Monday, August 9, 2010

My Totally Surreal Experience Lecturing on Problem Meds to Psychiatrists and Other Clinicians

In my two previous blog posts, I described my unequivocally frosty reception involving a grand rounds lecture I delivered on meds compliance two years back to a psychiatric facility in Princeton, NJ. My first section involved The Problem Patient, my last The Problem Clinician. Following is my version of the middle part of my talk, Problem Meds ...

Okay, maybe I went out of my way to piss off my audience. "Here's a question for you," I opened. "What is the one drug taken by 85 percent of those with schizophrenia and two in three with bipolar that they are 100 percent compliant with?"

They came up with nicotine right away.

We know that auditory gating is mediated by the alpha-7 nicotinic receptor. Those with schizophrenia have trouble filtering out background noise, thus have trouble concentrating. I recall Robert Freedman of the University of Colorado explaining this to a symposium of the American Psychiatric Association annual meeting a number of years before.

Dr Freedman and his colleagues noticed that those with schizophrenia seemed to experience a desperation that went way beyond normal cigarette cravings and decided to investigate. What they found was that in the brief time a cloud is in the patients' lungs, a cloud clears from the brain.

Mind you, this is hardly a long-term solution. But think about it. Nicotine works. With nicotine, some patients actually get their brains back - even if just for a precious few seconds. I don't know about you, but I don't take my brain for granted. Every precious second the reception comes in loud and clear is a gift to me.

Mind you, I'm not advocating cigarette use. But it appears that nicotine may be an effective drug for schizophrenia. Its major fault is the delivery system, but thanks to the research of Dr Freedman and others alpha-7 nicotinic agonists are in development.

"So, if you prescribe cigarettes," I joked, "you will get much better compliance than if you prescribe an atypical antipsychotic."

Zero degrees Kelvin frozen silence. It probably didn't help that earlier I had called out my audience for all the "No Smoking" signs on the grounds of the facility. (Mind you, perhaps thanks to the nicotine patch, patients and those who speak for them are putting up little resistance to hospital smoking bans.)

Now it was time to compare and contrast. Up on my PowerPoint went this slide from a 2007 editorial in the American Journal of Psychiatry:

Without adequate dopamine signaling, our patients do not feel ‘well.’ When dopamine systems are dysfunctional, patients seek a change. This may involve stopping a medication, such as antipsychotic drugs that block dopamine.

Rather than clearing the brain, these meds actually take major parts of the brain off-line. The major problem with schizophrenia is cognitive deficit. Up went a quote from leading schizophrenia researcher, John Krystal MD of Yale:

"Our medications are least effective for the most disabling symptoms of schizophrenia," namely, "the cognitive dysfunctions that seem to prevent people from performing in the workplace."

The pioneering diagnostician Emil Kraepelin, who "discovered" schizophrenia back in the early twentieth century, pointed to cognitive dysfunction as a core symptom, and we are also recognizing it looms large in bipolar.

I was just getting warmed up. "So, what's your answer?" I asked. "You give patients a drug that actually worsens the most pronounced feature of schizophrenia - and a significant feature of bipolar. Not only that, you're telling us we're going to have to take it the rest of our lives. Sure, it knocks out the psychosis, but so what?"

I could have gone on about the metabolic catastrophes from meds such as Zyprexa - surely the long-term risk to health was as bad as cigarettes - but I compassionately spared my audience. Instead, I simply drove home this point: 

"Far from lacking insight into their illness, even patients with schizophrenia have a much better understanding than the people charged with treating them. Far from refusing to put up with side effects, they are willing to put up with a drug with one of the worst side effects profiles in the world. Why? Because it works. It works where they want it to work."

"Let's face it," I concluded. "We've all been badly oversold on the new generation antipsychotics - you, me, family members. When all is said and done, these new generation atypicals are basically Thorazine with the tires rotated."

For some crazy reason, to my total amazement, they cracked up at that line. Then they went back to being bumps on a log.

"My question for you," I concluded in this part of my presentation, "is why did it take you so long to figure this out? The same info was in the journals you subscribe to, on the labeling of the meds you prescribe. More important, your patients have been telling you this for years. Why haven't you been paying attention?"

As I mentioned in previous blog pieces, my audience heard me out, then made for the exits the second my lips stopped moving.


Anne said...

I just read this blog post, so I'm not sure what you said during the rest of your speech. I know all about side effects, drugs that don't work and the occasional one that does. What do you think about alternative treatments like acupuncture or hypnosis? Do you think they work? I'm just tired of the current medical model where they give you a pill and send you on your way.

John McManamy said...

Hey, Anne. I think alternative (complementary) treatments are worth investigating, but keep in mind these are not regulated and quacks abound. Also, there is no magic bullet out there - whether it's a med or something else. At best, they do part of the job.

I think our frustration with the medical model lies in our overly-naive assumption that meds were supposed to be a godsend. That may be the case for a few lucky people.

I think we would be much more happy if we didn't expect too much from meds. For instance, antipsychotics are very good at knocking out psychosis. They are also good at short-term mood stabilization. But then comes the crucial what next? That's where we have to figure out which recovery tools work best for us.

Hope this helps ...

Willa Goodfellow said...

I don't smoke -- was a "pack a year" person many long years ago. I wonder if a nicotine patch would help me? What do you suppose the chances are that I could get a prescription now that the latest chemistry experiment has failed, and we are on to things without a lot of clinical evidence anyway?

John McManamy said...

Hey, Willa. I actually know someone who used to be a competitive marathon runner addicted to cigarettes. Something more than a mere addictive craving had to be going on (though this is only a guess on my part). The risk of going on a nicotine patch, of course, is you might become addicted to the nicotine and then want to take up smoking again (ultimate irony). But if your brain is in a fog, this is well worth discussing with your pdoc.

I'd also inquire into other meds that improve cognitive function: any dopamine-enhancer (Wellbutrin, ADD meds, Provigil, Parkinson's meds), or even Alzheimers meds. My impression is the pdocs don't pay enough attention to the fact that we appear depressed when really our dopamine (and related) systems aren't sufficiently booted up.

Are we depressed because we feel sluggish? Or are we just sluggish? Certainly, a lot of our meds make us sluggish.

At best, all these meds are blunt instruments, but in the hands of a smart pdoc willing to listen and go off-label there may be hope. But even then, you are a guinea pig.