| Folks
In my last Update, I botched the paragraph on NTT, Need To Treat. Eist pointed out that the wording should be number needed for an additional responder than otherwise expected. Note “additional.”
Next week, the APA Assembly will be asked to approve the draft of the next edition of the MDD Practice Guideline. Depression-focused psychotherapy alone is recommended as an initial treatment choice for pts with mild to moderate MDD. Also recommended for mild, moderate or severe depression, an SSRI, SNRI, mirtazapine, or bupropion. MAOIs should be restricted to pts who do not respond to other treatments. “In pts who prefer complementary and alternative therapies, SAMe or St John’s Wort might be considered, although evidence for their efficacy is modest at best. .; .” Odd, St. John’s Wort is mentioned, exercise is not. Please bring other major omissions to my attention, and we’ll attempt to amend the document at the Assembly.
A couple of clinical items from this month’s AJP:
1. A research report concluded, “For depressed pregnant women, both continuous SSRI exposure and continuous untreated depression were associated with preterm birth rates exceeding 20%.” An editorial reflecting on this study concluded “the evidence available from long-term studies, this author thinks that the risk of untreated major depression outweighs the risk of effects of SSRI treatment on neonatal outcomes. We need to consider not just short-term, but also long-term, consequences of our decisions. In addition to focusing on the child, the clinician needs to consider the risk of untreated major depression in the mother. These risks include exacerbation or recurrence of her underlying psychiatric illness, which can have adverse effects on her morbidity and mortality and can impair not only her functioning, but that of her
family and other children under her care.” Unclear in this editorial is why psychotherapy is not mentioned as the preferred choice in mild or moderately depressed pregnant women and ECT in the severe.
2. Second-generation antipsychotic use was associated with weight gain in women, with olanzapine and quetiapine in particular, and with unfavorable change in HDL cholesterol and girth with olanzapine. “The potential consequences of these effects suggest that patients with Alzheimer’s disease treated with second-generation antipsychotics should be monitored closely.” Men lost a little weight on average. The article was silent as to what to monitor.
Last Tuesday, the FDA notified healthcare professionals that it approved updated labeling for antiepileptic drugs used to treat epilepsy, psychiatric disorders, and other conditions. The increased risk of suicidal thoughts or behavior was generally consistent among the eleven drugs, with varying mechanisms of action and across a range of indications. This observation suggests that the risk applies to all antiepileptic drugs used for any indication.
“Healthcare professionals should closely monitor all patients currently taking or starting any antiepileptic drug for notable changes in behavior that could indicate the emergence or worsening of suicidal thoughts or behavior or depression.” The drugs included in the analyses include: Carbamazepine (marketed as Tegretol) Felbamate (marketed as Felbatol) Gabapentin (marketed as Neurontin) Lamotrigine (marketed as Lamictal) Levetiracetam (marketed as Keppra) Oxcarbazepine (marketed as Trileptal) Pregabalin (marketed as Lyrica) Tiagabine (marketed as Gabitril) Topiramate (marketed as Topamax) Valproate (marketed as Depakote, Depakote ER, Depakene, Depacon) Zonisamide (marketed as Zonegran) In the 1980s, Vitamin E seemed good for everything. In this decade it seems to be striking out with every study. But on April 30 at the American Geriatrics Society (AGS) Annual Scientific Meeting, it finally has had a good report: Patients with Alzheimer's disease who receive high-dose vitamin E [800 to 2000 IU/day] combined with a cholinesterase inhibitor [donepezil, rivastigmine, or galantamine [800 to 1000 U twice daily].had less long-term deterioration in their ability to perform activities of daily living than those who do not receive vitamin E and on an cholinesterase. However, because some studies have shown an increased
risk for death with vitamin E doses greater than 400 IU/day, high-dose vitamin E therapy for Alzheimer's disease fell out of favor a few years ago. Dr. Brangman, who is president-elect of AGS and who was not involved with the study, said: "I don't think this study alone gives enough information.”
We are advocating for Dr. Susan Rich’s [County private practice child, adolescent and adult psychiatrist] position that fetal alcohol syndrome should be in DSM-V. In the meantime, one can use ICD-9-CM’s 760.71, fetal alcohol syndrome.
The FDA has approved the med, iloperidone, as an antipsychotic, a product of Vanda, a Rockville firm whose CEO, Mihael Polymeropoulos, some of you knew when he was a resident at Saint Es.
Roger |
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