Problem Patients, Problem Meds
Sending a patient out the door with just a prescription is not treatment.
Meds compliance. The opening to this series on meds compliance focused on the middle portion of a grand rounds lecture I gave at a Princeton psychiatric facility in 2008. That part was called "The Problem Clinician," which went over like Slobodan Milosevic at a war crimes tribunal, only not nearly so well. We pick up on the action ...
The first part of my talk - "The Problem Patient" - went somewhat better.
'Marilyn walks into your office," I began. "She reveals her moods have been all over the place. Everything points to bipolar. Okay. How do you treat her?"
Believe it or not, no one raised their hands. I was the one who had to suggest that a mood stabilizer might be a good idea, then I had to make sure we had a consensus. Then I went to the catch, namely how does the most important person in the equation - the patient - feel? After all, even the best med in the world is useless if patients won't take it.
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Maybe we need to ask Marilyn a few more questions, I suggested. Consider:
Marilyn is literally larger than life. Over the top is her baseline. It's a legitimate part of her personality. How long do you think she is going to stay on her mood stabilizer if she thinks her personality is getting medicated out of her?
"For someone else to act like Marilyn," I said, "that may be hypomanic. For Marilyn to act like Marilyn - that's normal."
In support, I cited Ronald Fieve MD of Columbia University, who coined the term, "the hypomanic advantage."
"Keep in mind," I said, "a lot of us view the world through the eyes of artists and poets and visionaries and mystics. Not to mention through the eyes of highly successful professionals and entrepreneurs. We don't want to be like you."
How can I describe the look of surprise from my audience? Like I had let rip a roof-rattler and they were too polite to laugh - I think that best sums it up. Honestly, I've experienced seaweed with more personality. Then I blurted out: "To me, you all have flat affect."
Kelvin grade frozen stony cold silence. And this is the part of my talk that went over reasonably well, mind you. At this point I should have tossed away my script and tried to engage them in a dialogue. "Why should this be a surprise to you?" I should have asked. "Let's talk about this. Tell me where you're coming from."
We - those of us living with bipolar - are obviously a lot more animated than the general population, but the way I see it is that not all of this is pathological. Quite the contrary - the rest of the world should be more like us.
Instead I plowed ahead:
"We don't want to fly too close to the sun," I continued. "But don't clip our wings. Obviously Marilyn needs to be reeled in a bit. But how do we proceed? What do we have to go on?"
Believe it or not, there are zero published studies for treating hypomania. Zip, zilch, nada. The only solid evidence base involves the acute phase of full-blown mania, when we're bouncing off walls, 911 cases.
"So," I asked, "are you thinking of giving someone with hypomania an industrial strength dose?"
What else is going on with Marilyn? Personality issues? Quirky behavior? Does the bipolar itself affect her capacity to think rationally?
"You're the rational ones," I said. "We know where you are coming from. But do you know where your patients are coming from?"
I clicked to two slides:
Fear/feeling threatened, problems accepting authority, cognitive distortions ...
The list went on and on. "Looking like a lot of your patients?" I asked.
"Here's the point I'm making," I continued. "Not only are you treating the illness. You are treating any behaviors and attitudes that come in the way of treatment. And you're not going to find that out unless you talk to the patient - and listen."
I wasn't through: "Just sending a patient out the door with a prescription - in my opinion - is not treatment."
Back to Marilyn. She's Marilyn. She has enormous gifts and doesn't want her wings clipped. She has various personality issues. And her illness is affecting her judgment.
"We have the advantage of knowing the tragic outcome," I concluded. "Knowing what you know, are you happy just writing her a prescription and sending her out the door?"
Prescribing Cigarettes Instead
Okay, maybe I went out of my way to piss off my audience. "Here's a question for you," I opened in the next part of my talk, "Problem Meds": "What is the one drug taken by 85 percent of those with schizophrenia and two in three with bipolar that they are 100 percent compliant with?"
They came up with nicotine right away.
We know that auditory gating is mediated by the alpha-7 nicotinic receptor. Those with schizophrenia have trouble filtering out background noise, thus have trouble concentrating. I recall Robert Freedman of the University of Colorado explaining this to a symposium of the American Psychiatric Association annual meeting a number of years before.
Dr Freedman and his colleagues noticed that those with schizophrenia seemed to experience a desperation that went way beyond normal cigarette cravings and decided to investigate. What they found was that in the brief time a cloud is in the patients' lungs, a cloud clears from the brain.
Mind you, this is hardly a long-term solution. But think about it. Nicotine - on this level, anyway - works. With nicotine, some patients actually get their brains back - even if just for a precious few seconds. I don't know about you, but I don't take my brain for granted. Every precious second the reception comes in loud and clear is a gift to me.
Mind you, I'm not advocating cigarette use. But it appears that nicotine itself may be an effective drug for schizophrenia. Its major fault is the delivery system, but thanks to the research of Dr Freedman and others alpha-7 nicotinic agonists are in development.
"So, if you prescribe cigarettes," I joked, "you will get much better compliance than if you prescribe an atypical antipsychotic."
Zero degrees Kelvin frozen silence. It probably didn't help that earlier I had called out my audience for all the "No Smoking" signs on the grounds of the facility. (Mind you, perhaps thanks to the nicotine patch, patients and those who speak for them are putting up little resistance to hospital smoking bans.)
If Smoking Is Banned, Why Not Antipsychotics?
Now it was time to compare and contrast. Up on my PowerPoint went this slide from a 2007 editorial in the American Journal of Psychiatry:
Without adequate dopamine signaling, our patients do not feel "well." When dopamine systems are dysfunctional, patients seek a change. This may involve stopping a medication, such as antipsychotic drugs that block dopamine.
Rather than clearing up the brain, these meds actually take major parts of the brain off-line. The major problem with schizophrenia is cognitive deficit. Up went a quote from leading schizophrenia researcher, John Krystal MD of Yale:
"Our medications are least effective for the most disabling symptoms of schizophrenia," namely, "the cognitive dysfunctions that seem to prevent people from performing in the workplace."
The pioneering diagnostician Emil Kraepelin, who "discovered" schizophrenia back in the early twentieth century, pointed to cognitive dysfunction as a core symptom, and we are also recognizing it looms large in bipolar.
I was just getting warmed up. "So, what's your answer?" I asked. "You give patients a drug that actually worsens the most pronounced feature of schizophrenia - and a significant feature of bipolar. Not only that, you're telling us we're going to have to take it the rest of our lives. Sure, it knocks out the psychosis, but so what?"
I could have gone on about the metabolic catastrophes from meds such as Zyprexa - surely the long-term risk to health was as bad as cigarettes - but I compassionately spared my audience. Instead, I simply drove home this point:
Far from lacking insight into their illness, even patients with schizophrenia have a much better understanding than the people charged with treating them. Far from refusing to put up with side effects, they are willing to put up with a drug with one of the worst side effects profiles in the world. Why? Because it works. It works where they want it to work.
"Let's face it," I concluded. "We've all been badly oversold on the new generation antipsychotics - you, me, family members. When all is said and done, these new generation atypicals are basically Thorazine with the tires rotated."
For some crazy reason, to my total amazement, they cracked up at that line. Then they went back to being bumps on a log.
"My question for you," I concluded in this part of my presentation, "is why did it take you so long to figure this out? The same info was in the journals you subscribe to, on the labeling of the meds you prescribe. More important, your patients have been telling you this for years. Why haven't you been paying attention?"
As I mentioned before, my audience heard me out, then made for the exits the second my lips stopped moving.
Move on to the conclusion: Meds Compliance - Opportunity Lost
Previous piece: Meds Compliance - The Problem Clinician
Jan 12, 2011
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