Shirah Vollmer MD

The Musings of Dr. Vollmer

Archive for September, 2013

Brintellix and Rexulti

Posted by Dr. Vollmer on September 18, 2013

 

 

 

 

 

https://shirahvollmermd.wordpress.com/2010/01/24/luaa21004-a-game-changer/

http://en.wikipedia.org/wiki/Vortioxetine

http://www.prnewswire.com/news-releases/fda-accepts-takeda-and-lundbecks-submission-of-the-new-drug-application-for-vortioxetine-for-the-treatment-of-major-depressive-disorder-183210241.html

http://www.pharmabiz.com/NewsDetails.aspx?aid=75465&sid=2

“In vitro studies indicate that vortioxetine is a 5-HT3, 5-HT7, and 5-HT1D receptor antagonist, 5-HT1B receptor partial agonist, 5-HT1A receptor agonist and inhibitor of the serotonin (5-HT) transporter (SERT). In vivo non-clinical studies have demonstrated that vortioxetine enhances levels of the neurotransmitters serotonin, noradrenaline, dopamine, acetylcholine and histamine in specific areas of the brain.”

 

We need new modalities of treatment. We have SSRIs, SNRIs, which changed our game in 1988 dramatically, but since then, the rate of progress has slowed considerably. Now, we have deepened our field by understanding two new important aspects of serotonin functions. There are SEVEN serotonin (5-HT) receptors subtypes. http://en.wikipedia.org/wiki/5-HT_receptor. Second, as I posted about in 2010, there is a sertonin transporter, which can be altered leading to a change in the amount of serotonin floating around the receptors. This understanding opens the field to more targeted drugs. In October, 2013, the FDA will decide whether to approve Vortioxetine, likely to be called Brintellix or Rexulti, for the treatment of Major Depression. New drugs give hope to the many folks who feel despair with their symptoms, especially if they have tried multiple modalities, with little success. We, psychiatrists, call these folks “refractory,” but in fact, their persistent symptoms point to our limited tool box. Expanding our tools, of course, can also come with risk, but in the world of depression treatment, our pharmacological interventions have been exciting because the risk/benefit ratio is so favorable. In essence, the upside far outweighs the downside. This change in the risk/benefit ratio is how Prozac changed our world. Prozac did not bring about greater efficacy than our old tools of tricyclic antidepressants, but it did change this ratio to expand the number of people we could try to help. Further, Prozac also taught us that personality characteristics, such as impatience, could significantly improve with pharmacological intervention. So, we could treat more people, and we could treat folks who did not have a psychiatric illness, but who did suffer from irritability and then subsequent relationship issues. This Prozac story gives us hope with each new drug that our world can change again, in ways we do not even understand yet. Drugs come out on the market, and then we learn more about them through the individual tales of experience. Listening to how people experience their medication, to reference my last post, is a fun part of my job. I listen not only to how they experience the medication, but how they choose to tell me how they experience their medication. Having a new medication to use, creates the wonderful combination of excitement and fear, which with trust in the FDA, makes the fear tolerable, and the excitement grand. Sure, there is a lot of post-marketing learning, but the FDA gives us a safety net to explore the uses of new medication or new devices. It is interesting that each country has their own oversight organization, so one country might approve a medication, while another country waits for more data. I do not know what the FDA will do, but the data look promising that Brintellix (the likely name) will see the light of day, giving me a new tool. Once again, I feel appreciative for my medical background which gives me the privilege of using these tools. Once again, stay tuned.

Posted in Psychopharmacology | 14 Comments »

Why Be A Psychiatrist?

Posted by Dr. Vollmer on September 17, 2013

Who becomes a psychiatrist? Many would say those that can’t stand the site of blood. I always took issue with that half-joke, half-truth comment, because for me, I really really like blood. I like organs. I liked my surgery rotations. I liked drawing blood. I became a psychiatrist because I never wanted to get bored. At the time, all other specialties were following algorithms, meaning that once these were mastered, there seemed to be little challenge. With psychiatry, talking to people, is always new and different. I like that. I wonder if that same principle applies to my younger colleagues. Were they drawn to listen to stories, or were they drawn to the fun of psychopharmacology? Psychopharmacology is fun, in that people get better from medication and this, of course, is very satisfying. Still, I wonder how young people decide their specialty these days. A psychiatry rotation in medical school deals with chronic mental illness. It would be hard to extrapolate from that, my daily life as a private practice psychiatrist. I am sure there are the practical considerations of paying back loans, controlling one’s hours, and the amount of overnight call. I think I should ask my students. Stay tuned.

Posted in Professional Development, Professionalism | 4 Comments »

The Loss of Intellectual Capital

Posted by Dr. Vollmer on September 16, 2013

I have this conversation multiple times a day. “What jobs are out there for psychiatrists?” a student asks. “Psychopharmacology jobs,” I respond with a sense of horror and shame. Agencies dealing with the mentally ill, look to the psychiatrist for a prescription, and not for an assessment or treatment plan. This means that when psychiatrists look for employment, their jobs are to write prescriptions, with different employers having different expectations for how much time to spend with a patient in order to write this prescription. Adding on, agencies are also asking psychiatrists to trust the assessments done by other professionals, rather than taking the time to make their own opinion. This is my rant, a major incentive for my blog. How can this be? How can organizations not appreciate that we, as psychiatrists, bring so much more to the table than our prescription pad? We bring an understanding of the brain, the mind, and the body. We have lost our way, and now we need to get it back. We need to remind the public that our assessment skills are valuable and they take time, which will be well spent in developing treatment plans for patients. I will repeat this theme over and over again, as it stands now, psychiatry has to right itself. We are like an insect on our backs, flailing our legs to turn over so that we can  stand up and move on. I hope we turn over soon.

Posted in Psychiatry in Transition | 10 Comments »

New Yorker Entry: Another Hard One

Posted by Dr. Vollmer on September 16, 2013

 

“I just wanted to see if it was raining.”

Posted in Cartoons | Leave a Comment »

Greg Louganis

Posted by Dr. Vollmer on September 13, 2013

 Greg Louganis

 

http://www.latimes.com/sports/olympics/la-sp-plaschke-louganis-20130913,0,903841.column#axzz2emmEgRpF

 

The Greg Louganis story has returned to prime time, giving me the opportunity to remind my readers, and my students, that this is an example, of how not only do doctors care about their patients, but patients care about their doctor. In this case, the doctor was my beloved old boss, Dr. James Puffer. As the story goes, and some of you might remember, Greg Louganis hit his head during the Olympics of 1988, at which point, Dr. Puffer ran to stitch him up, enabling him to get back in the game and win a gold medal. Many years later he was quoted as saying that his biggest regret was that he did not tell Dr. Puffer that he was HIV positive. I tear up, as I think about this confession, as it speaks to the intensity of their relationship. Sure, the story has a happy ending. Dr. Puffer is HIV negative, and Greg Louganis is now 53 and seemingly enjoying his life. Yet, this story, even without it’s positive outcome, is a tale of connection, which I fear will be lost as medicine becomes more dependent on electronic devices. If a faceless doctor came to stitch him up, would Mr. Louganis have felt so bad? I do not think so. I think modern medicine has made it such that both physicians and patients believe that “buyer beware,” which in this case the buyer is the physician. This bond, where the patient cares about his physician, leading to the patient taking better care of himself, seems to me, is slipping away, as we, as a society, become more dependent on machines to evaluate our symptoms. The joke, on medical teams, is that the doctor will not believe the patient’s leg is amputated until he sees the X-ray. I am compelled to remind my readers that I love technology and I am excited about how modern science is rapidly changing how we track people and disease states. The complex area of following patients over time is much simpler with machines which contain the notes about  the last visit and the last time the medication was changed. However, if these tracking systems are valued over the personal connection between the doctor and the patient, then I fear that medicine will be less fun for doctors, and patients will lose incentive to take care of themselves. The human touch, remains in my mind, a vital force for promoting wellness. In the case of Greg Louganis, that human touch, could have had fatal consequences for Dr. Puffer, but luckily, instead, it brought to  light, the humanity between patient and doctor.

Posted in Doctor/Patient Relationship, Media Coverage, Primary Care | 2 Comments »

Do Pills Tell Patients They Are Sick?

Posted by Dr. Vollmer on September 12, 2013

Adam, thirty-two, wants medication to deal with his anxiety. On the one hand, this is a reasonable request, as there are many psychopharmacological options which can assist him. On the other hand, giving him medication colludes with his belief that he cannot cope with the stresses and strains of life. Therein lies the dilemma of the psychiatrist. Medication aids, but also detracts from self-esteem. Yet, some may argue that Adam reaching out for help, through medication, actually enhances his self-esteem, because he is taking a positive step towards wellness. Perhaps the physician should applaud his positive step, but re-direct him to other tools to cope. This narrow path between helping and hurting is the constant struggle in mental health treatment. One must be mindful of this delicate balance so as not to tilt too far in either direction. This will be my message to my students tomorrow.

 

Posted in Psychopharmacology, Teaching, Teaching Psychoanalysis | 6 Comments »

The Hypochondriac

Posted by Dr. Vollmer on September 11, 2013

Lacey, fifty-seven, insists that no physician can determine the cause of her multiple somatic complaints. Lacey, a physician herself, no longer practices medicine, as she feels disabled by her symptoms which she struggles to explain to others. She is not exactly tired, she says, but she does feel fatigue. She does not have headaches, but she does feel discomfort in her head. Her stomach is not quite right, although she eats a healthy diet and she maintains a healthy weight. She has consulted multiple tertiary care medical centers, all of whom, express confusion over her symptoms. She comes to me, not because she considers her symptoms secondary to her mental state, but because she is despairing that no physician can give her a diagnosis. George Vaillant MD in his article entitled “The Beginning of Wisdom is Never Calling a Patient a Borderline,” speculates that hypochondriacs need to be understood, in terms of their subjective suffering, and through this understanding, their personal trauma will eventually unfold, yielding a platform in which to work through childhood pain. In essence, primary care physicians need to entertain the notion of a hypochondriac as someone who is crying out to be heard, but patience and empathy must be present for a long time, before this will pay off with insight and symptom relief. Psychiatrists often cannot be helpful, as the hypochondriac will feel further dismissed and thereby get more angry. My job with Lacey is to work with her and her primary care physicians, mostly to help her other physicians understand how to work with her. My direct work with Lacey is to help her deal with her frustrations, while cracking the door open, that her symptoms, indeed very distressing, might be as a result of a painful internal mental state which reaches back to childhood trauma and the need to be heard and understood. Sad as it is, Lacey acts as if the only way people will listen to her is if she has medical complaints. It is as if she believes that if she were to say she were sad, anxious or scared, then she would be ignored, but if she insists that she has a serious medical problem, then her friends and family will attend to her. This pathological belief, likely stems from a childhood in which only physical problems yielded nurturing, whereas emotional issues were neglected. Maybe Lacey will come to understand that, but for now, the job is to give her the space to feel heard and understood, with the sensitivity to know that the slightest suggestion that her mind is producing these bodily complaints, will be heard with anger and despair.

Posted in Hypochondriac, Mind/Body, Psychotherapy | 4 Comments »

Immaturity

Posted by Dr. Vollmer on September 10, 2013

 

Immaturity is a curious word in psychotherapy. It is hardly ever used as evidence of psychopathology, and yet, it is a phenomena which explains how some folks do not ever seem to set their lives in the right direction. Graham, sixty-three, is a good example. He is single, never married, and yearns for a relationship. At the same time, he does not tolerate other people’s point of view, and he is easily frustrated when met with decisions that he does not like. If a group of people want to go to a restaurant, he pouts if he does not get to choose. He has never learned the art of compromise, and yet, he feels that the reason for his perpetually lonely life is that he “has just not found the right person.” He does not experience himself as difficult or immature, and yet this is the feedback he has received from those who tried to get close to him. Helping Graham see himself, as others see him, is the first step toward promoting maturity: moving him from a childlike position in the world, to a more grown-up adult who can compromise because he can hold on to a bigger picture. The immaturity speaks to a pressure in each moment, rather than seeing things from a more strategic or global point of view. Compromise is in his self-interest, but at the moment, he does not see things this way. Putting a developmental spin on “difficult” people allows therapists to see the person obstructed from growth, mandating a removal of the obstacles, so that development can resume. In Graham’s case, my hunch is that he is scared to venture forward in life, and this fear inhibits him from maturing. Gently approaching this fear is our work. So, to the difficult question about what I do. I want to say, “I help people grow up.”

Posted in Psychoanalysis, Psychotherapy | 6 Comments »

Hope In Mental Illness

Posted by Dr. Vollmer on September 9, 2013

 

http://www.ush.utah.gov/dvd_philosophy_of_treatment.html

 

I love this video. I love how it ends with a person swinging on a rope, as a symbol of freedom from mental illness. I love how the narrator describes the understanding of the patient, from multiple points of view, critical to the therapeutic value that the hospital offers patients. I appreciate the philosophy as one which embraces complexity, as opposed to reducing mental illness into a cookbook of treatments. I stumbled upon it because I am reading another George Vaillant MD article to prepare for being a discussant this Friday. He mentioned that their philosophy was a model of treatment for sociopaths, as it contains them, while at the same time, allowing individuals to work together to change-up their aggression for productivity. I am not personally familiar with the care at Utah State Hospital, but if they do what they say they do, I am impressed.

 

 

Posted in Health Care Delivery, Psychiatric Hospitalization, Sociopathy | 2 Comments »

‘Short Term 12″-Long-Term Pain

Posted by Dr. Vollmer on September 9, 2013

 

The healer needs to be healed. That is what I took away from this sweet, touching, and yet painfully unrealistic film in which abused teenagers are housed until a more permanent, sometimes less desirable placement is found. We, the audience, feel the pain of both the staff and the “inmates,” so to speak, feel as they try to heal each other. There is a deep sense of humanity in this film, as the victimization of childhood is shown in full color. As the audience, I imagine the collective group, wants to scream out and remind these unseen parents that no child asks to be born. The responsibility on these parents is clear, and yet, the helplessness to make people take good care of their children is also clear. As the movie unfolds, as with life, the victim becomes the victimizer, as the pain is shared in so many directions. The line between self-harm and aggression towards other is blurred. In a way, it does not matter. There is just a lot of pain. There is the agony of abandonment, physical and sexual abuse, and most of all, the absence of a nurturing figure. How can these abused teenagers break out of their past and not live in a world guided by emotional vulnerability? What kind of people are drawn to work in these residential care settings? Is the answer to the former, the latter? The movie makes us think that. I felt sad, really sad, experiencing this movie as the hours and days have gone by. Emotional pain begets more emotional pain. It is so hard to break out of that universe.

Posted in child abuse, Movie Review | 2 Comments »

 
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