1 Boring Old Man

Mickey,

In all of these conversations people seem to completely ignore the community psychiatry movement and the gaol of keeping people out of hospitals and living independently in their own homes or apartments. My first job was working with a team with an ACT team and during my three year tenure we reduced the time in hospital from 28 days per person to less than 2 and cut the medication requirement by 40%. A lot of TD improves or disappears when people realize that more things can be done in crises than increase the medication and what reasonable doses of medication really are.

George,

My first job too. Same results. And if given moderate resources, it could happen again. It’s not happening down here very much these days. At least not like it did before we passed the low water mark…

I see it as ironic that the system we have at present, in which psychiatrists too often fail to do comprehensive evaluations and establish a meaningful relationship with patients; also fail to gain patient medication compliance. To some extent, this may make less harmful than they otherwise might be the problems of inaccurate diagnoses, over medication, lack of effectiveness and/or excessive side effects of the prescribed medications, .

It’s not “ironic” at all.

It is a business model of care and it is called “cost effective” and it is poor quality. By the time people see me they have seen several “prescribers” and several therapists. They have taken many medications that they could have avoided including medications that I would have never prescribed. They don’t know what their diagnosis or more realistically what their real problem is. None of the previous prescribers was treating them with any concern about side effects or how the drug interacts with their medical diagnoses. They often are not as concerned about their hypertension and cardiac status as I am.

We have managed care systems right now that are doing mass screening for depression with a checklist that can be done in 5 minutes or less and an antidepressant prescription follows.

We have a system of inadequate care provided by the managed care industry and governments at all levels that keep people away from comprehensive evaluations (and treatment) by psychiatrists.

Well said, George. In the business model of care patients are commodities to be processed.

Thanks to Mickey for calling attention again to the issue of tardive dyskinesia. In the early days of the ‘atypicals’ or second generation antipsychotic drugs (SGAs) there were no data to speak of on TD except for some European suggestions that clozapine might treat TD arising from exposure to the old drugs. By sleight of hand, in the early 1990s that idea morphed into the notion that the incidence of TD was minimal with the SGAs. As the data Mickey shows above tell us, there remains a palpable incidence of TD even with the SGAs, and this problem is compounded by the expansion of indications beyond psychotic disorders. I have pushed back especially on the use of SGAs like risperidone and aripiprazole in nonpsychotic patients with so-called treatment resistant depression. By the time millions of these patients are dosed there is a great deal of TD out there.

Umm, have our colleagues all forgotten that people with mood disorders are at INCREASED risk for movement disorders with antipsychotics. Gee, I guess the second generation/atypical antipsychotics didn’t get the memo…

The timelines from the European Schizophrenia Study [financed by Lilly].

^{[note the truncated scale]}

The article by Predmore et al seems seriously flawed. They calculate cost savings using methods which they admit are quite imprecise. So what are the error bars on their estimate? Without those this is not a scientific paper.

They also forget that there are significant and costly dose-related side effects from antipsychotic medications. In particular obesity and diabetes. In fact, my impression from the literature is that is not clear that all cause mortality and morbidity is changed when patients take high doses of antipsychotics on an ongoing basis. Any gains from the reduction of psychotic symptoms are offset by increases in the cardiovascular consequences of obesity and diabetes.

This is all about promotion of the [still patented] long acting anti-psychotic drugs. Leaving aside the fact that there is no clear advantage over the much less expensive haloperidol and fluphenazine decanoate (especially if they are used at appropriately low doses), there is also decent emerging evidence that adherence mainly postpones rather than reduces risk of relapse.
This study by Gleeson et al from Patrick McGorry’s group found that an intervention aimed at improving adherence worked in the sense that adherence was improved and relapse was reduced in the short term but they also found that there was impaired functional outcome.
http://www.ncbi.nlm.nih.gov/pubmed/22130905
Wunderink found the same thing.
http://www.ncbi.nlm.nih.gov/pubmed/23824214
Interestingly, I also found a study which found the same thing. This was from Timothy Crowe’s group in the UK and was done in the 1980’s.

Drug compliance = drug company profits. This is true in all of medicine and extends to mandates and standards.

Compliance is a real problem and changes in medications, both quantity and type, will lead to better outcomes, we need to remember, as Mickey has pointed out, the drug company involvement in this discussion.

Steve Lucas

I’ve learned so much here about pharmaceutical companies and their hinky relationship with medicine. Thank you all.

Late last week I was awakened by a phone call from the V.A.. I was asked to opt for a new dose of Copaxone that only needs to be taken three times a week to “save money” ‘ so that more people could receive more care.’ I too readily agreed, then immediately upon hanging up realized that this was likely a ploy to extend Teva’s patent. In ten seconds of searching, I confirmed that with a recent news article in Haaretz.

At least, our Supreme Court won’t extend their patent for the daily shots.

So, tomorrow, I’m going to leave the message that I want to continue with my daily shots. According to a metanalysis I saw recently, none of the drugs used for MS are particularly efficacious. Given the flakiness of the disease and its tendency to progress, I’ll take it anyway in case it is helping, but I’d feel much better about it if I were taking a less screamingly expensive drug.

If the drug caused all kinds of problems, I might not take it. If it caused a lot of problems and I knew it wasn’t helping, I would stop taking it, as I did with many psyche drugs. I’m not schizophrenic or bipolar, so it’s not quite the same comparison, but there are a whole lot of perfectly good reasons why people with psychotic disorders don’t comply with any given medication.

The day after the call I thought to wonder if I had talked to an employee of the V.A. or a drug rep. The company sends nurses to train people to give themselves the shots, and in the beginning they send out all kinds of promotional material to encourage people to stay on the drug, and call twice a year. They have a number that can always be reached, and is answered by a human. It is very easy to get free replacement parts for the auto-injector ( I find it more convenient not to use it.) The last time they called and asked if I needed anything I told them that I like the refrigerator magnets, because I like refrigerator magnets. That’s the last call I got. It’s been a few years. I was and am taking the drug without their encouragement, so I really didn’t need or appreciate the “encouragement”.

Of course, a profitable corporation has more money and resources to encourage continuance and compliance, and even to provide some handy services, and that can be a good thing; but the conflicts of interest are out of control. And the naked attempts to extend the patents and keep the prices up when the cost/benefit ratio is not improved is something that needs to be quelled with vigor, because it drives up the cost of health care so that less care can be provided. When the drugs cause more problems for little benefit, of course…

I hope the V.A. purchases the generic dailies, instead of falling for this completely. It won’t save money, it will cost more, so they will provide less care.

You said:

“And so it has gone throughout history – the problem of Schizophrenia, of the psychotic states. Everyone has a solution for the part of the problem they are involved with themselves, and wants to overlook the other side of the coin”

Thanks Mickey. That’s an incredibly wise statement that really sums up for me our repeated failures to address what seems like an intractable, multi-faceted problem we all desperately want to solve. I’m going to reflect on that all day.

I cannot believe all the nonpsychotic people who are taking drugs like Seroquel or Abilify when there are so many alternatives including completely side effect free supplementation with Deplin and so on. Or add a SARI. Or many other strategies. I put this on doctors (mostly primary care) more than pharma…unfortunately the ultimate solution to this will be a major class action.

I had no idea Abilify is now number one. Talk about a war on women. I’ll let Dr. Julie Holland finish my argument:

http://www.nytimes.com/2015/03/01/opinion/sunday/medicating-womens-feelings.html?_r=2

The fact that TCAs or even MAOIs are almost never used for depression and Abilify is commonly used for it. Maybe we are collectively insane…that’s the irony. More afraid of a tyramine reaction which probably won’t happen versus multiple TD cases that certainly will? Huh?

Of course, we’re not really insane, we’ve just allowed ourselves to become stupid.

By the way, this is one reason I am not on the primary care bandwagon…primary care sounds great until you see how they deal with something in your area of expertise. Not that there aren’t mentally lazy psychiatrists.

I had no idea until this morning that Abilify was number one in sales:

http://rt.com/usa/204563-abilify-top-grossing-medication/

Makes one long for the “halcyon days” of Prozac or Valium being number one….

Frankly, I’m stunned by this. What a screwed up country we have become.