Podcast Summary
Polypharmacy: Too Many Medications Increase Risks: Polypharmacy can lead to decreased compliance, worsening side effects, and negative impacts on various aspects of life. Healthcare professionals should minimize the number of medications prescribed to each patient.
Polypharmacy, or the use of too many medications, is a common issue in healthcare that can lead to increased risks for patients. As the number of medications increases, so does the risk, not just linearly but exponentially due to interactions between medications at the level of pharmacodynamics and metabolism. These interactions can lead to decreased compliance, worsening side effects, and negative impacts on various aspects of life such as work, study, relationships, and sexual function. It's important for healthcare professionals to be aware of the risks of polypharmacy and strive to minimize the number of medications prescribed to each patient whenever possible.
Polypharmacy in Psychiatry: Complex Reasons for Multiple Medications: Polypharmacy in psychiatry can lead to increased side effects due to pharmacodynamic and metabolic consequences. Reasons for polypharmacy include patient expectations, psychiatrist's desire to help, and external pressures from pharmaceutical companies.
The use of multiple medications in psychiatry, also known as polypharmacy, can lead to an increase in side effects. This is due to both pharmacodynamic and metabolic consequences. However, it can be challenging to determine if the sickness is demanding more treatment or if the treatment is causing the adverse effects. The reasons for polypharmacy are complex and include patient expectations, the nature of psychiatrists to help and heal, and external pressures from pharmaceutical companies. These companies may try to influence psychiatrists to promote their new medications, even if the mechanism of action is not well understood in psychiatry. Ultimately, understanding the mechanisms behind the side effects of multiple medications can help us find ways to improve patient outcomes.
Pharmaceutical influence in medical education: Pharmaceutical companies can impact prescribing habits through seemingly insignificant means like providing lunches, making it essential for healthcare professionals to remain unbiased and provide balanced education.
The influence of pharmaceutical companies in medical education, even through seemingly insignificant means like providing lunches, can impact prescribing habits and potentially create biases. This is why some healthcare professionals strive to remain unbiased and provide a balanced education on various treatment modalities. The multibillion-dollar pharmaceutical industry is always looking for ways to influence doctors to prescribe their products, and it's essential to be aware of this influence and its potential impact on patient care. The base motivations of healthcare professionals, driven by the desire to help alleviate suffering and the constant pursuit of new treatment options, make them susceptible to this influence. The complexity of treating conditions like depression, with multiple treatment options and a lack of clear understanding of the best approach, further compounds the issue. Education on new mechanisms and treatment options can be exciting, but it's crucial to approach them with a critical and unbiased perspective.
Progressive strength training is crucial for mental health improvements: Progressive strength training with progressive overload leads to significant mental health improvements, potentially reducing the need for medication.
While many physicians may encourage walking as a form of exercise, it's not enough to achieve the desired effect for mental health, which is comparable to that of an antidepressant. Instead, progressive strength training, where weight is added over time for stress recovery adaptation, is crucial for improving both physical and psychological resiliency. This form of exercise, when done correctly with progressive overload, can lead to significant gains and better outcomes. Unfortunately, most physicians may not be knowledgeable about strength training and its benefits. Additionally, diet plays a significant role in mental health, with studies showing effect sizes similar to those of exercise. However, the impact of diet interventions may depend on the initial dietary habits of the patients and the role of placebo effect in the study design. Overall, incorporating progressive strength training and diet interventions into mental health treatment plans could lead to substantial improvements, potentially reducing the need for polypharmacy.
Placebo effect impacts perceived effectiveness of treatments: Maintain hope in treatment, keep expectations realistic, explore alternative modalities, and consider a holistic approach to mental health treatment.
The placebo effect can significantly impact the perceived effectiveness of medical treatments, including psychiatric medications. This was highlighted in the discussion with examples of deep brain stimulators and mammary artery ligation, where patients reported noticeable improvements despite no observable changes in their conditions. The problem arises when patients become reliant on medications and end up on multiple prescriptions, leading to a multitude of side effects. To address this, healthcare providers should maintain hope in treatment while keeping expectations realistic and focusing on the therapeutic alliance. Alternative treatment modalities like psychotherapy, sleep studies, and partial hospitalization programs should also be explored. Seroquel, a common sleep aid, was mentioned as an example of a medication with various pharmacological effects, but limited evidence for its use as a sleep aid. Overall, the conversation emphasized the importance of considering a holistic approach to mental health treatment, rather than relying solely on medication.
Seroquel's use for sleep not well-supported: While Seroquel may improve sleep quality, its potential side effects and lack of strong evidence make it a less favorable option compared to other sleep treatments.
While a study suggested that Seroquel could improve sleep quality in young people by increasing stage 2 sleep, its use for sleep is not well-supported by evidence due to potential side effects, particularly the risk of metabolic syndrome. Antihistamines and alpha blockers can also be sedating but have their own risks. The lack of compelling evidence and significant side effects make Seroquel a less favorable option for sleep compared to other treatments like benzodiazepines, Doxepin, or even marijuana in some cases. Prescribing Seroquel for sleep should be considered carefully, taking into account the individual's specific needs and potential risks.
Anticholinergic medications and cognitive function: Studies show that higher anticholinergic burdens from medications like Seroquel can lead to decreased cognitive function, which can be mistakenly attributed to the disease itself. It's crucial for mental health professionals to consider potential medication side effects and educate patients to make informed decisions.
The anticholinergic effects of certain medications, particularly Seroquel, can significantly impact cognitive function, leading to a decrease in IQ. This is especially concerning for individuals with schizophrenia or schizoaffective disorder, as the study by Yoshi in 2021 showed that higher anticholinergic burdens, meaning the more potent anticholinergic medications and the higher the number of those medications, resulted in lower cognitive scores. This decline in cognition can be mistakenly attributed to the disease itself, but it's essential for mental health professionals to consider the potential role of unnecessary medications in exacerbating cognitive impairment. For instance, prescribing anticholinergic medications like Cogentin or Benadryl to prevent extra pyramidal symptoms (EPS) in patients who have never experienced them is unnecessary and can lead to further cognitive decline. Instead, it's crucial to educate patients about the risks and benefits of these medications and provide them with accurate information to make informed decisions. By being vigilant about polypharmacy and the anticholinergic burden, mental health professionals can help mitigate the potential cognitive side effects and improve overall patient care.
Managing Multiple Antipsychotics for Schizophrenia: Despite limited evidence, many patients with schizophrenia require multiple antipsychotics. A study found increased hospital readmissions for antipsychotic combinations, but inpatient psychiatrists may struggle to justify their use. A suggested approach is to give one day's recommendation at a time and reassess patients afterwards.
The use of more than one antipsychotic medication to treat schizophrenia or psychosis is a common clinical practice, despite limited evidence supporting its effectiveness. This is due to the fact that a significant number of patients do not respond adequately to a single antipsychotic, leaving many requiring additional treatment. A study by Jari T. Hohen in 2019 examined combinations of antipsychotics using a large Nordic registry and found hazard ratios for readmissions to hospitals for antipsychotic combinations compared to no antipsychotics. However, the clinical reality often differs from the evidence, and inpatient psychiatrists may struggle to justify using multiple antipsychotics due to the lack of clear guidance. One approach to managing this challenge is to give one day's recommendation at a time and reassess the patient when that time is up, as suggested by Maldonado, a renowned CNL psychiatrist. This method helps minimize polypharmacy and ensures that patients are only receiving necessary medications.
Combining Clozaril and long-acting injectables for best results in inpatient psychiatry: Understanding the right combination and dosage of antipsychotics is crucial for effective inpatient psychiatry treatment and reducing readmission rates. Consider long-acting injectables and Clozaril, but ensure blood levels are checked and current meds maximized before adding another.
When it comes to treating patients in inpatient psychiatry with antipsychotics, understanding the right combination and dosage can significantly impact readmission rates. According to the discussed study, the best combinations include those with Clozaril and long-acting injectables. However, it's important to note that this study has limitations, such as not checking blood levels or pushing current medications to their therapeutic limit before adding another. Dr. Cummings, a mentor in the field, would likely argue that getting blood levels checked and maximizing the effectiveness of the current medication before adding another is crucial. He also emphasizes the importance of considering the consistency and high compliance rates of long-acting injectables before moving on to more complex treatments like clozapine. The study also suggests an interesting combination of Abilify and another antipsychotic, which warrants further exploration. Overall, this discussion highlights the importance of individualized treatment plans, thorough understanding of medications, and careful consideration before adding additional antipsychotics.
Minimizing Polypharmacy in Psychiatry: Psychiatrists should use SAIL to keep regimens simple, consider adverse effects, and ensure accurate lists to minimize polypharmacy. Understand patient motivations and abilities to gradually reduce medications and encourage lifestyle changes.
Minimizing polypharmacy is crucial in psychiatry to avoid irrational use of multiple medications and potential harm to patients. The SAIL acronym (Simple, Adverse Indication, List) can help guide decision-making by keeping regimens simple, considering adverse effects, and ensuring accurate lists. Polypharmacy itself can be seen as a clinical entity, and psychiatrists should consider the reasons for it and weigh the risks and benefits before making treatment decisions. Sometimes, polypharmacy may serve as a way for patients to connect with providers, but as the therapeutic alliance improves, medications can be gradually reduced. Additionally, understanding a patient's motivations and abilities is essential to determine when and how to bring down medications and encourage lifestyle changes, such as exercise and diet.
Beyond Medication Management: Building a therapeutic alliance that goes beyond medication management is crucial for effective mental health treatment. Mentorship and coaching can lead to significant personal and professional growth.
While medications play a crucial role in mental health treatment, they should not be the sole focus of the therapeutic relationship. Connection with patients through emotions, desires, pleasures, and relationships is essential for effective treatment. Psychiatrists, including Dr. Jake McBride, emphasize the importance of building a therapeutic alliance that goes beyond medication management. Additionally, mentorship and coaching, especially for early career professionals, can lead to significant personal and professional growth. Regarding Dr. McBride's personal life, he shared his concern about the impact of excessive screen time on older patients and the importance of physical and interpersonal challenges.
Exploring Values through Literature: Reading literature like The Iliad, The Hobbit, and The Lord of the Rings to children instills important values and wisdom, and fosters a love for learning. These books offer lessons on concepts like courage, hard work, and the corruptive nature of power.
Raising children involves finding ways to challenge them while keeping things playful and interesting. Parents can instill important values and wisdom through various means, including physically and intellectually challenging activities. Books like The Iliad, The Hobbit, and The Lord of the Rings offer valuable lessons that can help children understand concepts like courage, hard work, and the corruptive nature of power. Reading these books aloud to children also demonstrates their value and can help foster a love for learning. Western values, such as the corruptive ability of power and the importance of quiet heroism, can be introduced through literature and are essential for children to learn. The Hobbit, for example, is an accessible and valuable resource for teaching these concepts to children.
The Hobbit teaches us about the corrupting influence of greed and the importance of choosing the right path: The Hobbit illustrates the dangers of greed and the insignificance of wealth compared to other aspects of life. Bilbo's journey highlights the importance of courage, choosing the right path, and putting others before one's own comfort.
That stories like "The Hobbit" hold significant value as they impart valuable lessons, particularly about the corrupting influence of greed and the insignificance of money compared to other aspects of life. The story illustrates how both the dragon and certain characters were corrupted by gold, while the hero, Bilbo Baggins, remained relatively uncorrupted due to his disinterest in wealth. This lesson has resonated with the speaker's children, who now view life as more than just accumulating wealth. Additionally, Bilbo, as a humble hobbit, chose adventure and putting others before his own comfort, highlighting the importance of courage and choosing the right path even when faced with the allure of a comfortable lifestyle. This theme of choosing the right path and acting on it, even when faced with fear or comfort, is further emphasized by Gandalf's guidance to Frodo in "The Lord of the Rings." Overall, these stories serve as reminders to access the quieter voice of courage and choose the right path, even when faced with the temptation of comfort or fear.
Embrace the hero's journey in mental health practice: Prioritize individualized care and navigate complexities with expertise and judgment, seeking guidance from mentors and colleagues.
As psychiatrists and mental health professionals, we have a great responsibility to go beyond the easy solutions and engage in difficult conversations with our patients, even when it may be more convenient to avoid them. These conversations can be emotionally challenging, but they are essential for ensuring the best possible care for our patients. The opioid epidemic serves as a cautionary tale of what can happen when we prioritize convenience and wealth over the well-being of our patients. Instead, we should strive to be heroic in our practice, using our expertise and judgment to navigate the complexities of mental health treatment. It's important to remember that there is no algorithm that can replace the human touch and individualized care that we provide. Seek out mentors and colleagues who can offer guidance and support as you navigate the challenges of your practice. By embracing the hero's journey and committing to the highest standards of care, we can make a positive difference in the lives of our patients.