Boston Globe Article about Genetic Testing in Psychiatry

It would be fantastic to have a lab test to help us decide which drugs to prescribe in psychiatry. See Sunday's great Boston Globe article that picked up on our recent coverage of the GeneSight test. 

It's a promising technology, but the marketing has leap-frogged ahead of the science. 

This Wednesday afternoon I will be participating in a webcast with journalists and other doctors about this controversial issue. 

The chat will begin this Wednesday, 10/7, from 3:30 p.m. to 4:30 p.m. The conversation will appear in the embed below and on the New England Center for Investigative reporting page here. You can start submitting questions now though.

Live Blog What should you know about psychiatric genetic testing?

The TMS Wars: Psychiatry Goes High Tech

In the pages of The Carlat Psychiatry Report, we’ve covered transcranial magnetic stimulation (TMS) numerous times—most recently in the current issue. For those who haven’t heard of these devices, they work by pulsing magnetic fields into the brain. The magnetic fields stimulate neurons—far more gently than electroconvulsive therapy. The theory is that this gentle brain stimulation, focused on specific brain regions, eases depression.

After skeptically covering this technology for almost a decade, I’m finally convinced that it actually works.  A recent systematic review, funded by the U.S. Government and written by authors with no ties to any TMS company, endorsed the technology pretty strongly. They found that for patients who were treatment resistant (those who had not responded to at least two antidepressants), TMS was three times as effective as the sham (placebo) control group.

Admittedly, it’s a little creepy and science-fictiony that we are in an era when magnetic stimulators are actually effective for changing our moods. But so be it.

Now that we have an effective device in psychiatry, it’s kind of fun to see these manufacturers competing for market share. There are already two TMS devices on the market: NeuroStar and Brainsway.

Over the past couple of months, two new companies have jumped into the fray. I received this letter from a company called Magstim, announcing their new Rapid 2 Therapy System. Without going into too many technical details, this device, as you can see below, looks like a glorified dental chair with a sleek brain stimulator attached.

Magstim

MagVita

MagVita is an even newer device, just approved last month.

As is turns out, these two upstarts are threatening to shake the nascent TMS industry to its core. Why? Because they are entering the market with an offer that’s almost impossible to refuse: no per-use fee. Both Neurostar and Brainsway charge a bundle of money up front to buy or lease the device, then they charge an extra $100 or so per treatment for disposable “shields” which aren’t actually necessary. They are simply income generators.

Magstim and MagVita are chucking those shields—saving doctors thousands of dollars in pointless charges.

What does this mean for patients? Probably that the treatments will be more affordable—more insurers will cover the cheaper Magstim and MagVita devices, and patients who must pay out of pocket will have less sticker shock. And what does this mean for Neurostar and Brainsway? Lots of anxiety, and deep discounts to try to keep up with Magstim and MagVita.

Want to learn more about neurostimulation devices? 
The July/August issue on “Interventional Psychiatry” offers an overview of this fast-changing world and is available as an individual purchase which includes 2 category 1 CME credits.

• Summary of neurostimulation methods, including: transcranial magnetic stimulation (TMS), magnetic seizure therapy (MST), vagus nerve stimulation (VNS), transcutaneous vagal nerve stimulation (tVNS), transcranial direct current stimulation (tDCS).
• Expert Q&A on the past and future of TMS with Dr. Mark George of the Brain Stimulation Laboratory at the Medical University of South Carolina.
• Expert Q&A on what it means to be an "interventional psychiatrist" with Dr. Nolan Williams of Stanford University.
• Review of the Fisher Wallace and Alpha-Stim devices as treatment options for depression.
• A practical guide on which TMS device you should buy (if any) for your practice.

Flibanserin: 5 Things to Consider Before Passing Judgment on the “Female Viagra”

Flibanserin (brand name Addyi) has just received a controversial and complicated FDA approval for the treatment of low sex drive in women. There’s a lot of outrage in the blogosphere, much of it centered on the lobbying of the FDA by disease advocacy groups.  I agree that this politicization of what should be a scientific process is embarrassing to both Sprout and its supporters. Nonetheless, I'm not nearly as hard on flibanserin as some of my colleagues.

Here’s why.

1. Hypoactive Sexual Desire Disorder is as real as any other source of distress, and deserves treatment.
 
Sure, I get that when it comes to subjective problems, it’s easy to stretch the definition of what constitutes a disease. But who are we to judge whether an affliction is severe enough to merit treatment? An example is social anxiety disorder. Some call it the medicalization of shyness. But if you’ve ever treated someone with this problem, you know that extreme shyness can limit your potential for a normal, happy life.

Low sexual desire may not be a public health emergency, but it’s a real problem for about 10% of women.  If they want to take a pill to make their lives a little better, why not? We allow Botox for wrinkled eyebrows, Rogaine for hair loss, Provigil for jet lag. Why not a drug for low sexual desire?

2. Flibanserin is a female Viagra—just a much less effective version. 

Lots of bloggers are saying that Flibanserin is no female Viagra. I don’t buy it. Trivially, yes, they are different drugs because they have different mechanisms of action. Viagra and the rest of the PDE-5 inhibitors enhance erection by shunting more blood to the vessels of the penis. Addyi’s specific mechanism isn’t known, but the drug is a serotonin 1A receptor agonist and a serotonin 2A receptor antagonist and enhances sex via greater desire. But the purpose of both drugs is the same—they are supposed to improve peoples' sex lives. Whether they do it via blood flow or serotonin doesn’t really matter.

However, there is one huge difference between Viagra and Addyi—namely, Viagra is extraordinarily more effective than flibanserin. Studies of Viagra and other PDE-5 inhibitors have found that around 80% of men on the active drug report erectile improvements vs. 20-30% of men taking placebo. That means that 50-60% of men gain benefit over and above placebo. Flibanserin? The FDA’s analysis of the data concluded that 8-13% of women had some desire benefit beyond the effects of placebo. If Viagra is a Starbuck’s triple espresso, flibanserin is a Dixie cup of cafeteria coffee.

3. Flibanserin causes side effects. In addition, water is wet. 

Come on, the nature of all medical treatment is a balance between benefits and side effects. Antipsychotics cause weight gain, antidepressants cause impotence, Viagra causes lightheadedness and low blood pressure especially if combined with nitrates. Flibanserin causes side effects too, such as sedation, dizziness, and low blood pressure.

There’s also an interaction with alcohol but we don’t know how dangerous it is. The company did a study of 25 people (most of whom, oddly enough, were men), and found that one person fainted when combining flibanserin with a moderate amount of alcohol. Five people got dizzy on the combination, but three people also got dizzy in the alcohol plus placebo group, and 4 got dizzy with flibanserin alone. (For the results of the Alcohol Study, see page 77 of this PDF report.)

So it’s not clear from these data how concerned we should be. Certainly, Sprout needs to do more studies. An alcohol contraindication is reasonable. Do we really need to limit flibanserin scripts to certified prescribers? Do we really need a REMS, and the requirements for CME that will inevitably be funded by the manufacturer? It sounds like a case of FDA over-reaction to me. I’ve been prescribing MAOI antidepressants (another "dangerous" drug) to patients for years. There’s a long list of foods they can’t eat and meds they can’t use. Our discussion of side effects is part of a standard medical visit. I don’t need a special certification to talk to my patients about these things.


4. Flibanserin will, indeed, be prescribed off-label, just like virtually every other FDA-approved medication. 

The FDA indication for flibanserin is highly restricted. It’s indicated only if there is low sexual desire without any clear cause. Thus, if the patient is depressed or anxious, and you think that may be contributing toward the low desire, it’s off-label. If there’s a medical condition, like cancer, causing the problem, it’s off-label. It's undoubtedly true that in the real world, doctors are going to be prescribing the drug for these off-label populations and many more. That’s no different from most other meds we prescribe. In psychiatry, for example, almost all the medications we prescribe for children are off-label, because there are so few meds with FDA approval.

5. Adriane Fugh Berman said it best as quoted by the New York Times: Flibanserin is a “mediocre aphrodisiac with scary side effects.”
 
But often in medicine, that’s exactly what we have to work with: mildly effective medications with side effects. Flibanserin may be mediocre, but it’s not ineffective. I look forward to cautiously prescribing it to those women in my practice who might benefit from it. Time will tell whether it becomes popular. If it’s as mediocre as the data suggests, patients won’t refill their prescriptions—in which case the market will quietly close the door on the little pink pill.

Vyvanse: Is History Repeating Itself?

One of the benefits of having the Carlat World Headquarters here in beautiful Newburyport, Massachusetts is that we get to work next door to an iconic antiques barn called Oldies. It's a wonderful stockpile of odds and ends that range from decommissioned lobster traps to faded movie posters.

The other day I came across an old issue of LIFE Magazine with a cover story on “The Dangerous Diet Pills: How Millions of Women are Risking their Health with Fat Doctors.” The date? January 26, 1968, which was smack dab in the middle of the amphetamine epidemic that prompted Congress to pass the bill creating our current system of scheduled, and controlled medications.

What, if anything, does this issue of LIFE teach us about the potential dangers of Vyvanse’s recent approval for binged eating disorder? This “exclusive report” was based on investigative journalist Susan McBee’s undercover visits to 10 “fat doctors.” She was given cursory exams and, although she was not overweight (5’5”, 125 pounds), virtually every physician prescribed her various pills, including amphetamines, barbituates, sex hormones, and diuretics. One office insisted she pay cash--no personal checks--in order to receive the pills.

How is this nearly 50-year-old article relevant to the age of Vyvanse? This was a story of unscrupulous doctors running pill mills for women who wanted to lose weight. The diagnostic process--if there was one--was sloppy and all-inclusive. If you came to one of these doctors requesting amphetamine, you were assured of getting a script, regardless of your diagnosis.

As a recent New York Times article shows, history is repeating itself. The Affordable Care Act has a provision requiring coverage of obesity treatment, and doctors are taking advantage of this by opening chains of lucrative weight loss clinics. Some are selling medications directly to patients, such as phentermine, which, like Vyvanse, is an stimulant.

It seems only a matter a time before Vyvanse pops up in the menu of options for patients being seen by the new breed of diet doctors.

Don't get me wrong--Vyvanse is effective for binge eating disorder, as we discussed in our recent CME article (subscribers to The Carlat Psychiatry Report can read it here).

If a patient came to me and said, “Doctor, I’ve heard about Vyvanse for binge eating, and I’d like to try it,” I would carefully ask about their eating habits in order to establish an actual pattern of binge eating. But what if the patient was more of a grazer than a binger? What if I sensed that the patient was simply looking for a weight loss drug and had no binge eating problem at all? I wouldn't prescribe a drug that has a high risk of abuse and diversion.

As was true in 1968, doctors are free to prescribe meds for indications not approved by the FDA. I predict that many women (and men) will be asking for Vyvanse to lose weight, and will walk away with the prescription, whether or not they have BED.

It's been nearly a half century since the LIFE article, and we're still prescribing speed for weight loss Let’s not let it get out of hand.

Hospitality and Pharma: Relationship on the Rocks?

Decades of mutually beneficial economic ties have bound the fortunes of hotels, restaurants, and drug companies. But in an era of Sunshine Act disclosure, renewed calls for professional ethics, and ballooning healthcare costs, that relationship may be souring.

It used to be a veritable love-fest. As recently as 2011, I was writing about a restaurant's attempt to rebrand itself as a "pharmaceutical dinner facility."  In 2010, I debated a restaurant chain owner who was calling for the Massachusetts legislature to repeal the state's 2009 gift ban so drug companies could once again wine and dine doctors at his restaurants. His lobbying turned out to be successful. The state's previously strict law was revised in 2012. Now it allows industry representatives to purchase meals of a "modest value" outside the office or hospital as long as they provide educational information about their products between courses.

However, it turns out that while hospitality industry owners are working double time to book reservations for doctors and pharmaceutical reps, their employees have an entirely different idea. They--correctly--see drug company relationships with doctors as a driving force in their rising health care costs, and they want pharmaceutical companies to stop funding educational CME programs at their hotels.

Last week I wrote about this brave stance from the hospitality worker's union Unite Here ("Hotel Workers Against Industry-Funded CME?"). The Wall Street Journal​'s Pharmalot blog got in touch with me to discuss the matter further and yesterday they posted a follow up that includes more of my thoughts on the matter and more of ACCME's self-serving response.

Looking back over the recent history of these industry dynamics, it's easy to see more workers taking this stand against business as usual. After all, they go to work every day in the middle of a money storm while simultaneously seeing their health costs rise year after year. That's a pretty good reason for them to want to stand up.

You can help them out by signing the No More Drug Money petition they are promoting and by sharing it around.

Hotel Workers Against Industry-Funded CME?

In a fascinating new chapter in the battle over industry funding of CME, a huge hotel workers' union has started a campaign to end the practice. Unite Here represents 270,000 workers, and the organization claims that industry funding of CME drives up their health care costs, which is undoubtedly true. So they have created a website, No More Drug Money, to advocate their cause, and they are inviting us all to sign the Pledge: "Add your name here to encourage the ACCME to kick drug money out of CME for good."

You have to respect an organization willing to bite the hand that feeds them. Hotel workers are, after all, an integral part of the grand machinery transporting industry marketing messages into the hearts and minds of doctors. They're quite aware of this:

"We work in hotels, airports, and convention centers, and we do the hard work that make many CME meetings run. We cook the food, we change the sheets, we do the laundry, and we pass out the agendas. We see first-hand what kind of presence pharmaceutical companies have during these meetings. And we are ready for a better system."

For ACCME's formulaic response, click here.

Industry funding of medical education, whether accredited CME or promotional talks, has always created strange bedfellows, but now it has created particularly strange antagonists.

The GeneSight Test: A Wing, a Prayer and 13 Patients

We just published the May issue of The Carlat Psychiatry Report, and the topic is "Biomarkers in Psychiatry."

I contributed an article reviewing the evidence for the GeneSight genetic test, which is being quite heavily marketed as a way to choose the right medications for patients. According to company's website:

"Multiple clinical studies have shown that when clinicians used GeneSight to help guide treatment decisions, patients were twice as likely to respond to the selected medication."



That's misleading, I found. The vast majority of the GeneSight data are based on studies with an unreliable methodology. These were so-called "open label" studies in which patients were non-randomly assigned to two groups: guided treatment vs. unguided treatment. All patients and clinicians knew which patients were assigned to which group, leading to the very real possibility of various biases--along with a heavy helping of the placebo effect.

One single randomized, blinded study has been published (not even properly blinded, since the clinicians knew which patients were in which group). It enrolled 49 patients (25 in the guided group, 24 in the unguided group). There was no significant difference in the depression improvement scores between the groups. There was a secondary analysis of 13 patients showing a potential benefit for those whose meds were categorized by the test as being particularly problematic.

13 patients? I don't think I would use a genetic test based on good results from an N of 13--and I would suggest that you think twice before you do so!

By the way, I'm at the APA meeting in Toronto and will be going to a lecture today sponsored by Assurex, the maker of GeneSight--if I learn anything new I'll let you know.

How Drugs Collide: What Every Psychiatric Prescriber Should Know

Please file this blog post under "Shameless Self-Promotion."

I just published a new edition of my book, Drug Metabolism in Psychiatry: A Clinical Guide. You can buy it here, and you can read a free preview of the first two chapters here.

It's mostly a book for psychiatrists and psychiatric nurse practitioners. It's pretty short at 145 pages, but it's very concise and in my opinion fun to read.

If you are not a prescriber you might also find it useful because it explains in clear language how we make decisions about which drugs to prescribe based on how they are metabolized. Therapists, patients, and those simply interested in psychiatry might find it educational, and strangely entertaining.

Anyway, that's it. Sorry if you were looking for a piece of muckraking investigative journalism. Maybe next time!

How a New Blood Test for Depression is like Apple Recognition

Four years ago I wrote a blog post about the MDDScore blood test for depression. That was before there were any peer-reviewed publications describing it. Now there are at least two. The latest came out a couple of months ago in the Journal of Clinical Psychiatry, and you can access the article, along with two interesting commentaries, for free.

While I won't go into the article in any detail, suffice it to say that the overall accuracy of the test for diagnosing depression was between 91% to 94%, depending on the group studied. Based on this, the authors report that the test "has excellent performance in confirming a diagnosis of MDD (major depressive disorder)."

The article is a classic example of the pitfalls of focusing on glitzy-sounding statistics while downplaying the actual clinical usefulness, which in this case is close to nil, as both of the Journal's commentators agreed.

I recently discussed the same problem in an article I wrote for CCPR about the NEBA EEG test for ADHD. Like the MDDScore, the NEBA test promises to aid in the diagnosis of a psychiatric illness. The NEBA's accuracy is high, with a positive predictive value for ADHD of 96% for kids, and 81% for adolescents. But no matter how accurate it is, the crucial question is whether it adds value above and beyond the standard psychiatric interview. Neither the MDDScore nor the NEBA do.

In my article, I used a hypothetical analogy of a new test to diagnose apples:

"Let’s imagine that there’s a new apple-recognizing device on the market called the “Apple Rec,” which uses various technologies to measure the wavelength of light reflected by an object, its mathematical curvature, etc. The manufacturer provides impressive data showing that the Apple Rec has 100% sensitivity and 100% specificity for diagnosing (recognizing) an object as being an apple. Given these dazzling statistics, would you buy the Apple Rec? No, because even though it’s exquisitely accurate, it provides you with no useful diagnostic information beyond what you can obtain by looking at the apple yourself. However, if the Apple Rec provided you with added value, you might consider it a good investment. For example, if, in addition to correctly recognizing it as an apple, it also calculated its sweetness and crispness, the Apple Rec suddenly becomes a useful tool, because these are qualities that you would otherwise struggle to ascertain."

The apple principal applies to diagnostic tests in psychiatry. Before you refer your patients to an expensive test that diagnoses ADHD, depression, or anything else, you need to make sure that it does something that you can’t easily do yourself.  

Medscape Presents: The Brintellix Show

As I wrote in part one of my Medscape review, the website gets high marks for up-to-the-minute coverage of psychiatric news, and it deserves kudos for posting a ton of textbook-like content on disorders and drugs. I wasn’t so thrilled with its "un-privacy" policy, which results in your personal info and browsing history being sold to third parties. 

Today we get into the dark side of Medscape Psychiatry, which is their industry-funded CME. 

Medscape Psychiatry CME Overview

Medscape offers four different categories of CME on its “CME and Education” page.  "Clinical Briefs" and "Journal Articles" are mostly not industry funded, whereas "Patient Cases" and "Knowledge and Practice" are generally industry products.  

Brintellix (vortioxetine) Background

To give you a little context, Brintellix is the latest antidepressant to be FDA approved. It is being marketed as a "multimodal" antidepressant because it has effects on several different receptor sites. The company has produced some interesting data showing that Brintellix may cause fewer sexual side effects than other antidepressants, and that it may help improve the slowed-down thinking that is common with depression. But it is not FDA approved for either of these potential advantages, because thus far, the data are far from definitive.

Medscape and Takeda/Lundbeck

Medscape is the largest single recipient of pharmaceutical CME grants among all U.S. medical communications companies. According to an article in JAMA, it received $20,315,730 in 2010, the last year for which such data were aggregated. I don't know how much the company is receiving from Takeda/Lundbeck for producing CME programs, but it's probably a lot. If you click through Medscape's most technologically sophisticated online courses, a high proportion are funded by this duo.

Here are some of the titles of the courses:

• Strategies for Effective Communication With Patients With Major Depression
• Strategies for Improving Symptoms in Patients With Major Depression 
• Engaging Patients as Partners in Care: The National Quality Strategy in Practice
• Cognition in Major Depressive Disorder: Improving Quality of Life
• Updates and Perspectives in Major Depressive Disorder: Highlights From 2014 
• The Pharmacology of MDD Treatment: Building a Foundation With a Focus on 5-HT

Commercial Bias in One of the Courses

All of the courses listed above are likely biased in favor of Brintellix--there wouldn't be much point in paying Medscape to produce them otherwise. Since blogging is not my day job, I chose only one of them to watch: The Pharmacology of MDD Treatment: Building a Foundation With a Focus on 5-HT.

This course begins with four multiple choice questions, which are supposed to test your knowledge before you learn. Here's one of them:

Which of the following antidepressants manipulates the most serotonin receptors at once?

vilazodone

selegiline

quetiapine

vortioxetine

The correct answer? Vortioxetine. 

This is a clever way to prime the pump, to get the audience thinking about the promoted drug.

Next, we get a slide purporting to give an overview of the history of antidepressant drug development.

The big red bubble labeled MMD refers to "multimodal drug", ie., vortioxetine. That's the latest one. The implication is that it's the most technically advanced. 

Later in the program, there are a few slides highlighting "new antidepressants." Only one antidepressant gets prominently featured on two slides:

The more crucial question is not "how many ways can one drug manipulate 5-HT" (even the manufacturer states the "clinical relevance" of the drug's many serotonin actions is "unknown") but rather "how many ways can one communication company manipulate doctors's prescribing practices?"

To make their point crystal clear, one of the experts in the video glowingly endorses Brintellix, saying that its multimodal mechanism is like packing a bunch of great medicines into one:

"Vortioxetine is a great example of this multimodal thing we were talking about. It is a serotonin reuptake inhibitor, but it also is a very strong agonist at 5-HT_1A, which we said you want to have an agonist there. It also is a powerful antagonist at 5-HT₃ which and a powerful antagonist at 5-HT₇. On paper, here is a drug that has some of these qualities we have been talking about that could make it possibly a multimodal agent almost like a built in augmentation strategy in 1 pill, which certainly would be, just practically, a little easier for patients than having to take more than 1 medicine, which we often have to do.^[3-6]"

A bit later, he goes even further, implying that Brintellix uniquely targets three common symptoms of depression:

"Again, right now, the data clearly show the 3 most common residual symptoms, even with people who have a response to an antidepressant are insomnia, cognitive impairment, and fatigue. I think those are things that are not well addressed by an SSRI alone. Thinking more sophisticated, multimodal actions whether it is 1 pill that has that built in augmentation. I think that is where the field is going."

Summing up Medscape

Since the last time I reviewed a psychiatric website, I assigned a letter grade, I'll give Medscape one as well: a B-. 

Why? It gets an A for delivering bite-sized psychiatric news clips on its non-CME page, an A- for providing free but dry drug and disorders info, and an F for failing to comply with Standard 5 of ACCME's Standards for Commercial Support in its CME courses. Among other things, Standard 5 forbids a CME program from promoting a "specific proprietatry business interest of a commercial interest", and it requires that presentations "must give a balanced view of therapeutic options." 

I'm surprised that Medscape is still resorting to these shenanigans, but I guess that's what butters their bread. 

Medscape Psychiatry Review, Part One: The Good...

Medscape is the number one website for American physicians--a 2010 survey found that 57% of doctors read the site. I'll wager that proportion is higher in 2015.

I have not always been Medscape's number one fan. I've called the site out for pushing Cymbalta in a Lilly-funded "Pain TV" program and for touting Invega in a CME-accredited infomercial that was so blatant that Business Week ran a story about it.

But I have found that the site has improved over the past few years. For example, gone are the notorious sponsored resource centers, in which a single company would underwrite all coverage of a disorder (eg., Shire bought the ADHD section, and GlaxoSmithKline bought bipolar disorder.) There are plenty of ads, but Medscape appears to have understood the separation between church and state, and has stopped merging ads with articles...at least in their main pages.

So if you are a psychiatrist browsing for some reliable, free information, can you rely on Medscape? I'll give a qualified "yes."

Where Medscape really excels is in bringing up-to-date news written in an unbiased journalistic style.

For example, above is the psychiatry homepage from April 7, 2015. Yes, there is a big positive feature on a heavily promoted antipsychotic agent, Latuda. But there’s also an article praising lithium as an effective and underused generic drug. And there's a piece about how antidepressants can cause seizures even at normal doses. So at least on the homepage, Medscape is no longer the shill for drug companies that it once was.

If you drill into specific topics, you’ll also find that Medscape becomes a gigantic encyclopedia of medical knowledge. It covers all specialties, and in the psychiatry section alone there are over 100 articles. The articles have multiple sections and are comprehensive. They remind me of the truck-sized psychiatry textbooks that most of us felt we needed to buy earlier in our careers but which we have rarely cracked open. Like those textbook chapters, Medscape’s educational articles are quite dry – even, at times excruciatingly boring. But, nonetheless, the information is out there for you to read and it is scot-free.

Unfortunately, there are still a few dark sides to Medscape. A 2013 article in JAMA authored by Sheila Rothman and colleagues alerted all physicians to the fact that Medscape, along with other similar medical communication companies, is in the business of sharing all of your personal data with drug and device companies. You can read Medscape’s privacy policy here. It's a long document but I will give them credit for using pretty plain language as they disclose the myriad ways in which they are sharing your information. One of the creepiest technologies is called a "web beacon." This is a hidden drone of the Internet that tracks every click you make, every page you seek, and every breath you take. Your mental processes are then sold to "third parties". It's absolutely creepy.

Some will object that this is business as usual on the web. Google does it, which is why I see ads popping up in my gmail for an obscure car rack that I searched for last month. Tracking my car rack searching behavior is one thing--tracking how I'm thinking about saving patients' lives...well, I think there's a qualitative difference. 

In part two of my Medscape post I will cover their continued addiction with industry funded CME. I guess that pays their bills. But the crassness of these infomercials is pretty astonishing, particularly in the era of the Physician Payment Sunshine Act. To be continued…

Psychiatry Website Review: Rajnish Mago's "Simple and Practical Mental Health"

Lately I've been browsing for good psychiatry websites to harvest ideas for an upcoming redesign of The Carlat Psychiatry Report. Everything's fair game in my search, whether industry-funded or not. I'm not going to try to pretend that industry funding inevitably leads to tainted information. Clearly, sometimes it does, but sometimes it doesn't.

I've been finding a lot of quality information out there, much of it for free. So I'll spend the next few posts reviewing some of these sites.

One of the very best is called "Simple and Practical Mental Health" by Rajnish Mago, who is the director of the Mood Disorders Program at Thomas Jefferson University Medical College in Philadelphia. The website is oriented toward prescribing mental health practitioners, though I'd imagine both therapists and consumers would find the information helpful. The site itself doesn't appear to be funded by industry, though Dr. Mago does work with industry (see below).

The really great thing about Dr. Mago is his informal style of laying out information--without excessive jargon. For example, here is how he starts an article about omega-3 fatty acids:

"Do you routinely ask your patients with some form of clinical depression (depressive disorders) or bipolar disorder to take an omega-3 fatty acid supplement? If not, why not? There is data to support use of such supplementation as an adjunct in the treatment of these disorders. 

However, many clinicians may not be clear about which  omega-3 fatty acids to recommend, inwhat ratio, and in what dose. While there is more to learn about this topic, here is some practical information about how to get started in recommending this supplement:"

And then he goes on to give some extremely practical advice on how to decide which fatty acids to prescribe, what the doses should be, and so on. 

While the site is free, he does use it to sell a couple of books, both of which I bought. They're both excellent, but the better of the two is "Side Effects of Psychiatric Medications," which is chock full of down to earth clinical advice about preventing and managing side effects. This is not a particularly sexy topic in psychiatry, but it's important, so it's nice to see that a very smart clinician has put a lot of thought into it. 

I do have a couple of critiques: 

1. There is no clear link to his financial disclosures. He does list them on the site, but the page is almost impossible to find. I had to do a google search which brought me to a link on a different website which then looped me back to a page on the original site. Dr. Mago works with pharma, doing both research and consulting. Nonetheless, the site doesn't seem to be pushing any particular drug, though there is a pro-diagnosis feel to a lot of the articles, which might be seen as disease-mongering by those particularly sensitive to the issue. In his case, my sense is simply that he genuinely believes many psychiatric disorders are under-diagnosed. 

2. There is no search bar, so you have to rely on menu navigation to find anything. 

Overall, I give the site an A-, downgraded only because of the above two issues. Keep it up, Dr. M!

  

The Atlantic Slams Alcoholics Anonymous--The Carlat Take

The current issue of The Atlantic magazine has a fascinating article entitled "The Irrationality of Alcoholics Anonymous." In a wide-ranging and well-researched article, the author Gabrielle Glaser, begins with the story of a lawyer identified as "J.G."

"J.G." began drinking at age 15 and his habit ramped up through college and law school. Ironically, much of J.G.'s law practice is defending drunk drivers. On a typical court day, according to the article, he would start drinking after his first morning court appearance, and he bought himself a Breathalyzer to make sure he didn't end facing the same judge as his clients. At his worse, he was drinking a full liter of whiskey per day.

Eventually he checked into a rehab based on AA principles. AA famously maintains that complete abstinence is a requirement of effective treatment. It didn't work for J.G., and only led to a series of miserable white-knuckled periods of sobriety interspersed with relapses. Toward the end of the long article we learn that (spoiler alert) J.G. finally gets himself into a clinic that acknowledges the scientific evidence of the efficacy of medications for alcoholism. He is prescribed baclofen and the occasional Valium, and is now successfully sober.

In The Carlat Addiction Treatment Report (CATR) we've written at length about AA and we're generally in agreement with this article. The Cochrane Collaboration, which synthesizes the best evidence available, found only eight RCTs of adequate quality that looked at AA or 12-step Facilitation (TSF), the professional treatment approach that strongly encourages AA participation. The resulting meta-analysis concluded, “No experimental studies unequivocally demonstrated the effectiveness of AA or TSF approaches for reducing alcohol dependence or problems” (Ferri M et al, Cochrane Database Syst Rev 2006;3:CD005032).

The Atlantic article's timing was perfect for CATR as we just published an issue devoted to integrating medications and therapy in alcoholism treatment. You can read the article on pharmacotherapy for free here. 

The bottom line is that AA likely works for many people, particularly those who become active in meetings and who get a sponsor. But we know from placebo controlled trials that medications such as naltrexone and acamprosate are effective--and there's no reason not to combine meds with a 12-step program or psychotherapy. 

On Combining Antipsychotics, Top-Performing Therapists, and Procrastination

I woke up this morning and realized that I've allowed myself to become a victim of BPS--Blog Procrastination Syndrome. It happens to the best of us. We write a post, and days and weeks and months go by. "My next post has to be really, really good," we think.

Forget that. I'm just going to dive back in beginning today. "Done is better than perfect," someone once told me.

At The Carlat Psychiatry Report, we are busy planning future issues, and here are a couple of upcoming topics that I'm fired up about.

Combining Antipsychotics. 

Psychiatrists have gotten plenty of bad PR about our use of antipsychotics. And some of that bad PR is justified. We overuse Seroquel as a sleeping pill. We add too much Abilify to antidepressants because patients come into our office having been hypnotized by ads telling them that this is the drug that will finally help them kick their blues.

But sometimes the criticism is misguided. Lately, guidelines have been published discouraging us from combining antipsychotics. "That's not evidence-based practice," we're told. Fair enough. But when your patient on risperidone is still digging through the snowbanks looking for the transmitter that he's convinced is causing the world to hurtle toward oblivion, you need to something. You can increase the dose, you can switch, you can add, etc....

So I'm working with psychiatric pharmacist Kelly Gable on an article that says, "Look, we understand that combining antipsychotics can increase side effects and is not supported by randomized controlled trials. But sometimes we do it anyway, because our patients our suffering."

We're collecting a list of scenarios that typically lead to antipsychotic polypharmacy, and we're going to evaluate how reasonable these scenarios are. If you have any experience, positive or negative, with antipsychotic polypharmacy, please let me know by email or by commenting to this post.

Top Performing Therapists. 

I interviewed Scott Miller, PhD, the other day for our April issue on psychotherapy. Dr. Miller believes that the real key to improving our clinical success is systematically getting feedback from our patients on how well therapy is going (or medication treatment, or combined treatment, etc....).

He's also found that top performing clinicians spend three to four and a half times as many hours per week than others engaging in "deliberate practice". What does that mean?  You'll have to read about it in the issue. I'm still editing the interview and really enjoying it.

Phew. Feels good to clear out some of the blog-webs that have developed over the months. See you again soon. Really.