Neurogenesis and addiction

March 12th, 2010

A new study at UT Southwestern Medical Center is leading to the  hypothesis  that increasing the normally occurring process of making nerve cells in the brain may play a role in preventing relapses and perhaps even reduce the likelihood of addictions occurring.

The study’s findings, available in the Journal of Neuroscience, are the first to directly link addiction with the process, called neurogenesis, in the region of the brain called the hippocampus. Dr Inaba shares his perspective and insights.

 
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DSM-5 draft released for comment

March 3rd, 2010

The draft version of the new DSM – Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was released for public comment recently. The DSM is viewed as the bible of  the mental health community – used in defining what is a mental disorder by establishing criteria and terminology. Though the changes might appear cultural or semantic,   their  impact is far reaching – affecting legal matters, industry and government programs and  medical and mental health treatment – with a potential of billions of dollars at stake for pharmaceutical companies, insurance and government health plans, doctors, researchers and patiences advocacy groups. It was last revised in 2000, and won’t be  finalized until 2013. And controversy is swirling around it. Dr Inaba explains.

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Transcript (edited):

CNS:   Welcome to the CNS Podcast featuring Dr. Darryl Inaba, research director for CNS Productions.

CNS:   The draft of the new DSM, (Diagnostic and Statistical Manual Disorders #5) was released for public comment – it is produced by the American Psychiatric Association.  It’s viewed as the bible of the mental health community, in defining what a mental disorder is, by establishing criteria and terminology.  And on first look, it seems like an exercise in semantics. But the impact of changing is far reaching – effecting legal matters, industry, government programs and of course the medical and mental health treatment communities.  And, of course the billions of dollars at stake for pharmaceutical companies, insurance companies, government health plans, doctors, researchers, etc.  This is the first update since 1994, so it will be almost 20 years by the time it’s finalized and released in 2013.  Darryl, do you remember when the last version came out.

DARRYL:      That was…when DSM #4 was accepted and it created a stir. It is vitally important for reimbursement, for acceptance of certain conditions that are billable to insurance and anytime there is something that involves that much money there will be lot of politics.  They’re giving themselves 3 years to circulate the draft so people can either attack it or give input, before it is finalized in 2013, so that in itself tells me this will create a lot of controversy.

CNS:   So far the only behavioral addiction included is gambling, none of the other ones like internet and sex.

DARRYL:      That is a disappointment because the DSM #4 did recognize a lot of impulse control disorders that were well documented, and well accepted as a compulsive behavior that causes people tremendous harm and suffering, but it looks like they could not find enough scientific evidence for sex or internet addiction, so they are leaving those out now.

CNS:   What becomes of those?

DARRYL:      I imagine they’re going to be retained in some broader category.  When they can’t fit something neatly into a specific mode it is classified as “N.O.S.” which stands for “not otherwise specified” and I suspect there will be some of that because people like Tiger Woods are in the news – people who are actively in treatment for sexual addictions, for internet addictions, for obsessive text messaging…things like that.

CNS:   We’ve talked about the mechanisms and the obsessions of these behavioral problems before and I find it really interesting that they would exclude these things There are obvious  changes in terminology like “mental retardation” is now “intellectually challenged”,  but what is the thinking behind removing compulsive behaviors?  Is it a lack of credible science at this point?

DARRYL:      Well, that’s what the claim is. The architects and writers of the DMS are extremely politically correct.  They tend to be careful about naming things or identify things in ways not to offend any specific race or any specific group of people to prevent creating a stigma or making the prejudice against certain of these conditions worse.  Maybe people believe that we should not pay for somebody to get treated for sexual addiction or for shopping addiction or for   hording.

CNS:   Or maybe it’s viewed, at least by the framers of this document, as something so ubiquitous that it isn’t a mental disorder, but as a common part of society now.

DARRYL:      They are trying to eliminate things that are just a common part of human behavior that sometimes cause some people problems. Whenever we talk about any of these disorders – sexual disorder or even internet disorder – we’re careful to note that all of these things are a common part of most people’s lives, it is the abnormal participation, the extreme obsession that classifies the activity as a disorder.  Sexual addiction causes a person to have tremendous relationship problems, maybe even health problems. They are unable to participate in sex like most people do, they must do it obsessively and abnormally and that’s why I can’t understand the exclusion.  I believe there is a lot of evidence that shows that some people are totally obsessed with the internet, totally obsessed with shopping, obsessed to the point that they’re not accomplishing anything.  The shopaholics I’ve known will buy 5 Waterpick shower heads because they’re on sale even though they have only one shower in their house and it has a perfectly good shower head.  They just can’t prevent themselves from picking it up, putting it in the cart and getting some relief from the act of buying it.  They have maxed out credit cards, are deep in debt, experience tremendous suffering, relationship problems, family problems, yet they continue.  So, I believe that is a disorder that merits inclusion as a diagnosis and treatment.  You can treat it and help people get over it.  Shopping is a normal behavior, but not the pathology we see in a shopping addiction.  Gambling is included, and certainly a lot of people gamble.  They’re thousands of normal gamblers, these people are not pathologic or problem gamblers, but evidence shows that certain people are so beyond normal in their gambling activity that they sacrifice so much and have so many catastrophic consequences that it becomes pathological and thereby merits inclusion as the first behavior compulsion to be added to the DSM 5.  Maybe by 2013 we may see more inclusions.

I want to zero in on the changes in terms of addiction substance use disorder.  Back in 1994, DSM 4 changed the term to describe a compulsion to drugs and created a whole new nomenclature that I’ve been using for 20 years in order to gain wider acceptance of the term substance use disorder.  That term lifts the stigma attached to the word “addiction” and “addicts” and hopefully turns it into a more medically appreciated condition referred to as substance use disorder. That term indicates dependence and abuse.  Some people are applauding the prominent use of the word addiction, some people are not.  This highlights the politics that goes into the creation of this standard diagnostic manual.   Although everybody recognized that the word addiction has negative connotations and therefore may not be good to use as a descriptive term…what occurred or what the authors are dealing with is the fact that when they use substance use disorder and substance dependence or substance abuse, they believed that substance dependence was so connected to the term addiction that it created problems for psychiatrists for whom this is the standard bible for the diagnosis and treatment of neuropsychiatric disorders.  When psychiatrists prescribe antipsychotic medications, antidepressant medications, or mood stabilizing medications to treat those conditions – the medications produced dependence.  This created a tolerance – the body became used to medication and caused withdrawal symptoms.  The thinking that connected or confused the issue has to do with people thinking they were addicted because they took a major antipsychotic medication.  It’s important to separate that type of dependence.  A dependence on medication is okay because it is part of treatment versus addiction.  The term addiction describes the compulsivity and the drug seeking behavior that occurs in addicts…in anyone who is dependent on a drug that can cause addiction.

Cannabis use disorder is going to be included in the new DSM 5 and they’re proposing a new terminology for withdrawal.  It is called “discontinuation syndrome” instead of withdrawal and addresses what the treatment community has professed for years that cannabis dependence does occur – creating tolerance dependence and withdrawal symptoms.  So that’s a new one.  Caffeine is also included.  I’ve always believed in the need to consider caffeine as a major addictive substance.  And that rounds out the new spectrum of addiction and related disorders. I thought the spectrum would be much broader in terms of different behaviors and different ways people use this drug, but no…they’re just going to be defined by drug.  They are going add the severity terms – looking at moderate use versus severe cannabis use disorder and further describing what that means. It is not just “you’re dependant” or “not dependant”, but rather within a spectrum of severity. I think one of the most interesting things happening in the substance abuse field is the addition of drug craving as a criteria for defining a problem or defining somebody with say an alcoholic disorder.  That is big because up to now, even in DSM 4, it has been excluded.   Craving wasn’t considered a biological condition but rather just a manipulation by addicts to return to using their drug. Because the actual science of addiction is growing the addition of drug craving as a criteria for defining conditions and describing what those cravings are is huge. I hope that will result in changes in how we treat addiction and increase the resources available.  The one thing that I am happy to see is the elimination of law enforcement problems as criteria for diagnosing certain addiction problems.  In the old system, one of the elements that indicated a substance use disorder was a problem with law enforcement – if a person had been arrested or jailed…now they’re saying no…that’s out of the picture.  I think that’s good, maybe it is a move toward looking at the decriminalization of addiction.

CNS:   Sounds like an aspect of that.

DARRYL:      If we are going to decriminalize addiction, we have to augment the resources and interventions for treatment because it will be recognized as a medical condition so we need to address it as a medical problem.  I am always fearful of changes that don’t result in adding the necessary resources for treatment.  I certainly hope that doesn’t happen here.

CNS:   It sounds like some potent changes are included in this document along with some semantic and politically correct statements, but it’s going to be 2 ½ years or so before it becomes finalized so we will have the chance to talk about it more.  To those of you listening, please send us your comments or questions, we would love to hear them.  Stop by our website, cnsproductions.com and drop us a note and we will respond if we can.

 
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Children of Alcoholics Week and sweets, depression & alcoholism

February 19th, 2010

We look at a new study correlating craving sugar, depression and the tendency toward alcoholism in children; also this is the 2nd annual Children of Alcoholics Awareness Week.

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Transcript (edited):

CNS:   Welcome to the CNS Podcast featuring Dr. Darryl Inaba, research director for CNS Productions.

CNS:   Alcohol and depression in children are topics in this week’s news.   It is National Children of Alcoholics week, (February 14 -20, 2010) not just in this country, but around the world and there is a new study that just came out in Addiction Journal (http://www.addictionjournal.org/viewpressrelease.asp?pr=118) looking at the relationship between sweets, depression and the proclivity towards alcoholism.  How do you view this study?

DARRYL:      Well, it’s confirming what we’ve all suspected and actually clinically observed in treating alcoholics and interacting with their families and their children.  I believe the study looked at about 300 or more children, ages 5 to 12 or so, researchers carefully took their histories and they exposed them to different sugar solutions and asked the children which of the solutions they preferred.  The results showed that the children who preferred the sweetest of the solutions, I think it was 24% sucrose, which is equivalent to about 14 teaspoons of sugar in 8 ounces of water,  I think that is about double the amount of sugar there is in Coca-Cola, so that’s really, really sweet.

CNS:   And Cola’s are plenty sweet.

DARRYL:      Absolutely, and the children who preferred that level of sweetness had parents who were alcoholic and/or depressed and the children were also exhibiting depression.  So the conclusion from this study implies a need within children who may be predisposed towards alcoholism and depression to crave high amounts of sugar which creates the dopamine effect in the brain or in the reward reinforcement center that sends the message that a basic need is being fulfilled. Researchers believe this preference for more sugar is a need to stimulate that center to a higher level than normal. These children need a lot more dopamine released in their brains in order to appreciate it.  They are postulating that these kids need a lot more sugar, but get a weaker effect or get a weaker satisfaction from it.  That’s a prelude to alcoholism.  They’re not saying it actually predicts that the children are going to be alcoholics, but we do observe when alcoholics come into treatment, residential treatment is where we really see it, they really prefer sugar when they first come into treatment.  And they crave sugar any place they can get it…candy bars, whatever.

CNS:   Right, of course the alcohol breaks down into sugar.

DARRYL:      Right and they have, I guess, a greater need for more.  Even though they’re taking in a lot more it’s not satisfying them.  So…it is a common thing for the alcoholic, the heroine addict too, is first thing in the morning they reach for a  Jolt or a Coca Cola or something with a lot of caffeine and a lot of sugar in addition to their drug.  So there is, I think, a clinical correlation to this craving for sugar or need for more sugar that may be greater in those who are predisposed to or ill with the condition of alcoholism and addiction.

CNS:   Sounds like a bunch of double whammies, all on top of each other.  If you have sugar proclivity, #1 that’s going to inch you towards being overweight and obese and if you are one of those likely to become an alcoholic, then the alcohol turns back into glucose.

DARRYL:      This also speaks to the fact that there is an epidemic of metabolic disorder in the United States.  The tendency toward Type II diabetes is just horrendous.  I think the last report, indicated maybe a good third of the country or close to 30% of the population had either a diagnosisable Type II diabetic condition or are pre-Type II diabetic.  I don’t think that number is duplicated any place else in the world.  Something is certainly changing in our society in terms of the way we handle food and sugars and in turn, how we are dealing with the problems of addiction.

CNS:   Large scale processed food, fast food, is of our generation.  I remember when I was a kid, we lived right down the street from the first McDonalds, and there didn’t used to be so many.  We’re now seeing this profound shift in metabolic diseases.

DARRYL:      Well, I’ve become a compulsive label reader now.  I don’t buy anything without looking at calories, carbs, fiber, sodium and all the different fats. It is just shocking to see what is in our processed foods.  I heard someone saying that the best thing for you diet if you have Type II diabetes, is to stay away from anything that is in a box, a can or bottle.  And from what I’ve read and what I’ve seen that is basically true.  If we hearken back to when we were kids, most of our foods were prepared by our mothers from scratch – fresh vegetables, fresh fruits and fresh ingredients and then cooking them up.  But now…it’s pretty much the norm -even when cooking at home ..you’re cooking out of a box, a can or a bottle.  If there is this link with sugar and the link to the processes in the parts of the brain that reward center in the adult receptor sites and what we call the nucleus accumbens septi_ and if that’s all increasing, we’re also going to be looking at an increase in addiction and in the numbers of people per capita that are affected by alcoholism and other drug addictions.

CNS:   Those numbers have stayed relatively steady, have they not?

DARRYL:      They’ve been fairly steady.  We don’t have a good way of confirming them though.  I mean people usually conceal their addictions.  They don’t come forward with them.  They don’t answer questions honestly when we do a pre-screening for hospitals or medical health care…we still rely on the person telling us the truth when we ask them how much they drink, or if they have taken any drugs. Most people know how to avoid answering that question, so we don’t really know. All we have is based upon the percentage of people who are honest with us so perhaps we are just measuring honesty in America, not the actual incidence of alcoholism and drug addiction.

CNS:   Alcohol use is probably under reported because it is so much a part of society and it is more accepted than taking drugs. A study in England reported that alcohol use in that country is severely under reported.  If a social worker goes into a house for some reason, they make no note of obvious alcohol use, whereas if there is any evidence of blatant drug use, that is immediate cause for intervention or drastic steps.

DARRYL:      Yes, for removing the children and that’s a sad situation because it fails to recognize the impact that alcoholism has on children in an alcoholic family.  We have known for a long time, thanks to authors like Claudia Black, Rachelle Learner – and others, how parents’ use of alcohol, really impacts their children for a lifetime in extremely negative ways.  The national children of alcoholic’s week, now in its second year, brings attention to that. I’m glad to see it happen because it has been noted in the treatment community for as long as I’ve been in the field.  Alcoholism is selfish, and I’ve always used that when we do family therapy. Someone with an alcohol problem looks at themselves and they may feel guilt, and shame and they may feel concern about some of the personal consequences that their behavior brought about, but they fail to look at the consequences that their drinking had on the people who love them – their spouses their children and their families.  We’ve noted that the children of alcoholics, in order to deal with the uncontrolled drinking of their father or mother, develop very specific personality types that stay with them throughout their life and make it difficult for them to engage in relationships and to have an appreciation for life.  Oftentimes the oldest child is what we call the “model child” – they see so much dysfunction going on, they care for their siblings, and take on the role of the parents.  They kind of overdo the “goodie” role and cook for the parents, make teacher’s appointments for the parents and just take care of all the siblings and grow up with such a fear of drinking that they remain sober.  They don’t even experiment because they’re afraid of the process.  And then there is the “problem child who at an early age starts drinking, using drugs, starts to act out in delinquent ways, causes problems at school and is just a problem.  Alcoholic parents pay so much attention to drinking, that the kids get very little attention and one of the ways to get attention is to be a problem.  Because if you’re a problem – even though it’s negative attention – you get slapped or yelled at or…you get put down…you get time outs… you get all these punishments from parents, but its attention anyway and you’re getting your parents to interact with you.  Another personality type that has well been documented is the space case – this is the child who deals with the dysfunction in the family by ignoring the elephant in the living room.  They tune out of everything – they will step over their father on the way to school without even noticing they’re stepping over a drunken father; will not mention their parents and ignore them when they’re in a drunken state. They become totally spacey and detached from all things around them for the rest of their lives. Another way some kids deal with alcoholism is to become the family clown.  This child learns that humor seems to gloss over every single problem in the family.  So he or she learns to use humor inappropriately.  Everything becomes a joke and everything is humor.  But those are classic characteristics of children of alcoholic parents, documented by a number of authors.  The British noted that in America children of alcoholics are often abused in much higher percentages than children coming from parents who are not drinkers and children of addicts and alcoholics are 4 to 5 times more likely to develop those problems in their adult life than are children from non-alcoholics.

CNS:   Which is something like 1 in 20 people?

DARRYL:      Right.  There are also higher rates of assault and other criminal situations amoung addicts and alcoholics and that exposes their children to a lot more damage.  So basically, it is a well-known and well-documented fact that children of alcoholics are going to suffer tremendously…tremendous consequences from the act of their parents drinking and drugging and yet, as you mentioned at the start of this, our society and our social systems seems to pay less attention to alcohol than to other addictions. Case workers go into a home and see a parent actually involved with domestic violence, which is frequent in alcoholism, and they take the kids because of domestic violence, not alcoholism.  They see the parents smoking marijuana, they take the kids – but if the parents are drinking, it’s not a major alarm, in and of itself.

CNS:   Because it’s so ubiquitous in society and it’s legal.

DARRYL:      I think society has failed to realize that drinking and being an alcoholic has tremendous consequence on children. We tend to focus on the catastrophic consequences affecting the individual, how their lives are falling apart and the need to treat them that we forget that their behavior is impacting their families in a horrible way.  We can see that by looking into family health records once an alcoholic is identified.  It turns out that the families of alcoholics greatly overuse their health insurance and health benefits compared to families of non-alcoholics.   We can see the horrendous impact of alcoholism extending beyond the active drinker, onto their families who may or may not be drinking.

CNS:   The most important thing to do is to pay attention to this.  Pay attention to the family around you…to the people around you and…not just bury our heads.

DARRYL:      Well, that’s the good thing about this (Children of Alcoholics Week).  Although these issues have been around for as long as I’ve been in the business here and treating addicts and alcoholics for over 40 years, it’s sort of a tragedy that this is only the second year of a national awareness campaign…national awareness week, but I’m glad it’s happening.  So now some people may pay more attention to it and we may be able to generate resources.  There are Al-anon groups for families of addicts and alcoholics.  In good treatment programs and every program I’ve been involved with, we insist that families get some sort of family therapy.  Usually on weekends family members may be working or going to school, so on weekends we want the whole family to come in to learn about this condition, learn about how they are impacted by this condition and learn the resources available to help them regain a normal quality of life rather than having to continue to suffer from the effects of somebody’s alcoholism.

CNS:   We would love to hear comments on this topic or any others, so please do, if you have a comment or question, stop by our website and leave us a note or ask a question.  The website is cnsproductions.com.  And we will talk more about these and related issues in the weeks to come.

 
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Treatment alternatives, the placebo effect and FDA approval process

February 12th, 2010

We look at alternative aspects of treatment, such as the Buddhist 12-step program, and issues of “drunk-dreaming” as well as a new study review of anti-depression medication studies, the placebo effect and the FDA drug approval process.

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Transcript (edited):

Welcome to the CNS Podcast featuring Dr. Darryl Inaba, research director for CNS Productions.

CNS: There are some interesting things in the news this week that talk about different aspects of treatment that we haven’t looked at before.  The Buddhist approach to the 12-step program that was in the Huffington Post recently and an article by one of their regular commentators talking about “drunk dreams” experienced by people in recovery.  They do okay during the day, but apparently at night they’re tortured to some extent by their dreams.

DARRYL:  The concept of alternative treatment or complementary medicine as it relates to addiction is getting more attention and I think treatment programs should take a closer look.  Things like yoga have good evidence based studies that show it is effective in helping maintain recovery.  Buddhist meditation, mindfulness meditation or just mindfulness is also proving to be as effective as a 12-step program.  Acupuncture is considered alternative treatment and shows tremendous usefulness in the treatment of addiction.  So, what is considered alternative or complementary can help addicts.  Equine therapy, pet therapy, aroma therapy and energy focused techniques like tapping are beginning to show evidence that they are effective.

In regards to dreams, you can have two types or maybe multiple types, but the two types the article refers to were dreams about getting high.  People experience euphoric effects in their dreams – wake up and are triggered into missing their drug.  That’s something that mindfulness meditation and Buddhism could be really helpful for because in Buddhism you don’t shut out or get rid of your thoughts, your thoughts are there and what you do is learn how not to react to them in a negative way.  You learn to be aware of your thoughts, but not to react to them.  The other types of “using dreams” are nightmares.  They are terrifying dreams.  They’re dreams in which you are back in relapse, suffering a tremendous amount of negative effects but not getting high at all; or you’re at home and the cops are breaking in and you’re paralyzed.  You can’t move a muscle to swallow your stash or flush it down the toilet and so you’re going to get busted.  Those are terrifying nightmares of a user’ past even though they can be useful because they help reinforce how far some one has come and how much they have accomplished and what they need to do to stay focused on recovery.  The problem dreams referred to in the article are euphoric dreams.  The euphoric dreams recall the feeling of being high, you dream you’re stoned.

CNS:   This can act as a trigger and according to the article, it provoked guilt and fear that they were losing track of their recovery.

DARRYL:      Dreams are an access to the subconscious and they’re generated by what we call the memory spikes or the memory bumps that have formed in the brain from the use and involvement with drugs.  And, as far as I know, you never lose those memory bumps, those memory spikes, they’re always there.  The brain of a person in recovery doesn’t use or access those memories so they become weaker, less prominent.  This forces the brain to form loose networks of communication links that bypass those memories. But when you are in a sleep state, in a dream state, the access of memory is through the unconscious and through the networks that access the memory bumps associated with drugs. That can be extremely dangerous as we’ve seen with the stop paradigm in the control circuitry of the brain.  Once an addict initiates an action, those memories and those bumps will cause an addict to want to use again and almost nothing is going to stop them because of the dysfunctional control circuitry of an addict’s brain.  There are reports of people who have been 10 years, 20 years, maybe even 30 years in continuous recovery, having a using dream, waking up, and almost on a subconscious basis, picking up a hit. The next thing you know they’re in a full scale relapse.  So it’s something we need to pay more attention to, to help addicts plan a strategy that will prevent them from using if they experience one of these dreams.

CNS:   Another interesting story comes from Newsweek recently about the efficacy of placebos in contrast to antidepressant drugs.  A new study indicates that 75% of the people participating in a couple of studies responded positively to sugar pills as opposed to serious antidepressant medication.  What are your  thoughts about placebos in general?

DARRYL:      Well, first of all, Howard, the study does not surprise me at all.  People should never short change or under appreciate the placebo effect.  The medications that are developed to treat depression, to treat any kind of mental health issue, as well as any process in the brain, are simply mimicking or interfering or interacting with natural brain chemicals.  We already have this whole pharmacy in our brain that consists of natural chemicals that serve as anti depressants, that manages excitement, fear and things like that. Placebos access that natural chemistry without actually using a drug.  It’s the expectation of an effect or an expectation of some sort of benefit that causes a person to actually benefit from their own chemistry.  Placebos create a true and powerful physiological reaction in people.  I participated in placebo experiments as a student at University of California in Dr. Field’s laboratory.  He had a lot of pharmacy,  medical, and nursing students participate by taking a pill, which contained one of 3 possible drugs. All the pills were exactly the same so we didn’t know what we were getting and he didn’t know what he was giving us. This was a regular pharmacology double-blind crossover type of study, which is the Gold standard in terms of doing research on the efficacy of pharmacological substances.  We got either 10 mg of methamphetamine, or 60 mg of codeine or milk sugar, the placebo.  And it profoundly affects me to this day to remember that in this research, where nobody knew what they were getting, we had to measure our reaction…our blood pressure, pulse rate, our reaction ability, our ability to coordinate our muscles and our equilibrium.  We had to do all these studies 30 or 40 minutes after the pill was absorbed through the stomach to see what would happen.  Later on the code was broken, showing which student got which drug or the placebo and it was amazing to me that about 1/3 of the people who got only milk sugar had such dramatic physical reactions.  Their blood pressure changed.  Their heart rate changed. They experienced all kinds of physiological responses. I remember some people were actually hallucinating and experiencing a whole array of mental issues when in fact they got a placebo.  Placebos are powerful in their real responses.

The second thing the Newsweek article pointed out is that we don’t have a good way of really evaluating medication.  Double-blind crossover studies are designed to be used at the mid-point of research. For example, patient A who got pill #1 will get pill #2 at the crossover and patient B will switch from pill #2 to pill #1. This allows the researcher to get clarity on whether the patient is really reacting to the medication, to the placebo or to some other artifact of the study.  The problem with crossover double-blind studies is they sometimes present an ethical question.  That actually came up once during a syphilis study. The question was could a cynical compound or antibiotic treat syphilis.  Placebos were given and it became a huge ethical issue. If someone has this debilitating, horrible disease and they receive milk sugar, their disease could get worse and worse and the person could suffer tremendous biological or medical problems. So is that something we should be doing?   When a crossover design is not applied properly there is no way of determining the benefits from the pill. Is it a true antidepressant or are we seeing it as a partial placebo effect or a combination of placebo and antidepressant effects?

CNS: Another question addresses the FDA process which can take a long time and can keep drugs off the market here when they are in use already in Europe.

DARRYL:      America is restricted from a lot of medications that might be effective for people who are suffering a disease. Is the push to get them approved as quickly as possible for the benefit of the patient or the company with a vested interest in getting it approved? The faster they get approval, the more time they have to benefit from their patent.  A patent runs for 17 years after a drug is first registered. This includes development as well as the time the drug is put through the scrutiny process to determine its efficacy and its safety. The longer it takes to do that, the less time a drug company has an exclusive patent on the medication and the less money they will make.   So, there are those two conflicting problems and I can see both sides.  I can see the economic interests winning out sometimes in the pharmaceutical industry, but I also see the clinical issue. The FDA gets a lot of heat for the restrictions and difficulty in getting a medication approved that has the potential to ease suffering and save lives – there are people suffer or die waiting for drugs to be approved.  There are two sides to this coin and we may have to find a way to strengthen our ability to address both sides so medications can be approved quickly enough, but at the same time be sure that the medication is going to do what it says it will and be extremely safe and not cause more harm.

CNS:  Back to efficacy of the antidepressant medication. In many cases, it is the primary care physician, not the psychiatrists who are treating a patient for depression and it is easier for them to prescribe a pill rather than explore a whole range of things that might be most efficacious.

DARRYL:      That is a concern, I think in psychiatry and in all the medicine.  The majority of anti-psychotic, antidepressant, mood stabilizing drugs are prescribed by non-psychiatrists – by people who have very little training in regards to these medications and what they do, but more importantly very little training in the whole mental health diagnosis, prognosis and treatment alternative processes.  That’s something that has to be more effectively addressed because I do think we are not as effective as we can be in addressing the mental health treatment needs.

CNS:   Treatment is certainly on the front burner here in terms of a topic that is important and that’s going to be increasingly in the news as we see the mental health parody act go into effect.

We are always delighted to hear listeners’ comments or questions.  Stop by our website: www.cnsproductions.com.  Drop us a note and we will respond if we can.

 
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