Psychopharmacology: What Happened In 2011 and a Glimpse Ahead
Depression and Antidepressants: I’d never waste your time by referencing any scholarly work based on flimsy, poorly constructed data. This one’s on solid ground. A new study commissioned by the Centers for Disease Control and Prevention yielded these results: Rates of antidepressant use continue to rise, and as such, 11 percent of the general population now takes these medications. Antidepressants are now the 3rd most prescribed class of medications in the United States and are in 1st place within the 18-44 age group. They are increasingly being prescribed for the wrong people and for the wrong set of symptoms. Psychosocial stress accompanied by mild dysphoria is just not an indication for use. Getting better first requires an examination of what’s going on between one’s ears. And if runaway prescribing habits continue, antidepressants will become the “antibiotics” of physical medicine. Translation: Overall response rates will drop due to increasing drug resistance.
Bipolar Disorder and Mood Stabilizers: When it comes to complexity, comorbidity and nuance, bipolar disorder remains one of the most difficult mental health disorders to manage – ever. The profession will gradually transition to a different diagnostic system known as the “bipolarity index.” This index will focus on a series of manic and non-manic markers scored on a point system. This is a good move because we routinely index and scale symptoms in mental health treatment.
Medication management is still all over the place; treatment protocols upon which clinicians reliably agree are all but non-existent. Bipolar mania is generally easier to treat than bipolar depression. Lithium and Depakote remain the gold standards for mania; Seroquel and Abilify are emerging as the go-to agents for depression.
A hornet’s nest has been stirred with DSM-5’s decision to include Disruptive Mood Dysregulation Disorder (DMDD) in the soon-to-be-released manual. There is no credible research on DMDD; it has been inadequately studied and is a completely untested diagnosis. It will continue to fuel the fire pursuant to the already burgeoning diagnosis of mental disorders in youth.
Anxiety Disorder and Anxiolytics: Anxiety is a normal human response to uncertainty and we all have it. The majority of anxious moments or periods are a by-product of imagined fear. Most of us experience anxiety intermittently; when chronic, it rises to disorder proportions.
Medication management should not be first-line treatment – intense, acute stress and panic are exceptions. Diet and exercise work best but are eschewed in favor of a pill. Benzodiazepines are way overprescribed; rates of compliance are quite high as are placebo response rates.
The bulk of direct-to-consumer advertising is targeted to the treatment of insomnia. The hypnotic Lunesta® has recently launched an ad campaign entitled Follow the Wings. In November, our FDA approved the drug Intermezzo® as a sleep agent for managing middle-of-the-night awakenings accompanied by difficulty returning to sleep. The micromanagement of sleeplessness has arrived. Intermezzo® is no more than a short-acting Ambien® and will be ripe for misuse. It is not approved for actual bedtime use, only for early morning awakenings. Mark my words people will use it for both.
Schizophrenia and Antipsychotics. In any unbiased discussion of neurobiological complexity in mental health, schizophrenia uniformly emerges as the ring leader. The disorder brings multiple symptom domains into play and is associated with the dysregulation of several neurotransmitter systems making pharmaceutical and behavioral management challenging, to say the least.
The presence of numerous symptom domains – positive, negative, cognitive – strains the efficacy of antipsychotics. These medications have helped restore millions of schizophrenics to sanity, but non-adherence rates are extremely high – at 40 percent. And non-compliance goes way beyond the irrational belief that these drugs are poison or a form of mind control; they’re miserable to take. Weight gain and sedation are common; metabolic syndrome (elevated blood sugar, lipids and cholesterol) is most problematic.
The second-generation agents are the first-line pharmaceutical approach. There are now 10 such antipsychotics on the US market – five too many. Only Clozaril®, Risperdal®, Zyprexa®, Seroquel® and Abilify® are treatment-worthy. The others fall in the “me-too” category and can be extraordinarily expensive.
Attention Deficit Disorder and Psychostimulants. There’s a growing cadre of clueless parents contributing to the overdiagnosis of ADD by overscheduling their kids, rushing them from one activity to another. These children are no more ADD than I am. Their stress levels are so high, it’s no wonder they have difficulty focusing and paying attention.
On the other hand, underdiagnosis results when a youngster is labeled a “bad child” and accompanying ADD symptoms are seen as purposeful and under the child’s control if only he would try harder.
There’s nothing new on the medication front. With the exception of ADD-like symptoms associated with autism, psychostimulants are 70-90 percent effective, work immediately and make life less hard for kids. These drugs fall into two camps: the dextroamphetamine compounds (think Adderall) and the methylphenidate substances (Ritalin, Concerta). They are equally efficacious.
Big Pharma. The pharmaceutical companies take a double barreled approach to driving drug sales. For decades of course, they’ve attempted to influence prescribing habits by approaching physicians directly through company representatives. Enter direct-to-consumer advertising, targeting the buyer. This has proven to be a veritable boon for this industry, profit-wise. Physicians generally abhor patients bringing in internet and print ads claiming that drug A or B is right for their condition, yet some doctors have told me that it takes the burden off medication selection and satisfies the patient – assuming there are no obvious contraindications. Direct-to-consumer advertising is here to stay; the pharmaceutical industry lobbyists in Washington will see to that.
DSM-5. The long awaited 5th edition of our mental health bible is rife with controversy and is getting growing pushback from concerned clinicians. At the center of this controversy is the decision by the manual’s writers to expand criteria for current diagnoses, taking us yet another step closer toward pathologizing the symptoms of everyday life. Diagnostic expansion conceivably could lead to the point where practically everyone will qualify for a mental health disorder. Stay tuned, this will continue to brew.
Neuroscience. In modern medicine, we’re having a laboratory revolution. This signifies that verifiable biologic and chemical discoveries in the laboratory setting contribute significantly to diagnosis and treatment. It is abundantly clear that no such markers yet exist in the sphere of mental and emotional disorders. Neuroscience marches only to the beat of its own drum and it doesn’t help us one iota at the clinic level – where medication selection remains more art than science.
That’s the 2011 roundup, 2012 awaits!
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.