{"id":56717,"date":"2015-05-10T15:14:22","date_gmt":"2015-05-10T19:14:22","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=56717"},"modified":"2015-05-10T15:30:14","modified_gmt":"2015-05-10T19:30:14","slug":"doesnt-compute","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2015\/05\/10\/doesnt-compute\/","title":{"rendered":"doesn&#8217;t compute&#8230;"},"content":{"rendered":"<div align=\"justify\" class=\"small\">The article synopsized below comes from the <strong><font color=\"#200020\">Family Practice News<\/font><\/strong>, taken from a <a href=\"http:\/\/www.nvpsychiatry.org\/nevada-psychiatric-association--npa----karen-dineen-wagner\" target=\"_blank\">psychopharmacology update<\/a>  held by the <em><font color=\"#200020\">Nevada Psychiatric Association<\/font><\/em>. The speaker is <strong><font color=\"#200020\">Karen Dineen Wagner<\/font><\/strong> who is the  Vice Chair of the Department of Psychiatry and Behavioral Sciences and  Director of the Division of Child and Adolescent Psychiatry at the  University of Texas Medical Branch in Galveston. She is one of two candidates being currently voted on for <em><font color=\"#200020\">President Elect<\/font><\/em> of the <em><font color=\"#200020\">American Academy of Child and Adolescent Psychiatry<\/font><\/em>. But that&#8217;s hardly a full r\u00e9sum\u00e9. She was on <a target=\"_blank\" href=\"http:\/\/www.policymed.com\/files\/grassley_floor_speech_september_9_2008.pdf\">Senator Grassley&#8217;s<\/a> list of academic psychiatrists who had unreported pharmaceutical income. She was <strike>an author of<\/strike> on the byline of just about every industry created ghost-written Clinical Trial of antidepressants in adolescent depression &#8211; the 2004 Citalopam article drawing a public rebuke from the Journal Editor [and costing Forest $313M in fines] [see <a target=\"_blank\" href=\"http:\/\/1boringoldman.com\/index.php\/2014\/10\/16\/collusion-with-fiction\/\">collusion with fiction&hellip;<\/a>]:<\/div>\n<ul><span class=\"small\">       <\/p>\n<li>\n<div align=\"justify\"><strong><font color=\"#660033\">2001<\/font><\/strong>: <a target=\"_blank\" href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/11437014\">Efficacy of Paroxetine in the Treatment of Adolescent Major Depression: A Randomized, Controlled Trial<\/a>. &quot;<em>Paroxetine is generally well tolerated and effective for major depression in adolescents<\/em>.&quot;         <\/div>\n<div>by Keller MB, Ryan ND, Strober M, Klein RG, Kutcher SP, Birmaher B,  Hagino OR, Koplewicz H, Carlson GA, Clarke GN, Emslie GJ, Feinberg D,  Geller B, Kusumakar V, Papatheodorou G, Sack WH, Sweeney M, <strong><font color=\"#990000\">Wagner KD<\/font><\/strong>, Weller EB, Winters NC, Oakes R, and McCafferty JP<\/div>\n<\/li>\n<li>\n<div align=\"justify\"><strong><font color=\"#660033\">2002<\/font><\/strong>: <a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/12364842\" target=\"_blank\">Fluoxetine for Acute Treatment of Depression in Children and Adolescents: A Placebo-Controlled, Randomized Clinical Trial<\/a>.<em>  &quot;Fluoxetine  was superior to  placebo in the  acute phase treatment of  major  depressive disorder in  child and  adolescent outpatients with  severe,  persistent depression<\/em>.&quot; <\/div>\n<div>by Emslie GJ, Heiligenstein JH, <strong><font color=\"#990000\">Wagner KD<\/font><\/strong>, Hoog SL, Ernest DE, Brown E, Nilsson M, and Jacobson JG<\/div>\n<\/li>\n<li>\n<div align=\"justify\"><strong><font color=\"#660033\">2003<\/font><\/strong>: <a target=\"_blank\" href=\"http:\/\/jama.ama-assn.org\/content\/290\/8\/1033.long\">Efficacy     of sertraline in the treatment of children and adolescents with  major    depressive disorder: two randomized controlled trials<\/a>. &quot;&hellip;<em>sertraline is an  effective and well-tolerated  short-term treatment for children and  adolescents with MDD<\/em>.&quot;       <\/div>\n<div>by <strong><font color=\"#990000\">Wagner KD<\/font><\/strong>,  Ambrosini P, Rynn M, Wohlberg C, Yang R, Greenbaum MS, Childress A,  Donnelly C, Deas D; and the Sertraline Pediatric Depression Study Group<\/div>\n<\/li>\n<li>\n<div align=\"justify\"><strong><font color=\"#660033\">2004<\/font><\/strong>: <a target=\"_blank\" href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/15169696\">A randomized, placebo-controlled trial of citalopram for the treatment of major depression in children and adolescents.<\/a> &quot;&hellip;<em>treatment  with citalopram reduced depressive symptoms to a significantly greater  extent than placebo treatment and was well tolerated<\/em>.&quot;       <\/div>\n<div>by <strong><font color=\"#990000\">Wagner KD<\/font><\/strong>, Robb AS, Findling RL, Jin J, Gutierrez MM, and Heydorn WE<\/div>\n<\/li>\n<p align=\"justify\"><strong><font color=\"#200020\">[Paradoxically, Karen Wagner and some of her co-<em>authors<\/em> in these studies were later on the <a href=\"http:\/\/www.acnp.org\/\" target=\"_blank\">ACNP<\/a>  [American College of Neuropsychopharmacology] Task Force convened to  report on these questions after the Black Box Warning was added by the  FDA in 2004:]<\/font><\/strong><\/p>\n<li>\n<div align=\"justify\"><strong><font color=\"#660033\">2006<\/font><\/strong>: <a target=\"_blank\" href=\"http:\/\/www.nature.com\/npp\/journal\/v31\/n3\/full\/1300958a.html\">ACNP Task Force Report on SSRIs and Suicidal Behavior in Youth<\/a>.<\/div>\n<\/li>\n<div>by Mann JJ, Emslie G, Baldessarini RJ, Beardslee W, Fawcett JA, Goodwin FK, Leon AC, Meltzer HY, Ryan ND, Shaffer D, and <strong><font color=\"#990000\">Wagner KD<\/font><\/strong><\/div>\n<p>  <\/span><\/ul>\n<div align=\"justify\" class=\"small\">In this <em>update<\/em>, she recommends routine treatment of adolescent depression with antidepressants, off-label, ignoring the Black Box Warning, and gives a script of what to say to over-ride parent&#8217;s worries about suicidality with the SSRIs in kids. Speaking of scripts, she has one for tossing off treatment with psychotherapy [CBT] altogether [too slow for her liking I guess]. She&#8217;s a frequent contributor to the <a target=\"_blank\" href=\"http:\/\/www.psychiatrictimes.com\/authors\/karen-dineen-wagner-md-phd\">Psychiatric Times<\/a> where her articles  often play up psychopharmacologic efficacy and downplay safety  recommendations. <\/div>\n<blockquote>\n<div align=\"center\" class=\"big\"><a href=\"http:\/\/www.familypracticenews.com\/home\/article\/parents-are-key-in-treating-child-adolescent-depression\/135cbfefd00b0e9c3f1ca316e670f50c.html?ooct=FPN-comic\" target=\"_blank\">Parents are key in treating child, adolescent depression<\/a><\/div>\n<div align=\"center\" class=\"big\"><strong><font color=\"#200020\">Family Practice News<\/font><\/strong><\/div>\n<div align=\"center\" class=\"middle\">By WHITNEY MCKNIGHT<\/div>\n<div align=\"center\" class=\"small\">February 26, 2015<\/div>\n<div align=\"justify\">Taking a thorough family history and  understanding how to prescribe off-label medications can help physicians  achieve more favorable outcomes when treating children and adolescents  for depression, according to Dr. <strong><font color=\"#990000\">Karen Dineen Wagner<\/font><\/strong>. In addition, a willingness to prescribe newer,  virtual therapies increases the chance for remission of depression in  these patients, Dr. Wagner said at the annual psychopharmacology update  held by the Nevada Psychiatric Association. Left untreated, the severe depression that occurs in  just under 10% of U.S. teens and the more mild depression that occurs  in about 12% can lead to severe impairment later in life, she said.  <\/div>\n<p align=\"justify\">&ldquo;If you think about it, that&rsquo;s really a high  prevalence in an adolescent disorder,&rdquo; said Dr. Wagner, the Marie B.  Gale Centennial Professor of Psychiatry and Behavioral Sciences at the  University of Texas in Galveston. One out of six of these teens will go  on to have depression and other psychosocial impairment in adulthood, as  well as suicidal ideation [<a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC2946114\/\">J. Am. Acad. Child Adolesc. Psychiatry 2010;49:980-989<\/a>]. <\/p>\n<p align=\"justify\">Even with treatment, the odds for recurrent  depression later in life are 2:1 in favor of the mood disorder,  according to Dr. Wagner, who cited a study showing that of 140 teens  treated for depression, more than 90% experienced full remission, but  more than half were depressed again an average of 6 years hence. More  than three-quarters of those treated for depression went on to have  nonmood disorders such as anxiety, substance abuse, and eating disorders  [<a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/23829999\">J. Affect. Disord. 2013;298-305<\/a>]&#8230;<\/p>\n<p align=\"justify\">Repeated treatment failure, whether psychotherapeutic or pharmacogenic,  therefore, might be related more to parental depression than the child&rsquo;s  own. &ldquo;Check carefully for that. And keep in mind that the depressed  parent may not be the one bringing in the child or teenager for  treatment,&rdquo; Dr. Wagner said [<a href=\"http:\/\/archpsyc.jamanetwork.com\/article.aspx?articleid=1733254\" target=\"_blank\">JAMA Psychiatry 2013;70:1161-1170<\/a>]&#8230;&nbsp;           <\/p>\n<p align=\"justify\">Currently, the only approved pharmacologic options  for children and teens are fluoxetine, which is indicated for use in 8-  to 17-year-olds, and escitalopram, indicated for use in 12- to  17-year-olds. Dr. Wagner noted that escitalopram has only one study to  back its efficacy in teens and that a second study including children as  young as 6 years old was negative. Fluoxetine has three studies to back  its efficacy in children and adolescents. If the age-appropriate medication elicits no  response, the only pharmacologic treatments are off label. &ldquo;Be sure you  document that in the chart,&rdquo; Dr. Wagner said. <\/p>\n<p align=\"justify\">Having surveyed available data from controlled  pediatric depression trials, Dr. Wagner said the only two off-label  medications she recommended physicians consider for their pediatric or  adolescent patients were sertraline, which has been shown negative in  individual trials but in a priori pooled analyses was found positive  twice, and citalopram&#8230;<\/p>\n<p align=\"justify\">Even though some parents might worry about the  demonstrated link between suicide and some antidepressants in teens, Dr.  Wagner said clinicians should counsel families that the risk for  suicide in untreated depression was higher at 12% [most antidepressants  are around 1%] [<a href=\"http:\/\/archpsyc.jamanetwork.com\/article.aspx?articleid=1555602\">JAMA Psychiatry 2013;70:300-310<\/a>].<\/p>\n<p align=\"justify\">Making it somewhat easier to predict treatment  courses is that about 60% of adolescents who respond early to  antidepressant treatment will go on to remission, Dr. Wagner said.  Resisting pressure from parents and patients to end the course of  treatment too soon if they see early signs of recovery as synonymous  with cure is important for avoiding relapse. Dr. Wagner recommended  &ldquo;starting the clock from the time when the child shows signs of having  gotten well, and then adding 1 year.&rdquo; She also said that tapering dosage  over &ldquo;a couple of months&rdquo; was a valid approach, depending on the  original dose&#8230;<\/p>\n<div align=\"justify\">Given that there is a notable placebo response rate  in this population, and CBT is not thought to have harmful side effects,  physicians might be tempted to start there, but Dr. Wagner said the  combined effectiveness of CBT with medical management of depression was  more efficacious than CBT alone. She cited a study showing that after 12  weeks, adolescents treated with fluoxetine in combination with CBT  achieved a 73% response rate, whereas CBT only had a 48% rate. It wasn&rsquo;t until week 36 in the study that the two  methods reached parity. Fluoxetine alone in this cohort reached a 62%  response rate by week 12, and an 81% response rate at week 36. &ldquo;So,  that&rsquo;s what I say to parents, &lsquo;Do we really have the time for  psychotherapy alone to work?&rsquo;&thinsp;&rdquo; [<a href=\"http:\/\/archpsyc.jamanetwork.com\/article.aspx?articleid=210055\">Arch. Gen. Psychiatry 2007;64:1132-43<\/a>]&#8230;<\/div>\n<div align=\"right\" class=\"small\"><strong><font color=\"#200020\">hat tip to 1boringyoungman&#8230;<\/font><\/strong>&nbsp;<img decoding=\"async\" height=\"25\" border=\"0\" align=\"absmiddle\" src=\"http:\/\/1boringoldman.com\/images\/hat-tip.gif\" \/><\/div>\n<\/blockquote>\n<div align=\"justify\" class=\"small\">Robert Whitaker has a new article on Mad in America [<a target=\"_blank\" href=\"http:\/\/www.madinamerica.com\/2015\/05\/psychiatry-through-the-lens-of-institutional-corruption\/\">Psychiatry Through the Lens of Institutional Corruption<\/a>] in which he discusses his and Lisa Cosgrove&#8217;s new book. I&#8217;m holding off until I&#8217;ve actually read the book [<a href=\"http:\/\/www.madinamerica.com\/product\/psychiatry-under-the-influence\/\">Psychiatry Under the Influence<\/a>], but in this article there&#8217;s an interesting distinction where he contrasts <em><font color=\"#200020\">Institutional Corruption<\/font><\/em> versus <em><font color=\"#200020\">Individual Corruption<\/font><\/em>&#8230;<\/div>\n<blockquote>\n<div align=\"justify\">it is important to distinguish individual, quid-pro-quo, corruption  from institutional corruption. The former is a story of &ldquo;bad apples.&rdquo;  For instance, a politician takes a bribe in return for a political  favor. That is quid-pro-quo corruption. <em>Institutional <\/em>corruption  is of a different&mdash;and more societally damaging&mdash;type. Institutional  corruption is a not a &ldquo;bad apple&rdquo; problem, but a &ldquo;bad barrel&rdquo; problem. The basic concept of institutional corruption is this: There are  &ldquo;economies of influence&rdquo; that create &ldquo;incentives&rdquo; for behaviors by  members of the institution that are antithetical to the institution&rsquo;s  public mission. When this happens, the &ldquo;corrupt&rdquo; behavior may become  &ldquo;normative,&rdquo; and even go unrecognized as problematic by those within the  institution&#8230;&nbsp; <\/div>\n<\/blockquote>\n<div align=\"justify\" class=\"small\">&#8230; and I had that in my mind when I read this article in <strong><font color=\"#200020\">Family Practice News<\/font><\/strong> about Wagner&#8217;s Update. To me, this one smacks of both a &quot;<em><font color=\"#200020\">bad apple<\/font><\/em>&quot; <u>and<\/u> a &quot;<em><font color=\"#200020\">bad barrel<\/font><\/em>&quot; candidate. It&#8217;s hard for me to get my mind around the fact that her biased recommendations on the treatment of adolescent depression based on publicly discredited studies, ghost-written with her name on the bylines, preaching a gospel of off-label prescribing and ignoring the FDA Black Box Warning, would have her in an endowed chair in a respected Department of Psychiatry, and in the running for President of the <em><font color=\"#200020\">American Academy of Child and Adolescent Psychiatry<\/font><\/em>. It just doesn&#8217;t compute&#8230;<\/div>\n","protected":false},"excerpt":{"rendered":"<p>The article synopsized below comes from the Family Practice News, taken from a psychopharmacology update held by the Nevada Psychiatric Association. The speaker is Karen Dineen Wagner who is the Vice Chair of the Department of Psychiatry and Behavioral Sciences and Director of the Division of Child and Adolescent Psychiatry at the University of Texas [&hellip;]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[5],"tags":[],"class_list":["post-56717","post","type-post","status-publish","format-standard","hentry","category-opinion"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/56717","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/comments?post=56717"}],"version-history":[{"count":25,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/56717\/revisions"}],"predecessor-version":[{"id":56742,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/56717\/revisions\/56742"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=56717"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=56717"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=56717"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}