Doctors Page

DOCTORS PAGE

Jack C. Schoenholtz, M.D., L.F.A.C.Psych.

(The information is a regular work in progress. Material is culled from many professional sources.)

With pharmaceutical agents occupying so much of our relationship with patient-care today, of great significance is the physician's awareness of each patient's lifestyle as it may relate to their intake of medication. Aside from reliability in following instructions, knowledge of their cardiac and renal status are the initial keys for entering upon the xenobiotic pathways. However, the patient's diet, daily hydration, other [possibly competitive] medications and bowel habits are essential considerations for successful prescribing.

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"Bed Toxicity"


Rye Hospital Center is acutely aware of patient risk-safety issues and keeps up-to-date on related research and actuarial findings. As an example, a recent FDA Bulletin regarding hospital beds came to the hospital's attention.

Nursing homes and some hospitals had a series of mishaps based on hospital-bed accidents. Senile, elderly, drug-obtunded or delirious patients were getting entrapped in side rails and received serious injuries, some resulting in death.

The Joint Commission on Accreditation of Health Care Organizations noted in our last accreditation survey, that we had removed all side rails from our hospital beds, but kept some admission beds for emergency purposes.

Moreover, our medical staff noted that psychiatric admissions of patients with unknown previous histories had been increasingly placed on the newer medications, many of which were unsafe because of drug-drug interactions. Our medical staff decided that medical prudence would require beds in which patients could be placed quickly in Trendelenberg position if serious hypotensive episodes occurred.

Below, note the FDA's most recent findings (March, 2006), and click on the link for further information.


Hospital Bed Entrapments: FDA: Hospital doctors, risk managers and supervisory nursing service staff
[Posted 03/09/2006] The Food and Drug Administration issued a guidance designed to reduce the occurrence of hospital bed entrapments that occur when part of a patient's body becomes caught between parts of the bed, such as in the space between the mattress and the side rail. This can cause strangulation and death. Entrapments have occurred in a variety of patient care settings, including hospitals, nursing homes, and private homes. The guidance identifies special issues associated with hospital bed systems, provides design recommendations for manufacturers of new hospital beds and provides suggestions for health care facilities on ways to assess existing beds for potential entrapment risks.

Click on the following FDA link to find Rye Hospital Center's understanding of hospital-bed problems. http://www.fda.gov/cdrh/beds/

Note: Rye Hospital Center does not use beds with side rails. A few of our admission beds are reserved for patients with complicated medication problems, who may require emergency procedures, depending on their response to medication.

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From the Medical Director:

Dear Doctor:

Never before has the need arisen for clinicians to be able to rely on the medications they give their patients. Indeed, the medical profession in general and psychiatry in particular, have been left with few options for verifying the validity of drugs, devices and treatment techniques promoted from outside the profession by an intrepid pharmaceutical industry and an increasingly lax FDA.

If we have learned anything clinically startling in recent years, it’s that opening the human genome offered an explosion of knowledge about the complex processes underlying pharmacotherapy. What we simply called "drug-drug interactions" is a thing of the past. We can now talk about "xenobiotics," "genetic polymorphism" and "isoenzymes," and their role underlying why some patients react to the same doses quite differently from others. And we can speak with greater clarity about how some of the drugs we are asked to use may create more problems than they were designed to solve.

At Rye Hospital Center, our clinical eye is focused especially on the adolescent patient’s individual metabolic profile. Because of the potential of iatrogenic pancreatitis and non-reversible diabetes mellitus, from use of the newer "atypical" anti-psychotic medications, blood glucose and body-mass index are monitored regularly. Also, since many of these drugs may dangerously prolong the QTc interval, patients receive serial EKGs; and careful attention is paid to simultaneous use of other medications such as antibiotics, anti-allergy, antiarrythmics, migraine and over-the-counter drugs which, when added to these psychotropics can lead to fatal tachyarrhythmias. Indeed, aside from the troubling new information about suicidality from the SSRIs, we also pay careful attention to emergence of the serotonin syndrome, its insulin resistence and the potential for rebound diabetogenic effects on the patient when the medications are changed or stopped.

Pharmacokinetic drug interactions are potential sources of adverse outcomes in our patients. Over the past several years, we have been clinically focused on the role of the cytochrome P450 system and how it is influenced by specific drugs and drug classes. As research efforts have broadened, we are now becoming more knowledegable about other non–cytochrome entities which may significantly affect drug disposition.

Most important, is that we meanwhile provide a broad therapeutic experience, pertinent schooling for children and intensive psychotherapy in an open-hospital environment, and we return the patient to you with confidence in the role we played in their recovery.

Call us for more information about what we can do to help you with your problem patients.

914 967-4567

Sincerely yours,

Jack C. Schoenholtz, M.D,, F.A.C.Psych.

Medical Director

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HOW TO MAKE PSYCHIATRIC DIAGNOSES

Modern psychiatric diagnosis in the United States follows the "Multiaxial" methodology developed by the American Psychiatric Association in 1980. Approximately every 7 years, the APA has revised the manual. The present one in use is "DSM IV-TR" a transitional manual to the fifth edition expected by 2007. The International Classification of Diseases (ICD) is the one most used for coding purposes, while the multiaxial system hopes to facilitate a comprehensive and systematic evaluation of features of the diseases.

In Axis I, are listed the "Clinical Disorders"; Axis II are the Personality Disorders plus the Developmental one such as Mental Retardation; Axis III are the co-existent (or co-morbid) General Medical Conditions; Axis IV the Psychosocial and Environmental Problems; Axis V, a Global Assessment of Functioning scale.

Most psychiatric illnesses, more so than most other medical conditions, arise in the context of longstanding pressures and stresses from the external environment, which affect, through adaptation, and in turn are affected by, the psychophysiological stucture of the individual. To the extent that maladaptation is the compensatory result, we give names to those conditions that distinguish the individual so affected from the range of conventionally expected norms in an average predictable social environment. The following, are some of the larger categories to be found in psychiatric literature:

Schizophrenia

Bi-Polar Disorders

Major Personality Disorders

Children and Adolescents

Schizophrenia

Frequently, symptoms of schizophrenia begin to show themselves before adulthood. Although proper diagnosis is essential, it does not fully guide the treatment of schizophrenia, since there are too many unpredictable lifetime events that will subsequently occur, which could affect outcome. As a result, after diagnosis, clinicians should engage with patients families and significant others--as well as with the patient--the need for early intervention, the long-term prognosis, risks of treatment with antipsychotic medications and the value of psychotherapy as applicable to the case.

Diagnosis

Astute clinical judgment is first and foremost the most effective guide in diagnosing psychopathology. This can come about in a number of ways. A well-documented historical review of the patient's life, expectations, and family support potential can form the basis for proper case management as the patient's needs change. Since people with schizophrenia tend to have downward economic mobility, stop taking medication, miss appointments and otherwise reject treatment by weak alliance with the therapist, it is crucial that alternative strategies, pre-arranged with the support system, be developed to keep the patient in treatment. Early assessment of the reliability of the latter should make clear the concern of the therapist in working with the patient. Of course, in the acute phase of psychosis, therapeutic alliance with a patient who has limited reality testing ability, requires either hospitalization or strenuous surrogate involvement, the latter often too much for family, friends and the community at large.

Although formal psychological testing may help define the underpinnings of a mental profile in subtler situations of psychotic disorders, it can be of greater help in revealing the cooperativeness of patients whose personality disorders limit them from forming successful alliances.

After interview, once schizophrenia is suspected, a formal mental status examination should be conducted; then a complete medical history (illnesses, medications, allergies, etc.) and a physical examination (the latter, preferably not by the proposed treating physician) should be obtained. If the patient offers limited (or limits) obtaining information, the family may be consulted with the patient's permission; however, in emergency situations, patient consent must be considered secondary.

Suicide

Because suicide is the leading cause of death among people with schizophrenia, especially when depression accompanies the symptomatology, the assessment of that potential should be up-front in the psychiatrist's evaluation, and at all stages of the illness.

The risk factors include, first and foremost, a previous attempt or family history. Sociological factors include being male, white, single, substance abuse, and depression or hopelessness. Ironically, young persons with schizophrenia, those with a high IQ and high premorbid level of scholastic achievement, and those with insight into the malignant nature of the disease are specifically includable in the high risk group. So, too, undertreatment can be a factor.

If a patient, at first diagnosis, exhibits a significant range of such risk factors they should be evaluated in the least restrictive, closely monitored, psychiatric unit or hospital, since hospitalization itself is a stress. Note: Simply asking such people whether they are contemplating suicide, should not suffice. If there is a significant paranoid component, such patients rarely admit to hearing voices, having command hallucinations or openly discuss suicide plans. Careful and calming words in the interview, such as: "Did the voices tell you that?" will often get either get a simple denial or an acceptance of the interviewer's concern, and evoke a straight answer like: "No, I don't hear voices," or a simple, "Yes."

In hospital, psychosis and depression can be vigorously treated. Signs of suicidal urges diminishing include patient engagement with others and recognition of their recent self-destructive ideation.

A side effect of most psychotropic medications is increased thirst. This has been found to be associated with long hospitalizations, and may be an independent variable among chronically ill patients. Aside from a rare case of water intoxication, copious amounts of water may disrupt the dosing of the medication by hemodilution. Such patients must be assessed for primary polydipsia (caused by diabetes mellitus and diabetes insipidus, among others) in contrast with secondary polydipsia caused by the medication. (Patients on lithium carbonate may also feel excessive thirst and carefully monitored, reasonable water restriction may be necessary to keep levels within the therapeutic range. With lithium treatment, a type of diabetes insipidus [nephrogenic] may be caused by the lithium itself and treated separately.)

Drug treatment

Although humans are of one species, there is increasing evidence of genetic, gender and subcultural differences (including genomic ones) in response to metabolism of medications and dosage levels. However, these phenomena require much more research before definitive conclusions may be drawn regarding specifice drug-treatment methods. At present, clinical correlation and knowledge based on awareness of risk, are the only acceptable bases for off-label drug treatment. Part of the difficulty resulting from rigid application or acceptance of approved pharmaceutical company information, is that it is largely based on Food and Drug Administration guidelines for licensure acceptability: formal clinical trial protocols, etc., since FDA approval, while rigorous, is subject to subtleties of language when presented in the labeling brochures. Additionally, such premarketing data vary from patent concerns, safety from drug-drug interactions, and efficacy in relation to placebo and comparator studies. Hundreds of patients may have been treated in open-label, blind and double-blind crossover studies--all carefully separated from as many confounders as possible. Ironically, such research sophistication often identifies both responders and nonresponders among populations "sanitized" from influences otherwise normal in average environments. We believe, millions of doses need to be distributed before clinical effectiveness can be assessed dependably outside the clinical-study premarketing laboratory or post-marketing environment.

Prescribing problems

Except for diseases expressly starting in infancy and childhood, ethical constraints have limited research on pregnant women and on children and adolescents. This has not stopped their use, however. As the search for new drugs has slowed, pharmaceutical companies have increasingly promoted "off-label" uses for their products, with sales for such uses nearly doubling from 1998 to 2003. Off-label “promotion” is a freely used term, but by FDA definition it means any communication of favorable information by or for a pharmaceutical company about use of a product that is not covered by approval labeling. An analysis by the Knight-Ridder newspapers revealed the following growth in off-label use of drugs used by psychiatrists for medicating emotional disorders: Neurontin (anti-seizure) 90%; Topomax (anti-seizure) 79%; Seroquel (antipsychotic) 79%%; Risperdal (antipsychotic) 65%; Trazodone HCL (antidepressant 56%; remeron (antidepressant) 46%; Zyprexa (antipsychotic) 42%; Wellbutrin SR (antidepressant) 27%; Depakote (anti-seizure) 25%. These off-label uses have enabled the pharmaceutical companies to sell more than 6 billion dollars worth of medications neither approved for nor researched on the populations for which they were prescribed.

An example of highly sophisticated promotional use can be seen in the following cases:

LAMICTAL© (lamotrigine), an anti-seizure medication, has received the approval of the FDA for "the maintenance treatment of Bipolar I Disorder to delay the time to occurance of mood episodes (depression, mania, hypomania, mixed episides) in patients treated for acute mood episodes with standard therapy." Yet, the prescribing information brochure goes on to say: "The effectiveness of LAMICTAL in the acute treatment of mood disorders has not been established." And, in the same brochure approved by the FDA, the following contradictory sentences appears: "Bipolar Disorder. The effectiveness of LAMICTAL in the maintenance treatment of Bipolar I Disorder was established in 2 multicenter, double-blind, placebo-controlled studies in adult patients who met criteria for Bipolar I Disorder (see Clinical Studies, Bipolar Disorders). The physician who elects to use LAMICTAL for periods extending beyond 18 months should periodically re-evaluate the long-term usefullness of the drug for the individual patient."

Abilify©, is another new drug, FDA-approved only for the treatment of schizophrenia. Its use in psychosis accompanying Bipolar Disorder was submitted in 2003. Yet, language-dilution of the potential approval has already started, and while there is still no approval for its use in other illnesses (adults or children) the following "online" information may be found:

"In the Winter 2003 Edition of The Bipolar Child Newsletter, Janice Papolos and Demitri F. Papolos, M.D., reported that the findings above 'have prompted adult and child psychiatrists to begin to prescribe Abilify for both indicated and off-label applications, including for early-onset bipolar disorder in children and adolescents.' Dr. and Mrs. Papolos report encouraging results from several sources, but point out that 'Abilify is only beginning to be studied in children, and a more balanced picture is certain to evolve as data accumulates.'"

And: "At the May 2003 Annual Meeting of the American Psychiatric Association, two studies were presented showing impressive results for Abilify in the treatment of bipolar mania. As reported by HealthyPlace.com, in these studies patients "showed significant improvement in their symptoms and significant higher response rates compared to either haloperidol (Haldol) or placebo," with rapid onset of improvement and significantly fewer problems with side effects than with Haldol."

Note: HealthyPlace.com is wise enough to have a clear disclaimer on its website, among which is the following:

"It is important to understand that HealthyPlace.com is a community of people providing mental health information, support, and the opportunity to share experiences helpful to others. Much of the information on our site comes from individuals who are NOT medical or psychological professionals of any sort. Unless it is clearly stated that the author or person imparting information is a medical or psychological professional, you are to assume that they are NOT."

Of late (Wall Street Journal, 3/24/04), there is an effort by the pharmaceutical industry to concentrate on detailing information to primary care physicians, so that they can prescribe antipsychotic medication to their medical patients. One of the ways revealed is for the PCP to take the patient who has already been evaluated and prescribed such medications by a psychiatrist, and continue treating them. Although this practice could have many arguments for it (lower cost than seeing a psychiatrist; reducing fears of stigma, etc.), this practice is fraught with danger. Most important, is that a psychiatrist's training and focus should be on therapies and medications specific to mental disorders, and keeping up on the latest research, FDA Advisories and Warnings. In most cases, research studies have revealed that simply prescribing drugs--without also offering trained-psychiatrist therapies--is significantly less effective. Moreover, the use of drugs for conditions which do not have FDA approval, while legal, is considered unethical by many, if patients who receive them are not properly informed.

Rye Hospital Center believes that it should be of utmost concern for medical professionals, that these anecdotal, or peer-reviewed studies not FDA-approved, and off-label prescribing may be fraught with danger for patients on whom they are used, and for the professionals who prescribe them.

Children and Adolescents

Of increasing interest is the plethora of new psychotropic drugs offered for children and adolescents without the FDA approval process based on clinically validated studies. The off-label uses of the "older" psychotropics have, at least, been validated by decades of off-label use. The fact that all powerful medications require keen followup becomes much more difficult when there is not much of a drug history to go by. A case in point, is the widespread use of the newer "atypical" antipsychotics. Some of these have been shown to markedly increase the electrical conduction of portions of the pathway of each heartbeat. In particular, the "QT" interval--the part of the EKG measurement which, if artificially prolonged, can lead to fatal arrythmias (tachyarrythmias).

Because this use of some of these drugs in children and adolescents (especially incombination with non-psychotropic drugs--even some antibiotics--that can be additive), Rye Hospital Center, with its large adolescent population, has begun to measure the QTc (corrected) interval on all patients receiving such medications. The doctors on the staff have been made keenly aware of watching very carefully the possible changes in cardiac conductivity and reducicing or removing such drugs from their patients.

A discussion follows:

Cardiac Effects of New Psychiatric Medications

With increasing concern over potential toxic effects of new drugs on the heart, Rye Hospital has begun to measure special aspects of electrocardiograms that could signify the possibility of a dangerous event occurring.

The case in point is the measurement of what is called the "QTc" interval--that electrical part of the heartbeat which may be prolonged either by certain drugs or by combinations of drugs that could produce fatal arrhythmias.

All patients are routinely given a "baseline" cardiogram. Those who require the use of the newer drugs or combinations of drugs that can be additive in their cardiac conduction effects, and prolong the QT interval, have repeated studies to determine whether they should need a change.

Indeed, because even some antibiotics can cause such critical, additive problems, we constantly endeavor to make our doctors aware of the latest findings by researchers.

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SUICIDE

Because it is the third leading cause of death in children over 15, we are starting off with a review article updated by: David Taylor, M.D., Department of Psychiatry, University of Pennsylvania Medical Center, Philadelphia, PA. Review provided by VeriMed Healthcare Network.

Definition

Suicide is the act of deliberately taking one's own life. Suicidal behavior is any deliberate action with potentially life-threatening consequences, such as taking a drug overdose or deliberately crashing a car.

Causes, incidence, and risk factors

Suicidal behaviors can accompany many emotional disturbances, including depression, bipolar disorder, and schizophrenia. More than 90% of all suicides are related to a mood disorder or other psychiatric illness. Suicidal behaviors often occur as a response to a situation that the person views as overwhelming, such as social isolation, death of a loved one, emotional trauma, serious physical illness, growing old, unemployment or financial problems, guilt feelings, and alcohol or other drug dependence. In the U.S., suicide accounts for about 1% of all deaths each year. The highest rate is among the elderly, but there has been a steady increase in the rate among adolescents. Suicide is now the third leading cause of death for those 15 to 19 years old, after accidents and homicide.
Suicide attempts that do not result in death far outnumber completed suicides. Many unsuccessful suicide attempts are carried out in a manner that makes rescue possible. They often represent a desperate cry for help.

The method of suicide varies from relatively nonviolent methods (such as poisoning or overdose) to violent methods (such as shooting oneself). Males are more likely to choose violent methods, which probably accounts for the fact that suicide attempts by males are more likely to be completed.
Suicide attempts should always be taken seriously and mental health care should be sought immediately. Dismissing them as "attention seeking" can have devastating consequences.

Relatives of people who seriously attempt or complete suicide often blame themselves or become extremely angry, seeing the attempt or act as selfish. However, when people are suicidal, they often mistakenly believe that they are doing their friends and relatives a favor by taking themselves out of the world and these irrational beliefs often drive their behavior.

Symptoms

Early signs:
· depression
· statements or expressions of guilt feelings
· tension or anxiety
· nervousness
· impulsiveness

Critical signs:
· sudden change in behavior (especially calmness after a period of anxiety)
· giving away belongings, attempts to "get one's affairs in order"
· direct or indirect threats to commit suicide
· direct attempts to commit suicide

Treatment

Emergency measures may be necessary after a person has attempted suicide. First aid, CPR or mouth-to-mouth resuscitation may be required.
Hospitalization is often needed, both to treat the recent actions and to prevent future attempts. Psychiatric intervention is one of the most important aspects of treatment.

Expectations (prognosis)

All suicide threats and attempts should be taken seriously. About one-third of people who attempt suicide will repeat the attempt within one year, and about 10% of those who threaten or attempt suicide eventually do kill themselves.

Complications

Complications vary depending on the type of suicide attempt.
Call your health care provider.
A person who threatens or attempts suicide MUST be evaluated by a mental health professional promptly. NEVER IGNORE A SUICIDE THREAT OR ATTEMPT!

Prevention

Many people who attempt suicide talk about it before making the attempt. Often, the ability to talk to a sympathetic, nonjudgmental listener is enough to prevent the person from attempting suicide. For this reason suicide prevention centers have telephone "hotline" services. Again, do not ignore a suicide threat or attempted suicide.

As with any other type of emergency, it is best to immediately call the local emergency number (such as 911). Do not leave the person alone even after phone contact with an appropriate professional has been made.

Update Date: 1/25/2003