New Poll Results: Meds in Our Treatment - How Does "Smart" Factor In?

"How well have your meds worked for you?" I asked you in a poll I ran here through the month of May. Of the 168 who responded, only 14 percent of you answered, "very well." In other words, only a small percentage of you thought your meds worked like gang-busters. The overwhelming rest of you had reservations.

Thirty-six percent of you - about one-third - responded, "conditionally well." In other words, your meds may not be perfect but they were meeting your expectations. When you add in the "very well" group, fully half you reported satisfactory results with your meds.

So, can we put a positive spin on the results? Hold that thought.

One in five of you (19 percent) told me that your meds were "rather problematic." In other words, you're not happy with your meds, but you are experiencing some benefit.

Nearly one in five (17 percent) responded that your meds were "very problematic" and 11 percent told me your meds were "a complete disaster." Added together, nearly one-third of you have given an unambiguous thumbs down to your meds.

So, how do we interpret the results? Keep in mind this is hardly a scientific survey. Let's go negative, first:

The fact that more than eight in ten of you reported that your meds are not working "very well" - for whatever reasons - speaks volumes. Add to that the fact that the "complete disaster" group is running in a virtual dead heat with the "very well" group and we are talking very low levels of customer satisfaction.

In other words, if meds were automobiles, car makers like General Motors would be in bankruptcy. Wait, let me rephrase that. Uh, never mind ...

Now let's go positive. This means first seeing possibilities in the "rather problematic" grouping. Suppose, for instance, half of you in this group were to graduate to "conditionally well." Then 60 percent of you - nearly two thirds - would at least be reasonably satisfied with your meds. Suppose we could get similar conversion rates from the "very problematic" and "complete disaster" groups. Then three-quarters of you would be happy customers.

How is that possible?

The meds are constant in this equation. The two variables are you and your psychiatrist. First imagine a smart patient working with a smart psychiatrist. Now picture a naive patient placing his or her trust in a lazy psychiatrist. Are we likely to see dramatically different outcomes? I rest my case.

Okay, one example: You come to your psychiatrist depressed. He diagnoses you with clinical depression. The antidepressant doesn't work. In fact, it makes you feel worse. The psychiatrist tries you on another antidepressant, then another. You are starting to feel like you are crawling out of your skin.

Then your psychiatrist gets a bright idea - or rather a thought implanted in him by a drug rep the day before. Based on his conversation with someone way too dumb to get into med school in the first place but attractive enough to take up a career in modeling (whether male or female), he now decides that the answer to your problem is an atypical antipsychotic to kickstart the antidepressant.

A smart psychiatrist will know exactly the right situation to make this call, but in your case would probably never have to make it. Instead, after not getting a good result with your second antidepressant, she - the smart psychiatrist, that is - would probably revisit the diagnosis. It could turn out - on further enquiry - that you have bipolar or something in the bipolar spectrum. So she takes you off the antidepressant and puts you on a mood stabilizer.

If the mood stabilizer works, your "complete disaster" scenario has been turned around. Maybe not all the way. In all likelihood, in fact, you still have a long way to go. But now, at least, you are in a position to learn more, to move up to from being a naive patient to a smart one.

What a difference "smart" makes in the equation.

For Discussion: The Dopamine Cocktail

In response to a blog post from two days ago on meds compliance, Cretin, who is on Zyprexa, commented:

"After a neurological test implicated working memory as the problem, my doctor had me try adding dextroamphetamine (Dexadrine). In essence we are adding in more dopamine to the system while blocking enough D2 receptors with olanzapine (Zyprexa) to avoid any psychotic symptoms. So far that has worked. It would be interesting to see if this combination would lead to greater compliance with medications."

Funny you should raise that, Cretin. I've been on a kick about "smart" dopamine meds for some time now. The ones we're working with are pretty dumb. Here's the situation:

Working one side of the street are antipsychotics, which block dopamine. Too much dopamine tends to result in over-excitement and psychosis. Antipsychotics such as Zyprexa work well against psychosis, but often at the expense of cognitive function, awareness, and motivation, not to mention pleasure and reward, which tends to involve instant eunuch-hood.

In addition, shortage of dopamine can result in temporary and permanent Parkinson's-like tremors known respectively as EPS and tardive dyskinesia.

Working the other side of the street, for lack of a better term, are "dopamine enhancers." These include anti-Parkinson's agents, ADD meds such as Ritalin, and the wakefulness agent Provigil. In addition, MAOI antidepressants and the antidepressant Wellbutrin have a modest dopamine effect.

Last but not least, we have methamphetamines, which tend to get abused as street drugs, plus street drugs with no medicinal value. For the sake of extreme over-simplicity, think of ADD meds and Provigil as methamphetamines with brakes.

A "smart" dopamine med would restore dopamine balance without over-shooting the mark in one direction or the other. It would also dispatch dopamine to certain parts of the brain where more is needed and slow it down in other areas where less is needed.

The problem is, a smart dopamine med doesn't exist. But we can still come up with smart strategies based on the meds we have. Cretin and her doctor did just that. Think "dopamine cocktail."

I stumbled upon this by accident about four years ago when someone I know raised with her psychiatrist the idea of Wellbutrin to deal with a particular side effect of the antipsychotic she was on. The Wellbutrin turned out to be a dud in this regard, but unexpectedly her head cleared up. She could "think" again.

Thinking - something people with no mental illness or who have never been on a psychiatric med take for granted.

Two-and-half years ago, I began researching dopamine in earnest. Soon after, a friend landed a part-time research position, which represented a major step in his recovery - if he could hold onto the job.

My friend has a masters degree and teaching experience, but his previous employment was parking cars, and even that was a struggle for him. Between his illness and the antipsychotic he was on, his brain had a hell of a time booting up.

I suggested he ask his psychiatrist about Provigil. In essence, something to counteract the antipsychotic. A dopamine cocktail, if you like. I won't say the med brought his brain completely back online, but what he reported was a miracle. He could function. No longer was he overwhelmed by work and the people around him. He credits the Provigil with saving his job.

There is a twist to this. Thanks to our system of mangled care, my friend was deprived his Provigil. His psychiatrist was smart enough to substitute an ADD med, which didn't work as well, but nevertheless got the job done until my friend managed to get back on the Provigil.

Clearly, psychiatrists are willing to give dopamine cocktails a try, but the fact we don't hear more from people such as Cretin indicates this is clearly not widespread practice. What gives?

For one, there is no evidence base to go on, much less any CME courses to educate physicians, much less FDA indications for using meds in this capacity. In short, the only thing guiding psychiatrists is their own clinical wisdom.

For another, there is legitimate fear of abuse and addiction (a small study that just came out in JAMA found potential for addiction in Provigil).

Add to that my own strong belief that doctors tend to err on the side of overmedicating and over-sedating us. The thought of us cracking jokes and solving differential equations while we dance with the stars seems to set off a primal reaction in just about every card-carrying psychiatrist I have known.

Finally, there may be other and possibly safer alternatives to dopamine-enhancers, such as meds that work on the cholinergic system (for instance, Alzheimer's meds). A good psychiatrist will take these and other matters into consideration.

Obviously, this is an extremely complex issue. Any decision needs to be an informed one between you and your psychiatrist. By all means, let's get a conversation going, but until we learn more, let's not jump to any premature conclusions.

More to come in future blogs ...

From mcmanweb:

Dopamine - Serotonin's Secret Weapon

The April 2007 American Journal of Psychiatry features an editorial by Bruce Cohen MD, PhD and William Carlezon PhD, both of Harvard, entitled "Can’t Get Enough of That Dopamine." As the authors point out, "through their many connections, dopamine neurons participate in the modulation of expectation, reward, memory, activity, attention, drives, and mood - the very substrates of psychiatric illness." ...