PT Lapse and the Problem of AntiPsychotics for Mood Disorder

Psychology todayPsychology Today seems to be guilty of a journalistic ethical lapse of major proportions.  The December 2013 issue arrived with a cover sticker, partially obscuring the magazine’s title, announcing, “UNRESOLVED DEPRESSIVE SYMPTOMS? Learn about an add-on treatment for depression on p.43”.   At first glance, it appears to be an article about depression.  But turn to page 43 and you find there is no such page.  The content goes from page 42 to page 45, and where 43/44 would be is a two-page advertisement for Abilify, an anti-psychotic medication.   The lapse is the confusion of editorial with advertising, and in this case it appears deliberate.  PT is after all a psychology magazine.  And there is no little “advertisement” notice on the sticker. I hadn’t noticed this until a patient, who is a nurse, showed it to me with concern. There has been a trend toward over-use of of anti-psychotics for mood disorders in psychiatry, pushed by pharmaceutical industry (Big Pharma) promotion.  Drugs such as Abilify, Geodon, Soroquel, Risperdal, and Zyprexa have obvious advantages in treating psychotic symptoms in the extremes of mood disorders.  Even here they can be over-prescribed (see my position, below).  Over the years, studies have found that some of these medications, and a new one, Latuda, can reduce the acute and chronic symptoms of depression in bipolar patients. In the United States, the estimated number of annual patient visits to doctors in which an antipsychotic medication was prescribed as an adjunct therapy for depression nearly doubled (from 2 million to 3.9 million visits) from the mid-1990s to the late-2000s. A decade ago, in my practice, I foreswore using atypical antipsychotic medications for mood disorders, except for rare circumstances.   The costs in terms of immediate ill effects and long-term adverse consequences are too heavy for the questionable and modest benefits. And I have other tools in neurofeedback and intensive therapy that let me manage mood disorders more benignly. My position was strongly supported earlier this year when Glen Spielmans and colleagues published a major meta-analysis on PLOS Medicine published on line.  The study is worth reviewing in detail.  It is clearly presented and is available at this link.  Their Conclusion is:

 Atypical antipsychotic medications for the adjunctive treatment of depression are efficacious in reducing observer-rated depressive symptoms, but clinicians should interpret these findings cautiously in light of (1) the small-to-moderate-sized benefits, (2) the lack of benefit with regards to quality of life or functional impairment, and (3) the abundant evidence of potential treatment-related harm.

Even though there are low-order benefits, “In terms of quality of life and how well people were functioning, there was really not much evidence that these drugs did anything,” said Spielmans in an interview with Susan Perry posted on The adverse consequences of anti-psychotic drugs include weight gain, akathisia (a feeling of restlessness often accompanied by an urge to physically move), sleepiness and abnormal results from cholesterol and other metabolic-related laboratory tests. The more benign tools in my clinical practice of neurofeedback and intensive psychotherapy do not work sufficiently for a small number of my patients—those people either drop out of my practice (west Los Angeles is busy marketplace) or I refer them for psychopharmacological consultation.  Of course, the beauty of both neurofeedback and intensive psychotherapy is that they increase self-regulation and emotional stability without adverse side effects. As a side-note, the Abilify advertisements say,

“How ABILIFY Is Believed to Work  The exact way that ABILIFY (aripiprazole)—or any other medicine for depression—works is unknown.” 

That true statement echoes what I wrote in my prior blog post, Neurofeedback WORKS—How?  There I discussed many of the contributing factors underlying EEG biofeedback efficacy, but had to conclude that we don’t know precisely how neurofeedback leads to improved stability and brain function. To conclude, Psychology Today tends to be a magazine I am pleased to have in my waiting room.  Most of the articles are short and offer something interesting about the mind and emotions.  It is a successful new occupant of the Readers Digest niche.  But the December 2013 does not have an article on depression on page 43 as the cover seems to promise.  It just drives us toward an ad for a medication—an overused medication of marginal value.  The latter point can be reasonably debated, but there should be no debate that the cover sticker violates current journalistic standards by confusing the reader.

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