Showing posts with label medication. Show all posts
Showing posts with label medication. Show all posts

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You want to do what?!?! The importance of informed consent in treatment





By Gail  A. Edelsohn, MD, MSPH





We come across ads in print, on television
and on the Internet for medications and therapies that promise to make your child
do his homework without a screaming match, behave better and generally restore
harmony to home life. Not so easy, taking a medication raises a host of
questions:  How long does the therapy
take? Should I as the parent sign off on this? What about the possible serious
side effects, such as significant weight gain, thoughts about suicide, risk of
diabetes or a life-threatening condition?








Parents and legal guardians make
decisions about psychosocial therapy and medication treatment for children and
adolescents every day. But who should give permission and sign informed
consent?  What should parents, advocates,
guardians be looking for or consider before signing informed consent? Is
signing a form enough?  What about the child
or teen - do they have a voice regarding their own treatment?


What is Informed Consent?


Psychiatric informed consent
involves a parent or legal guardian giving
permission for his/her child to undergo evaluation and treatment.  It is a
process which partly involves receiving sufficient relevant information about
the condition, prognosis, risks and benefits of treatment to be given and other
types of treatment available. Informed consent is NOT simply a signed and dated
form. Parents and guardian should expect informed consent to include:




  The purpose of the treatment


  • To address a specific condition or diagnosis?



  • To lessen symptoms?



  •  To change behaviors?


  The effects of treatment


  • How will you know if it is working?



  •  How long till you see an effect?


  Risks of treatment


  • Side effects of medications



  • Consequences of psychosocial treatment (e.g., therapy
    can be emotionally difficult)


  Risks of NO treatment


  • Will symptoms improve over time without
    treatment?



  • Will things get worse or lead to other
    consequences? (e.g., Untreated individuals are more likely to use substances,
    get into legal trouble)


  What alternative treatments are available?
  

For medication


  • Is it FDA approved for this age and condition?
    (i.e., prescribed FDA on label)



  • If it is prescribed off-label, why?



  • Are there any FDA warnings about the medication
    and what do they mean?



  • What is the plan for stopping or phasing out the
    medication?









     Parents and legal guardians are
asked to give legal permission or informed consent for treatment.  If a child is in foster care, it may be the
parent or it may be child welfare service or court that can give consent.   Where a child is living (home, out of home
placement) does not tell you who the legal guardian is.  In some states an adolescent may give
informed consent for psychiatric treatment depending on the state’s legislation
about mental health procedures. Ideally the parents/guardians and the child
should be involved in treatment decision making.



Children also have a voice in
this process.  Children and youth should
be involved in giving assent.  Assent involves providing the child or teen
with information about the therapy or medication in terms appropriate to their
age and stage of development. The assent process should include opportunities
for the child/adolescent to ask questions and have their concerns addressed.






Gail A.
Edelsohn, MD, MSPH, is senior medical officer with Community Care Behavioral
Health, clinical professor of psychiatry and human behavior,  Jefferson
Medical College, and clinical professor of psychiatry and behavioral science,
Temple University School of Medicine.

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How Psychotherapy Changes the Brain

By Serina Deen, MDMPH



When I first see patients for evaluation, they often tell me
that they’ve debated starting a “biological” treatment such as medication,
versus a “psychological” treatment such as psychotherapy. I’m happy to report
that as brain imaging technology advances, we’re finding that this distinction
may be obsolete. 




Psychotherapy is also “biological” in that it can lead to
real functional and structural changes in the brain.   In fact, sometimes psychotherapy and
medication produce surprisingly similar changes in the brain.  We still have a lot to learn about the topic,
but below are some examples of what researchers have been finding so far.

Functional Changes in
the Brain:

In one study, researchers at UCLA found that people who
suffered from depression had abnormally high activity in an area of the brain
called the prefrontal cortex.  Those who
got better after they were treated with a type of therapy called interpersonal
therapy (IPT) showed a decrease in activity in the prefrontal cortex after
treatment.  In other words, IPT seemed to
“normalize” brain activity in this hyperactive region.



Another study looked at people who have obsessive compulsive disorder (OCD), who tend to have an overactive area of the brain called the
caudate nucleus.  Treatment with a type
of therapy called cognitive behavior therapy (CBT) was associated with a
decrease in the hyperactivity of the caudate nucleus, and the effect was most
evident in people who had a good response to CBT.  In other words, the better the therapy seemed
to work, the more the brain activity changed.




Changes in Brain
Volume:




People with chronic fatigue syndrome (CFS) suffer from debilitating
fatigue.  People with CFS tend to have a
decrease in a type of brain tissue called grey matter in the prefrontal cortex
of the brain.  Researchers in the
Netherlands gave people with CFS 16 sessions of CBT, and found significant
increases in gray matter volume in the prefrontal cortex.  This seems to suggest that the CFS patients
were able to “recover” some gray matter volume after CBT.


Similarities and
Differences to Medications


Psychotherapy sometimes seems to work in similar ways as
medications, and other times appears to have different mechanisms of action.


In the study mentioned previously about people with
depression, both IPT and the antidepressant paroxetine (Paxil) showed a
decrease in prefrontal cortex activity.  And
with OCD patients, both CBT and the antidepressant fluoxetine (Prozac) produced
similar decreases in activity in the caudate nucleus. 


However in a different study, the antidepressant Venlafaxine
(Effexor) produced changes in different parts of the brain than IPT in
depressed patients.  This shows that there
is variability in how different treatments work in the brain.


How Psychotherapy
Produces Brain Change


We now know that the brain keeps changing, even after we
become adults.  Learning leads to the
production of new proteins, which in turn can change connectivity in our brains
in a process called neuroplasticity.   Indeed, researchers in Germany showed that
certain neurochemicals involved in neuroplasticity increased in depressed
patients who got better after a course of interpersonal therapy. 






Picking a Treatment
that Works Best for You

Even though we know that both medication and psychotherapy
can change our brain, we still have a long way to go in learning exactly how
that happens and when to use what treatment. Given a specific mental illness,
sometimes medications work best, sometimes psychotherapies are the best option,
and sometimes it’s a combination of the two. 
In addition, there are different types of psychotherapies that work for
different illnesses, just as there are many different types of
medications.  If you’re considering
seeking help for mental illness, it would be helpful to talk with a trained
professional about what would work best for you. 





Read tips on what to expect during your first visit with a psychiatrist  





"Let's Talk Facts" brochure on Psychotherapy




Brain Awareness blog post from NIMH Director Tom Insel, MD








APA Releases List
of Five Uses of Psychiatric Medication to Question









Six tips for talking to your doctor about medication









For more information about psychotherapy














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Effective Addiction Treatments are Available




By John Renner, MD and Frances Levin, MD






We are all saddened by the death of Philip Seymour Hoffman and the many other
individuals who have died because of overdoses of heroin or pain
medications.  For all of those individuals who struggle with opioid use
problems, it is important to realize that help is available and that effective
treatment can restore them to productive lives.  Some 4.7 million people
in the U.S. have used heroin at least once in their lives.  It is estimated that nearly a quarter of
people that use heroin become dependent on it.



Whether it be through mutual support programs such as NA, long-term residential
treatment, or addiction pharmacotherapy with buprenorphine, methadone or ER
naltrexone, no individual need fear that their condition cannot be
treated.  Friends and family members also need to be educated in the use
of intra-nasal naloxone for the reversal of opioid overdoses.  



APA has long fostered the development of addiction focused training programs
for psychiatrists.  Many psychiatrists have been specifically trained
to provide office-based addiction pharmacotherapy and to manage the
co-occurring psychiatric disorders that often complicate recovery from
substance use disorders.  






More information:

·        
Information on addiction

·         Opioid Overdose Prevention Toolkit (SAMHSA)

·        
Substance
use treatment locator (SAMHSA)

·        
Buprenorphine Physician
and Treatment locator (SAMHSA)

·        
For psychiatrists:  Providers
Clinical Support System for Medication Assisted Treatment






Blog
contributors:




John
Renner, MD

Member, APA Council on Addicition Psychiatry (Past Chair)
Director of Addiction Fellowship Program,

Professor of Psychiatry,  Boston University School of Medicine



Associate Chief of Psychiatry, VA Boston Healthcare System


















Frances Levin, MD



Chair, APA Council on Addiction Psychiatry
Kennedy-Leavy Professor of Psychiatry, Columbia University Medical Center

Director, Addiction Psychiatry Fellowship,

New York Presbyterian Hospital

New York State Psychiatric Institute










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APA Releases List of Five Uses of Psychiatric Medication to Question


Continuing
the Conversation about Choosing Wisely:
The American Psychiatric Association Releases List of Five Uses of Psychiatric Medication to Question





Joel Yager, MD, 


Professor, University of Colorado School of Medicine


Chair of the APA Council on Quality Care





Recently the APA released a list of
“Five Things Physicians and Patients Should Question” in Psychiatry as part of
the Choosing Wisely®
campaign, led by the ABIM Foundation. The list
identifies five specific evidence-based recommendations that can help
physicians and patients make wise choices about their care.





The APA list contains the following
five recommendations:


  • Don’t
    prescribe antipsychotic medications to patients for any indication without
    appropriate initial evaluation and appropriate ongoing monitoring.

  • Don’t
    routinely prescribe two or more antipsychotic medications concurrently.
     

  • Don’t
    prescribe antipsychotic medications as a first-line intervention to treat
    behavioral and psychological symptoms of dementia.    

  • Don’t
    routinely prescribe antipsychotic medications as a first-line intervention
    for insomnia in adults.   

  • Don’t
    routinely prescribe antipsychotic medications as a first-line intervention
    for children and adolescents for any diagnosis other than psychotic
    disorders    .



Why
was this list created?


This list was created to help
clinicians and patients reduce the number of times that certain medications are
routinely prescribed in situations where other initial treatments might be
preferable, and where risks of these medications’ harmful side effects could be
decreased or avoided. 





Does
this list apply to the care of children or adolescents?


For
any indication and for any patient, the potential harms of treatment must be
weighed against the potential benefits. For the Choosing Wisely campaign, the APA recognizes that for some young
patients in some circumstances an antipsychotic medication may turn out to be an
appropriate choice of treatment if the clinical benefits are judged to outweigh
potential harms after the patient receives appropriate initial evaluation and will
receive ongoing monitoring. However, the APA advises physicians and patients to
question the routine use of
antipsychotic medications in children and adolescents for clinical
circumstances where these medications are not endorsed by available clinical
practice guidelines or lack explicit FDA approval indications for their use.





Why
the Choosing Wisely Campaign?


The facts driving the Choosing Wisely effort are well known: Current
health care practices in America spend too much money on unnecessary tests and
procedures that do not benefit patients and that may even cause unintended harm.
According to a report from the Institute of Medicine, up to
30 percent of health care delivered in the United States is wasteful. Providers
and economists agree that these costly unnecessary practices threaten America’s
ability to provide the highest quality of care possible to all patients.





Choosing WiselyThrough the Choosing Wisely campaign and by publishing this list, the APA hopes
to spark conversations between its members and patients about whether certain
tests and treatments are really necessary or the best ones to choose. The APA joined
the campaign because it recognizes
that physicians have professional, moral and ethical responsibilities to take
the lead in addressing these challenges.





While the APA has taken a bold step in
identifying and developing the list, our work doesn’t stop here. Over the
coming months and years, the APA will be working with the ABIM Foundation,
Consumer Reports, and a variety of other Choosing
Wisely campaign stakeholders to raise awareness of these lists and to make
them available to patients and the public at large.     





Learn more about Choosing Wisely and read all the lists released to date at www.choosingwisely.org.







www.choosingwisely.org

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What to do about side effects of antidepressant medications?


By Felicia K. Wong, M.D.





There are various treatment options for depression including therapy and medication. Antidepressant medications can be extremely helpful to the recovery and healing process of someone suffering from depression. However, sometimes medications that are meant to help may cause unpleasant side effects. The most common symptoms my patients report include headache or upset stomach. These typically improve after a few days and go away within a few weeks. If such side effects remain, you should discuss other options with your doctor / psychiatrist. He or she can try a different medication or treatment option; just be sure to stay in touch with your physician to find the best treatment choice for you.





If the side effects seem intolerable, you may be tempted to stop taking an antidepressant or to reduce your dose on your own. Don't do it. Stopping your antidepressant suddenly may cause your symptoms to return and could cause an unpleasant withdrawal-like reaction. That’s why it’s so important to talk to your doctor.



The Mayo Clinic provides a wonderful resource with practical tips for coping with some of the most common side effects of antidepressant medications that includes explanations for the side effects. For example, sometimes people may gain weight because of fluid retention or lack of physical activity, or because appetite returns or improves when depression symptoms ease up. The resource also presents coping strategies such as cutting back on sweets and sugary drinks, avoiding fast food, and getting regular exercise most days of the week – since exercise is also known to help with depression.





Find more tips at Mayo Clinic online.

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Should your Doctor be your Friend?

By Jeffrey Borenstein, M.D.


Last Friday, October 14th, I was asked to be a guest on the Dr. Drew show to address the important issue of the doctor-patient relationship. Our discussion centered on the friendship between Dr. Conrad Murray and Michael Jackson and the inappropriate crossing of boundaries.


First and foremost, the doctor-patient relationship is special, centered on trust, caring, and helping. But it is not a friendship – friendships are two way streets. The therapeutic alliance in the doctor-patient relationship is a one-way street – the doctor’s role is to help the patient. 


Another issue we discussed was “doctor shopping." When a person who has a diagnosis of chemical dependency gets prescriptions from various doctors in order to misuse medications, typically pain meds or anti-anxiety meds (benzodiazepines), it's called "doctor shopping." When a physician is aware of this behavior or even suspects "doctor shopping," it's the doctor's duty to take action and stop filling prescriptions rather than enable such destructive behavior.


If you have a friend or family member misusing medication in this way, don’t sit by quietly. Taking appropriate action could save a life. Encourage your loved one to seek appropriate treatment. On the Healthy Minds Public Television series, we have two episodes which focus on chemical dependency, episodes #111 and #112 which can be seen at www.wliw.org/healthyminds. 

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Six Tips for Talking to your Doctor about Medication

By Claudia L. Reardon, M.D.



In my last blog, I addressed the factors psychiatrists consider in choosing a given psychiatric medication for a patient. I emphasized the importance of medication selection being a collaborative process between the physician and the patient. In the midst of an appointment with a psychiatrist, though, it can be difficult for a patient to know what to ask, and when and how to ask it. This article includes tips for patients to help them work with their physicians in finding the best medications.

  1. Ask the psychiatrist, “How did you pick that medicine?” Even if you can think of nothing else to ask during an appointment, this single question will probably lead to a wealth of useful information. For example, it might lead to a discussion of the target symptoms, how the medication affects other medications or medical conditions, and side effects.

  2. Make a list of medication questions to ask your psychiatrist at your next appointment. I find it extremely useful when my patients come in with a list of questions they have made since I last saw them in my office. This way, patients are sure not to forget to ask anything important to them.

  3. Take notes during your appointments. It can be difficult to remember everything your psychiatrist says during your appointment, and so bringing a note pad and pen along to take notes can be useful so that later you can remember what was discussed.

  4. Read books. There are a number of excellent books available for patients on psychiatric medications. In my experience, patients find especially useful the book Instant Psychopharmacology by Ronald Diamond, M.D.

  5. Visit websites. Patients should be careful about which websites they visit, as not all are reliable sources of medication information. However, in addition to www.HealthyMinds.org, another reputable site is the NAMI medication website. Go to the NAMI webpage (www.nami.org) and click on the “Medications” tab on the top toolbar.

  6. Try not to be embarrassed. Many patients are embarrassed to talk about concerns they have about medications, especially side effects that they find difficult to discuss. However, remember that physicians hear about all kinds of different side effects, and it is pretty hard to embarrass a physician when it comes to talk about the human body!

In addition to these strategies, you might have found others that work for you in keeping you engaged in your medication treatment. It is imperative to keep the lines of communication open with your psychiatrist and to remember that your physician is there to answer any questions you have.

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Which Medicines and When: Collaborative Process of Finding the Right Medicines

By Claudia L. Reardon, M.D.



Many patients have long and trying journeys on the way to finding medication regimens that work for their psychiatric symptoms. It isn’t always obvious why psychiatrists choose certain medications and avoid others for given patients. In this blog post, I will review the process by which a physician chooses a psychiatric medication. The more the patient knows about how the psychiatrist is thinking through the medication decision-making, the more active a role that patient can play in the process. 


Psychiatrists consider the following issues when prescribing a medication:

  1. Target symptoms. A patient might have many different symptoms, for example, depressed mood, anxiety, trouble with concentration, and severe insomnia. It is important to decide which symptoms should be addressed first, since it is likely that one single medicine will not help all of the symptoms. Doctors often prefer not to start multiple medications at the same time, as it otherwise can be difficult to figure out which medicine is helping or which is causing side effects. Thus, in a patient with the above symptoms, the physician might first choose to address the patient’s depressed mood with an antidepressant. Since trouble with concentration and severe insomnia could be caused by depression, it is possible that treatment with an antidepressant will help those symptoms as well. It is important to address the symptoms in the order that makes the most sense.

  2. Psychiatric diagnosis. The physician cannot simply treat a target symptom with a medication without knowing the overall psychiatric diagnosis. For example, depressed mood could be due to many different diagnoses, including major depressive disorder, bipolar disorder, schizoaffective disorder, drug or alcohol abuse, or medical problems such as low thyroid. All of these would have different treatments. Major depressive disorder would be treated with antidepressants, while antidepressants can actually sometimes worsen bipolar disorder. Likewise, if a patient’s depression is caused by a medical problem, it is essential that the medical problem be addressed rather than simply “band-aiding” the symptom of depression with an antidepressant.

  3. Medical conditions and other medications. It is critical that the physician be aware of all the patients’ medical issues and other medications they are taking. Certain psychiatric medications would be dangerous if prescribed to patients with certain medical problems. For example, some medications can worsen seizure disorders, cause abnormal heart rhythms, or worsen diabetes. Additionally, some psychiatric medications can have dangerous interactions with other medications.

  4. Side effects. Psychiatrists must consider how a given medication’s side effects will impact a given patient. For example, a patient who drives heavy machinery for a living should probably not take a medication that causes drowsiness. On the other hand, sometimes physicians can “take advantage” of side effects. For example, if a patient is sleeping and eating poorly, the doctor might prescribe a medication with sleepiness and increased appetite as side effects.

  5. History of response. If a patient or his or her family member has had a good response to a medication in the past, that might be a good reason to choose that medicine now.

  6. Patient preferences. Finally, and most importantly, the physician must make sure that the patient is willing and able to take the medication being prescribed. If the patient feels that the side effects are intolerable, or simply cannot afford it, it doesn’t matter how reasonable the choice of medication might be since the patient will not take it. The physician should check with patient to ensure they are comfortable with the medication being prescribed. Likewise, patients should not hesitate to speak up if they have concerns about a medication being prescribed for them.



In summary, physicians consider a multitude of factors in choosing a psychiatric medication for a patient. Ultimately, the decision about a medication should be a collaborative one between the psychiatrist and the patient.

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What’s the difference between all these medications?

By Sara Coffey, D.O.





This is a question I am often asked by my patients. Several times a day we see commercials for prescription pills to treat a variety of diseases from high cholesterol to heart disease and treatment for mental illness is no different. Today I would like to talk about one of the most common mental illnesses, Depression and its treatment.



Depression affects roughly 15 million Americans adults, and it is an illness that can be readily treated with antidepressant medications, talk therapy or a combination of medication and talk therapy. Antidepressants have been around for decades and include several classes of medications that work on different chemicals in the brain, but today the first line treatment for depression are medications called, SSRI’s or Selective Serotonin Reuptake Inhibitors. For the most part medications in this class are very similar; they work by increasing the amount of serotonin between nerve cells which is thought to play a role in depression. Unlike a pain pill that works right away, antidepressants can take up to 4 to 6 weeks to have an affect.



Which SSRI a doctor chooses will depend on each individual patient. Just like every other medication, antidepressants can have side effects and interact with the body or other medications in a way that may be dangerous or uncomfortable for patients. Some SSRI’s may be more likely to make a person tired or sedated, while others may have a tendency to give a patient more energy. Depending on an individual’s depressive symptoms, your doctor might prescribe a medicine that would be more likely to help you fall asleep or feel more alert and energetic. Furthermore, certain SSRI’s have been studied more in patients with a particular medical disease, like heart disease for instance and this might leave a physician to try a medication that has research data to show that the medication is safe for their patient. Certainly, some medications work better in some patients than others, and after a period of 4-6 weeks of adequate dosages if no improvement in symptoms occurs your doctor will likely recommend increasing your dose or switching to another antidepressant to treat your depression. In some instances a physician might recommend augmenting your medication by adding another medication that works in a different way to treat your Depression.



Even if the first anti-depressant doesn’t seem to work for you, there are still other options for treatment. Newer medications that work on norepinephrine and dopamine in the brain are also used quite frequently to treat depression, and older medications to treat depression, although they often have more side effects are still effective in treating depression and can be used in refractory cases.



As a patient it is important for your prescribing doctor to know about your symptoms, side effects, and other medical history and current medications that you are taking. And, as always if you have any questions about the medications you are being prescribed don’t hesitate to ask your doctor about your concerns.

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Won’t they do other drugs?



By R. Scott Benson, M.D.



This is a question I get every time I talk with a family about medication treatment for their child with attention deficit hyperactivity disorder (ADHD). And the best answer has been “some will, some won’t”.



But at the APA meeting in New Orleans there was a report from the research group at the Mass General in Boston. They have been able to suggest answers to a lot of question about the outcome of children with ADHD. There is a higher rate of substance use problems in adolescents and adults who have a diagnosis of ADHD. But in this 10 year follow-up of children they asked “What are the predictors?”



Their data confirmed that a diagnosis of ADHD was associated with an increased incidence of drug and alcohol problems. But the finding of severe conduct problems in these children was even more highly associated with future substance use problems.



The take home message for me is that medication alone will not be sufficient to address the severe problems that many children with ADHD present. Parent training, especially for those with severely disruptive behaviors, is a necessary, integral part of their treatment.

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Eight Questions Parents Should Ask About Psychiatric Medications



By R. Scott Benson, M.D.



As a child and adolescent psychiatrist I talk to many parents about treatment options for their children. Whether it be talk therapy or medication, any recommendation for treatment should be based on a thoughtful evaluation.



If medication is recommended, parents find the following questions help in navigating this process. This dialogue with your child's doctor is a first step in forming a team effort for your child's treatment.



  1. How will the medication help my child? How long before I see improvement?

  2. What are the side effects which commonly occur with this medication?

  3. Is this medication addictive? Can it be abused?

  4. Are there any tests which need to be done before my child begins taking the medication? Will any tests need to be done while my child is taking the medication?

  5. How will my child's response to medication be monitored? How often?

  6. Are there any other medications or foods to avoid?

  7. How long will my child need to take this medication?

  8. What do I do if a problem develops (e.g. if my child becomes ill, doses are missed, or side effects develop)?





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