Spring 2013 Maryland Psychiatrist
By Bruce Hershfield, MD
On March 23, 2013, MPS members and guests—75 of us—attended “Psychopharmacology: Updates, Advances, and New Information” at Sheppard Pratt in Towson.
Neil Sandson, MD led off with “Atypical Antipsychotics: What’s New?” His opening “caveats” included “Newer often/usually does not mean better.”, “Novelty in itself should not enter into the risk-benefit calculation.”, and “Beware the hype.” He talked about Latuda, Saphris, Fanapt, Invega Sustenna, long-acting olanzapine, and Loxapine inhalation powder. He concluded that, “We have had a few refinements and improvements perhaps, but no true ‘home runs’ that I can see in the immediate future.” (see, also, Dr. Sandson’s article in this issue)
Dr. Constantine Lyketsos then brought us “up-to-date” on “Care for People with Alzheimer’s & Related Dementia & Their Families”. He began by telling us why dementia is becoming a true public health crisis, delineated its major sub-categories, and went on to describe why “anti-amyloid” therapies have failed despite our understanding of the “amyloid hypothesis”. Progression of Alzheimer’s disease varies (there really are “slow progressors); female gender and younger age at onset are factors that tend to favor faster progression. Potentially modifiable factors like medical co-morbidity can be important in determining the course of the disorder. He emphasized that “dementia care”, though not widely used, is an established, evidence-based approach that needs to be placed in all relevant healthcare settings. Its common features include treating neuropsychiatric symptoms, reducing “medication load”, managing co-morbidities, and preventing delirium. He concluded that the needs of both patients and caregivers can, and must, be addressed.
Next, Gloria Reeves, MD talked about “Challenges in Pediatric Antipsychotic Treatment: safety considerations, informed consent, & providing effective care”. She told us there was a four-fold increase in the prescribing of antipsychotics to those 2-18 years old between 1995 & 2002, and that more recent data show more of an increase in those who have Medical Assistance than in those who have private insurance. Prescribing of antipsychotics to children under 5 is “off-label”, she pointed out, and she told us the AACAP practice parameters advise “marked caution” in treating this age group. She made it clear that the requirement for “metabolic labs” needs to be taken seriously. In her “final comments” she emphasized the importance of getting informed consent and said that clinicians who have “outlier practices” should be sure to carefully monitor for safety and to ask for consultations. She advised using psychosocial treatments when possible to reduce “antipsychotic burden”.
Dr. Karen Swartz then followed with “Optimizing Treatment for Depression & Bipolar Disorder”, pointing out that the average time until people who have these disorders first get help is 8 years for the former and 6 years for the latter. She reviewed the STAR*D results, went over the choices of available antidepressants, compared antidepressants and CBT, and concluded that there is “no clear winner among classes of medications” and that there is no “second step” strategy that is better than all the rest. She then reviewed the guidelines for treating bipolar depression and the risks and benefits of trying to treat it with antidepressants. She recommended trying to treat it first with lithium, divalproex, or carbamazepine, adding an antidepressant if there is no cycling and when there are ongoing, significant depressive symptoms, and then possibly adding lamotrigine. Furthermore, she advised that a combination of lithium and divalproex should be considered for severe, mixed, states or for rapid cycling.
In the last talk, Scott Aaronson, MD, the President-Elect of the MPS, spoke about “Mood Disorders 2013: Neuromodulation, Novel Targets, & Pharmacogenomics”. He explained vagal nerve stimulation, concluding it is “an effective treatment for serious, chronic treatment resistant depression”, then went on to describe transcranial magnetic stimulation, suggesting better localization and the use of “deep TMS” may eventually turn out to be more helpful. He then talked about “new pharmacologic targets” and medications, like ketamine, that might be used to reach them. He talked about NMDA and opioid receptors, then speculated about how significant our understanding of the serotonin transporter system could become. Finally, he touched on the importance of the cytochrome P450 system, emphasizing how genetic variants, causing some people to be ultra-rapid metabolizers and some to be extensive metabolizers, can put patients at risk for clinical failure, for drug-induced side effects, and for drug-drug interactions.
We are fortunate indeed to have such talented and hard-working psychiatrists, well-versed in research and in clinical care, willing to donate their time and expertise on a Saturday in early spring so that we can learn the latest about how to best care for our patients.