Mental Health Disorders and Psychopharmacology: The Year 2010 In Review
Depression: The World Health Organization predicts that depression is expected to become the world’s second largest health problem – after heart disease – by 2020.
– Clinicians should avoid thinking of depression as a “diagnosis,” but instead as a cluster of symptoms with many possible influences. These influences may be environmental, medical, medication-induced, hormonal, or substance abused-related. All of these should be assessed one-by-one.
– Many people who have been crippled by major depression throughout their adult lives are often doing much better in their 70’s.
– Instilling hope and optimism remains the single most viable intervention when working with depressed clients.
Antidepressants: The only new patent issued by the FDA for the treatment of depression in 2010 was for Oleptro (trazodone extended-release). I emphasize the term new patent because Oleptro is not a new drug. It is no more than a long-acting offspring of the popular immediate-release antidepressant trazodone.
– Thirty three percent of the response to antidepressants is attributed to the placebo effect. This high placebo response rate has stymied innovative antidepressant development.
Bipolar Disorder: From a diagnostic perspective, bipolar disorder is complex, highly nuanced and does not lend itself to black-or-white judgments. As a profession, we are in transition to a different diagnostic system known as the “bipolarity index.” This index will focus on a series of manic and non-manic bipolar markers scored on a point system, eschewing the oversimplified yes-or-no categorical system of the DSM.
– The diagnosis of bipolar disorder in children and adolescents is currently the most hotly debated issue in pediatric mental illness. It is enormously controversial and depending on who you listen to, it has either reached epidemic proportions or it is virtually non-existent. Misdiagnosis is the major problem; whether the disorder is overdiagnosed or underdiagnosed only fuels controversy and is the wrong question anyway.
Mood Stabilizers: Lithium continues to demonstrate high efficacy as a first line agent for the treatment of bipolar disorder. It seems to be more effective for mania than bipolar depression. Lithium is more effective than Depakote as monotherapy for bipolar disorder; symptom improvement is only marginal when both are used together.
– Seroquel and Abilify are emerging stars in the treatment of bipolar depression. Some studies indicate robust results with Seroquel.
– Traditional antidepressants have little if any benefit in the management of bipolar depression.
– The nuances of study design do not yet support second generation antipsychotics as first line agents for bipolar disorder.
Anxiety Disorder: There’s nothing new to report about anxiety itself. That’s because it’s a normal human response; some of us experience it intermittently, other chronically. Most of the attention in this class of disorders is on PTSD and OCD.
– PTSD has aroused debate especially surrounding the definition of the traumatic event that anchors the symptoms. It is not controversial that intense traumatic events qualify as criterion, but what about purely psychosocial events without physical injury? DSM IV does not require that someone directly experience the trauma. The traumatic event may just be witnessed or heard about via television events, etc. Suggestions are being made that PTSD criteria be tightened up such that only those directly experiencing a trauma receive the diagnosis. If this comes to fruition in DSM 5, look for fireworks.
– Deep Brain Stimulation – the bilateral implantation of two electrodes at specific areas in the brain where they release continuous, low-voltage electrical shocks – is gaining more attention for the treatment of severe, intractable OCD.
Anxiolytics: It comes as no surprise to me that no new releases occurred in this drug category during 2010. The most recent approval was Edular (zolpidem tartrate) in the latter part of 2009. Sound familiar? Edular is simply a brand-name clone of the now generically available Ambien. It is an oral disintegrating preparation, which means it doesn’t have to be taken with fluids. One gets to pay about $150 for this little perk. Absolutely none of the anxiolytic sleep agents (Ambien, Sonata, Lunesta, Edular) consistently keep people asleep. Television advertisements continue to be misleading.
Schizophrenia: Positive symptoms (delusions, hallucinations, disorganization) improve with age. Negative symptoms (apathy, anhedonia, avolition) also improve with age. Cognitive symptoms (incoherence, loose associations, informational processing impairment) worsen with age.
Antipsychotics: One new release in 2010 – Latuda (lurasidone). Latuda possesses no novel characteristics that I can see. Add it to the list of “me-too” second-generation agents.
Attention Deficit Disorder: ADD is being overdiagnosed and underdiagnosed. Overdiagnosis is a by-product of rising academic expectations. American children are expected to sit longer, concentrate more, and read and write earlier than ever before. Children are rushed from one activity to another. All these factors contribute to a child not focusing and paying attention. Underdiagnosis results when a youngster is labeled as a “bad child” and the accompanying ADD behaviors are seen as purposeful and under the child’s control. It’s the unfortunate “if only he would try harder” mantra.
ADD Medications: The experts I’ve spoken with over this past year concurred that the most important sign that medication might be warranted is that immediate results are evident when the child begins the medication. These experts add one other simple yet important nugget of information: Medication makes life less hard for ADD kids. There were no new releases in 2010. Like them or not, 90 percent of children treated with stimulants elicit a positive response.
Big Pharma: Nine pharmaceutical companies, including Pfizer, AstraZeneca, Eli Lilly and Roche agreed this year to pool data on drug trials in an effort to streamline the methodology for developing new medications for mental health disorders. It’s about time! In 2010, the FDA approved only two psychotropics – Latuda (lurasidone) for schizophrenia, and Oleptro (trazodone extended-release) for major depression. This is a paltry track record for the year, to say the least. By working together, hopefully this will be one step to help reverse the dearth of new medications in psychiatry.
Joe Wegmann is a licensed clinical social worker and a clinical pharmacist with over 30 years of experience in counseling and medication treatment of depression and anxiety. Joe’s new book, www.pesi.com. To learn more about Joe’s programs or to contribute a question for Joe to answer in a future article, visit his website at www.thepharmatherapist.com, or e-mail him at firstname.lastname@example.org.