Sunday, September 30, 2007

Zyprexa may get OK for teen use - Senior regulator overrules peers on drug's benefits for adolescents

Eli Lilly and Co.'s best-selling schizophrenia drug Zyprexa is poised to get U.S. approval for treating adolescents diagnosed with mental illness after a senior government regulator overruled his colleagues.
A three-member Food and Drug Administration team initially urged rejecting the drug for pediatric use because of inconsistent data from studies in U.S. and Russian teens. In an April 29 memo posted on the FDA's Web site, Thomas Laughren, head of the agency's psychiatry division, said the drug's benefits in some studies outweighed the reviewers' concerns.
Zyprexa, with $4.4 billion in global sales in 2006, is Lilly's biggest revenue producer and the best-seller among five drugs known as atypical antipsychotics.
The drug's market leadership has slipped because of surging pediatric prescriptions for competing products and side effects linked to Zyprexa. Johnson & Johnson's Risperdal last month became the only drug in the class cleared for pediatric use though doctors long have prescribed the pills to children, according to market research.

READ MORE @ Indianapolis Star

Saturday, September 29, 2007

Genes Tied to Bad Reactions to Antidepressant Drug

Variations in two genes may increase the likelihood that a person will report suicidal thoughts after taking an antidepressant, researchers reported yesterday. The finding could help doctors develop tests to predict which patients will do well on such medications and which will react badly.

The authors of the study, which was released to reporters yesterday and will appear in The American Journal of Psychiatry on Monday, said that the findings were preliminary and would need to be verified by further testing.

The study focused on reactions to only one drug, Celexa from Forest Laboratories, and found no link between the gene variations and dangerous behavior like suicide attempts.

READ MORE @ NY TIMES

Friday, September 28, 2007

Report Assails F.D.A. Oversight of Clinical Trials

The Food and Drug Administration does very little to ensure the safety of the millions of people who participate in clinical trials, a federal investigator has found.

In a report due to be released Friday, the inspector general of the Department of Health and Human Services, Daniel R. Levinson, said federal health officials did not know how many clinical trials were being conducted, audited fewer than 1 percent of the testing sites and, on the rare occasions when inspectors did appear, generally showed up long after the tests had been completed.

The F.D.A. has 200 inspectors, some of whom audit clinical trials part time, to police an estimated 350,000 testing sites. Even when those inspectors found serious problems in human trials, top drug officials in Washington downgraded their findings 68 percent of the time, the report found. Among the remaining cases, the agency almost never followed up with inspections to determine whether the corrective actions that the agency demanded had occurred, the report found.

READ MORE @ NY TIMES

Thursday, September 27, 2007

Fear Mongering Suicide Statistics to Revive Antidepressant Sales

It's been a busy year for pharma, creating new diseases to make healthy people take pills, reformulating existing drugs to win "new! improved!" patents, hiring high heel wearing reps to intercept the doc before ailing patients--and fear mongering suicide statistics to revive waning antidepressant prescriptions.

Long before the New York Times reported this month that youth suicides were up 8% from 2003 to 2004 and experts blamed an "antidepressant deficiency" big pharma was trying to plant the story.

There's too much money in diagnosing children with major psychiatric illnesses and keeping them on psychotropic drugs their whole lives to let a little thing like the black box warnings the FDA imposed on antidepressants for children in 2004 ruin sales.

READ MORE @ FOOD CONSUMER

Wednesday, September 26, 2007

Patch could up Alzheimer's medication compliance

The European Commission has on today approved the use of a transdermal patch to deliver medicine to patients with mild-to-moderately severe Alzheimer's disease.

The patch is the first type of transdermal treatment for Alzheimer's disease and is applied once a day to the back, chest or upper arm of patients.

Experts say the patch improves compliance for Alzheimer's patients and also reduces side-effects.

READ MORE @ NURSING IN PRACTICE

Tuesday, September 25, 2007

A Plan for Better Troop Mental Care

The Department of Defense has released a plan to improve mental-health care for American troops who are facing multiple tours in war zones.

The report lays out a "road map for change" in an effort to "put psychological health and fitness on an equal footing with physical health and fitness." The recommendations address findings from a report released earlier this year that found that troops going to war face increasing levels of anxiety and depression with each successive deployment, with shorter "dwell times," or times at home with their families.

READ MORE @ US NEWS & WORLD REPORT

Monday, September 24, 2007

Use of atypical antidepressants in elderly patients

Late-life major depressive disorder (MDD) is a common disorder that is associated with severe symptoms and substantial functional impairment. With an estimated prevalence of 3% in people aged 60 years or more, MDD has growing health implications for the aging population. In addition, MDD is often associated with physical disability in this age group as well as a high mortality rate. Conditions leading to chronic pain, the presence of comorbid medical illnesses, social isolation, and dysphoria secondary to life-cycle issues predispose the elderly population to the development of depression. These factors also point elderly individuals with depression in the direction of more severe symptoms and a relatively poor outcome.
While it is a commonly known psychiatric disorder, depression in the geriatric population is under-recognized and under-treated, leading to unnecessary impaired social and occupational functioning.1 Studies suggest that approximately 25% of patients aged 65 years or more who have a chronic medical illness also experience symptoms of depression. Evidence supports the increased prevalence of depression in several specific chronic medical illnesses, including vascular disease, diabetes mellitus, and arthritis; the relative risk for depression is 2-3 times higher in these patients than in individuals without these comorbidities.1 Depression in the geriatric population has also been reported to be more somatic and less ideational than depression in younger adults. Elderly people who suffer from comorbid depression and medical illness have an increased morbidity and mortality.1 Authors have also noted a brittle response to antidepressant therapy and an increased risk for chronic depression in the elderly population.2 Safe, effective, well-tolerated antidepressants are needed for elderly patients with MDD, especially for those who are also struggling with chronic medical illness.1

READ MORE @ ABKHAZIA

Sunday, September 23, 2007

Risperidone Approved to Treat Schizophrenia in Children

FDA-requested pediatric studies provide valuable clinical evidence on the safety, efficacy, and dosage of antipsychotic drugs in children and adolescents.

The U.S. Food and Drug Administration (FDA) has approved the use of risperidone (Risperdal) in children and adolescents to treat schizophrenia and mania or mixed episodes of bipolar I disorder, making it the first atypical antipsychotic drug approved for either disorder in young patients.

The FDA announced last month that risperidone is approved for the treatment of schizophrenia in adolescents aged 13 to 17 and for the short-term treatment of manic or mixed episodes of bipolar I disorder in children and adolescents aged 10 to 17. Risperidone was approved in October 2006 for treating irritability associated with autistic disorders in children and adolescents aged 5 to 16 years.

READ MORE @ PSYCHIATRIC NEWS

Saturday, September 22, 2007

Senate approves FDA drug-safety bill

Congress gave final approval Thursday to legislation designed to transform the Food and Drug Administration from a passive monitor to an active detective seeking out medications that have been approved for sale but turn out to be hazardous -- a problem linked to an estimated 15,000 deaths a year.

The drug-safety provisions were the centerpiece of a massive bill that also would renew industry user fees that fund the FDA's review of medications and medical devices submitted for approval.

The Senate passed the bill without objection Thursday evening after the House overwhelmingly passed it Wednesday. The White House has not commented on the final version of the bill, but President Bush is expected to sign it, congressional aides said.

In addition to building a new computerized system to spot drug risks, the bill would strengthen the FDA's enforcement powers and require greater disclosure of private and public clinical research and of agency decision-making. It also would take steps to reduce FDA reliance on outside advisors with financial conflicts of interest, as well as create a new program to review drug company advertising.

READ MORE @ LOS ANGELES TIMES

Friday, September 21, 2007

Personalised treatment for depression

The 31 million antidepressant prescriptions written annually in the UK could see a marked drop saving the NHS millions, thanks to groundbreaking research recently published by the University of Cambridge’s Brain Mapping Unit.



The study, reported this week in the journal Biological Psychiatry, has found that it may be possible to predict whether patients will respond positively to antidepressant treatment, creating the possibility of tailor-made treatment solutions to the increasingly common condition.

Using magnetic resonance imaging (MRI), a team from the University’s Brain Mapping Unit, led by Prof Ed Bullmore, found that it was possible to forecast the benefits a patient might see from undertaking different types of treatment for depression.

READ MORE @ BUSINESS WEEKLY

Thursday, September 20, 2007

The ‘Poisonous Cocktail’ of Multiple Drugs

A 78-year-old woman was found unconscious on the floor of her apartment by a neighbor who checked on her. The woman could not remember falling but told doctors that before going to bed she had abdominal pain and nausea and had produced a black stool, after which she had palpitations and felt lightheaded.

Her medical history included high blood pressure, coronary artery disease, atrial fibrillation, congestive heart failure and osteoarthritis. She also had a cold with a productive cough. For each condition, she had been prescribed a different drug, and she was taking a few over-the-counter remedies on her own.

READ MORE @ NY TIMES

Wednesday, September 19, 2007

Are ADHD Medications and Cardiac Risks Linked?

According to a September 17th AHRQ press release, The Agency for Health Research and Quality (AHRQ) together with the Food and Drug Administration (FDA) plan to conduct a huge examination of data from 500,000 patients who are taking medication for Attention Deficit Hyperactivity Disorder (ADHD) to see if the medication increases the risk of cardiovascular problems. The data of both children and adults will be examined, and the study is expected to last two years.

It is already known that medications for ADHD can increase heart rate and blood pressure in patients taking the drug regime, and there have been case study reports of cardiac incidents, according to Dr. Gerald D. Pan, MD of the FDA's Office of Surveillance and Epidemiology, as stated in the AHRQ press release. The study is to determine whether there is a causal relationship between cardiac problems and a person's taking ADHD medications or whether cardiovascular problems are due to the person's already being at risk for the cardiac incidents. The data to be examined is from a preliminary seven FDA year study which ended in 2005.

READ MORE @ ASSOCIATED CONTENT

Tuesday, September 18, 2007

It's premature to blame FDA for suicide rise

The front page headline in the Washington Post was alarming: "Youth suicides increased as antidepressant use fell." A new study argued that a record increase in youth suicides in 2004 may have been the unintended consequence of federal warnings that antidepressants such as Prozac can trigger suicidal thoughts in children. Media outlets across the country reported the painful irony that the Food and Drug Administration's attempt to prevent suicides seemed to have increased them by discouraging doctors from properly treating depressed young people.

"We may have inadvertently created a problem," lamented Thomas Insel, director of the National Institute of Mental Health, to the Post earlier this month.

But a closer look at the numbers suggests that the suicide fears are at least premature, if not baseless, say people who specialize in health statistics.

READ MORE @ BOSTON GLOBE

Monday, September 17, 2007

Kids with ADHD have reason to hope

A.J. Copeland, 13, of Washington, D.C., started eighth grade this month with an announcement: "He said, 'I'm going to make all A's this year,' " recalls his mother, Tamara Copeland.

For a boy who was diagnosed at age 6 with attention deficit/hyperactivity disorder (ADHD) and who has struggled with school, that statement might seem unrealistic. But his mother is cautiously optimistic: Thanks to years of trial and error with medications and behavior-changing strategies, A.J. may well be turning a corner, she says. Though improvements have been "erratic," A.J.'s new attitude is a good sign, she says. "It says to me that he is beginning to understand he is part of controlling his destiny."

The Copelands and millions of other families have reason for hope as another challenging school year begins for children with the common disorder: According to a study updated this summer, most children treated for ADHD — whether with medication, behavioral therapy or both — do improve over time.

The roles of specific therapies and educational strategies remain unclear. Children who received medication, with frequent checkups to adjust doses and drug choices, did best in the first 14 months of the study. But that advantage waned by the three-year mark, according to a set of reports in the August Journal of the American Academy of Child and Adolescent Psychiatry.

READ MORE @ USA TODAY

Sunday, September 16, 2007

Darkness Invisible

Here is the question lurking behind the recent news of Owen Wilson’s suicide bid: In a culture that encourages outing everything from incest to pedophilia, is depression the last stigma, the one remaining subject that dares not gossip its name? Does a disclosure about depression, especially from someone who seems to have it all, violate an unspoken code of silence — or, at the least, make us radically uncomfortable with its suggestion of a blithe public face masking a troubled inner life?

Most of us have experienced the everyday, transient blues — the emotions nibbling around the edges of depression (whether they manifest themselves as a sense of malaise, dejection or comic-tinged despair) that can be brought on by a shift in the weather or an unfortunate event. They may be chronic yet benign, the sort of moroseness that causes the narrator of Camus’s “Stranger” to stand around listlessly puffing on a cigarette. Sadness is probably more endemic to the human subtext than sanguine spirits, which is why funereal songs like Billie Holiday’s “Gloomy Sunday” strike a universal chord and why Freud conjectured that “ordinary unhappiness” (as opposed to what he called “hysterical misery”) was the best the talking cure could hope to achieve.

READ MORE @ NY TIMES

Saturday, September 15, 2007

Complementary Therapies for Schizophrenia: Expanding the Clinician's Toolbox

Clinicians and patients are increasingly seeking nonconventional treatments as adjuncts to conventional therapies for schizophrenia. Here, a discussion of the most promising complementary therapies and how to use them.

Given the burdens of living with schizophrenia and other psychotic disorders, and the increasing emphasis on improving patients' quality of life, it's no wonder that clinicians and patients are seeking additional treatment options for psychotic disorders. Clinicians who use, study and advocate for nonconventional or "complementary" therapies in psychiatry -- treatments ranging from dietary supplements to Chinese herbs to yoga -- see an opportunity to expand the acceptance and use of these therapies as adjuncts to conventional treatments for schizophrenia.

These practitioners acknowledge that the evidence supporting most nonconventional therapies for schizophrenia is still decidedly modest: The number of rigorous, well-designed studies is limited, and research findings on several of the therapies are inconsistent.

Still, dozens of studies in recent years have found evidence that when combined with antipsychotics, several nontraditional therapies -- most notably Omega-3 fatty acids, glycine, folate, Chinese herbal medicines, yoga practices and spiritually focused group therapy -- yield measurable and sometimes clinically significant benefits in some schizophrenic patients. Based on limited and mainly small or uncontrolled studies, nonconventional therapies may be effective particularly in easing negative symptoms, cognitive symptoms and/or antipsychotic side effects.

READ MORE @ PSYCHIATRIC TIMES

Thursday, September 13, 2007

The endocrine effects of the psychiatric drug Zyprexa are extremely dangerous, says Swedish Professor in Psychiatry

Speaking out about the harmful effects of the psychiatric drug Zyprexa, the Swedish Professor in Psychiatry, Rolf Adolfsson, said: “There is nothing worse than seeing a young person 17-18 years with a weight gain of 40-50 kg, and no one does anything! What is Swedish psychiatry doing?”

The psychiatrist spoke out in Swedish national television, in a program covering the illegal marketing of Zyprexa and the harmful effects of the new so called atypical neuroleptics. Zyprexa is the 6th most sold drug in Sweden, all categories.

Despite the fact that nine States in the US are suing the manufacturer of Zyprexa, Eli Lilly, and despite the fact that almost 30.000 persons have been awarded 1.2 billion dollars due to the injuries caused by Zyprexa, there has been a complete silence about this affair in Sweden.

Until now.

The Professor, who according to the program has been investigating harmful effects of drugs for the last 7 years, further said: “I’ve seen so many complications, and I have met so many patients – that I completely choke. Are we so damned gullible, and it must be – there is only one thing – marketing.”

READ MORE @ TRANSWORLDNEWS

Wednesday, September 12, 2007

Antidepressant as Good as Antipsychotics for Dementia

The antidepressant citalopram (Celexa) may be as effective as often-prescribed antipsychotic drugs to control the agitation and psychotic symptoms associated with dementia, a new study suggests.

Agitation and psychotic symptoms are often more disturbing than the memory loss associated with Alzheimer's and other forms of dementia and are also the most difficult challenge for family members caring for an elderly person. Currently, antipsychotic drugs such as risperidone (Risperdal) are used to control these symptoms. But often the side effects, including sedation, tension and apathy, can be debilitating, the study authors said.

READ MORE @ WASHINGTON POST

Tuesday, September 11, 2007

When Antidepressant Drugs Are Not Enough - A New Study On Their Combination With Psychotherapy

A group of Dutch investigators has reported on a new study on the combination of antidepressant drugs and psychotherapy in the September issue of Psychotherapy and Psychosomatics.

Although several forms of effective therapy exist for outpatients suffering from major depressive disorder, many patients do not profit from treatment. Combining psychotherapy and medication may be an effective strategy. However, earlier studies have rarely found a clear advantage for the combination. Where an advantage was found, a possible placebo effect of adding 2 types of treatment could not be ruled out as cause for the superior effect of the combination. A total of 353 patients were screened, of whom 193 were randomized over 4 conditions: nefazodone plus clinical management, interpersonal psychotherapy (IPT), the combination of the two or the combination of IPT and pill-placebo. All patients suffered from major depressive disorder and had a score of at least 14 on the 17-item Hamilton Rating Scale (HAMD).

READ MORE @ INNOVATIONS REPORT

Monday, September 10, 2007

Adverse drug reactions rise sharply, study says

The number nearly triples since the FDA began a new reporting system in 1998. The main culprits are painkillers.

The number of serious adverse events and deaths attributed to prescription medications has nearly tripled since the Food and Drug Administration initiated a system in 1998 to make it easier to report significant side effects, researchers said today.

Twenty percent of drugs accounted for 87.1% of adverse effects, and the biggest offenders were painkillers and drugs that modify the immune system to treat arthritis, according to the report in the Archives of Internal Medicine.

A quarter of the increase could be attributed to a boost in prescriptions and another 15% to the introduction of new biotechnology drugs since 1998, but the rest of the increase could not be explained, said drug safety expert Thomas J. Moore of the Institute for Safe Medication Practices in Huntingdon Valley, Pa.

READ MORE @ LOS ANGELES TIMES

Sunday, September 9, 2007

Suicides up after warning, study shows

A 22% drop in prescriptions for antidepressants for teens and children following government warnings about hazards of the drugs led to a sharp increase in suicides the following year, according to Chicago researchers.

The change in labeling in 2003 warned that use of the drugs could increase suicidal thoughts and behavior among youths, but the labeling seems to have backfired, according to a report in the September issue of the American Journal of Psychiatry.

In the year after the change in labeling, the suicide rate rose 14% among those younger than 19, the largest increase since the government started collecting suicide statistics in 1979, said biostatistician Robert D. Gibbons and his colleagues at the University of Illinois at Chicago.

READ MORE @ CHICAGO TRIBUNE

Saturday, September 8, 2007

McGill study promises faster-acting anti-depressants

A McGill University study has found that a new class of drugs known as serotonin4 (5-HT4) receptor agonists may take effect four to seven times faster than traditional selective serotonin reuptake inhibitors (SSRIs). The study, led by former McGill post-doctoral fellow in psychiatry Guillaume Lucas with his supervisor, the late Dr. Guy Debonnel, was published in the September 6 issue of the journal Neuron.

Existing SSRI-class drugs, widely prescribed as anti-depressants, can take up to six weeks to become effective, with potentially serious clinical consequences. Dr. Lucas, now an associate researcher at the Centre de Recherche Fernand Séguin of Université de Montréal, said, "These delays are not only a matter of patient comfort, it's really important, especially when you are treating major depressions that could lead to suicide."

READ MORE @ EUREKALERT

Friday, September 7, 2007

Teen antidepressant warning had ripple effect

Following the US Food and Drug Administration's warning about the possible risk of suicide among teens when they're treated with antidepressant drugs known as SSRIs, the rates of diagnosis and treatment of depression among adults have declined significantly, according to a new report.

"While some degree of decline in antidepressant prescribing was not unexpected after the black box warning was issued, few if any had predicted diagnosing to decline, or that other modes of treatment (psychotherapy or other medications) would remain relatively unchanged," Dr. Robert J. Valuck told Reuters Health. "It was thought that the latter two may increase to compensate for fewer antidepressant prescriptions being written."

READ MORE @ REUTERS

Thursday, September 6, 2007

Study Provides Snapshot of ADHD Prevalence in U.S, Children

Almost 9% of U.S. children ages 8 to 15 meet standard diagnostic criteria for attention-deficit/hyperactivity disorder (ADHD), but less than half of them receive treatment.

Only 47.9% of the 2.4 million who met Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) criteria for ADHD had reportedly had their conditions diagnosed by a health care professional or been treated with medication, according to a report in the September issue of the Archives of Pediatrics & Adolescent Medicine.

A research team led by Tanya E. Froehlich, M.D., of Cincinnati Children's Hospital Medical Center did a cross-sectional phone survey of the parents or caregivers of 3,082 eight- to 15-year old children who were participants in the National Health and Nutrition Examination Survey.

READ MORE @ MEDPAGE TODAY

Wednesday, September 5, 2007

Lilly's Schizophrenia Drug Targets Different Brain Chemicals

Eli Lilly and Co.'s experimental schizophrenia drug, which may replace its top-selling Zyprexa, was just as effective without causing patients to gain weight, according to a study.

Unlike other schizophrenia medicines on the market, the new compound doesn't target dopamine, a chemical that functions within the brain's reward system. It affects glutamate, involved in learning and memory. The study showed the new drug candidate to be as effective as Zyprexa in reducing symptoms such as hallucinations and social withdrawal.

The new drug candidate, dubbed LY2140023, would be the first for the disorder affecting glutamates, a company official said. Zyprexa, with $4.3 billion in 2006 sales, now faces competition from less expensive copies in Canada and Germany, the Indianapolis-based company said on June 8. The drug's U.S. patent expires in 2011.

``Discovering an antipsychotic drug that doesn't work through dopamine is the holy grail of drug development,'' said Gerald Marek, Lilly's chief scientific officer of psychiatric disorders, in an Aug. 30 telephone interview. ``It looks like we've hit upon a target that will ultimately do this.''

READ MORE @ BLOOMBERG

Tuesday, September 4, 2007

More Children Being Treated for Bipolar Disorder

The number of American children and adolescents treated for bipolar disorder increased 40-fold from 1994 to 2003, researchers are to report on Tuesday, in the most comprehensive study to look at the controversial diagnosis. And experts say the numbers have almost certainly risen further in the years since.

Most experts believe the jump reflects the fact that doctors are more aggressively applying the diagnosis to children, not that the number of new cases has gone up. But the magnitude of the increase is surprising to many experts, who say it is likely to intensify a debate over the validity of the diagnosis that has shaken the field of child psychiatry in recent years.

READ MORE @ NY TIMES

Sunday, September 2, 2007

Practice guideline for the assessmet and treatment of patients with suicidal behaviors

BIBLIOGRAPHIC SOURCE(S)
American Psychiatric Association. Practice guideline for the assessment and treatment of patients with suicidal behaviors. Arlington (VA): American Psychiatric Association; 2003 Nov. 117 p. [846 references]
GUIDELINE STATUS
This is the current release of the guideline.
MAJOR RECOMMENDATIONS
Each recommendation is identified as falling into one of three categories of endorsement, indicated by a bracketed Roman numeral following the statement. The three categories represent varying levels of clinical confidence regarding the recommendation. Definition of grades of recommendation [I-III] are presented at the end of the "Major Recommendations" field.

Suicide Assessment

The psychiatric evaluation is the essential element of the suicide assessment process [I]. During the evaluation, the psychiatrist obtains information about the patient's psychiatric and other medical history and current mental state (e.g., through direct questioning and observation about suicidal thinking and behavior as well as through collateral history, if indicated). This information enables the psychiatrist to 1) identify specific factors, signs, and symptoms that may generally increase or decrease risk for suicide or other suicidal behaviors and that may serve as modifiable targets for both acute and ongoing interventions, 2) address the patient's immediate safety and determine the most appropriate setting for treatment, and 3) develop a multiaxial differential diagnosis to further guide planning of treatment. The breadth and depth of the psychiatric evaluation aimed specifically at assessing suicide risk will vary with setting; ability or willingness of the patient to provide information; and availability of information from previous contacts with the patient or from other sources, including other mental health professionals, medical records, and family members. Although suicide assessment scales have been developed for research purposes, they lack the predictive validity necessary for use in routine clinical practice. Therefore, suicide assessment scales may be used as aids to suicide assessment but should not be used as predictive instruments or as substitutes for a thorough clinical evaluation [I].

READ MORE @ ABKHAZIA

Saturday, September 1, 2007

Topics to Review with Patients When considering use of antidepressants

University of Oklahoma College of Medicine
INTRODUCTION
To increase the chance of successful pharmacologic antidepressant therapy for patients with depression, clinicians should review several specific topics with their patients before the initiation of such therapy. Discussion points range from alternatives to pharmacologic therapy to common adverse effects of specific medications.
Clinicians can begin the discussion by soliciting specific aspects of the patient’s condition, including any previous experience with antidepressant therapy, the patient’s expectations for therapy, and any external sources of information regarding therapy. After establishing expectations and understanding the past history of the patient’s condition, alternatives to drug therapy may be considered and discussed.

READ MORE @ ABKHAZIA