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Sombrero galaxy

Sombrero galaxy. The state of psychiatric medications from a grass roots perspective ORCA conference 11/9/13. Ted Sundin, M.D. Psychiatrist in private practice Psychiatric Consultant, Jackson County Health and Human Services Cell: (541) 621-9182 Email:sunt@grrtech.com. Background:

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Sombrero galaxy

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  1. Sombrero galaxy

  2. The state of psychiatric medications from a grass roots perspectiveORCA conference 11/9/13 Ted Sundin, M.D. Psychiatrist in private practice Psychiatric Consultant, Jackson County Health and Human Services Cell: (541) 621-9182 Email:sunt@grrtech.com

  3. Background: Until age 29 lived in Sweden including medical school. Grew up in dysfunctional home with ETOHism, serious suicide attempt by mother and arguments between parents. 5 years boarding school. From age 13 multiple episodes of Major Depression and Hypomania Residency in psychiatry at OSH and OHSU 10 years inpatient psychiatrist on psychiatric unit at RRMC 11 years working in secure residential treatment facilities 10 years psychiatrist outpatient county mental health center 14 year private practice focusing on treating healthcare professionals, patients with bipolar disorder and holistic/integrative care Presently 4 days a week private practice, 1 at jackson County Mental Health Run bipolar support group 2 times monthly. Weekly Wellness Group at CMHC and private practice, long-term process/retreat group monthly

  4. Case presentations • Patient with long-term hospitalizations, antipsychotic medications and diagnosis of schizophrenia • Retired healthcare professional with 30 year plus history of benzodiazepine use • Short versus long-term reduction of medications

  5. Are we as a psychiatric profession unbiased and objective? Probably not Are the DSM IV and V criteria based on science and not influenced by conflict of interests? No Are psychiatric medications effective? Short-term/long-term? Are there chemical imbalances? -Probably not Do psychiatric medications cause up/down regulations of receptors for neurotransmittors? Yes Could this cause long-term beneficial/harmful effects? Yes

  6. Financial ties between DSM IV panel and the psychopharmaceutical industry • “Of the 170 DSM members 95 (56%) had one or more financial associations with companies in the pharmaceutical industry. One hundred percent of the members of the panels on ‘Mood disorders’ and ‘Schizophrenia and other Psychotic Disorders had financial ties to drug companies. The connections are especially strong in those diagnostic areas where drugs are the first line of treatment for mental disorders.” (Cosgrove 2006 in Psychotherapy and Psychosomatics)

  7. The top 10 psychiatric medications by number of U.S. prescriptions dispensed in 2009, according to IMS Health

  8. Are benzodiazepines effective? • Benzodiazepines are overused and should in the vast majority of cases only be taken short-term. They are often very difficult to get off. Patients are often not warned of the potential dangers including dependency and severe withdrawal symptoms. Several of us are trying to help patients slowly wean off this medications, for many a very difficult process.

  9. Are Benzodiazepines effective? • Short-term mostly yes (maybe first weeks) • Long-term no • When long-term users have withdrawn from benzodiazepines they “become more alert, more relaxed, and less anxious, and this change was accompanied by improved psychomotor functions”. Those who stayed on the benzos were more emotionally distressed than those who got off. Rickels (1999) • Barker et al. (2004) concluded that long-term benzodiazepine users compared with controls were significantly impaired in all cognitive domains that were assessed.

  10. Antidepressants • Antidepressants are overused in our community often without a clear Procedure/Alternative/ Risk /Informed consent process. This is also true for benzodiazepines • No clear evidence presently that SSRI’s are significantly superior to placebo in mild to moderate depression • In severe depression significant difference based on reduced placebo effect? Kirsch 2008 • 50 % of drug withdrawn patients relapse within 14 months. The longer a person was on a antidepressant, the greater the relapse rate following drug withdrawal Baldessarini 1997 (Viguera

  11. What to do? • Consider using alternative treatments to antidepressants for mild to moderate depression • Are there real life stressors that need to be addressed such as relationship issues, unemployment, finances, illegal drug use, sedentary lifestyle etc., etc.? • Antidepressants should always be used for the shortest effective course. • Since there is scant evidence for continuing antidepressants beyond 12 months, and since there is accumulating evidence for long term harm associated with antidepressant use, any treatment plan that includes antidepressant use for longer than 12 months should include a provider-client conversation about tapering protocols.

  12. Antipsychotics • There seems to be conflicting long-term outcomes on treatments for especially Schizophrenia. Some smaller studies seems to indicate that creating social supports, minimal or no medications may have better outcomes. than treatment as usual including antipsychotic medications. See Whitaker’s presentation for more info. • It is difficult to know what influences long-term outcomes including culture, interpersonal and societal stress levels, alcohol and drug issues, poverty etc, etc has on outcomes

  13. Helix Nebula

  14. What have we done in Southern Oregon? “Anatomy of an Epidemic” study group and conference. What happened? What came out of that? Created closer knit community across disciplines Anxiety disorders PI CME Walking your talk PI CME7 Keys Wellness OptimizationMedication Optimization Peer specialists/ recovery versus remission Strength based versus pathology focus

  15. Lessons learned from our “Anatomy of an epidemic” study group • Many of us came to a place of clearly wondering: • What clients should be on psychiatric medications? • If they are on meds should it be short-term, long-term and just targeted? • Who are the clients that safely can go off the medications • Over what length of time? • How much do you reduce the medications at a time?

  16. Lessons learned from our “Anatomy of an epidemic” study group • Patients need to be fully informed of the pros/cons of being on psychotropic medications especially the long-term outcome risk/benefits • They need to make an informed decision about whether they should start taking the medications, stay on them or taper. This process should in my opinion be done on a at least on a yearly basis • We need to stop telling patients that : • they have a “chemical imbalance”-there is little evidence for that • “You need to be on these meds for your whole life”-we don’t know that and it may detrimental to be on them for years, but could also be detrimental if you are not. • Tapering medications is often a very complicated and difficult process. Just stopping psychiatric medications may be dangerous and counter therapeutic. If patients have been on psychiatric medications for years a very slow tapering process is often indicated paired with the development of a toolbox to cope and excel in a reality without or on minimal amount of medications

  17. Our clients may need to develop the skills including distress tolerance if they are to reduce or go off their psychiatric medications Going off medications without tapering can be dangerous especially if the client has been on them long-term. 10% at the time?? Do you evaluate their toolbox? Are there any clear patterns when reducing or weaning off meds-No Is the theory that patients do better going off their meds if they have a bigger tool box? What are the skill deficits that the patient had when they went on the drug. They will likely still be there. Developmental arrest?? How many patients want to work really hard and are willing to have significant distress? A few, but not many

  18. Wellness Wheel Client evaluates themselves in areas of: • Diet x • Sleep • Exercise x • Mindfulness • Social Contact • Daily Relaxation • Medical • No addictions x • No self harm • Distress Tolerance • Self Soothing • Self Empathy X= areas most chosen by Wellness Group participants at Jackson County Mental Health

  19. How can we as counselors assist our clients in making healthy choices regarding psychiatric medications? Try to avoid taking a rigid stance, pro/con meds Get clear that the client has received full PARQ (procedure, alternatives, risks and questions) regarding the medications. If they haven’t suggest they ask the prescriber for this process and they educate themselves about the medications. Help the client connect with their own Wisdom Mind and Intuition regarding taking psychiatric medications. Trust their wisdom and own unfoldment Consider developing a Wellness program, including group and buddy system to increase support

  20. How can we as counselors assist our clients in making healthy choices regarding psychiatric medications? Have your client self evaluate with Wellness type wheel. Score from 1-10 on where they are at. Have them chose areas they want to work on. Evaluate what skill deficits the client has that would make it difficult for them to be off/reduce medications, including having to deal with past traumatic issues. Are you, would you be willing to meditate, exercise with your clients? In the workshop after this lecture we will start addressing this more personally for each counselor

  21. Thank you for providing all the service you do for our clients Thank you for being willing to see and experience all this suffering that humanity is enduring Thank you for giving service and care to all these clients no matter how you feel! Thank you for your courage!

  22. Cat’s eye nebula

  23. References: Barker M “Cognitive Effects of Long-term Benzodiazepine Use: A Meta-analysis”. CNS Drugs 18 (2004): 37-48 Cosgrove L, Krimsky S (2012) A Comparison of DSM-IV and DSM-5 Panel Members’ Financial Associations with Industry: A Pernicious Problem Persists. PLoS Med 9(3): e1001190. Ho, Andreasen et al “Long-term Antipsychotic Treatment and Brain Volumes: A Longitudinal Study of First-Episode Schizophrenia” Arch Gen Psychiatry Vol. 68(No 2), Feb 2011: 128-137 Kirsch I et al “Initial severity and antidepressant benefits: A Meta-analysis of data submitted to the Food and Drug Administration”. Plos Med 5 (2008): 260-268 Rickels K “Psychomotor performance of long-term benzodiazepine users before, during and after benzodiazepine discontinuation”. Journal of Clinical Psychopharmacology 19 (1999): 107-113 Turner E “Selective publication of antidepressant trials and its influence on apparent efficacy”. NEJM 358 (2008): 252-260 Viguera A “Discontinuing antidepressant treatment in major depression”. Harvard Review of Psychiatry 5 (1998): 293-305 Whitaker R “Anatomy of an Epidemic”. Crown Publishers 2010

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