Ted Sundin, M.D. Psychiatrist in private practice Psychiatric Consultant, Jackson County Health and Human Services Cell: (541) 621-9182Email:firstname.lastname@example.org
Background: Until age 29 lived in Sweden including medical school. Grew up in dysfunctional home with ETOHism, serious suicide attempt by mother and arguments between parents. 5 years boarding school. From age 13 multiple episodes of Major Depression and Hypomania Residency in psychiatry at OSH and OHSU 10 years inpatient psychiatrist on psychiatric unit at RRMC 11 years working in secure residential treatment facilities 10 years psychiatrist outpatient county mental health center 14 year private practice focusing on treating healthcare professionals, patients with bipolar disorder and holistic/integrative care Presently 4 days a week private practice, 1 at jackson County Mental Health Run bipolar support group 2 times monthly. Weekly Wellness Group at CMHC and private practice, long-term process/retreat group monthly
Case presentations Patient with long-term hospitalizations, antipsychotic medications and diagnosis of schizophrenia Retired healthcare professional with 30 year plus history of benzodiazepine use Short versus long-term reduction of medications
Are we as a psychiatric profession unbiased and objective? Probably not Are the DSM IV and V criteria based on science and not influenced by conflict of interests? No Are psychiatric medications effective? Short-term/long-term? Are there chemical imbalances? -Probably not Do psychiatric medications cause up/down regulations of receptors for neurotransmittors? Yes Could this cause long-term beneficial/harmful effects? Yes
Financial ties between DSM IV panel and the psychopharmaceutical industry “Of the 170 DSM members 95 (56%) had one or more financial associations with companies in the pharmaceutical industry. One hundred percent of the members of the panels on ‘Mood disorders’ and ‘Schizophrenia and other Psychotic Disorders had financial ties to drug companies. The connections are especially strong in those diagnostic areas where drugs are the first line of treatment for mental disorders.” (Cosgrove 2006 in Psychotherapy and Psychosomatics)
2009 Rank Brand name (generic name) Used for…U.S. Prescriptions 1. Xanax Xanax (alprazolam) Anxiety 44,029,000 2. Lexapro Lexapro (escitalopram) DepressionDepression, AnxietyAnxiety27,698,000 3. Ativan Ativan (lorazepam) AnxietyAnxiety, panic disorderpanic disorder25,868,000 4. Zoloft Zoloft (sertraline) DepressionDepression, Anxiety, OCD, PTSD, PMDDAnxietyOCDPTSD PMDD 19,500,000 5. Prozac Prozac (fluoxetine) DepressionDepression, AnxietyAnxiety19,499,000 6. Desyrel Desyrel (trazodone) DepressionDepression, AnxietyAnxiety18,873,000 7. Cymbalta Cymbalta (duloxetine) DepressionDepression, Anxiety, fibromyalgia, diabetic neuropathyAnxiety 16,626,000 8. Seroquel Seroquel (quetiapine) Bipolar disorderBipolar disorder, DepressionDepression15,814,000 9. Effexor XR Effexor XR (venlafaxine) DepressionDepression, Anxiety, Panic disorderAnxietyPanic disorder14,992,000 10. Valium Valium (diazepam) AnxietyAnxiety, Panic disorderPanic disorder14,009,000 The top 10 psychiatric medications by number of U.S. prescriptions dispensed in 2009, according to IMS Healthmedications
Are benzodiazepines effective? Benzodiazepines are overused and should in the vast majority of cases only be taken short-term. They are often very difficult to get off. Patients are often not warned of the potential dangers including dependency and severe withdrawal symptoms. Several of us are trying to help patients slowly wean off this medications, for many a very difficult process.
Are Benzodiazepines effective? Short-term mostly yes (maybe first weeks) Long-term no When long-term users have withdrawn from benzodiazepines they “become more alert, more relaxed, and less anxious, and this change was accompanied by improved psychomotor functions”. Those who stayed on the benzos were more emotionally distressed than those who got off. Rickels (1999) Barker et al. (2004) concluded that long-term benzodiazepine users compared with controls were significantly impaired in all cognitive domains that were assessed.
Antidepressants Antidepressants are overused in our community often without a clear Procedure/Alternative/ Risk /Informed consent process. This is also true for benzodiazepines No clear evidence presently that SSRI’s are significantly superior to placebo in mild to moderate depression In severe depression significant difference based on reduced placebo effect? Kirsch 2008 50 % of drug withdrawn patients relapse within 14 months. The longer a person was on a antidepressant, the greater the relapse rate following drug withdrawal Baldessarini 1997 (Viguera
What to do? Consider using alternative treatments to antidepressants for mild to moderate depression Are there real life stressors that need to be addressed such as relationship issues, unemployment, finances, illegal drug use, sedentary lifestyle etc., etc.? Antidepressants should always be used for the shortest effective course. Since there is scant evidence for continuing antidepressants beyond 12 months, and since there is accumulating evidence for long term harm associated with antidepressant use, any treatment plan that includes antidepressant use for longer than 12 months should include a provider-client conversation about tapering protocols.
Antipsychotics There seems to be conflicting long-term outcomes on treatments for especially Schizophrenia. Some smaller studies seems to indicate that creating social supports, minimal or no medications may have better outcomes. than treatment as usual including antipsychotic medications. See Whitaker’s presentation for more info. It is difficult to know what influences long-term outcomes including culture, interpersonal and societal stress levels, alcohol and drug issues, poverty etc, etc has on outcomes
“Anatomy of an Epidemic” study group and conference. What happened? What came out of that? Created closer knit community across disciplines Anxiety disorders PI CME Walking your talk PI CME 7 Keys Wellness Optimization Medication Optimization Peer specialists/ recovery versus remission Strength based versus pathology focus
Lessons learned from our “Anatomy of an epidemic” study group Many of us came to a place of clearly wondering: What clients should be on psychiatric medications? If they are on meds should it be short-term, long-term and just targeted? Who are the clients that safely can go off the medications Over what length of time? How much do you reduce the medications at a time?
Lessons learned from our “Anatomy of an epidemic” study group Patients need to be fully informed of the pros/cons of being on psychotropic medications especially the long-term outcome risk/benefits They need to make an informed decision about whether they should start taking the medications, stay on them or taper. This process should in my opinion be done on a at least on a yearly basis We need to stop telling patients that : they have a “chemical imbalance”-there is little evidence for that “You need to be on these meds for your whole life”-we don’t know that and it may detrimental to be on them for years, but could also be detrimental if you are not. Tapering medications is often a very complicated and difficult process. Just stopping psychiatric medications may be dangerous and counter therapeutic. If patients have been on psychiatric medications for years a very slow tapering process is often indicated paired with the development of a toolbox to cope and excel in a reality without or on minimal amount of medications
Our clients may need to develop the skills including distress tolerance if they are to reduce or go off their psychiatric medications Going off medications without tapering can be dangerous especially if the client has been on them long-term. 10% at the time?? Do you evaluate their toolbox? Are there any clear patterns when reducing or weaning off meds-No Is the theory that patients do better going off their meds if they have a bigger tool box? What are the skill deficits that the patient had when they went on the drug. They will likely still be there. Developmental arrest?? How many patients want to work really hard and are willing to have significant distress? A few, but not many
Wellness Wheel Client evaluates themselves in areas of: Dietx Sleep Exercisex Mindfulness Social Contact Daily Relaxation Medical No addictionsx No self harm Distress Tolerance Self Soothing Self Empathy X= areas most chosen by Wellness Group participants at Jackson County Mental Health
Try to avoid taking a rigid stance, pro/con meds Get clear that the client has received full PARQ (procedure, alternatives, risks and questions) regarding the medications. If they haven’t suggest they ask the prescriber for this process and they educate themselves about the medications. Help the client connect with their own Wisdom Mind and Intuition regarding taking psychiatric medications. Trust their wisdom and own unfoldment Consider developing a Wellness program, including group and buddy system to increase support
Have your client self evaluate with Wellness type wheel. Score from 1-10 on where they are at. Have them chose areas they want to work on. Evaluate what skill deficits the client has that would make it difficult for them to be off/reduce medications, including having to deal with past traumatic issues. Are you, would you be willing to meditate, exercise with your clients? In the workshop after this lecture we will start addressing this more personally for each counselor
Thank you for providing all the service you do for our clients Thank you for being willing to see and experience all this suffering that humanity is enduring Thank you for giving service and care to all these clients no matter how you feel! Thank you for your courage!
References: Barker M “Cognitive Effects of Long-term Benzodiazepine Use: A Meta-analysis”. CNS Drugs 18 (2004): 37-48 Cosgrove L, Krimsky S (2012) A Comparison of DSM-IV and DSM-5 Panel Members’ Financial Associations with Industry: A Pernicious Problem Persists. PLoS Med 9(3): e1001190. Ho, Andreasen et al “Long-term Antipsychotic Treatment and Brain Volumes: A Longitudinal Study of First-Episode Schizophrenia” Arch Gen Psychiatry Vol. 68(No 2), Feb 2011: 128-137 Kirsch I et al “Initial severity and antidepressant benefits: A Meta-analysis of data submitted to the Food and Drug Administration”. Plos Med 5 (2008): 260-268 Rickels K “Psychomotor performance of long-term benzodiazepine users before, during and after benzodiazepine discontinuation”. Journal of Clinical Psychopharmacology 19 (1999): 107-113 Turner E “Selective publication of antidepressant trials and its influence on apparent efficacy”. NEJM 358 (2008): 252-260 Viguera A “Discontinuing antidepressant treatment in major depression”. Harvard Review of Psychiatry 5 (1998): 293-305 Whitaker R “Anatomy of an Epidemic”. Crown Publishers 2010