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.

Earth to Psychiatry: Let Patients Smoke

Susan's When You're Going Through Hell Keep Going blog comments on a Newark (NJ) Star-Ledger item that reports:

"Beginning today, smoking will be banned in all areas of the Greystone Park and Ancora psychiatric hospitals, with similar bans to follow at three other state psychiatric facilities ..."

Smoking is already prohibited inside all state psychiatric hospitals in New Jersey. Says Susan:

"I would like to know what genius convinced Governor Corzine this is a good thing. They sure as hell didn't ask me. I have been in private and public hospitals - and what do you do in them? You smoke."

Susan goes on to say:

The last time I was in a hospital, the smokers were going off the wall, craving their cigarettes. The nurses were giving them patches, but the thing is about a patch, you want something to hold in your fingers, to put in your mouth, to shake into an ashtray, to grind the butt down. It's not just the process of lighting the cigarette, putting it to your lips and inhaling, it's everything.

Take it away from people in psychiatric hospitals, what do you get? A bunch of unhappy smokers who are forced against their will to wear patches and crave a cigarette. They get unhappy. They snap at the doctors, and nurses. They are miserable, crabby, and just not pleasant to be around.

According to the Star-Ledger article, the ban was instituted in the name of "wellness and recovery." According to an official, quoted in the article: "Our intent is to increase the life-spans of our patients, not to shorten them."

Ahem. Excuse me. I have a friend here in California. Last year, hospital staff picked a fight with her brother, Jeffrey, age 25, over whether he could have a cigarette break. Staff decided to show him who was boss. He was placed in five-point restraints, belly down, where he died.

Earth to psychiatry: Let patients smoke.

Individuals are admitted to psychiatric facilities in a state of crisis, generally in extreme agitation and often traumatized by a very recent event. They find themselves - usually against their will - in a strange environment that they rightly perceive as threatening.

Locked units with buzzing doors, strange people, police walking in and out, uniformed security, burly men poised for a takedown ...

So what do authorities do? They take away the patient's one comfort, the one thing that may help them settle into their new environment.

Psychiatric hospitals exist to take an individual out of crisis and move him or her into a state of conditional stability before sending them back out into the street, typically disoriented and confused. Patients don't get "well" in these settings. But they need all the help in the world getting them through the experience.

How misguided is psychiatry? The same profession that purports to be concerned about the patient's long term health when it comes to nicotine is the same profession that puts them on meds that demonstrably shorten their life spans over the long term.

Sorry for raving, but this hypocrisy bugs the hell out of me.

Last year I was in New Jersey, giving a ground rounds lecture at a private psychiatric facility in Princeton. No Smoking signs were all over the grounds. My talk was on meds compliance, and part of my prepared message included the fact that as opposed to the low compliance rates for meds over the long term (because they leave an awful lot to be desired), tobacco has a 100 percent compliance rate (because it works).

One reason that most people with schizophrenia and bipolar crave cigarettes is because for the brief time a cloud is in their lungs, their head clears up. People with schizophrenia in particular have difficulty filtering out distractions, which interferes with their ability to think. This changes when nicotine molecules lock onto the neuron's alpha-7 nicotinic receptors.

In the drug development pipeline are nicotinic agonists.

Patients are sending a message loud and clear, I told the psychiatrists and therapists in the audience. They will take a drug that works, even one with the worst side effects profile in the world.

I happened to jokingly add that maybe they should be prescribing cigarettes to their patients. I also called them out over the No Smoking signs I saw on the hospital grounds.

My audience showed their appreciation by emptying the room as soon as my lips stopped moving.

Psychiatrists I have talked to in private also don't get it. They have been conditioned to believe that smoking is a bad thing - which it is - that should not be encouraged. They forget that there is a crucial distinction between short-term and long-term treatment. Getting a person out of crisis is not the time to be worrying about what may or may not occur a quarter century from now. That's why doctors overmedicate with drugs that are blatant metabolic and diabetes risks. That's why patients should be allowed to smoke.

You don't facilitate getting a patient through a crisis and moving toward stability by taking their one security blanket from them.

(Recovery Innovations, based in Arizona, seems to be the one exception. At the emergency facility they operate in Phoenix, they have a policy of zero restraints. Significantly, they allow patients to smoke.)

Long-term care is a different kettle of fish. You leave the patient on high side effects meds only if you have to. You promote good diet, exercise, and all the rest. If the patient is smoking, you encourage various smoking-cessation regimens, when the patient is ready.

Sorry for raving on. I never smoked. I hate idiots who think they have a First Amendment right to blow fumes in my face. But what I hate worse is innocent people dying alone in five-point restraints, all because of an argument over a cigarette.

If Jeffrey had been allowed to have his smoke, he would be alive right now.