More Americans taking drugs for mental illness

Many more Americans have been using prescription drugs to treat mental illness since 1996, in part because of expanded insurance coverage and greater familiarity with the drugs among primary care doctors, U.S. researchers said on Tuesday.

They said 73 percent more adults and 50 percent more children are using drugs to treat mental illness than in 1996.

Among adults over 65, use of so-called psychotropic drugs -- which include antidepressants, antipsychotics and Alzheimer's medicines -- doubled between 1996 and 2006.

"What we generally find is there has been an increase in access to care for all populations," said Sherry Glied of Columbia University in New York, whose study appears in the journal Health Affairs.

READ MORE @ REUTERS

For Old Drugs, New Tricks - Advice Veers Away From Flushing Unused Pills

At the Leesburg Pharmacy, located in a Loudoun County strip mall, a big, round fish tank sits atop the prescription counter. There are no fish inside, not even any water: The tank is a repository for unused medications. People can drop off the Vicodin that didn't get used once the pain of a root canal subsided. Or the heart pills remaining after a grandmother's death. Or an asthma inhaler that had passed its expiration date. Or an antidepressant that turned out to have unpleasant side effects.

Once a week, the tank is emptied; the drugs are packed in cartons by pharmacy personnel and ultimately incinerated by a commercial waste firm.

"Our customers are thrilled because they had no idea what else to do with this stuff," said Cheri Garvin, chief executive of the employee-owned pharmacy.

These are customers who are trying to do the responsible thing. Over the years, Americans have been alerted to the dangers of a lot of problematic waste materials -- paint thinner, batteries, air conditioners. But leftover pills can seem so small, so easily disposable, that many people routinely flush them down toilets, wash them down sinks or throw them in trash that goes to a landfill.

And then they often end up in places where they shouldn't be, like the public water supply.

The average American takes more than 12 prescription drugs annually, with more than 3.8 billion prescriptions purchased each year, according to the Kaiser Family Foundation. The most commonly cited estimates from Environmental Protection Agency researchers say that about 19 million tons of active pharmaceutical ingredients are dumped into the nation's waste stream every year.

READ MORE @ WASHINGTON POST

Why Antidepressants Don't Live Up to the Hype

In the '90s, Americans grew fond of the idea that you can fix depression simply by taking a pill — most famously fluoxetine (better known as Prozac), though fluoxetine is just one of at least seven selective serotonin reuptake inhibitors (SSRIs) that have been prescribed to treat hundreds of millions of people around the world.

But in the past few years, researchers have challenged the effectiveness of Prozac and other SSRIs in several studies. For instance, a review published in the Journal of Affective Disorders in February attributed 68% of the benefit from antidepressants to the placebo effect. Likewise, a paper published in PLoS Medicine a year earlier suggested that widely used SSRIs, including Prozac, Effexor and Paxil, offer no clinically significant benefit over placebos for patients with moderate or severe depression. Meanwhile, pharmaceutical companies maintain that their research shows that SSRIs are powerful weapons against depression. (Here's a helpful blog post that summarizes the debate.)

Now a major new study suggests that both critics and proponents might be right about SSRIs: the drugs can work, but they appear to work best for only a subset of depressed patients — those with a limited range of psychological problems. People whose depression is compounded with, say, substance abuse or a personality disorder may not get much help from SSRIs — which is unfortunate for the 45% to 60% of patients in the U.S. who have been diagnosed with a common mental disorder like depression and also meet the criteria for at least one other disorder, like substance abuse. (Multiple diagnoses are known in medical parlance as comorbidities.)

READ MORE @ TIME

New Route To Treat Depression - Finding could help people failed by current antidepressants

A NEW TARGET for treating depression, discovered by researchers in Iowa, may offer an alternative to current antidepressants, which target other mechanisms to treat the condition.

"The mechanism issue is important because if a patient doesn't respond to one drug, the chances of them responding to another drug that works through the same mechanism are low," says John A. Wemmie, who led the research team. Wemmie is an associate professor of psychiatry and neurosurgery at the University of Iowa and a staff physician and researcher at the Iowa City Veterans Affairs Medical Center.

Wemmie's team focused on a biochemical pathway involving acid-sensing ion channel (ASIC) proteins expressed by neurons. ASICs are activated by protons that are believed to act as neurotransmitters (C&EN, Jan. 14, 2008, page 10). Wemmie and his colleagues concentrated on the ASIC1a class of these ion channels, which are abundant in regions of the brain associated with mood.

The research group had previously shown in mice that ASIC1a activity is associated with anxiety, which often accompanies depression. In the new work, the researchers showed that mice lacking the gene for ASIC1a were less susceptible than normal mice to depression caused by stress. In a second experiment, the researchers treated normal mice with A-317567, an experimental ASIC inhibitor that Abbott Laboratories has been studying for pain treatment. Wemmie's team reports that blocking ASIC1a in this way produced antidepressant effects in the animals (J. Neurosci. 2009, 29, 5381).

READ MORE @ CHEMICAL & ENGINEERING NEWS

AAN: Atypical Antipsychotic Reduces Autism Irritability

Aripiprazole (Abilify) may be effective off-label for treating the irritability associated with autism, researchers here said.

The atypical antipsychotic fared significantly better than placebo on a parent-rated scale of irritability (P<0.05), Donald Lewis, M.D., of Sentara Norfolk General Hospital in Virginia, and colleagues reported at the American Academy of Neurology meeting.

It also had significant advantages over placebo with regard to clinician assessments of Aripiprazole and hyperactivity.

Only one atypical antipsychotic -- risperidone (Risperdal) -- is currently FDA approved for irritability associated with autism. However, treatment guidelines recommended that other atypical antipsychotics be considered for behavioral problems in autism.

Researchers involved in the current study could not comment on whether aripiprazole was in the process of FDA approval for this indication.

But Benjamin L. Handen, Ph.D., of the University of Pittsburgh, who was not involved in this study but is involved in similar trials, said FDA approval for the indication would give doctors an alternative for children who respond poorly to risperidone.

READ MORE @ MEDPAGE TODAY

Drugs 'can help mild depression'

Antidepressants can help mild to moderate depression and should not just be used in bad cases, researchers say.

Current guidelines urge doctors to avoid antidepressants as an initial treatment in mild depression.

But an NHS-funded study of 200 patients from across England found the drugs, called SSRIs, were more effective than GP advice and support alone.

The team hope national advisers will look at their findings, reported on the Health Technology Assessment website.

Study leader Professor Tony Kendrick, a GP and researcher at the University of Southampton, said although the National Institute of Health and Clinical Excellence wants doctors to restrict SSRIs to the most severe cases, GPs frequently prescribe them for milder cases.

"Just because someone has mild depression does not mean it is a mild illness, because it can cause them to be off work for months," he said.

"And often you don't have psychological treatments to offer because they're not available so you end up prescribing quite frequently."

READ MORE @ BBC

Researchers find common genetic variations in autistic people

Findings show that many autistic people have a deviation in a portion of their DNA that affects the way brain cells connect with one another. The discovery may lead to treatments.

Researchers have found that many people with autism share common genetic variations, a discovery that may improve diagnosis and offers the promise of developing treatments for the frustratingly mysterious disorder.

Their findings, published in the journal Nature, compared the genomes of thousands of autistic people with those of thousands of people without the disorder -- a massive task that new technology has only recently made possible. The genome is the complex system of DNA coding that builds and runs the human body.

The review showed that most autistic people examined have a genetic variation in a portion of their DNA that affects the way brain cells connect with one another. Scientists also reported a link between autism and small "mistakes" in another DNA segment involved with cell communication. Both reports add weight to the idea that autism is related to problems with the way brain cells connect.

READ MORE @ LOS ANGELES TIMES

Off-Label Prescribing

Medications cannot be marketed in the United States without an FDA determination that they are safe and effective for their intended use. To obtain such certification, pharmaceutical companies submit their products to rigorous scrutiny (eg, in vitro studies, animal studies, human clinical trials) and present the subsequent data to the FDA, which determines whether the medication in question is safe and effective for a specific purpose. FDA approval comes with specific labeling requirements for the product, including the approved indications for use, the appropriate dosing, and the specific populations for its use. Once a medication has been approved for a specific use, physicians and other prescribers are permitted to prescribe the medication for conditions not covered by the approved use.

Several recent studies have dem­onstrated that off-label prescribing is very common among physicians, particularly among psychiatrists. Legal scholars have estimated that approximately 40% to 60% of prescriptions are for off-label use.1 In one important study, researchers examined office-based prescribing patterns for 160 commonly prescribed medications and determined that approximately 21% were for off-label use. In this study, off-label use was most common for cardiac medications (46%), anticonvulsant medications (46%), and asthma medications (42%). The investigators also found that most off-label use (73%) had limited or no scientific support.

The greatest disparity in the percentage of scientifically supported versus unsupported off-label use occurred with psychiatric medications. In 96%, the off-label use was determined to have little or no sound scientific evidence for the condition for which the drug was prescribed.2

READ MORE @ PSYCHIATRIC TIMES

What Is Neuropathy? What Causes Neuropathy?

Neuropathy is a collection of disorders that occurs when nerves of the peripheral nervous system (the part of the nervous system outside of the brain and spinal cord) are damaged. The condition is generally referred to as peripheral neuropathy, and it is most commonly due to damage to nerve axons. Neuropathy usually causes pain and numbness in the hands and feet. It can result from traumatic injuries, infections, metabolic disorders, and exposure to toxins. One of the most common causes of neuropathy is diabetes.

Neuropathy can affect nerves that control muscle movement (motor nerves) and those that detect sensations such as coldness or pain (sensory nerves). In some cases - autonomic neuropathy - it can affect internal organs, such as the heart, blood vessels, bladder, or intestines.

READ MORE @ MEDICAL NEWS TODAY

Are we cherry picking participants for studies of antidepressants?

People with depression often excluded from clinical studies and tend not to fare as well as study participants

Findings from clinical studies used to gain Food and Drug Administration approval of common antidepressants are not applicable to most patients with depression, according to a report led by the University of Pittsburgh Graduate School of Public Health. Published in the May issue of the American Journal of Psychiatry, the study suggests only a small percentage of people with depression qualify for these studies, and those who do not qualify are often treated with the same medications but may suffer poorer clinical outcomes.

A part of the National Institute of Mental Health-funded Sequenced Treatment Alternatives to Relieve Depression (STAR*D) project – the largest study of the treatment of depression conducted in the United States – researchers compared symptoms and outcomes in depressed patients who met phase III study inclusion criteria to those who did not. Phase III studies for antidepressants determine the effectiveness of the drug in comparison to a placebo. The inclusion criteria for these studies are not standardized nor subject to federal guidelines, resulting in some variation from study to study in the profile of eligible patients. Typically excluded are patients with milder forms of depression, who might be more likely to respond to a placebo drug, and those who may have chronic depression or psychiatric and medical co-morbidities – additional illnesses or conditions.

After assessing 2,855 patients treated with citalopram, a commonly prescribed selective serotonin reuptake inhibitor for mood disorders, study authors concluded that fewer than one in four, or 22.2 percent, of the patients met the usual criteria for inclusion in phase III antidepressant trials.

"Only a small percentage of depressed patients in our study would have qualified for inclusion in phase III efficacy trials of depression drugs," said study lead author, Stephen Wisniewski, Ph.D., professor of epidemiology and co-director of the Epidemiology Data Center, University of Pittsburgh Graduate School of Public Health. "This raises major concerns about whether results from traditional phase III studies can be generalized to most people with depression, who also often suffer from anxiety, substance abuse and other medical and psychiatric problems."

READ MORE @ EUREKALERT

No Data Supporting Antipsychotic Drug for Low-IQ Kids With ADHD

A new Cochrane review finds no evidence to support the use of risperidone to treat attention- deficit/hyperactivity disorder (ADHD) in people with intellectual disabilities, even though the review authors say this is a common prescribing pattern.

Risperidone, or Risperdal, is a second-generation antipsychotic drug. Long-term use of these drugs is associated with serious side effects, including weight gain and increased risk for type 2 diabetes.

“People who have intellectual disability are more likely to receive treatment with second- generation antipsychotics for ADHD,” said lead review author Dr. Alex Thomson. “Doctors should be aware that there is no research to demonstrate the effectiveness of risperidone for ADHD in people with intellectual disability, and should carefully monitor each case and consider alternative treatments before trying risperidone.”

Laurel Leslie, M.D., an associate professor at Tufts University School of Medicine whose research centers on pediatric mental health, concurred: “This study demonstrates that we have a gap between what we’re doing clinically and what we have any research evidence for. It’s an important study, as it highlights the need for careful consideration of how we treat children’s mental health issues.” Leslie has no affiliation with the Cochrane review.

Thomson’s research group did not find one study that met their criteria for inclusion among more than 2,000 studies that they initially identified. The group analyzed 15 studies in depth, but ultimately rejected them all.

READ MORE @ NEWSWISE

Medication Errors Could Be Cut: Experts - Two reports show promise of computers, pharmacists for proper prescribing

Medication errors and adverse drug reactions cost lives and dollars each year in the United States, but two new reports suggest ways hospitals and pharmacists can work to reduce these mistakes.

Medication errors are one of the most common medical errors, affecting at least 1.5 million people every year and costing the health-care system between $77 billion and $177 billion annually, researchers point out in the April 27 issue of the Archives of Internal Medicine.

In the first report, researchers led by Dr. Jeffrey L. Schnipper, of Brigham and Women's Hospital and Harvard Medical School, used a computer system to keep track of the medications patients were taking when they were admitted to the hospital and the medications they were taking when they were discharged.

"It turns out that we commit about 1.5 errors per patient either for the admissions orders in the hospital or, much more commonly, in the discharge orders, which is kind of appalling," Schnipper said. "These are errors with potential for patient harm. There are about three times as many errors without potential for patient harm."

READ MORE @ FORBES

Study: Medicaid patients get wrong drugs

Drugs designed to treat severe mental illnesses are being prescribed to Medicaid patients at inappropriately low doses, at considerable expense and for conditions where their benefits haven't been proven, a team of mostly Oregon researchers reports.

Scientists from the Oregon State University College of Pharmacy, Oregon Health and Science University and Columbia University's psychiatry department reviewed records for 830 Oregon Medicaid patients who had been given antipsychotic medications approved for conditions such as schizophrenia and bipolar disorder. The researchers found the majority of those patients did not have the underlying mental conditions for which the drugs were approved for prescription. Instead, they were given to patients to treat health concerns such as depression, anxiety, post-traumatic stress disorder or insomnia.

READ MORE @ STATESMAN JOURNAL

Depressed and Coping: Treating Depression When Medication Fails

Various lifestyle approaches make drugs more effective or help relieve depression on their own.

James Russo has wrestled for some 60 years with his "black dog" of depression, since the days back in high school when a B left him feeling like an utter failure. He tried Valium, a tricyclic antidepressant, and Prozac before finding some relief in Paxil. Still, says Russo, 74, of Bernville, Pa.: "My disease lives in the corner of my mind, sometimes sleepy enough to let me enjoy a little optimism but ever ready to ruin a day or a week or a year." What has become abundantly clear in the antidepressant age—the drugs are now the most commonly prescribed medications in the country—is that depression is terribly difficult, if not impossible, to cure. Many primary-care doctors, who treat 80 percent of depressed people, labor under the assumption that a prescription is a panacea. But antidepressants completely alleviate symptoms in only about 35 to 40 percent of people compared with 15 to 20 percent of those who take a placebo—a fact not publicized in pharmaceutical ads. And about 70 percent of people who successfully beat one bout can expect to face another.

"We just don't have one magical pill that will do the whole trick," says Madhukar Trivedi, a professor of psychiatry at the University of Texas Southwestern Medical Center in Dallas. He recently participated in the government-funded "Star*D" trial of more than 4,000 patients with difficult-to-treat depression, which showed that success rates of antidepressants could be increased but that it sometimes took four tries of various drugs plus therapy. Even then, in 30 percent of those who completed the yearlong study, symptoms still lingered. And 5 percent of study participants, according to new Star*D data published last week, actually had a worsening of their symptoms while on an antidepressant. In an effort to better combat treatment-resistant depression, the Food and Drug Administration last month approved a combination pill for those who aren't helped by antidepressants alone. The drug, called Symbyax, combines the antidepressant Prozac and the antipsychotic Zyprexa.

READ MORE @ U.S. NEWS & WORLD REPORT

A New Way Of Thinking For Schizophrenia Treatment

The effectiveness of psychiatric drugs varies considerably in individuals being treated for depression or schizophrenia. These drugs act on serotonin, a neurotransmitter (chemical messenger) central to the regulation of moods. Scientists from Oxford and Belfast have discovered more about emotional processing and genetic variations that will help to inform treatment strategies.

The long-held view that serotonin levels are low in people with depression has been challenged by Philip Cowen, professor of psychopharmacology at Oxford University. "We asked what evidence is there that the action is abnormal and this stimulated new thinking about how anti-depressants work," he said at the British Neuroscience Association meeting in Liverpool today (21 April).

READ MORE @ MEDICAL NEWS TODAY

Comorbidity: Psychiatric Comorbidity in Persons With Dementia

The assessment and treatment of psychiatric symptoms in persons with cognitive dysfunction are becoming increasingly important. Prevalence estimates of dementia in the United States range from 5% in those aged 71 to 79 years to 25% to 50% in those 90 or older. Up to 90% of patients with dementia have psychiatric comorbidities.1,2

Physicians who treat patients with dementia must remember that dementia is not merely a problem with memory. The presence of one or more additional cognitive disturbances, including aphasia, apraxia, or agnosia, is required to make the diagnosis according to DSM-IV-TR criteria. Furthermore, some patients may present with changes in personality or deficits in executive function rather than memory impairment, which complicates the initial diagnosis.3 Additional mental and behavioral disturbances often affect patients and caregivers as much as memory deficits and may influence quality of life, the need for institutionalization, mortality, and caregiver burden.2,4,5

This article emphasizes neuropsychiatric disturbances with the greatest prevalence and morbidity in persons with dementia. It also addresses comorbid depressive and anxiety disorders, as well as psychological and behavioral disturbances associated with dementia—psychosis and agitation/aggression.3,6

READ MORE @ PSYCHIATRIC TIMES

F.D.A. Rules on Drug Ads Sow Confusion as Applied to Web

WHEN the Food and Drug Administration sent letters to 14 major pharmaceutical companies late last month, the warning was strong. The companies’ search advertisements — the short text ads that run beside Google results — had to start including risk information about each drug or else be rewritten or removed.

Just how the companies were supposed to comply was not so clear. In the 95 characters that Google allowed for search ads, there was no way to include all the required information, the companies argued.

Now, as the companies change their search ads to comply with the letters, industry executives say the solution is worse than the problem: their ads are even more confusing and misleading now, they say. And they worry that regulators will enforce standards that were created for magazines and television, rather than making new rules that acknowledge how Internet ads have evolved.

The letters were sent to almost all of the major pharmaceutical companies, including GlaxoSmithKline, Pfizer, Merck and Eli Lilly. The letters said ads for widely prescribed drugs, including Celebrex, Propecia and Yaz, did not include the paragraphs of precautions the agency required.

READ MORE @ NY TIMES

Alzheimer’s Patients on Atypical Antipsychotics Experience “Significant” Weight Gain

Some newer, atypical, or second-generation, antipsychotic medications have been found to have two serious adverse reactions. The drugs both lower so-called “good” cholesterol and cause weight gain in older Alzheimer patients.

HealthDay News reports that in a study of over 400 elderly patients, medications such as Zyprexa (olanzapine) and Seroquel (quetiapine) were both linked to “significant” weight gain, saying that those patients specifically taking Zyprexa “experienced increases in waist circumference and declines in HDL cholesterol,” as well. The study also revealed that the weight gain correlated to the amount of time the patient was on the medication; the longer the patient was taking the drug, the more weight gained, said HealthDay News.

The findings from the Clinical Antipsychotic Trials of Intervention Effectiveness—Alzheimer’s Disease (CATIE-AD) study, were funded by the U.S. National Institute of Mental Health (NIMH), said HealthDay News, and appear in the April 15 issue of the American Journal of Psychiatry. “These findings are especially troubling, because antipsychotics are associated with a higher risk of death and cerebrovascular adverse events in patients with dementia. They’re often used to minimize disruptive symptoms (such as psychosis or agitation), but patients should be monitored more closely,” said lead investigator Dr. Lon S. Schneider, in an American Psychiatric Association news release, quoted HealthDay News. The team noted that similar “metabolic side effects” have been seen in schizophrenia patients taking the newer antipsychotics, said HealthDay News.

READ MORE @ NEWS INFERNO

What Should Count as a Mental Disorder in DSM-V?

If sick men fared just as well eating and drinking and living exactly as healthy men do . . . there would be little need for the science [of medicine].
attributed to Hippocrates

Well, while I’m here, I’ll do the work—and what’s the work? To ease the pain of living. . . .
Allen Ginsberg

What exactly is a “mental disorder”? For that matter, what criteria should determine whether any condition is a “disease” or a “disorder”? Is “disease” something like an oak tree—a physical object you can bump into or put your arms around? Or are terms like “disease” and “disorder” merely abstract, value-laden constructs, akin to “injustice” and “immorality”? Are categories of disease and disorder fundamentally different in psychiatry than in other medical specialties? And—by the way—how do the terms “disease,” “disorder,” “syndrome,” “malady,” “sickness,” and “illness” differ?

Anyone who believes there are easy or certain answers to these questions is either in touch with the Divine Mind, or out of touch with reality. To appreciate the complexity and ambiguity in this conceptual arena, consider this quote from the venerable Oxford Textbook of Philosophy and Psychiatry:



The term “mental illness” is probably best used for those disorders that are intuitively most like bodily illness (or disease) and, yet, mental rather than bodily. This of course implies everything that is built into the mind-brain problem!1(p11)

In a single sentence, we are already grappling with the terms “illness,” “disorder,” and “disease,” not to mention Cartesian psychology! And yet—daunting though these issues are—they are central to the practical task now before the DSM-V committees: figuring out what conditions ought to be included as psychiatric disorders.

READ MORE @ PSYCHIATRIC TIMES

Comorbidity: Schizophrenia With Obsessive-Compulsive Disorder

The co-occurrence of obsessive-compulsive symptoms (OCS) and psychotic illness has been a challenge for clinicians and investigators for more than a century.1 Over the past decade, interest in this area has burgeoned because of recognition of higher-than-chance comorbidity rates of schizophrenia and obsessive-compulsive disorder (OCD), and observations of appearance or exacerbation of OCS during treatment of schizophrenia with atypical antipsychotics.2-6 Emerging neurobiological and genetic evidence suggests that persons with comorbid OCD and schizophrenia may represent a spe­cial category of the schizophrenic population.

The evidence for a putative schizo-obsessive disorder is examined and practical treatment suggestions for this subgroup of patients are outlined in this article.7-9

Comorbidity between OCD and schizophrenia
The lifetime prevalence for schizophrenia is 1% and for OCD it is 2% to 3%.10 Comorbidity rates for OCD in the schizophrenia population are substantially higher than what would be expected to occur randomly. In the schizophrenic population, the reported prevalence of clinically significant OCS and of OCD ranges from 10% to 52% and from 7.8% to 26%, respectively.11-23

The higher-than-expected comorbidity rate for OCD and schizophre­nia suggests a nonrandom association and possibly an integral relation between these 2 conditions.9 The question is whether this comorbid group with schizo-obsessive disorder represents a more severely ill group with greater brain dysfunction that could, in part, be caused by common neuro­developmental predisposing factors, or whether the 2 conditions are part of a more complex syndrome that rep­resents a distinct diagnostic entity. The answer could be clarified in part if neurobiological studies were to dem­­onstrate a distinct neuroanatomical substrate in this comorbid group rather than the summation or superimposition of neurobiological lesions observed in the separate disorders.9

READ MORE @ PSYCHIATRIC TIMES