Rerun: Treating Marilyn

My most recent blog piece touched on a section of a grand rounds I delivered on meds compliance two years ago at a psychiatric facility in Princeton. That section, "The Problem Clinician," received a decidedly frosty reception from my audience of clinicians. This section, from "The Problem Patient," went over a lot better.

This piece first appeared on my blog in Feb, 2009.

The following is based on the first part of a talk I gave to clinicians on meds compliance as part of a grand rounds at a psychiatric facility in Princeton:

'Marilyn walks into your office," I began. "She reveals her moods have been all over the place. Everything points to bipolar. Okay. How do you treat her?"

Believe it or not, no one raised their hands. I was the one who had to suggest that a mood stabilizer might be a good idea, then I had to make sure we had a consensus. Then I went to the catch, namely how does the most important person in the equation - the patient - feel? After all, even the best med in the world is useless if patients won't take it.

Maybe we need to ask Marilyn a few more questions, I suggested. Consider:

Marilyn is literally larger than life. Over the top is her baseline. It's a legitimate part of her personality. How long do you think she is going to stay on her mood stabilizer if she thinks her personality is getting medicated out of her?

Hypomania is the first thing to come to mind when thinking of Marilyn, but the operative word from the DSM regarding this type of behavior is "uncharacteristic."

"For someone else to act like Marilyn," I said, "that may be hypomanic. For Marilyn to act like Marilyn - that's normal."

In support, I cited Ronald Fieve MD of Columbia University, who coined the term, "the hypomanic advantage."

"Keep in mind," I said, "a lot of us view the world through the eyes of artists and poets and visionaries and mystics. Not to mention through the eyes of highly successful professionals and entrepreneurs. We don't want to be like you."

How can I describe the look of surprise from my audience? Like I had let rip a roof-rattler and they were too polite to laugh - I think that best sums it up. I should have thrown away my prepared talk at that stage. Seriously, I should have said. We don't want to be like you. Why should that surprise you?

Instead I plowed ahead:

"We don't want to fly too close to the sun," I continued. "But don't clip our wings. Obviously Marilyn needs to be reeled in a bit. But how do we proceed? What do we have to go on?"

Believe it or not, there are zero published studies for treating hypomania. Zip, zilch, nada. The only solid evidence base involves the acute phase of full-blown mania, when we're bouncing off walls, 911 cases.

"So," I asked, "are you thinking of giving someone with hypomania an industrial strength dose?"

What else is going on with Marilyn? Personality issues? Quirky behavior? Does the bipolar itself affect her capacity to think rationally?

"You're the rational ones," I said. "We know where you are coming from. But do you know where your patients are coming from?"

I clicked to two slides: Fear/feeling threatened, problems accepting authority, cognitive distortions ...

The list went on and on. "Looking like a lot of your patients?" I asked.

"Here's the point I'm making," I continued. "Not only are you treating the illness. You are treating any behaviors and attitudes that come in the way of treatment. And you're not going to find that out unless you talk to the patient - and listen."

I wasn't through: "Just sending a patient out the door with a prescription - in my opinion - is not treatment."

Back to Marilyn. She's Marilyn. She has enormous gifts and doesn't want her wings clipped. She has various personality issues. And her illness is affecting her judgment.

"We have the advantage of knowing the tragic outcome," I concluded. "Knowing what you know, are you happy just writing her a prescription and sending her out the door?"

Postscript: This first part of my talk - "The Problem Patient" - went fairly well, perhaps because the audience could spin my message in a way that assigned all blame to the patient. There was no way they could do that with the next two sections, "Problem Meds" and "The Problem Clinician," and I got a very different reaction.

More later ...

Trick Question: Meds Compliance

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?

Answer: Nicotine.

I posed this question last year to 50 or 60 clinicians at a grand rounds lecture I presented at a psychiatric facility in Princeton. Just prior to asking the question, I cited a 2006 study in which four in five patients on Zyprexa dropped out of the long-term phase of the trial.

This is not an isolated finding. The drop-out rate figure fluctuates between 40-to-100 percent over the long term across a broad range of psychiatric meds and diagnoses.

What's different about nicotine? In my talk, I showed a slide citing the research of Robert Freedman MD of the University of Colorado that connected "auditory gating" disturbance to nicotine craving. Apparently, individuals with schizophrenia have trouble screening out the second of two repetitive sounds, which does hell to their concentration.

This gating response is mediated by - drum roll, please - the alpha-7 nicotinic receptor.

Nicotine works. With nicotine, patients actually get their brains back - even if just for a precious few seconds. Apparently, in the brief time a cloud is in the patients' lungs, a cloud clears from the brain.

The only thing that is wrong is the delivery system, but in the drug development pipeline are nicotinic agonists.

Here's where I won over my audience: "So, if you prescribe cigarettes," I said, "you will get much better compliance than if you prescribe an atypical antipsychotic."

(Clinicians like to show their appreciation by looking like they're holding in their lower intestinal tract versions of auditory gating.)

"Now, compare that with an atypical antipsychotic," I went on to say. "Rather than clearing the brain, these meds actually take major parts of the brain off-line."

For support, my slide quoted 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 taking a medication, such as antipsychotic drugs that block dopamine."

Then I quoted John Krystal MD of Yale from a lecture he gave to the American Psychiatric Association the year before:

"Our medications are least effective for the most disabling symptoms of schizophrenia," namely, "the cognitive dysfunctions ..."

Cognitive dysfunction also looms large in bipolar.

Let's start connecting the dots: We have psychiatrists prescribing patients a class of drugs that work well against psychosis at the expense of worsening the most pronounced feature of schizophrenia and a significant feature of bipolar. No surprise - low compliance rates.

Meanwhile, we have a drug that doctors try to ban that actually helps bring patients' brains back online for a few precious seconds. Surprise, surprise - high compliance.

You tell me: Who are the smart people in this equation?

"Far from lacking insight into their illness, from refusing to put up with side effects," I said, "patients 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."

I was just getting warmed up:

"Let's face it," I said, "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."

I wasn't through:

"The CATIE studies brought this out loud and clear. My question for you 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?"

This part of my talk was interrupted by a spontaneous display of stony cold silence. The temperature in the room literally dropped ten degrees.

What were they expecting? A CME lecture sponsored by Eli Lilly with free "Zyprexa" pens and coffee mugs?

Treating Marilyn

The following is based on the first part of a talk I gave to clinicians on meds compliance as part of a grand rounds at a psychiatric facility in Princeton:

'Marilyn walks into your office," I began. "She reveals her moods have been all over the place. Everything points to bipolar. Okay. How do you treat her?"

Believe it or not, no one raised their hands. I was the one who had to suggest that a mood stabilizer might be a good idea, then I had to make sure we had a consensus. Then I went to the catch, namely how does the most important person in the equation - the patient - feel? After all, even the best med in the world is useless if patients won't take it.

Maybe we need to ask Marilyn a few more questions, I suggested. Consider:

Marilyn is literally larger than life. Over the top is her baseline. It's a legitimate part of her personality. How long do you think she is going to stay on her mood stabilizer if she thinks her personality is getting medicated out of her?

Hypomania is the first thing to come to mind when thinking of Marilyn, but the operative word from the DSM regarding this type of behavior is "uncharacteristic."

"For someone else to act like Marilyn," I said, "that may be hypomanic. For Marilyn to act like Marilyn - that's normal."

In support, I cited Ronald Fieve MD of Columbia University, who coined the term, "the hypomanic advantage."

"Keep in mind," I said, "a lot of us view the world through the eyes of artists and poets and visionaries and mystics. Not to mention through the eyes of highly successful professionals and entrepreneurs. We don't want to be like you."

How can I describe the look of surprise from my audience? Like I had let rip a roof-rattler and they were too polite to laugh - I think that best sums it up. I should have thrown away my prepared talk at that stage. Seriously, I should have said. We don't want to be like you. Why should that surprise you?

Instead I plowed ahead:

"We don't want to fly too close to the sun," I continued. "But don't clip our wings. Obviously Marilyn needs to be reeled in a bit. But how do we proceed? What do we have to go on?"

Believe it or not, there are zero published studies for treating hypomania. Zip, zilch, nada. The only solid evidence base involves the acute phase of full-blown mania, when we're bouncing off walls, 911 cases.

"So," I asked, "are you thinking of giving someone with hypomania an industrial strength dose?"

What else is going on with Marilyn? Personality issues? Quirky behavior? Does the bipolar itself affect her capacity to think rationally?

"You're the rational ones," I said. "We know where you are coming from. But do you know where your patients are coming from?"

I clicked to two slides: Fear/feeling threatened, problems accepting authority, cognitive distortions ...

The list went on and on. "Looking like a lot of your patients?" I asked.

"Here's the point I'm making," I continued. "Not only are you treating the illness. You are treating any behaviors and attitudes that come in the way of treatment. And you're not going to find that out unless you talk to the patient - and listen."

I wasn't through: "Just sending a patient out the door with a prescription - in my opinion - is not treatment."

Back to Marilyn. She's Marilyn. She has enormous gifts and doesn't want her wings clipped. She has various personality issues. And her illness is affecting her judgment.

"We have the advantage of knowing the tragic outcome," I concluded. "Knowing what you know, are you happy just writing her a prescription and sending her out the door?"

Postscript: This first part of my talk - "The Problem Patient" - went fairly well, perhaps because the audience could spin my message in a way that assigned all blame to the patient. There was no way they could do that with the next two sections, "Problem Meds" and "The Problem Clinician," and I got a very different reaction.

More later ...