Evidence-based medicine is valuable only to the degree that what is presented is done so in a thorough, encompassing way.   

Many of the studies I read to stay abreast of what’s trending in the Psychopharmacology field aren’t worth the paper they’re written on or the cyberspace in which they’ve been transmitted. Take the FDA approval process for example. All that’s needed to pass FDA muster is that a potential new drug candidate outperform placebo. In blunt terms, it needs to beat out sugar. The fact is many of these drugs are weakly beating placebo! We’re supposed to be excited about that? As a consumer, an informed prescriber or Psychopharmacology speaker (me), you want to know how well a possible newcomer stacks up against the existing competition. That is, you want to know how it ranks head-to-head compared to other established agents within the genre. This is a real weakness with the FDA approval process, and I should add that it’s a process and content problem with all medication classes within the bounds of physical and mental health medicine.

As consumers, when we’re bombarded by direct-to-consumer advertising to buy something, our dukes go up because we’ve learned the hard way that it’s vital we protect ourselves from misrepresentation and outright fraud. By contrast, we healthcare professionals tend to have very little skepticism when it comes to what we read and digest in medical journals.

Realize that the peer review system is not perfect and is subject to publication bias and that a study which reads professionally and is footnoted to the hilt doesn’t necessarily render it credible. “Studies” and “clinical evidence” should be but one component of your overall decision-making. Also, look for who published the data – that is, consider the source. If the authors are employees of the pharmaceutical company, or if they’re in the company’s speakers’ stable, be wary and takes those conflicts into account.

Threatening or salacious news sells, regardless of the medium in which it is delivered. The lead story is uniformly negative; the “feel good” story comes at the tail end of a broadcast.

Perhaps exposing ourselves to some bad news can be timely and germane, but when we’re inundated with doom and gloom, it becomes increasingly more difficult to refocus our energy on what’s uplifting and positive.

There’s an ample supply of good news in our world. Finding it and aligning ourselves with optimistic people who support it makes for an incalculable investment in our sanity.

The risk of death in dementia patients utilizing antipsychotics varies rather widely, depending on the agent employed, according to a study published online in the British Medical Journal in late February, 2012. The study examined 75,000 nursing home patients (large sample size) with dementia for risk of possible death within six months of the initiation of antipsychotic medication. The study looked at Haldol, Seroquel and Risperdal, in particular.

Patients placed on Haldol demonstrated a doubling in their risk of mortality compared with those placed on Risperdal – while Seroquel users were significantly less likely to expire compared to the Risperdal users.

Seroquel, although seemingly safer than others in this sample, didn’t work as well in dementia patients. This finding comes as no surprise to me.

I’ve taught that Risperdal is the agent of choice within the 2^nd generation antipsychotic group for years now in my Psychopharmacology seminars. It is satisfying to know that the aforementioned study seems to agree from both a safety and efficacy standpoint. This does not mean that Risperdal is void of risk, but at low dose (less than 1 or 2 mg per day) the drug has minimal side effects; whereas Haldol is prone to cause extrapyramidal symptoms, thereby exacerbating agitation and disruptive behavioral sequences in these patients.

Nondrug intervention strategies should always be utilized first in elderly dementia patients.

These are sincere people and I am appreciative of their confidence in me. Some of them give me an incredulous stare when I say that I am unable to comment rationally on medication options given my very limited knowledge of the client’s circumstances.

There is a prevailing belief system among many in the mental health industry that medicating emotionally dysfunctional or unstable patients is linked to some formula, recipe, decision tree or algorithm. The real pros among us know that this isn’t true and that medication management is not akin to cooking – where formulas and recipes are critical to the success of a good tasting dish.

Experience tells me that medication selection is predicated on five factors:

1. Comparative studies. It’s obviously important to know whether a drug consistently outperforms placebo based on well-designed, clinically relevant studies. Another important factor is how well a drug stands up to other competitors within the same genre.
2. Biases. Biases are influenced by our belief systems and they exist in practically every area of our lives. Medication is no exception.
3. Clinician experience. If a drug has a consistently favorable track record across a range of applications, it will be utilized again and again.
4. Colleague consultation. We seek the masterminds among us for recommendations and advice.
5. Pharmaceutical industry influence. These representatives are compensated handsomely for getting prescribers to use their drug.

An issue with these five factors is that they’re too widespread in scope. Here are four others that are more measurable and better predictors of treatment response:

• Patient previous experience with psychotropic medication. When it comes to a specific drug or drug class, find out whether the individual has used it before. If yes, what were the results; if it was discontinued, why? If it worked, try it again, unless the patient’s clinical condition has changed enough to no longer warrant its use.
• Family history. Does the client’s history include a family member who was prescribed a medication for a similar syndrome and responded to it favorably? If so, use the DNA/RNA phenomenon to the current client’s advantage by employing the same agent.
• Initial response. This one’s very important. After the first swallow, and with waxing and waning for at least a few days, there will be side effects. Some side effects are therapeutic. For example, a side effect of benzodiazepines is sedation, but some sedation, at least, is considered a goal when one is anxious. Most side effects however, are a nuisance and tend to annoy patients, so when in a vulnerable state, it’s easy for them to give up. If you believe the patient may be at risk for non compliance or stopping the medication altogether, some cheerleading may be necessary because the most critical phase of medication management is the first 7-10 days of treatment. Encourage clients to stay with it because most side effects will abate within a week of medication initiation. And be clear with them as to when noticeable results are likely to come – within one to two weeks for antidepressants; a few days for antipsychotics and within several hours for psychostimulants.
• Drug characteristics. Match medication selection to the patient’s symptomatic presentation as best you can. For example, because Prozac and Wellbutrin have activating properties, they’d be better choices than Celexa or Paxil for a lethargic, melancholic depressed patient. For managing psychosis accompanied by acute positive symptoms, the heavy hitters would be Risperdal, Zyprexa or in treatment-resistant instances, even Clozaril. Ordinarily, Seroquel, Geodon and Abilify don’t measure up in this scenario. The point here is that one size never fits all drug-wise, and requires a clinician to be discriminatory.

What about combination strategies? These abound across all psychotropic drug classes and are as long as my arm. Augmentation is viable when a patient is not responding to monotherapy or could benefit from the additive effects of other medications; it should not be employed simply because new symptoms emerge. There’s not a drug for every symptom and we never want a patient’s drug regimen to become too bloated. When this happens, it’s difficult to discern what’s working and what isn’t.

There must be a clear rationale for each and every drug choice; decision trees and algorithms should be for reference purposes only. Haphazard selection makes for a tedious process which can test a client’s patience; so involving the client in the decision-making process is a wise strategy, because more often than not, an empowered client is a more compliant one.

We’re not here to be alone – none of us, yet this is precisely what depression invites. Aloneness totes along the demons negativity and stinking thinking; life then becomes cocoon-like and few other people, if any at all, are granted entry into the bubble.

As a mental health professional, I’ve found that two of the hardest concepts for depressed individuals to grasp are that they’ve got to get moving, and they’ve got to get out of their head. Both of these are counterintuitive to the ubiquitous notions among the depressed that the depression itself keeps them from moving and that it’s “all about them.” So pushing oneself is the essential key and it’s doable.

Management is largely dependent on how immobilized one has become. Those with severe depressive symptoms should take baby steps at first. This means poking a pin in the protective bubble that depression provides and getting out of the house. A simple walk to the curb or around the block in the sunshine can serve as a humble start to a regular exercise regimen.

The next step is talking to a trusted, caring family member or friend who has the capacity to listen and empathize. I’m a therapist by trade, but it’s my belief that depressed people should begin the unburdening process with someone they already know, unless they’re a danger risk to themselves or others. This is a much less threatening approach; therapy or counseling can come later.

Then there’s the effect of religion and spirituality on getting out of the self-absorption sphere which feeds social isolation. Turning over one’s tribulations to a Supreme Being not only helps get a depressed person out of their head – which is often an irrational place; there’s also peace and contentment in doing so. There are some situations in life where other human beings are merely supportive stand-ins with God as the defined safe haven. This is centering and grounding and if one’s belief is firm, feelings of isolation, and for that matter, isolative behaviors are diminished in that God is only a prayer or a plea or a place of worship away.

Do antidepressants play a role in minimizing the social isolation component of depression? Yes and No. Yes, in that many of these drugs have an energizing effect that is a key to getting moving. No, in that ongoing motivation to isolate less is a decision. Drugs don’t make decisions for anyone but they may very well facilitate getting the ball rolling.

Isolation fuels depression and vice versa. Remedies go something like this: talk, move, meds and consultation with The Man Upstairs.

Charge them a monthly rent, and have them pay 25 percent of the monthly utilities. Also have them pay a fixed sum for food and other household expenses, again monthly. As you collect the money each month, place it in a savings or money market account.

Then, establish a firm date for when you want them out, and stick to it. You know your child best, what’s reasonable? One year? Eighteen months? Please, two years maximum.

At the end of the time period you’ve specifically defined, give them back all of the money and add that they’ve got 30 days to find a place of their own.

Accomplishments? You’ve conveyed the importance of them contributing to their own subsistence and they’ve got a stash of cash to get started. That’s win-win in my book, and it keeps your relationship with them on firm ground by elevating personal responsibility.

When it’s in balance, a relationship is unencumbered to be about those in it. That’s when each partner behaves, for the most part, as he/she would when alone with respect to tastes, habits, mannerisms, views of the world, moods and attitudes toward responsibility, etc.

A relationship is balanced when partners accept each other as they are, naturally. And this, in turn, is when you know you’ve identified someone good for you.

If your relationship needs more balance, you can prod it in that direction by making a conscious decision to be more tolerant of your partner, and yourself, as-is. Then watch the interaction change.

Primary insomnia is comprised of three components – difficulty getting to sleep, trouble staying asleep and early morning awakenings. A more apt word for insomnia is sleeplessness and people with chronic sleep difficulty may experience all three of these components.

The first step to attaining reasonably sound, restful sleep is to confront yourself. Think medical first. Are you having difficulty breathing? Are you in pain? What about restless legs? Significant advances in pharmacotherapy render all of these conditions readily treatable, so consult your doctor. Next, consider what’s going on between your ears. Bedtime is not conducive to worrying about wayward children or cracking the code to a better relationship with your obtuse boss. You’ve got to do these things during the day when you’re naturally more alert.

Then there’s the prickly issue of sleep sabotage. Here’s a short list for delaying your appointment with the sandman:

1. Anything with an “i.” i-phones, i-pads, i-pods, i-tunes.
2. A light-filled sleeping space.
3. Room temperature.
4. A heavy meal.
5. Alcohol, caffeine, decongestants.
6. Stimulating movies (Halloween, Nightmare on Elm Street and The Exorcist are way up there).

Sleep induction, on the other hand is conducive to the following:

1. If it has an On/Off switch, choose “Off” at least 30 minutes before bedtime.
2. Set the sleeping room temperature at a level comfortable for you, ideally somewhere between shivering and sweating.
3. Pray, meditate or read something soothing or boring.
4. Take all medication one hour before bedtime. The last thing you need after getting to sleep is a bathroom interruption.
5. Tire the mind and the body. Tiring the mind is generally the easier of the two. Getting through the workday means focusing, studying or concentrating on the task at hand. This helps you get to sleep. Tiring the body means moving the body, no matter the vehicle for doing so. This helps you stay asleep.
6. If you do nothing else, get the sleeping room as dark as possible. This helps stimulate the secretion of melatonin, a naturally occurring sleep hormone.

What about pharmaceutical sleep aids?

1. When taken responsibly, prescription drugs such as Ambien and Lunesta are safe and effective as long as you know what you want the drug to do and for how long. If you’re grieving an uncomfortable loss or traveling through many time zones, it’s perfectly acceptable to take these for a few nights at a time. Months, or even years of use, is an exercise in futility as dosage increases will be inevitable. This is a recipe for dependence.
2. Take for 2-3 days and assess the results. Insomnia is often temporary.
3. Over-the-counter melatonin, prescription melatonin (Rozerem) or Benadryl may be all you need.
4. Keep in mind, that none of these agents, prescription or OTC, will consistently help you stay asleep; they’re more effective at helping you get to sleep. 

While you sleep, your brain transforms your day’s experiences into memories and learning, and it releases hormones that fuel growth, build muscle mass and repair tissue. Sleep also releases hormones that fight infections and influence your diet and weight. And since science has yet to uncover why we need it, it’s best to just accept that we do.

According to the National Institute of Mental Health, multiple human studies have measured the effects of melatonin supplementation on sleep in healthy individuals. Although most of the trials have been small and brief, the weight of scientific evidence suggests that melatonin decreases the time needed to fall asleep and increases feelings of sleepiness. For use in adults in the management of insomnia, doses within the range of 0.6 mg – 3mg at bedtime, preferably one hour before retiring, are generally sufficient.