a close family member to illness.  Many people have heard of the Kubler-Ross stages of grief:  anger, denial bargaining, depression, and acceptance.  You may go through each of these stages and additional stages– like feeling betrayed.  Remember that mourning does not occur in a straight line;  you will likely have good days and bad days.  If the general trend is not positive, you may want to consider seeing a psychiatrist to learn the medication options.  In general I will prescribe an SSRI, as that type of medication (like prozac, celexa, or zoloft) will often raise the floor under your mood, and will also help keep you from obsessive fear that you will never work again.  Sometimes a valium-type medications will be very helpful for a short period of time– a couple weeks– while waiting for the SSRI to start working.

How do you know if you should seek help?  Certainly if you are having thoughts of harming yourself.  In fact, in such cases you should seek help immediately from a crisis service or emergency department.  If you are not sleeping or if you have lost your appetite you should seek help, as both are signs of a serious depression.  Finally if you are feeling ‘numb’ al the time, or if you are feeling as if you are outside of your body and watching your actions from a distance,  you would likely benefit from psychotherapy and/or medication.  Keep in mind that many of the medications take time to start working and many offices have a delay before getting on the schedule, so try to be proactive;  avoid waiting until you have become desperate.

If you have lost a job, please leave a comment about what you would find helpful during this difficulty time.  As always, you are welcome to contact me for an appointment either in person or by telepsychiatry.  Take care, and I hope things turn around for you soon.