When A Patient Gets Political

Disclaimer: This blog post reflects the author’s present recollection over time. Characters and dialogue have been recreated and rearranged. Events have been fictionalized and any resemblance to actual persons, living or dead, is purely coincidental.

A well-groomed, middle-age woman walked into my office and said, “Doctor, my anxiety is shooting through the roof!”

I expressed dismay and asked her what has changed since our last visit.

“It’s this damn fake election!” she exclaimed. “The Democrats are going to undo all the great things that Trump has done for this country. I can’t stand seeing these BLM rioters and Muslim invaders and Antifa terrorists on television. And now they’ve stolen our democracy! It’s terrible! And so many businesses are still shut down because of this stupid Chinese virus. I felt safer with Trump as president.”

Okay. I felt my heart pounding. I heard a low buzz in my ears. My body was entering fight-or-flight mode. I repressed the urge to stand and leave the room.

This puzzled me. Why was I feeling so afraid?

It made no sense. My patient was sitting in a non-threatening posture and more than six feet away, the result of social distancing precautions. She spoke at a moderate pace in a mildly anxious tone. She was even smiling at me as if she expected me to agree with her.

In my role as a psychiatrist, I take care of people who are intoxicated, delirious, and emotionally labile. This happens, especially in an emergent setting. Many of my patients had been brought to the hospital against their will, and they are usually afraid. Fear leads to irrationality, irrationality leads to unpredictability, and unpredictability leads to violence. I have tolerated a lot of verbal abuse from patients. I’ve endured misogynistic comments and racial slurs. I am trained in verbal de-escalation. I have talked many, many people down from screaming at me to thanking me. Despite these measures, I’ve had several patients attempt to physically assault me. One actually did.

Any front-line healthcare worker understands. As a group, we are remarkably prone to encountering verbal and physical abuse. Nationwide, 78% of emergency department physicians reported being targets of workplace violence (Behnam 2011). 82% of US nurses have been assaulted at least once during their careers, and 73% believe that assault was just part of their job (Speroni 2014). Verbal aggression is just as serious. In a 2016 review article, Phillips writes, “The importance of recognizing verbal assault as a form of workplace violence cannot be overlooked, since verbal assault has been shown to be a risk factor for battery. When verbal abuse and low-level battery are tolerated, more serious forms of violence are invited.” Verbal violence affects not only the victimized individual but also the entire health care system. Verbal violence can lead to demotivation, poor job satisfaction, early burnout and compassion fatigue. Overall, workplace violence affects the delivery of health care, decreasing quality and accessibility (Watson 2020).

I can handle that. But this smiling woman in my office was different. This felt new, in a strange, subtle, gut-twisting way. Maybe it was because this patient was not intoxicated or psychotically delusional and was speaking with a linear thought process. Maybe it was because this took place in the ostensibly safe space of my office. Maybe it was the inflection in which the word “Chinese” is said – with an elongated and emphasized sound of “chai” followed by the derisive sneer of “neez”. Maybe it was because I never expected this type of hate speech from this particular patient, who I had formerly thought of as a friendly, pleasant lady. Or maybe it was because I was vividly reminded of past hurts, of the childhood peers who would smile to my face and then make fun of my “chinky” eyes behind my back.

I took a slow breath. She seemed to sense my emotional turbulence. We looked at each other silently. I wondered what she saw.

My physical presentation is as a petite, Asian-American female. Would she think of me differently if she knew that I was not born in the United States? That despite my adopted American accent and soft southern drawl, my mother tongue is Mandarin Chinese. Or would she tell me that, oh no I’m not racist, you’re one of the good ones, without thought of how that implies the opposite – that in order for me to be different, the rest of my peer group must share common negative traits.

As a rule, I don’t bring up politics with patients. But what do I do, when a patient gets political?

“I don’t agree. I feel less safe,” I said. “You know, it has been really difficult being an Asian person in this pandemic.”

To my relief, she offered an olive branch.

“I’m sorry for talking about politics,” she said. “I don’t mean to bring all that negative energy in here.”

And we talked about it. I told her that I want my office to be a safe place where she can bring her worries. That I wanted to hear about the triggers for her anxiety, so that I could better understand her and be a better doctor for her. At the same time, I told her that her words can be hurtful. That although she was certainly not responsible for my feelings, perhaps she could be a little more mindful and understanding about what she says and how she says it – because I am a person, too.

Then we moved on to discuss her medical care.

Although it may be uncomfortable, I think that it is important to think about how race and politics can color interactions between health care providers and patients. As we seek to understand each other, these conversations need to be ongoing and authentic. NBA player Jeremy Lin spoke out earlier this week as a guest on “Race in America: A Candid Conversation.”

“I feel bad for somebody who harbours hate for somebody else, who they’ve never met, just based on skin colour,” he said. “That makes me want to do something. It makes me want to educate people… speak out and find ways to make a difference. Honestly, it goes from anger to just heartbreak.”

He also posted on his Instagram: “Being an Asian American doesn’t mean we don’t experience poverty and racism. Being a 9 year NBA veteran doesn’t protect me from being called ‘coronavirus’ on the court. Being a man of faith doesn’t mean I don’t fight for justice, for myself and for others.” (Didion 2021)

There has also been a rise in hate crimes against people of Asian descent. Recent data released in major cities show a shocking growth in the number of racially-motivated attacks (Wells 2021, Sturla 2021). As I discussed above, serious physical assault does not occur in a vacuum; it is frequently preceded by verbal abuse and low-level battery. I strongly suspect that there are numerous unreported events of verbal abuse and microaggressions. Knowing this, I can begin to understand why I felt the way I did. My feelings of danger have root in truth.

What happens out in the world gets brought into doctors’ offices. And when this happens again – when, not if, because problems of hate and intolerance do not simply fade away – then I can be better prepared for it.

More Information

Behnam M, Tillotson RD, Davis SM, Hobbs GR. Violence in the emergency department: a national survey of emergency medicine residents and attending physicians. J Emerg Med 2011;40:565-579

Speroni KG, Fitch T, Dawson E, Dugan L, Atherton M. Incidence and cost of nurse workplace violence perpetrated by hospital patients or patient visitors. J Emerg Nurs. 2014;40(3):218-228. doi:10.1016/J.JEN.2013.05.014

Phillips JP. Workplace Violence against Health Care Workers in the United States. N Engl J Med. 2016 Apr 28;374(17):1661-9. doi: 10.1056/NEJMra1501998. PMID: 27119238.

Watson A, Jafari M, Seifi A. The persistent pandemic of violence against health care workers. Am J Manag Care. 2020 Dec 1;26(12):e377-e379. doi: 10.37765/ajmc.2020.88543. PMID: 33315330.

Didion, A. Warriors’ Jeremy Lin Reveals He Has Been Called ‘Coronavirus’ on Court. NBC Sports Bay Area. February 26, 2021. Accessed February 27, 2021. Link: Warriors’ Jeremy Lin Reveals He Has Been Called ‘Coronavirus’ on Court – NBC Bay Area

Wells, N. Anti-Asian Hate Crimes Are Up 717% In Vancouver. Canadian Press. February 18, 2021. Accessed February 27, 2021. Link: Anti-Asian Hate Crimes Are Up 717% In Vancouver | HuffPost Canada (huffingtonpost.ca)

Sturla, A, et al. Anti-Asian attacks are on the rise in NYC. The city is pushing to combat it. CNN. February 27, 2021. Accessed February 27, 2021. Link: Anti-Asian attacks are on the rise in NYC. The city is pushing to combat it. – CNN

Inside Asylum Walls

“Nobody will ever convince me that the splendor of individual courage cannot triumph over all the fates. Neither family death, nor personal illness, nor “hard times,” nor heavy responsibility solely borne, nor hazards met without warning can defeat one man standing alone who refuses to relinquish his courage. I knew such a man. He was my father.”


– Dorothy Powers, In Tribute to My Dad.

About a year ago, I visited a small bookshop in Spokane, Washingon. As an independent book store for nearly four decades, 2nd Look Books was full of second-hand treasures and local history. A bright red book caught my eye. Boldly titled: “Dorothy: POWERS TO THE PEOPLE”, it contained a collection of columns written by journalist Dorothy Rochon Powers for the pages of The Spokesman-Review.

The inside cover had a hand-written note from the author dated September 16, 1989. It was addressed to a dedicated reader, perhaps the author’s friend. “I wish you many happy memories in these pages. Thank you for reading my column! – DRP”

As per my usual habit, I flipped open the book to a random page. To my surprise, the book fell open to an article titled, “Inside Asylum Walls: The Patient’s View.” It must be fated for this book to land in the hands of a psychiatrist, I thought, and so of course I purchased the book.

Published in December 1957, the article by Powers reported on conditions at Eastern Washington State Hospital. As part of her research, Powers repeatedly visited the institution and conducted interviews with members of the staff. Then with the assistance of officials, she got herself “committed” and spent time there disguised as a patient.

What she found was disturbing. The institution was overcrowded and understaffed. “To a state mental hospital with 2,064 patients — and facilities for 1,861; to a staff of 13 doctors, where the American Psychiatric Association standards show 28 are needed; to an institution with 20 nurses instead of 166,” Powers wrote (pg 99). This was shocking. In comparison, the institution where I am currently training as a resident physician can provide services for up to 99 patients, with four attending psychiatrists on-site every workday and a half-dozen resident psychiatrists serving as helping hands. The physicians are supported by a robust staff of nurses, techs, and social workers.

In 1957, there were too few hands on deck at the Eastern Washington State Hospital. Members of the staff did their best, but the amount of work was overwhelming. Not only were they outnumbered, but they also cared for some of the most severely mentally ill people in the state. There would have been people who were diagnosed with debilitating illnesses such as chronic schizophrenia or catatonia. Some would be so paralyzed by their minds that they depended entirely on caretakers for basic functions, such as eating, bathing, and toileting. Powers described their despair. “‘It’s all we can do to keep them clean,’ sighs an attendant, ‘much less spend any time working with them'” (pg 101).

Remember, this was before the advent of psychopharmacology, before antipsychotic medication such as chlorpromazine and haloperidol and clozapine revolutionized psychiatric medicine. This was before the 1960s, when the social movement for deinstitutionalization of the chronically mentally ill gained momentum and lead to the replacement of long-stay psychiatric hospitals with an outpatient care-focused model and the goal of reintegrating patients into the their community. Powers’ article, among many others across the nation, helped instigate change. Today, Eastern Washington State Hospital has a patient capacity of just over 280 beds, according to Wikipedia. The changes over the years are reflective of our society’s evolving attitudes and growing understanding towards mental health.

The picture that Powers’ paints may seem foreign and strange, as the landscape of behavioral healthcare has transformed so drastically. But some things remain familiar. As I read, I was vividly reminded of people I have met in my current work in psychiatric wards. The 1950s were not so long ago – some of these patients may still require care today. Powers provided powerful quotes: “‘You keep wondering why you’re different, what the people at home are saying. Right now, I worry whether the neighbors will still let their children come see me, when I get home… if I get home'” (pg 100).

People in the past as they do today still yearn for home, fear rejection, and desire healing. They have hopes and fears and dreams that, though clouded with their illness, remain deeply, unconditionally, and essentially human.

The remainder of the book is a fascinating documentary of life in the eastern side of Washington State. Powers captured the highs and lows of the human experience. She flew in a giant Air Force refueling jet at 40,000 feet in the air at 600 miles an hour. She mingled with inmates in Washington State Penitentiary. She climbed a 15-story bare steel scaffolding. She reported on the thunderous eruption of Mount St. Helens. Throughout it all, she described people with understanding and compassion.

When I travel, I love these pieces of local history. Upon my next visit to Spokane, I plan to return the book where I found it so that someone else can also discover its treasures. May the next lucky person also find inspiration in Powers’ stories!

More Information

Powers, DR. Dorothy: Powers To The People. Cowles Publishing Company. 1988. Print.

Let’s Learn Psychopharmacology A to Z: Bupropion

“Happiness is not something you have to achieve. You can still be happy during the process of achieving something. So if you change your perspective a bit, although many of you may be going through tough times right now, this could also be the most beautiful moment of our lives.”


Kim Nam-joon, 2015. “The Most Beautiful Moment In Life Concert” Seoul, South Korea

Welcome to another post in the “Let’s Learn Psychopharmacology A to Z” series! This series is dedicated to discussing some of the most highly-cited, landmark articles in psychopharmacology.

Disclaimer: This discussion is intended to briefly and superficially review the medical literature that describes the use of a medication. As new studies are published every day, information presented here may be obsolete. Ultimately, selecting a medication remains a decision between a patient and their doctor. Doctors recommending and patients using these medications are strongly advised to consult information provided by the manufacturer.

Today’s topic is bupropion (brand names: Wellbutrin, Aplenzin, Zyban [branded for smoking cessation]).

First, let’s have some background. Bupropion is a norepinephrine and dopamine reuptake inhibitor. Since dopamine is inactivated by norepinephrine reuptake in the frontal cortex, which largely lacks dopamine transporters, bupropion can increase dopamine neurotransmission in this part of the brain (Stahl 2017). Bupropion is FDA-approved for major depressive disorder, seasonal affective disorder, and nicotine addiction. It is also used off-label for bipolar depression, ADHD, and sexual dysfunction. Bupropion decreases depression relapse and also extends time to relapse for depression (Weihs et al 2002). Studies comparing bupropion and SSRIs have all shown comparable efficacy (Clayton 2007).

Bupropion is offered in three formulations: immediate release (IR), sustained release (SR), and extended release (XL). Both SR and XL formulations are FDA approved for major depressive disorder. Only the SR formulation is FDA approved for nicotine addiction. Bupropion can be used with SSRIs (such as citalopram or sertraline) to treat partial responders or to improve SSRI-induced apathy and SSRI-induced sexual dysfunction. Bupropion is also used as an augmenting agent to mood stabilizers and/or atypical antipsychotics (such as lithium or olanzapine) in bipolar depression. 

This brings me to today’s discussion, which I am titling, “Bupropion Mythbusters.” As I reviewed literature for this post, I was surprised that a number of oft-repeated “truths” by my colleagues and mentors were, in fact, not so firmly set in stone. Some may be controversial, or perhaps the data simply isn’t conclusive. In any case, I have selected three which impressed me the most and presented them below.

!!! Bupropion Mythbusters !!!

Myth #1: More is Better

Guidelines allow for use of up to a total of bupropion 450 mg daily for the treatment of depression, with most patients taking a 300 mg daily dose. But there is little to no evidence of a clear dose-response effect. One 8-week multicenter study of bupropion SR showed no difference between 150 and 300 mg daily doses measured on depression rating scales (Reimherr et al 1998). A possible explanation for this is presented in an early study that demonstrated a potential inverted curvilinear plasma concentration-response curve for bupropion, meaning that concentrations above or below the maximum response range may correlate with a poor response for depression (Preskorn 1983). 

This finding may not be absolute. In contrast, there is a positive linear dose- and concentration-response observed for smoking cessation with bupropion. Johnston et al showed that higher daily doses of bupropion were correlated with increased likelihood of smoking cessation, up to 300 mg daily. 

In practice, I would still support increasing doses of bupropion for depression, as it may help some patients reach the maximum response range. However, my expectations for symptom reduction would be guarded. 

Myth #2: Bupropion will make anxiety worse

Hypothetically, bupropion may increase anxiety due to its stimulant properties. However, this theory has remained unproven. A randomized, parallel-group, double blind, multicenter trial compared anxiety response between sertraline (n=126) and bupropion SR (n=122) in people with major depressive disorder. No difference in anxiolytic efficacy or time-to-treat effect was observed between the two groups. Furthermore, there was no evidence for worsening of anxiety with bupropion over the course of the 16-week trial (Rush et al 2001). In a review article, Foley et al state that in their experience, anxiety is an occasional self-reported cause of intolerance, yet bupropion also appears to lower anxiety in the majority of psychiatric patients. These findings suggest that bupropion is not anxiogenic.

Myth #3: Stop bupropion for smoking cessation if there isn’t an intent to quit smoking

Bupropion is useful in improving both initial and long-term abstinence rates and at preventing relapse (Ferry 2003). Its principal mode of action seems to be the alleviation of withdrawal symptoms following smoking cessation. A randomized, double-blind trial comparing bupropion versus placebo showed that bupropion may be used long-term in people who are unwilling to quit or who perceive themselves as being unable to quit smoking. Fourteen percent in the bupropion group sustained a 4-week continuous abstinence period versus 8% in the placebo group. The researchers also showed that the number of cigarettes smoked per day and the time until the next cessation attempt were decreased during bupropion treatment (Hatsukami 2004). Therefore, bupropion can provide a positive benefit even in the absence of intent to stop or cut down tobacco use. The effects are not sustained after bupropion is discontinued. 

In conclusion, bupropion has been widely studied for a variety of uses and has been proven to be safe and effective. Its unique mechanism of action relative to other SSRIs and SNRIs make it a valuable option in antidepressant treatment.

References

Stahl, Stephen M, and Meghan M. Grady. Stahl’s Essential Psychopharmacology: Prescriber’s Guide. 2017. Print.

Weihs KL, Houser TL, Batey SR et al. Continuation phase treatment with bupropion SR effectively decreases the risk for relapse of depression. Biol. Psychiatry 51(9), 753–761 (2002).

Clayton AH . Extended-release bupropion: an antidepressant with a broad spectrum of therapeutic activity? Expert Opin Pharmacother 2007 ; 8 (4): 457 –66. 

Reimherr FW, Cunningham LA, Batey SR et al. A multicenter evaluation of the efficacy and safety of 150 and 300 mg/d sustained-release bupropion tablets versus placebo in depressed outpatients Clin. Ther. 20(3), 505–516 (1998). 

Preskorn SH. Antidepressant response and plasma concentrations of bupropion. J. Clin. Psychiatry 44(5 Pt 2), 137–139 (1983).

Johnston JA, Fiedler-Kelly J, Glover ED et al. Relationship between drug exposure and the efficacy and safety of bupropion sustained release for smoking cessation. Nicotine Tob. Res. 3(2), 131–140 (2001).

Rush AJ, Trivedi MH, Carmody TJ et al. Response in relation to baseline anxiety levels in major depressive disorder treated with bupropion sustained release or sertraline. Neuropsychopharmacology 25(1), 131–138 (2001).

Foley KF , DeSanty KP , Kast RE . Bupropion: pharmacology and therapeutic applications . Expert Rev Neurother 2006 ; 6 (9): 1249 –65. 

Ferry L , Johnston JA . Efficacy and safety of bupropion SR for smoking cessation: data from clinical trials and five years of postmarketing experience . Int J Clin Pract 2003 ; 57 (3): 224 –30. 

Hatsukami DK, Rennard S, Patel MK et al. Effects of sustained-release bupropion among persons interested in reducing but not quitting smoking. Am. J. Med. 116(3), 151–157 (2004).

Cultural Competence in Clinical Psychiatry: A book review

I’ve always found cultural considerations in psychiatry to be a fascinating but difficult topic to understand. Perhaps this is because the topic is so broad; lessons from one culture may not necessarily be applicable to others. Or perhaps it is because in formal education and exam prep books, there is a lot of focus on abstract, theoretical and conceptual issues. Many questions quiz on specific culture-bound syndromes such as “koro,” “hwabyung,” and “ataque de nervios.” The theme, if any, is usually some variation of: “People have many different viewpoints. Treat all of them with respect.” But usually, big questions remain: How do cultural differences affect, in a concrete, tangible way, the relationship between a psychiatrist and their patient? How does this impact management decisions and outcomes? And how exactly can physicians best communicate with patients who hold views, beliefs, values, and attitudes different from their own?

Well, this book answers those questions.

I recently borrowed this book from one of my attendings. Published by the American Psychiatric Association in 2004, a dozen psychiatrists contributed to the book and illustrated the impact of cultural differences in psychiatrists in different clinical settings with an emphasis on clinical applications.

My favorite part of this book were the clinical vignettes. Each chapter was neatly separated by clinical setting or subspecialty, and included up to 5 clinical vignettes. Memorable examples include a teenage Hispanic female with psychosis; a 6-year-old boy being evaluated for ADHD; a Samoan schoolteacher with psychogenic weakness of the legs. I won’t spoil the conclusions to the cases, but I will reveal that they had numerous twists and turns and that I found them fascinating. Within the book, each case’s cultural components were carefully analyzed and discussed.

I especially liked that the clinical vignettes provided an easily accessible means for classroom discussion. After an initial description of the presenting problem, students could be asked for their ideas in formulating a differential diagnosis. Then the instructor can guide students towards a final diagnosis and provide education. Each case presentation can conclude with a classroom discussion on treatment, management, and communication with the patient in a culturally appropriate manner.

My criticism of the book stems from a personal dislike of repetition. Because the chapters are divided by clinical setting or subspecialty, the same themes are reinforced again, and again, and again. By the sixth chapter or so, I began to tire of seeing the same idea presented in yet another new sentence, and would skim it quickly just until I found another clinical vignette. Please don’t misunderstand me – there were certainly sections of the discussion between cases that were novel and different among the chapters. It was only the sections that were similar that I would not miss.

Would I read the entire book again? Probably not. But would I use it as a reference material for an instructional series? Absolutely.

More Information

Tseng, WS, Streltzer, J. Cultural Competence in Clinical Psychiatry. American Psychiatric Publishing, 2004. Print.

Let’s Learn Psychopharmacology A to Z: Acamprosate

“Better is possible. It does not take genius. It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try.”


Better: A Surgeon’s Notes on Performance, Atul Gawande

Welcome to the first post to start the “Let’s Learn Psychopharmacology A to Z” series! Through this series, I will discuss some of the most highly-cited, landmark articles in psychopharmacology. A lot of this knowledge is relatively new. Medications were introduced into the practice of psychiatry in the 1950’s starting with the use of chlorpromazine and lithium. Since then, the list of psychotropic medication has exploded. There are 143 drugs described in Stahl’s Essential Psychopharmacology, Prescriber’s Guide, Sixth Edition (which is a highly recommended reference material decorating many psychiatrists’ offices) and more are being developed in pharmaceutical pipelines.

Disclaimer: This discussion is intended to briefly and superficially review the medical literature that describes the use of a medication. As new studies are published every day, information presented here may be obsolete. Ultimately, selecting a medication remains a decision between a patient and their doctor. Doctors recommending and patients using these medications are strongly advised to consult information provided by the manufacturer.

Today’s topic is acamprosate (brand name: Campral).

Let’s start with basic facts. Acamprosate is an amino acid derivative of taurine that acts as a modulator of GABA neurotransmission. It is FDA-approved for maintenance of alcohol abstinence. Theoretically, it reduces excitatory glutamate neurotransmission and increases inhibitory GABA neurotransmission. Because alcohol withdrawal can lead to excessive glutamate activity and deficient GABA activity, acamprosate can act as “artificial alcohol” to mitigate these effects.

"How Acamprosate Works" © Jennifer Hsu
“How Acamprosate Works” © Jennifer Hsu

Acamprosate appears to work best for individuals who have already abstained from alcohol. Other medications used frequently for alcohol use disorder include naltrexone and disulfiram.

In 2004, Bouza and colleagues published a meta-analysis of 13 acamprosate studies with 4000 total participants. The major findings confirmed that acamprosate improved the continuous abstinence rate with a number needed to treat of 10, and also significantly improved cumulative abstinence. Unfortunately, this study also showed that the rate of adherence to prescribed medication was a problem. Compliance varied widely among the studies, ranging between 40% to 90%. Overall, only about half of the people receiving acamprosate continued to take it throughout the assigned treatment period. The reasons for drop-out are unclear, though a minority reported discontinuation of medication due to adverse side effects, with gastrointestinal issues affecting approximately 17% of patients assigned to take acamprosate.

Next up is a randomized controlled trial – the COMBINE study, which was published in JAMA in 2006.

The COMBINE study is one of the largest studies on acamprosate. It was a randomized controlled trial that studied medication management (MM) and combined behavioral intervention (CBI) for the treatment of alcohol use disorder. Medications used include acamprosate and naltrexone. Primary outcome measures were 1) percent days abstinent and 2) time to first heavy drinking day. A heavy drinking day was defined as ≥ 4 drinks per day for women and ≥ 5 drinks per day for men

Participants were first divided into three groups: 1) MM only, 2) MM+CBI, and 3) CBI only. Within the groups that received medication management (MM), participants were further divided into four groups: acamprosate only, naltrexone only, both acamprosate + naltrexone, and placebo. This resulted in nine total groups.

Surprisingly, the COMBINE study showed that acamprosate had no significant effect on drinking versus placebo, either by itself or with any combination of naltrexone, CBI, or both. This result was different from the prior studies. The authors hypothesize that the negative result is perhaps because the COMBINE trial required only 4 days of abstinence before participants could join the trial, versus a longer pretreatment abstinence period.

A meta-analysis published in 2008 stated that acamprosate is efficacious, but in different ways than naltrexone. Rösner and colleagues write that acamprosate improves continuous abstinence rates over placebo with a number needed to treat of 8. However, acamprosate did not influence alcohol consumption after the first drink (i.e. reducing the amount consumed or risk of a lapse becoming a relapse.) Naltrexone reduced relapse rates, time to relapse, and also reduced heavy drinking in a subgroup of non-abstinent patients. From this, acamprosate appears to be the treatment of choice if the goal is complete abstinence, whereas naltrexone is preferred if choosing a harm-reduction strategy to prevent excessive drinking in non-abstinent patients.

“Individually allocating patients to treatments according to their motivational status could further enhance the effectiveness of treatments of alcohol dependence.”


– Rösner and colleagues 2008, citation below

The final article presented here was published in 2008 by Kranzler and colleagues. This report contributed to the United States Food and Drug Administration (FDA) approval of acamprosate for use in conjunction with psychosocial support in the maintenance of abstinence in alcohol-dependent patients. Kranzler et al re-analyzed three European pivotal trials, which were published in 1995, 1996, and 1997. These trials took place in France, Belgium, and Germany and examined a total of 623 patients.

Krazler et al applied a more rigorous definition of abstinence than the initial studies; for example, patients with missing data or with unknown status were also considered non-abstinent. With a more restrictive definition of abstinence, the calculated rates of abstinence were lower than the rates previously published, but remained significantly higher for patients treated with acamprosate than placebo. Rates of complete abstinence for placebo ranged between 9-13%, while rates for acamprosate ranged from 16-38%. Secondary outcomes for percent days abstinent and time to first drink also showed efficacy favoring acamprosate.

Overall, acamprosate is a well-studied, safe, and effective medication. There is also some evidence to show that the benefits of acamprosate in maintaining sobriety can extend for at least up to 12 months after drug discontinuation. Acamprosate has some limitations in its use. For example, it is most likely to be successful in people who have already maintained a period of sobriety. However, it can still be a valuable treatment option for many people.

References

Bouza C, Angeles M, Muñoz A, Amate JM. Efficacy and safety of naltrexone and acamprosate in the treatment of alcohol dependence: a systematic review. Addiction. 2004 Jul;99(7):811-28. doi: 10.1111/j.1360-0443.2004.00763.x. Erratum in: Addiction. 2005 Apr;100(4):573. Magro, Angeles [corrected to Angeles, Magro]. PMID: 15200577.

Anton RF, O’Malley SS, Ciraulo DA, Cisler RA, Couper D, Donovan DM, Gastfriend DR, Hosking JD, Johnson BA, LoCastro JS, Longabaugh R, Mason BJ, Mattson ME, Miller WR, Pettinati HM, Randall CL, Swift R, Weiss RD, Williams LD, Zweben A; COMBINE Study Research Group. Combined pharmacotherapies and behavioral interventions for alcohol dependence: the COMBINE study: a randomized controlled trial. JAMA. 2006 May 3;295(17):2003-17. doi: 10.1001/jama.295.17.2003. PMID: 16670409.

Rösner S, Leucht S, Lehert P, Soyka M. Acamprosate supports abstinence, naltrexone prevents excessive drinking: evidence from a meta-analysis with unreported outcomes. J Psychopharmacol. 2008 Jan;22(1):11-23. doi: 10.1177/0269881107078308. PMID: 18187529.

Kranzler HR, Gage A. Acamprosate efficacy in alcohol-dependent patients: summary of results from three pivotal trials. Am J Addict. 2008 Jan-Feb;17(1):70-6. doi: 10.1080/10550490701756120. PMID: 18214726.

A Brief Discussion on the International Pilot Study of Schizophrenia

I’ve been trying to make a renewed and dedicated effort to both read and write more. I’ve realized that waiting for the inspiration to strike doesn’t happen. If I want to read and write more, then I need to set aside time to cultivate the skill. It has been more difficult that I thought.

Still, this is part of that effort. And so today, I decided to review and write about my thoughts on a very important psychiatric article – The International Pilot Study of Schizophrenia: five-year follow-up findings.

Published in 1992, this article is an “oldie but goodie.” It is best known for its provocative finding that people with schizophrenia have better clinical and social outcomes in developing countries when compared with developed countries. In other words, a person with schizophrenia in Agra (India) or Ibadan (Nigeria) was significantly less ill and suffered less occupational and social impairment than someone with the same diagnosis in London (United Kingdom) or Washington, DC (United States).

As discussed in the article, one suggested explanation for this finding is incompleteness of follow-up at the sites in developing countries. However, when they further examined the data, they found that this was an unsatisfactory explanation for the results. A second suggested explanation was if a greater proportion of patients in developing countries had an acute, rapidly resolving psychosis with an inherently better prognosis. This explanation, too, was not supported upon further data modeling.

A third proposed explanation involved greater tolerance and acceptance of the behaviors displayed by people with schizophrenia by their families. This hypothesis had partial support, as a sub-study related to this project showed that patients in Chandigarh (India) who had families with low levels of Expressed Emotion had better clinical outcomes.

Low levels of Expressed Emotions are favorable; alternatively, families with high Expressed Emotion interact more frequently with negative and intense verbal exchanges. Relationships are oppositional or conflictual in nature, and interaction patterns are rigid. Conversations are marked by increased criticism, hostility, and emotional overinvolvement. As described by Amaresha & Venkatasubramanian in a 2012 article, “Researchers have positioned Expressed Emotion within the diathesis-stress model of psychopathology, characterizing it as an environmental stressor that can potentially precipitate/cause relapse of psychosis among people with a genetic vulnerability.”

However, the study concluded with a statement that an exact definition of the elements of culture and society that improve outcomes remains unclear.

There have been additional follow-up studies to this impactful article. In 2000, Hopper and Wanderling revisited this question and hypothesized that cultural factors promoting recovery may include: 1) supportive kin, 2) auspicious or alternative beliefs, 3) flexibly configured work, 4) forgiving domestic space, and 5) more socially integrated subjectivities. They also point out that, subtracting Hong Kong, the remaining sites in the “developing” group are all located within India, which simplifies the question of culture.

“The extraordinary engagement of Indian families in the course of treatment – from the initial decision to seek help, to attending to basic needs and medication adherence during hospitalization, to support afterward, including monitoring medications and functioning – is surely one of the signature features of psychiatry in that country.”


Hopper & Wanderling 2000, “Revisiting the Developed Versus Developing Country Distinction in Course and Outcome in Schizophrenia.”

I can further appreciate this finding while I was reading The Quiet Room by Lori Schiller. The Quiet Room is a biography describing one woman’s experience with schizophrenia. About midway into the book, Lori’s mother realizes that she had seen her own mother, Lori’s grandmother, display the eccentric and psychotic behaviors that Lori appeared to be experiencing. Lori underwent multiple psychiatric hospitalizations and trials of medications. Meanwhile, Lori’s grandmother, who was the daughter of a wealthy man and a housewife, did not. As a quote from the book describes, “My mother [Lori’s grandmother] was rich, and so she was allowed to be eccentric.” (Schiller & Bennett 1994, pg 82)

Lori, who faced the pressures of being a high-achieving, upper-middle class young adult, newly graduated from college, suffered greatly not just from the symptoms of psychosis but also from the loss of her place in society.

“I have lost many things: the career I might have pursued, the husband I might have married, the children I might have had.  During the years when my friends were marrying, having their babies and moving into the houses I once dreamed of living in, I have been behind locked doors.”


Schiller & Bennet 1994, The Quiet Room, pg 5

It brings to mind the pressures that society may place on its members to conform. Of course, conforming is not necessarily bad. Conforming to social norms regulates our social interactions, reduces anxiety, brings us closer to one another, and helps us feel safe. But perhaps there is a price for conformity – a price that is paid by the marginalized among us.

References

Leff J, Sartorius N, Jablensky A, Korten A, Ernberg G. The International Pilot Study of Schizophrenia: five-year follow-up findings. Psychol Med. 1992 Feb;22(1):131-45.

Hopper K, Wanderling J. Revisiting the developed versus developing country distinction in course and outcome in schizophrenia: results from ISoS, the WHO collaborative followup project. International Study of Schizophrenia. Schizophr Bull. 2000;26(4):835-46.

Amaresha AC, Venkatasubramanian G. Expressed emotion in schizophrenia: an overview. Indian J Psychol Med. 2012;34(1):12-20.

Schiller, L., & Bennett, A. The Quiet Room: A Journey Out of the Torment of Madness. New York: Warner Books. 1994.