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Author Archives: Robert Pollack

Robert Pollack

About Robert Pollack

Board Certified Psychiatrist in practice over 42 years. Currently focused on Genomic Assessments as part of our treatment assessments and Transcranial Magnetic Stimulation (TMS) therapy along with general adult psychiatry. Currently serve on adjunct faculties of UCF, FSU, USF and Uof F. We currently accept most Insurances.

Prevalence of Prescription Medications With Depression as a Potential Adverse Effect Among Adults in the United States

June 12, 2018

Key Points

Question  How frequently do US adults use prescription medications with depression as a potential adverse effect and is use of these medications associated with concurrent depression?

Findings  In this cross-sectional US population-based survey study conducted between 2005 and 2014, the estimated overall prevalence of US adults using medications with depression as a potential adverse effect was 37.2%. The adjusted percentage of adults with concurrent depression was higher among those using more concurrent medications (eg, estimated 15% for ≥3 medications).

Meaning  Use of prescription medications that have depression as a potential adverse effect was common and associated with greater likelihood of concurrent depression.

Abstract

Importance  Prescription medications are increasingly used among adults in the United States and many have a potential for causing depression.

Objectives  To characterize use of prescription medications with depression as a potential adverse effect and to assess associations between their use and concurrent depression.

Design, Setting, and Participants  Five 2-year cycles (2005-2006 through 2013-2014) of the National Health and Nutrition Examination Survey, representative cross-sectional surveys of US adults aged 18 years or older, were analyzed for use of medications with depression as a potential adverse effect. Multivariable logistic regression examined associations between use of these medications and concurrent depression. Analyses were performed among adults overall, excluding antidepressant users, and among adults treated with antidepressants and with hypertension.

Exposures  Prescription medications with depression as a potential adverse effect (listed in Micromedex).

Main Outcomes and Measures  Prevalence of any use and concurrent use of medications with a potential to cause depression and prevalence of depression (PHQ-9 score ≥10).

Results  The study included 26 192 adults (mean age, 46.2 years [95% CI, 45.6-46.7]; women, 51.1%) and 7.6% (95% CI, 7.1%-8.2%) reported depression. The overall estimated prevalence of use of medications with depression as an adverse effect was 37.2%, increasing from 35.0% (95% CI, 32.2%-37.9%) in the cycle years 2005 and 2006 to 38.4% (95% CI, 36.5%-40.3%) in 2013 and 2014 (P for trend = .03). An estimated 6.9% (95% CI, 6.2%-7.6%) reported use of 3 or more concurrent medications with a potential for depression as an adverse effect in 2005 and 2006 and 9.5% (95% CI, 8.4%-10.7%) reported such use in 2013 and 2014 (P for trend = .001). In adjusted analyses excluding users of antidepressants, the number of medications used with depression as possible adverse effects was associated with increased prevalence of concurrent depression. The estimated prevalence of depression was 15% for those reporting use of 3 or more medications with depression as an adverse effect vs 4.7% for those not using such medications (difference, 10.7% [95% CI, 7.2%-14.1%]). These patterns persisted in analyses restricted to adults treated with antidepressants, among hypertensive adults, and after excluding users of any psychotropic medication.

Conclusions and Relevance  In this cross-sectional survey study, use of prescription medications that have depression as a potential adverse effect was common. Use of multiple medications was associated with greater likelihood of concurrent depression.

July 19, 2018
Robert Pollack

About Robert Pollack

Board Certified Psychiatrist in practice over 42 years. Currently focused on Genomic Assessments as part of our treatment assessments and Transcranial Magnetic Stimulation (TMS) therapy along with general adult psychiatry. Currently serve on adjunct faculties of UCF, FSU, USF and Uof F. We currently accept most Insurances.

Magnetic Brain Stimulation Flops in VA Trial: Both sham and active rTMS produce high remission rates; unclear why

  • by Elizabeth Hlavinka, MedPage Today InternJune 27, 2018

About 40% of patients with treatment-resistant major depression achieved remission in a randomized trial of repetitive transcranial magnetic stimulation (rTMS) — but the rate was virtually the same with sham treatment versus active stimulation, researchers said.

Among 81 patients in Veterans Affairs medical centers assigned to active rTMS, 33 (40.7%) achieved remission at the end of treatment, compared with 31 of 83 (37.4%) receiving sham treatment, reported Jerome Yesavage, MD, of Stanford University School of Medicine, and colleagues in JAMA Psychiatry.

After a 24-week follow-up phase, 16 out of the 81 receiving active treatment (19.8%) remained in remission while 13 (15.7%) of the sham did.

“On the surface it’s puzzling why the active would not be better than the sham and why both groups showed such a high resistance rate,” Charles Nemeroff, MD, PhD, of the University of Miami, who wrote an editorial accompanying the study, told MedPage Today. Most other rTMS studies have shown benefit, though not always large, relative to control.

“When patients are enrolled in clinical trials and they get a great deal of attention from healthcare providers,” Nemeroff said, “there’s a therapeutic effect that I think would explain to some extent the higher rate of remission in the sham treatment.”

Indeed, strong placebo responses and spontaneous remission with no treatment are common in major depression, as the FDA noted in a recent update to its guidance on antidepressant trials.

Treatment options for patients with treatment-resistant major depression are limited and typically invasive in nature, using monoamine oxidase inhibitors or electroconvulsive therapy. More recently, ketamine and derivative drugs have shown promise for rapid relief of severe depressive symptoms, but these have not been formally approved and are used clinically only in emergency situations.

Such methods may be necessary in suicidal patients, but for more moderate cases, researchers hypothesized that treatments such as rTMS could provide a less invasive solution, particularly in veterans, who often have multiple existing medical and psychiatric diagnosis that can reduce their response to treatments.

Previously, a similar sham-controlled study conducted by George Lisanby, MD, and colleagues (OPT-TMS) found that 14% of participants who received rTMS treatment successfully achieved remission, compared to 5% in the control group. Other studies in treatment-resistant depression, such as the landmark STAR*D trial, also found remission rates far lower than in the VA study.

In his editorial, Nemeroff said it was hard to explain the current trial’s high rates. But he noted that the VA population differs in several ways from patients in most depression studies, most notably that VA patients are mostly male, whereas traditional study samples are typically two-thirds female.

Yesavage and colleagues also pointed out that their treatment sessions were about twice as long as those in the OPT-TMS study.

The researchers said they hope, in the future, to target more concentrated areas of the brain and use different types of stimulation such as theta burst and TMS coil type, depending on biological differences in participants. Nemeroff said future studies might also include sampling for genetic markers or brain imaging to control for potential confounding variables.

To enter the trial, participants had to have failed at least two prior drug therapies and meet DSM-IV criteria for major depressive disorder. Patients with certain psychiatric comorbidities were excluded, but not all: 49.4% of the sample had post-traumatic stress disorder and patients with substance use disorder comprised 53.7%. Of the 40 patients with PTSD, 13 (32.5%) demonstrated remission, as did 13 patients in the sham (31.7%). No significant effects were seen at the end of acute or follow up phases across patients with PTSD, as well as across rates of suicidality and quality of life. Substance use disorder did not affect study results.

Of the 81 who received rTMS, 60 completed the treatment, nine discontinued treatment during the acute treatment phase, and 12 terminated during the follow-up phase, compared to 65 fully completing the treatment of the 83 in the control group, nine terminating during the acute stage, and nine withdrawing during follow-up. Subjects cited being lost to follow-up appointments, burden of visits, unable to return to clinic, adverse medical event, and withdrew from study as reasons for discontinuing their treatment. Other limitations included the small sample size and the fact that the study was conducted during 2012-2016, and hence newer rTMS protocols were not tested.

“It’s fabulous that VA leadership in research agreed that this was an important question in our depressed veterans,” Nemeroff told MedPage Today. “What we really want to know with a patient sitting in our office who’s depressed is, out of the myriad of treatments available, what is the best treatment for them. This is a very active avenue of investigation.”

[Read the Original Article Here]

June 28, 2018
Robert Pollack

About Robert Pollack

Board Certified Psychiatrist in practice over 42 years. Currently focused on Genomic Assessments as part of our treatment assessments and Transcranial Magnetic Stimulation (TMS) therapy along with general adult psychiatry. Currently serve on adjunct faculties of UCF, FSU, USF and Uof F. We currently accept most Insurances.

PASWFL is Now a Member of the American Society of Ketamine Physicians

What is ASKP? 

The American Society of Ketamine Physicians is a group of professionals dedicated to the safe clinical use of ketamine for mental health disorders and pain conditions.

The mission of the American Society of Ketamine Physicians

  • to advocate for the safe and effective use of ketamine in the treatment of mental illness and pain disorder
  • to promote high scientific, ethical, and professional standards among physicians providing ketamine therapy for mental illness and pain disorders
  • to maximize quality of care by furthering knowledge, collaboration, and the exchange of ideas and research in the use of ketamine and other psychotropic medications for the treatment of mental illness and pain disorders.
  • to expand access to ketamine therapy nationwide

Basics of Administration

All of the providers in our group ascribe to the same basic tenets of safety when administering Ketamine for Non-Anesthetic Indications (KNAI).

1.  Patients should be screened for and have been found to have a condition that is appropriate for ketamine treatment – Unipolar Major Depression, Bipolar Depression, PTSD, OCD, Fibromyalgia, CRPS and chronic pain.

2.  A full history and physical including psychiatric disorders and substance abuse disorders should be completed in the patient’s chart.

3.  The patient’s medications and allergies should be documented to reduce reasonable risk of medication interaction and side effects.

4.  Given the off-label nature of ketamine use for these disorders, appropriate consent should be obtained.

5.  The usual starting dose for patients should be .5 mg/kg to 1 mg/kg IV over 40-60 minutes.  Dose escalation may be necessary to achieve desired response.  Chronic pain conditions typically require higher doses over longer periods.  A practitioner should have their established protocol either published online, or be willing to share with other practitioners.

6.  The patient’s vital signs should be monitored during administration and return to pre-administration values before discharge from the clinic.  A provider credentialed in ACLS should be present during the administration as well.

7.  Patients receiving ketamine therapeutically should not be allowed to drive themselves home from their appointment, or for 12 hours after their infusion.

8.  We do not support the use of medically unsupervised parenterally administered ketamine.

June 25, 2018
Robert Pollack

About Robert Pollack

Board Certified Psychiatrist in practice over 42 years. Currently focused on Genomic Assessments as part of our treatment assessments and Transcranial Magnetic Stimulation (TMS) therapy along with general adult psychiatry. Currently serve on adjunct faculties of UCF, FSU, USF and Uof F. We currently accept most Insurances.