a story: getting near the ending[s]…

Posted on Monday 28 December 2015

Starting to work in a public clinic after 20 years in practice as a psychotherapist and five years of retirement was something of a shock. Besides the general polypharmacy, the number of people taking Atypical Antipsychotics was staggering to me. At the time, Seroquel® was the number one selling drug in the country, and everyone was on it. I didn’t understand how that had come to be, but I did know what to do about it. So by my second year back at work, no patients in our clinic who were not psychotic were on those drugs.

Recently, they changed the policy at the clinic, and so we’ve taken on a new crop of patients. And here they come again – this time on a greater variety, though primarily on Seroquel® and Abilify®. And this time around, I’ve seen three cases of Tardive Dyskinesia [TD]. Mercifully, two were mild and seem to be slowly clearing, but one isn’t. It’s the patient I wrote about in blitzed… and some truths are self-evident… who was on an outrageous drug regimen. The further along we get with tapering the drugs, the more apparent her TD symptoms – the worst case I’ve personally ever seen. She’s never been psychotic, and her diagnosis is probably best characterized as an attachment disorder.

That’s the case that’s in my mind as I read these Atypical-Antipsychotic-Augmentation-of-Treatment-Resistant-Depression articles, and probably why I’ve stayed glued to this topic for so long. I’ve realized what others may have already known – the Atypical-Antipsychotic-Augmentation-of-Treatment-Resistant-Depression has been advertised far and wide and has given permission to clinicians of many ilks to add Atypicals to their poly-pharmacy regimens. And it’s no surprise that the cases I’ve seen are on Seroquel® and Abilify®. They’re the only two FDA Approved for this indication, and are legally allowed to advertise:

Both Seroquel® and Abilify® are now off patent, so the ads will disappear. But now the FDA has approved Rexulti® for this indication based on these lackluster-at-best clinical trials I’ve been reviewing, so we can count on seeing in Rexulti®-in-Depression ads soon. Even worse, it has gotten that approval at the beginning of its patent life, so it will be with us for a very long time, perpetuating this practice of Atypical-Antipsychotic-Augmentation-of-Treatment-Resistant-Depression. Can the Direct-to-Consumer ads be far behind?

What’s doubly tragic to me, is that as this patient has awakened from her drug-induced-stupor, it’s obvious that she’s a particularly kind of patient well known to me and others in my tribe. She’s a person with an attachment disorder [often called Borderline Personality] whose adulthood has been chaotic because of her difficulty with and in relationships. She’s been seen by a variety of mental health types, and has been obviously chronically overmedicated [with her participation]. Such patients finally wear out trying to make the world adapt to their volatility and childish needs, and become very treatable in later adulthood. This process has been called a Hegira of therapies [Gerald Adler]. So here she is, finally ready to perhaps live a different and more fulfilling life, and she may have developed an unnecessary and disfiguring iatrogenic illness to contend with for the rest of her days.

In-so-far as I can tell from my recent review of the literature, there’s no real treatment for TD except not to get it in the first place. And although there are exceptions [some early onset cases], one’s chance of developing TD on antipsychotics increases steadily the longer you’re on the drugs. Add to that the danger of developing what’s called the Metabolic Syndrome [weight gain and Diabetes] and the risk side of the risk/benefit equation becomes very heavily weighted. Furthermore, these days, people are kept on medicines once started indefinitely. So this approval of Rexulti® for Atypical-Antipsychotic-Augmentation-of-Treatment-Resistant-Depression has the potential to do some real damage – as that done in my patient to absolutely no good purpose. No short term RCT is ever going to make this risk apparent. And no case of TD is worth the minimal effects the drugs might have on depression.

So that’s an additional reason I’m so stuck on this particular story. On to the endings…
    December 28, 2015 | 1:06 PM

    In my experience, the best way to address the inappropriate use of atypicals is to provide the patient with written informed consent with special emphasis on the neurological and metabolic side effects of the medication. In the state where I practice it is mandated by statute but still rarely happens. In every person I see on these drugs at the end of my initial assessment – I point out that I do not think that they have any of the diagnostic indications for taking these drugs. At that point they typically tell me that it was started for sleep.

    When I go over the side effects – many of them have already occurred and the patient wants off of it and usually tells me that they were never informed that weight gain and diabetes could be a possible side effect.

    December 28, 2015 | 6:47 PM

    Thanks George,
    It’s a good plan. It’s a sad story that we have to have one. When I explain the possible harms, I hear the same thing. People cling to Benzodiazepines, but they’ll jettison the Atypicals in a heartbeat…

    James O'Brien, M.D.
    December 28, 2015 | 7:25 PM

    Primary care susceptibility to this kind of pharma-ganda is a strong argument against collabo-care. 78% percent of PMDs fail to dx bipolar in patients presenting with symptoms of unipolar MDD. So the patients are getting SGAs when what they really need are mood stabilizers and increased monitoring for suicide risk. How that kind of thing gets figured out when the psychiatrist never sees the patient is beyond me. Collabo-care is a recipe for even more biploar patients falling between the cracks. It will work about as well as community mental health centers did for schizophrenics during deinstitutionalization.

    December 29, 2015 | 1:49 PM

    I have run across a lot of folks in 12-step– particularly younger women, though not always– who are on atypicals because they seem to have what I call UCB — undifferentiated cluster B, often with pretty florid symptoms that interfere greatly with quality of life. Usually there’s a history of pretty severe trauma and pretty serious attachment problems. Many of these kids seem to be deliberately misdiagnosed as bipolar to justify giving them atypicals, even though their psychiatrists say things like, “Well, you may not really have Bipolar, this has some borderline features.”

    As a friend, I try to say reassuring things like, “A lot of this is developmental, and many of these symptoms are gonna blow out in your late 30s or early 40s– and possibly sooner if you work a good program, find a good therapist, and make a few close friends and stick with them no matter what. When you see your psychiatrist, ask about side effects, and if you don’t want more medication, don’t be afraid to say so. By the way, did you call your sponsor this week and do you have an appointment with your therapist yet? Why not try that first?”

    And it does seem like things really do seem to settle down for them, even by their mid-30s sometimes. I met one young intern recently, about 36 five years sober who got themselves off everything but Effexor, and is just a terrific sponsor, will probably be a fine therapist.

    To a client, strangely, I can’t be as direct because of scope-of-practice issues, but I do not see many clients on atypicals, or haven’t yet. In this neck of the woods, prescribing habits are (finally) getting a little more conservative, though I’m running into some clients on crazy high doses of SSRIs and SNRIs.

Sorry, the comment form is closed at this time.