Psychiatry & Psychotherapy Podcast - Polypharmacy in Psychiatry

Episode Date: September 9, 2022

Becoming an expert at reducing polypharmacy requires being an expert in not only psychopharmacology, but being a coach that directs a patient toward a holistic path. In this episode, I am joined by Jacob McBride, D.O., a psychiatrist in Pittsburgh, PA. We will be discussing some issues within polypharmacy and encouraging more holistic care for patients.  By listening to this episode, you can earn 1.25 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Hello and welcome to the Psychiatry and Psychotherapy Podcast. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. One thing that created a lot of burnout and angst for me was trying to get continued medical education right at the last minute. So why not join the CME membership and do CME while listening to this podcast. Go to Psychiatrypodcast.com, sign up, sign in, take the test, and the certification is emailed to you in seconds. Dr. Pudor and Dr. McBride have no conflicts of interest to report. Let's start the show. All right, welcome back to the podcast.

I am joined today with Dr. Jake McBride. He is a psychiatrist in private practice and also runs a consultant liaison practice for a hospital in Pennsylvania, in Pittsburgh. And he is someone I've known for a while. We've had many conversations together. Meaningful conversations about life, about psychopharmacology, psychotherapy, and today we're going to be focusing on polypharmacy. And so Jake, or should I say Dr. McBride, what do you want me to call you? Let's do Jake. Let's do Jake. Just kind of broadly give a definition and sort of an intro to the topic of polypharmacy. Yes, I think you and I decided

polypharmacy was important. Polypharmacy is dangerous, unlike anything dangerous. And like anything we must confront it. Polypharmacy is common. So, you know, it depends on how you define it, but roughly speaking about a third of outpatients at any time will be under polypharmacy. In the 1970s, about 5% of people walking out of an inpatient unit would have polypharmacy. In the late 1990s, 2000s, that number is more like 40%. So depending on how you define it, it's common, very common. Okay. Just how would you, I mean, my general definition is too many medications. Yes, yeah, exactly.

Polly meaning many, pharmacy meaning medications, so many medications. How would you define it? The same way. You know it when you see it. When it's too many, it's polypharmacy, is my working definition. A lot of authors will say two medications, a lot of authors will say four medications. A lot of authors will say it's only polypharmacy if you're using more than one medication. in the same class. There's many ways to cut it, but I'm very fond of your opening move here. You know when it's too much, too many medications. Okay.

And so, you know, as we were looking at this, we have our experience, which we're going to talk about, you know, from seeing thousands of patients, we have our experience. You were an inpatient psychiatrist, now you do C&L outpatient, mostly. And then, you know, all of the papers that we've read on polypharmacy. And there's a couple main ones that we're going to kind of blend together and discuss broadly, which of them. And we'll put those in the article that we write with this episode. So you can go to Psychiatrypodcast.com and get that, get those articles and dig deeper. But where do you want to start out when we're talking about polypharmacy?

Should we talk about the why this is important to talk about? Yeah, let's open with the risk. I think that's the hook. Okay. What are the main risks that you see? Okay. So the first risk is obvious. Every medication has its risks.

So as you add medications, the risk proceeds linearly. If the first medication has its risks, you add the second medications risks. Fairly obvious. I think the biggest risk is that the risk also proceeds exponentially because these medications interact. They interact at the level of pharmacodynamics. So you know they might have the same or related actions at certain receptors in the body. And they could overlap in terms of metabolism.

So in this day and age, we think about CYP enzymes often in terms of what medication impacts the other's metabolism, but there's other ways that they can mess up each other's metabolism as well. It can impact compliance. People don't like to take more than one medication. I'm lucky if I take my vitamins every day. I know every time I'm going to start a patient on a four-time. a day of medication we have to sit and say okay you know four times a day is this something you can do and likewise if you're going to be adding even more medications you know in general people take their

medications half the time and you have to think about that as you pile these medications on yeah i was looking at one specific article that was talking about the side effects of medications and when they moved from one to two to three to four you know the their sex life progressively decreased their work and study decreased in functionality, their close relationships had more issues. And, you know, pretty much every interpersonal thing across the board got worse as many medications were added. Now, as I read that article, I was thinking to myself, well, the people that are on a lot of medications also have worse issues often. And so I was thinking to myself, well, it's not like a direct causal relationship that life gets worse on multiple medications, or is life worse and then that leads

them to be on multiple medications? Any thoughts on that? That's a good question. So for some of these side effects, like sexual difficulty, for example, we have some theory to back us up. So we know that serotonergic actions are going to decrease interest in sex. So it makes sense that as you pile them on, such as in this paper from John Reed, that the amount of side effects goes up as a pharmacodynamic consequence, and likely also as a metabolic consequence as well. Yeah, that's commonly an issue we have to separate out from the evidence base in psychiatry is sicker people get more treatment. So when you make your claims about that, it's sort of a, what's the right metaphor? I wouldn't say exactly putting the card before the horse,

can be hard to separate that out. Is it the sickness demanding more treatment or is it the treatment making people get these adverse effects? I think it's a really good point because as we look at people who, for example, on multiple anticholinergic medications, we have a mechanistic understanding for why they have more cognitive doling, poor working memory, poor, you know, therefore concentration, you know, and then all the other things that goes along with that. So I think I like the way that you said that. It's like if we have a mechanism that makes sense on why multiple medications would disturb one particular functioning like sex life, then we might better understand what to do next

to improve it. So we talked a little bit about the why. Any other thoughts that you wanted to get out about the why? in terms of why we end up in the situation, why there is polypharmacy? Well, okay. Why is there polypharmacy? So there's a lot of reasons. Some of those, I think, are located in our patients. You know, we have a culture. We always have, if you ever looked in the history of patent medicine and so forth. In the United States, that when you have a problem, you leverage capitalism to get that solution.

You go, you get a thing, you take the thing, and it solves the problem. Many authors have blamed this is one reason why there's a push towards polypharmacy. We, the psychiatrists, have a variety of reasons to engage in similar behavior. We like to heal. We like to help. We also like to confront a problem with a solution. And so when people come to us, it is our nature. Some would say our duty to treat it as best we can.

You know, you and I might have a conversation about should we always be reaching for the prescription pad. But the fact is that we do. I'm sure even you and I that might be a little more inclined to treat with other means, still do that. There's also some difficulties that can happen if we lose our nerve in treatment. So very often we do things like cross-titrated medication. If we think the first medication is failed, we will proceed to a second. We bring the dose of the first medication down.

We bring the dose of the second medication up. Well, what happens if the patient gets better during that cross-titration? Very often, we lose our nerve and we pause there. I've done that several times. I shouldn't do it. I'm sure many of our listeners who are psychiatrists have done the same. Another set of reasons comes from forces that are much greater than us. You chilled me to the bone when we were talking earlier,

and you talked about the way that some of these pharmaceutical, pharmaceutical companies are trying to, what's the word, to use you and your base to generate business in a way that I hadn't heard of before. if you don't mind sharing that with us again? Yeah, so there was a specific pharmaceutical company that's coming out with a new medication for a disease with a specific mechanism of action, which is fairly unknown to psychiatry.

And so what they wanted was they wanted me three years out to start talking about the mechanism. And, you know, these grants are, these grants are so big that they would like pretty much double my, income, you know, just one of the, and so it's something that, you know, is when I, you know, I met with a moral quandary, right? Do I, do I take the grant or do I not take the grant? Do I take the money from the pharmaceutical company? And so far I've said no. But because it, it bothered me to think that,

okay, I'm going to be priming psychiatrists with the knowledge of this mechanism. You know, if you look at most CME psychopharmacology activities, you will see a host of pharmaceutical companies that are supporting. And, you know, we know from data that if pharmaceutical companies give us lunch, will be more likely to prescribe their medication, which is why I also don't eat lunches. I'm not judgmental if you do, but I feel personally, because of my role in education, I should not have any undue influence. But even with a lunch we're influenced, imagine getting several hundred thousand dollars a year.

And so, you know, there's no way that you'll then be unbiased, even if you sort of collude in your unconscious that you are unbiased. To be a thought leader. You know, I'm often, I used to think the phrase thought leader was just a platitude they gave us, but that's really sophisticated. You would actually be a thought leader laying the intellectual groundwork for their product. Yeah. And so I kind of, I kind of think that, you know, I hope that through the podcast, we provide a balanced source of education on multiple modalities that work so that we can look. in a relatively unbiased way to pick the best way to help people, you know, whether that's exercise or therapy or, you know, ketamine treatment or, you know, some other things coming up

the pipeline or old medications. So I've done a ton of episodes on like super cheap medications. And I think if you're listening to this episode and you're a patient and you're not incultrated in a medicine, you have to realize like doctors are not paid anymore or any more or any less if they give expensive or cheap medications. Actually, it could be argued that we have many reasons to give cheaper medications because prior authorizations are like something the insurance companies require, and they are just absolutely painful for doctors to do. But there's a $1.8 trillion pharmaceutical industry that knows that, and it's thinking,

how else can we get these doctors to prescribe our products? and I'm very impressed with you that you have resisted some of that pressure. Well, I almost want to say resisted for now. Oh, David. But no, because I feel the internal, like, pull, you know, but knowing myself, my guilt would get the best of me. You know, like I have a very sort of, I have sleepless nights when I sort of venerable. venture away from my conscience.

So, yeah. Can I make a pop culture reference? Sure. Go ahead. Okay. Spoiler alert for Westworld. Very good show. So in the course of that show, they're making these synthetic humans, and they're

trying to dictate their behavior. And the people doing this really struggle with exactly programming what they do, the details of what they do. So the analogy here might be giving us a lunch to try to convince us to prescribe a certain medication. But they ultimately find that if you just write the base motivations of these synthetic sentient beings, that you get the behavior you want almost every time, just with a couple base motivations. So how does that connect? Well, they're trying to write our base motivations if they can educate us on the mechanisms that they want to educate us on. It lays the groundwork for them.

They don't have to convince us to write the prescription. We'll leap at the opportunity. especially because in our field it's not always clear what medication is best so it's exciting to learn about a new prospective mechanism we'll want to investigate that and go out with that i think i think also like we are we are prone to see people suffer every day and therefore prone to want to come up with new ways of helping them and this is this is one reason why i think polypharmacy happens and you and i didn't prepare to talk about just NPD plain depression, but let's for a moment. So, you know, if you think about, say, the Stardee trial, you have a patient that's on their fourth medication trial, what's the probability that your next move pharmacologically is going to make any difference? It's

less than 10%, right? And I think that's why we keep trying medications. This would be more of a linear polypharmacy over time. But I think it's that disconnect between the objectives we want to accomplish and our power to do it that makes us just keep piling on. medications. Now, I think our lack of knowledge about alternatives also compounds polypharmacy. Do you feel like the efficacy of diet and exercise is well known in our field? It's, I don't think so because most physicians will not know how to talk about strength training even in a way that actually I think would be helpful. So most physicians are happy if their patients go for a walk. And that's where it's stop.

right oh great you're walking oh 10 minutes a day fantastic you know it's like no that's that's not going to get the dose effect that you need you need progressive you know strength training where you add weight slowly over time so that you have stress recovery adaptation so over time you have a physiologic adaptations to stress where it takes more stress to basically make you unravel and more stress physically or psychologically because our stress systems are one and the same. Like when you get stressed out, it's not like you have like two different stress systems, one psychological, one physical, they're all the same. So if we can slowly progressively increase the resiliency of our stress system,

whether psychologically through psychotherapy or physically through exercise, I think we get the desired result. So now I don't think very many physicians, all know how to talk about exercise. And the desired result is an effect size comparable to an antidepressant, correct? So it's hard to do a head-to-head with like strength training and antidepressant, but like strength training versus weight list is like an effect size of more than one in a lot of studies.

So it's very strong. And it's and the more you have a gain of strength, the better the outcome. So the patients who gained the most, the most, you know, the more. gained the most strength through the strength training in one particular study had the best outcome. So it's not just enough to do the same exercise each time you go to the gym. It's like, can you add one pound to the bar each time? You know, if you're doing banded chin-ups, for example, and you're using two different bands, add one pound to your pockets and then add two pounds the next time and add three pounds. And over the course of a year, I went from

doing chin-ups with three bands. I've never been good at chin-ups to doing it with 20 pounds dangling from me. And this was like progressive overload that changes my physiology and stress systems. So yeah, most people do not know how to coach someone in terms of strength training.

Cardio is another thing that there's very specific ways of thinking about how to get someone doing good cardio. I think it's the same thing, like progressive. How can you progressively stress them in a way that improves their cardiovascular respiratory fitness? And then diet, you know, like there's, I mean, just, I don't think that most of us are even entertaining that diet could be something that you could manipulate it with the patients to make their life better. With an effect size, I would say, similar to the kinds that we were discussing with exercise,

You know, no RTC, not much in the way of RTCs comparing it to an antidepressant, but compared to nothing else, you get effect sizes north of one easily. And I, I see, I failed to really get you excited about that, but I personally am very excited about the potential for these interventions. And I think that's part of the mastery of our field and part of how we can get out of polypharmacy. Well, okay, so I don't know, did I not look excited when you said that? You do not, no. You love lifting so much. You looked exciting, you looked excited telling us about the

Okay, so here's my hesitancy with the diet stuff. One study that I looked at, it did seem like it made a big impact. Specifically, they targeted in their selection of patients, people with already a bad diet. Is this the Smiles study? I think it may be. And so they targeted bad diet and they removed a lot of processed food. And, you know, I think, it did make a big impact. Like these people, the effect size was significant. I think my caveat is when we look at randomized control trials with medications, the control arm is never a wait list. It's never not doing anything. It's always a placebo.

And placebos themselves are powerful because of the connection with the person that's giving you the placebo. And so that's where maybe the psychotherapy, therapy takes, you know, takes a role. You know, placebos, like, for example, in Parkinson's disease, there's been placasibas that increase dopamine in the brain. So just the believing I'm going to take something

that increases dopamine actually increased dopamine. Or even a deep brain stimulator, not telling someone when you turn it off. There's some evidence that, or at least anecdotal case studies, where people that claim the deep brain stimulator does wonders if you turn it off without them knowing, it doesn't change things. Right. Sham, or just even getting away from psychiatry, sham surgery,

like sham lower back surgery, is very potently powerful. You know, it's more powerful than a pill. My favorite example of that is mammary artery ligation. People used to ligate a mammary artery and artery coming off pretty close to some of the cardiac arteries, thinking that it would promote collateral circulation. Okay. help people with angina and people said it worked like a charm you know i can't think of the study i just remember people they said it worked awesome but when you look at their hearts not any different

okay so this this is an important thing about polypharmacy specifically because there are some patients that when you change their meds they'll get better for a couple weeks and then they won't be and I've you know tend to have borderline personality disorder the belief in your med change will make it better for a little bit until it's not better anymore so it's like there is a placebo there are people out there there's my argument that come back to doctors in every single time they want a med change and they've put their hope and faith in meds for a very long time and a med change because of the placebo effect does make things better the problem is is that these people get put on more and more meds because they're asking for it often. And then they get to a place where they're on like six or eight meds. And now they're starting to have so many side effects that they're actually having real problems. That's a real dilemma.

You're right because we know that patient confidence in treatment increases its efficacy. Our confidence, as the providers, increases its efficacy. But it leads to exactly the problem that you stated. I personally do my best to maintain hope in the treatment overall and try to disconnect that hope from the medication a little bit with statements such as, you know, these medications we're going to expect that they help in a statistical fashion. You're not going to feel better in a week or two. Maybe looking back one month from now, you might be able to say, yeah, maybe I feel a little bit better and maybe it's the medication. And also to stress the therapeutic alliance, how you're going to work on this together and get better, and to stress the alternative treatment modalities that we discussed, assuming it's depression and anxiety. that we're still talking about.

Yeah. I think coming back to this like Star D type of thing, when you get on to the fourth med and you're looking for potentially less than a 4% response rate, when I see these patients, it's like, okay, what are the other options we have that are potentially more efficacious or different, you know? Like have they done psychotherapy? Have they had a sleep study to rule out? sleep apnea? Have they done like a partial or an IOP program? Have they done exercise or diet changes?

And then trying to work with them and trying to encourage them in the right direction. Because often they don't want to follow through if they're not feeling very well. So you have to have some patience. Absolutely. Patience and art and full engagement with everything our field has to offer, not just medication. Right. Yep. So tell me a little bit about, like, are there special things that you wanted to talk about? Specifically, you wanted to talk about Syracool. A couple special things.

Let's talk about Syracquel. You know, when we were talking about this initially, you thought one of the good models to discuss polyformists would be Syracquel, and you are, Syracquel used for sleep. I'm sorry, specifically. And you are right. So Serriquel is a very common sleep aid, fourth common sleep aid after the benzodiazepines and tracidone. but there's not much evidence for its use. Now, there are reasons to use Seroquel. It's a bit of a Swiss Army knife pharmacologically.

At lower doses, it's an anhystamine, which can help get you to sleep. It's an alpha-1 blocker, which can also help get you to sleep. At moderate doses, you get some serotonin modulation, which can be sedating, and at higher doses, dopamine blockade. So, assuming you're trying to avoid the GABA potentiators, the direct sedatives, like, benzodiazepines and Z drugs. Assuming that, Seroquel looks appealing on paper in terms of what you think it can do. There's a little bit of evidence that it's helpful in the early 2000s. It was a guy named Coors. He studied 14, I want to say kids, but young men gave them Seraquale either 25 or 100 milligrams of Seraquel. Studied them every three days, I believe it was, with polycinography,

and they slept better. They had better, longer, to sleep and it was related to dose. So the 100 milligram guys had better sleep than the 25 milligram guys, you know, 14 young people. It's not a randomized controlled trial, but I find that study a little bit compelling. And you have to compare that to other sleep aids, again, with the exception of maybe doxapin and also the Z drugs and the benzodiazepines. There's not a ton of evidence for some of the things we like to use for sleep. That being said, the evidence for the use of Syracool just isn't there, and there are risks. So all of the things that I just said were potentially good reasons to use Syracwell are also

bad reasons. So antihistamines can be sedating even when you wake up. Same with alpha blockers. An alpha blocker can drop your blood pressure. So whenever we stand up, we use our, let's say, adrenaline and epinephrine to constrict our blood vessels so that when we stand up, we generate a nice blood pressure and don't pass out. Serriquel can interfere with that.

That's especially an issue with elderly people. And then, of course, you can get neurologic problems from blocking dopamine as well, stiff muscles, extra paramil syndrome. Worst of all, at low doses even, it can cause metabolic problems. So it's a famous issue in our field that all antipsychotics, especially the newer low-potency agents can cause weight gain, they can cause increase in insulin resistance, and they can cause problems with your cholesterol.

Cerepo does that, and there's many studies that show it does that at low doses. So if any of our peers out there think that giving someone 50, 100 milligrams of Sarekwell avoids metabolic syndrome, they are mistaken. It does not avoid metabolic syndrome. There was a paper by Williams studying some soldiers across two military bases, and he found that people, with one month, with one month, less than 100 milligrams or 100 milligrams, gained about half a pound after a month, five pounds in six months, 10 pounds in a year. That's 10 pounds on low-dose serraquil, which if you're an outpatient psychiatrist and you're trying to help someone sleep is unfortunately easy to do. So to my mind, it's less the posse of evidence that discourages seracol use. It's more the side effects, chief among them, metabolic syndrome. What do you think about seracquel for sleep?

I'm very hesitant to use sarahuel for sleep. I think I reserve it for people who I consider have bipolar disorder who need an antipsychotic and also need to sleep. You know, bipolar disorder, you can also use lithium. Some people, lithium is not enough. So I would always start with something for bipolar that is like a mood stabilizer before an antipsychotic because of the side effects. But it depends on the person, depends on what side effects you're more concerned about.

So there's a lot of nuance there, of course. But yeah, I tend to reserve it for someone with true bipolar. Good. I wanted to encourage your nuance. I've said it before and I'll say it again. I think fully engaging with the sophistication of these problems prevents polypharmacy and failure to do so. Just writing for Syracwell because you don't want to give them a benzodiazepine, which is maybe good. It's just not adequate to the task of caring for our patients.

So you're exactly right to make it an integrated. process. I would add it can also help with PTSD. So the alpha blockade there does help. It's comparable to Prazacin, but people drop out more with Serraqa. Yeah, I think I'm hesitant. Well, it's always, it's always like something you have to consider, right? If you're using it for depression, you have to consider how bad is the depression is treating it with this and the potential help, partial help that you're going to get from it worth the potential. side effects and, you know, have you optimized other treatment forms? Like, for example, let's say they do have PTSD, really bad PTSD, and are they able to do psychotherapy? If they can't even tolerate

psychotherapy, but they're motivated to potentially do psychotherapy, then I'm going to try to get them on medications so that they'll be able to do psychotherapy. And I'm going to get them on medications that don't mess with the psychotherapy itself, like the benzodiazepines, specifically, or marijuana. It's the common, like, marijuana helps. Well, why can't I just use marijuana? Well, laying down new memories, short-term memory issues, marijuana. Have you done an episode on that out of curiosity?

I did an episode on the increased risk of psychosis, and I did a general overview before that on marijuana and the different cognitive issues. and prolonged, intense use can decrease IQ, it seems. Yeah, five points in a couple of years, I believe. Six points, yeah, pretty close. You're probably right. For one specific aspect, I'm probably right for the other specific aspect.

It's five or six, the same thing. Yeah, so Seraquel, use it with caution. Any other drugs jump out as like personal pet peeves? Yeah, and, you know, it's more than a, a pet peeve, if we're going to be worried about polypharmacy and it's danger, I think we need to start with the most dangerous things. So I'm glad that you wanted to go into Serraquo. And potentially, one of the most dangerous things out there is the anticholinergic effects of these medications. So let's discuss that for a bit. So anticholinergic effects referring to a blockade of

acetylcholine, which is kind of a workhorse neurotransmitter and the brain and body can have a variety of adverse effects, makes your mucous membranes dry, dulls you cognitively across the board, and it can make you constipated. You gave me, I forget, did you give me the Yoshi paper? Did I bring this up? I think you gave me this. You can own it.

Go ahead. Okay, so Yoshi in 2021 studies the anticholinergic burden with people with schizophrenia and what the cognitive adverse effects are. So there's a whole suite of adverse effects to worry about, But here we're only worried about cognition. There's about 1,000 people studied. They use the anticholinergic burden scale, which I have one, one criticism of that scale, but not a major one.

And they use an anticholinergic burden scale to categorize medications as either having a risk of one, two, or three, depending on how anticholinergic they were. They added up that for every patient, and they gave them a battery of tests, the main one being the pen-computerized neurocognitive battery, and they found that across the board, the higher the antichulnergic burden, meaning the more potent the anticholinergic medication and the higher the number of those medications, the lower the score. No cognitive domain was impacted more than the others significantly just across the board,

decline in cognition, which, of course, can happen naturally with schizophrenia. But here they, you know, they were comparing all people with schizophrenia or schizaffective disorder, actually, and found there was a big decrease. I think that's important to note because sometimes with schizophrenia we can be like, well, of course they're cognitively dulled. That's the negative symptoms of schizophrenia that's hard to treat. But what we don't want to miss as psychiatrists and mental health professionals is sometimes it's not the disease, it's the medications. And it's the unnecessary medications. So it's the like one of my pet peeves is why would you put someone who's never had any,

the EPS, so extra pyramidal symptoms, like spasms of your neck, you know, the neck jerks to one side. I'm so glad this is your pet peeve. I'm sorry. I'm so glad to hear it. Go ahead. I hope I'm not stealing your thunder here. No, thunder away. It's a mutual pet peeve. Why would you stick someone who's already on an antipsychotic who has never had EPS on just cogenton or Benadryl to prevent someone? thing that they've never had, which will dull their cognition, working memory. You know, these are very strong anticholinergic medications. And often what's happened, like I had this patient on chlozapine, on cogentin. I've seen that too many times.

And just to let you guys know, chlozapine is very anticholinergic. And so why would you need to stick them on another anticholinergic to prevent EPS. It's like, it's absolute, it's absolutely unnecessary. And its profile of binding to dopamine receptors is, if anything, favorable in terms of EPS. You know, this is not a potent medication like howd all binding 90% of the D2 receptors at all. It is, it is crazy. And in this study, they found that people had higher anticholinergic burdens if they were on monotherapy for an antipsychotic on typical agents, not atypical agents. And it's because of the Kijitin. It's because of the Benadryl.

For, like you said, EPS that they don't have with a 5% chance per year of getting it. Maybe more if they're an African-American male, probably more if they're elderly. But still, a low chance. Yeah. So, you know, what do I do? I tell the patients what EPS is that it is a rare side effect. And if they have it, they can either go to an emergency room or take Benadryl and then go to an emergency room. That's what I usually tell people to do.

Yes, that's one of the pet peeves. Any more on that pet peeve? Anticholinergic schizophrenia? No, it's almost too bad. We share the same pet peeve and we don't have an opponent process here. Because many of the people that trained me, one man that trained me said that if you give someone, how though you're obligated to give them, Kugent. he was talking about a more elderly population

but still it's so common and I just don't get it maybe they've had someone with a laryngeous spasm once and it freaked him out because that can be deadly maybe they don't maybe they think their patient's not going to appear again in six months and the EPS is going to start progressing to a heart of dyskinesia kind of process I just I truly I truly don't get why you would worse

why you would worsen negative symptoms of schizophrenia which are maybe more more more devastating than the possibility. symptoms for many people. Okay, here is a clinical pearl that I learned from Maltanado, who is a famous CNL psychiatrist, which if anyone is friends with them over there at Stanford, please get me in contact with them

so I can have them on the podcast. But at a conference, he said, one of the ways that he monitors the success of an antipsychotic being given for delirium is that EPS happens. It will not happen. as long as the person is in a delirium state. It will never happen.

So you can give huge doses of howl, and they will not go into EPS if they are in a state of delirium. As they come out of the delirium, if they're still on huge doses of howl doll, they potentially could have EPS. Cool pearl, huh? A cool pearl. I don't know if I would have the guts to use that.

curl very often, but that is very interesting. I wonder. He's not using it as like he's trying to push them into EPS. What he's noticing is that if the moment they have any EPS, he's gone too high, and they may be coming out of delirium. And so the way he doses, supposedly, is that he gives one day's recommendation at a time. And he says that because often if a Stanford psychiatrist puts an older patient on a medication, and then the patient is discharged, they will be on that medication forever. And this is a good polypharm tip as well. And David, you don't have to be a Stanford educated psychiatrist. That happens, I wish I knew the number. I want to say almost all the time. Yeah, so he specifically specifies the days that he wants this person on this medication,

and then he will reassess them when that time is up. He must write them to a expire in a day. Otherwise, they could put it on the discharge summary and get him out there before he has a chance to respond. No, yeah, I think he's fairly exacting in the way that he runs his CNL team to do it day by day, but I may be wrong. That's what it sounded like. CNL tendings often have to be exacting. And minimizing polypharmacy is one of those reasons. Polypharmacy is not all bad, though. And I'd like to touch on that unless you have something else Dan. Okay. Prove that to me. Yeah. Okay. So when I was a wee lab being trained, I was told there's no evidence, no good evidence for using more than one antipsychotic to treat schizophrenia

or psychosis in general. Because of that, don't do it. And here's your rotation on the inpatient psychiatric unit where you will do that every day. There's a big disconnect between the evidence for using more than one antipsychotic and the clinical reality. So, you know, a third of people with psychosis will respond well to an antipsychotic, but a third will have only a partial response, a third will have no response. You can roll the dice on that again with clausero, which has its own issues, but that leaves millions of people that are probably going to require some kind of treatment for psychosis, and there's adjuncts that are not antipsychotics, but that are probably going to require more than one antipsychotic. If you're an inpatient

psychiatrist, this is a problem because you don't have a lot of evidence to pay. which antipsychotic, let alone to even justify using more than one antipsychotic in the first place. Jari T. Hoan has a couple of papers out about this. I want to turn our attention to a paper he wrote in 2019, examining combinations of antipsychotics. So he studied one of those giant Nordic registries they have of, you know, thousands of patients over over a decade. And he was able to assemble hazard ratios of antipsychotic combinations versus not any psychotic combinations or readmission to hospitals. Any produced the list, I highly recommend anyone who's doing inpatient psychiatry or even consult psychiatry. Go to your website, check out the article so they can get this chart.

Because assuming that readmission is a decent enough proxy for treatment, which beggars can't be choosers, like I said, we don't have a lot of evidence in this field, there's decent evidence that I'll pull it up here. If you're watching the YouTube, you can see it right now. Decent evidence that Quasaril and Nabilify are the best combination out there. So this list for those who can't see proceeds, except for maybe the top choice, pretty much as you would expect, any combination with quasaril is high on the list. Any combination with a long-acting injectable is high on the list. I would be really curious what, say, Dr. Cummings would say in terms of, you know, why is it that intentionally the most indirect treatment, we have in terms of D2 receptor occupancy is the best combination therapy.

I do not know, but there it is. You'll see, Syracwell has a hazard ratio of almost one, implying that it's no treatment at all. In part, that's because in this study, he was looking at the actual prescriptions that were filled, and people were filling pretty low prescriptions for Syracwell. So it's not known whether they were actually written at low doses or if that's just what the patient ended up filling. but for Seraquel in particular, the actual doses dispensed were low and probably not therapeutic.

I think I could conjecture or guess what Dr. Cummings would say. Please do. Having been mentored by him for so long, he would say the problem with this study is that they're not checking blood levels and they're not taking a singular medication up to the limits of the therapeutic blood level. and so what he would say is when you're treating someone before you jump to a second one get the current one up to a up to a blood level that would get it near like where beyond that point it's futile and he would say you know if you have like let's say you're starting with risperol or zyprexa and those aren't working maybe you go to an injection maybe that's not working or actually let's say the same

is my sort of line of thinking, okay. Go for it. So you start with something that's oral. That's not working. You get blood levels, push it up. One, you get blood levels. You know if they're taking it or not. And then if that's not working, you go injection.

Injections are very consistent, which is why they usually work. The compliance is very high. If that doesn't work, you could try Clozapine, which takes a lot more work. You have to get weekly blood draws at first. They have to have some family that. that's willing to help them navigate and take care of this. And then if that, if clozapine doesn't work, then you could consider adding something

with some more D2 blockade. But I think it's interesting what you show here about the Abilify, closepine combination. That is an interesting combination that I haven't thought too much about. So I'm glad you drew my attention to that. It's an odd combination, you know?

So often our clinical reasoning, is more D2 blockade. If you ask a trainee, why do you choose Resperidone over another atypical? Their answer probably should be, well, it's a high potency atypical, something of that sort, higher D2 occupancy.

And yet, in this study, which does have the limitations that you cited, we have a mixed agonist of the D2 receptor with the bilify, and we have, well, plausible is very hard to describe, but certainly not a robust binder to,

to D2 receptors. Yeah. And this data is limited in the way that you say, but there's not that much data, you know, so yes, you're absolutely right. We should be, we should know what the blood level of our agents are is before we proceed to a second antipsychotic. But so often this dilemma will creep up that you have to, you don't have to, that you strongly are considering a second antipsychotic.

And I think T.O.N's work here can give you some help in that. Further in the paper, he also assembles hazard ratios for comparing specific antipsychotics with their potential combinations. And I think that's informative as well. Okay. Well, I'll put this there for the listeners to look at further and to consider and definitely bring it up with Dr. Cummys next time I talk to him and see what he thinks. I'd be very interested. Okay. else on polypharmacy that you definitely want to touch on before we wrap things up?

Mostly those special issues, you know, this is a complicated issue. It can be so troublesome for our patients. I think it's a big issue in psychiatry for a number of reasons, some of which we've discussed, but we work with syndromes that are so often poorly defined, the mechanisms can be poorly defined. There's such a wide variety of options at our disposal for psychiatrists that I think we're really called to get it right. Otherwise, we risk engaging in irrational polypharmacy and putting our patients at needless risk. You know, I suppose we never did have an organized discussion about how to minimize polypharmacy, shall we, before we run out of time? Sure. So there's a somewhat famous four-letter acronym, Sale by Lee, assembled in the 1990s. It's general advice. So sale is simple,

adverse indication and list, keep your regimen simple. Be mindful of adverse effects. Be mindful of the indication. So, for example, with Serecwell, if you're going to use it for sleep, think twice. If you're going to use it for sleep in bipolar disorder, maybe that's better, as you said. And then his last bit of advice list doesn't really apply in the age of EMRs. You know, our list should always be accurate, and that's easy to do. I personally advocate for considering polypharmacy as its own clinical entity and integrating that into your decision-making. So much like an internal medicine doctor will list in their note every medical issue and will comment on how they interact. I, and this is something I do in my practice, if they're on a handful of psychiatric medications

such that we get that gut feeling that it's too many, just like we opened with, I will opine about polypharmacy. And think through and reason why you are suffering polypharmacy, what the risks are, and why it's worth it or why it's not worth it and then make a treatment decision to reduce polypharmacy even if it sacrifices some potential therapeutic benefit. Very cool. I would say my closing remarks on polypharmacy would be when I see someone on too many medications, I wonder, is being in a state of disease bringing them connection that has led to them to be on this many medication. So for example, someone with borderline per seizs disorder could end up in a GI clinic with lots

of GI issues. Ten surgeries later, you know, could be diagnosed with something or could have real issues now. But maybe at first it was like exploratory, not know what's going on, not know what's going on, not what's going on, you know, they can put on this and that. Someone with borderline persuasive disorder could be in a neurologic clinic. and be with psychogenic seizures, chronic migraines, you know, all sorts of psychosomatic issues there, and be, you know, exploding head syndrome, you name it,

but all of a sudden now they're talking to subspecialists, they have people doing research on them, they have connection with staff that they needed. So I see the same sort of thing happen in psychiatry sometimes, where they took the medications as a way of, connection with providers over the years and it didn't necessarily help them or it did help them maybe for a time but but maybe not as necessarily now that they're in a good iop partial program and as they're getting really good therapy we can start to sort of unwind to the medications

and in the iop partial that i run i usually wait three to four weeks to start to unwind medications or to push them on quitting marijuana or something like that. If they're open to decreasing marijuana right away, then I will be more than happy to have them decrease that. But if I sense that it's going to be a, you know, I'm going to leave the program if this guy pushes me too hard. I'm going to let them get connected with the therapist, start to do the work,

and then as time goes on, start to have the conversation that allows them to get off certain medications. and maybe with exceptions of if there are very cognitive doling medications, I would potentially try to get those off sooner than later. So I think one more point is that as the alliance improves, then I try to convince them to do things like exercise and diet. If someone is very high conscientious, they may wonderfully engage my recommendations. However, a lot of people are not high conscientious, and if they're low

conscientious, they may need either a trainer or some sort of group to exercise with or some sort of structure that's outside of their own abilities to create for themselves. So you really have to know the person. You have to know what they're motivated to do, how motivated they are to do it, to know how and when you can bring medications down, and when you can bring them more into therapy and lifestyle orientation to the cure or the thing that's going to help resolve the issue that they come in with. It sounds like medications are not at the core of your work with them. For some people it is.

Schizophrenia. I have people on antipsychotics. And that's very core. I suppose what I mean to say is it's not the core of your relationship with them. So I agree there are cases where, of course, the medication is front and center. But it's not the core of your relationship with them. For me, choosing and deciding the medications is not the full conversation. it's about three to four minutes of a conversation.

So if I am, you know, a lot of these patients I'm treating now, they're seeing me for 25 minutes to 50 minutes. Absolutely, I'm not talking about medications the whole time. But I think that if you were a psychiatrist that did, that may lead, it may teach the patient that the way I get connection with this very important person is through talking about medications and the side effects. And so, I mean, that's what I found in this program that I run,

where we have very complex medical patients, some of which, not all, but some of which have gained connection through medical illness. And so I have to connect with them outside of medical illness. I need to connect with them in their emotions, in the things that they desire, and the things that bring them pleasure, in their connections with other people and their connection with myself.

It's a fine thing to model for someone in terms of how they relate to their own internal states. And hopefully I'm a good enough psychiatrist, you know. I'm not always, you know, sometimes it takes a tribe to raise an individual. Well, that's the beauty of the IOP setting. I'm sure many of your listeners will agree that you're probably a most excellent psychiatrist. And I think if we're all sophisticated enough to deal with polypharmacy forthrightly, not make medication the center of what we, I should back up,

not make medication the center of our relationship to our patients, even when it is the center of our work, I think we can minimize polypharmacy and just thrive in the treatment alliance in all direction. Cool. Well, I hope if anyone is in Pennsylvania, that and practicing therapist, psychiatrists, they'll reach out to Dr. Jake McBride, connect with them. He has a private practice there, and I'm sure you would love to take anyone out to eat. You would pay for their lunch, I imagine. Well, certainly it's fun just to connect and get to know other providers in town. And obviously talking about referrals is something I'd be very interested in. I will most certainly buy anyone lunch who's a therapist,

primary care doctor, anyone of the sort. We're not happy to talk. Can I do a little plug for you and then I have a personal question as well? Go ahead. So you and I had worked together for some time and I want to encourage anyone listening that's thought about consulting you for coaching to reach out and do so. I strongly believe, especially if you're early in your career, there's a huge opportunity cost to not getting mentholed.

mentorship and coaching. You're falling behind, not reaching your potential, and you need somebody. I tell my friends, you know, I tell any young professional that's trying to figure out what they want to do or just how to do what they are doing better, that you need good advice. If you have good manners, God bless you, that's good, but consider a coach of some kind. And you were most excellent coach to me, and I thank you for that. Well, you were an enjoyable to coach, and I think our friendship has developed. Luckily, coaching is a little bit different than therapy in that you can become friends afterwards. With therapy, I have very strict boundaries, of course.

So, yeah, seeing you prosper, seeing you get to the next stage in your career. You know, you made a shift from inpatient to outpatient, cash pay. And I think you're enjoying it. So it's been fun to see that. I sure am. One last question. I'm curious about your activities in parenting. You know, you've talked on the program a little bit about the challenges you've set up for your children. I think you were building a cannon to shoot them out of or some kind of stress or I wonder if you have any updates? No, no canon. Yeah. You know, so what I have seen in older patients

who come to me, and I fear more than anything else, is people who have spent weight. too much time in front of their screens and not enough time being challenged physically, interpersonally. And so what I like to do is try to figure out a way to do something that's a little bit challenging and try to keep my kids at the edge of like their interests, what's challenged and playful. So none of it's, all of it is they are asking for it. They're begging for it practically. So this morning, my son did sprints up a little hill, which in Florida is a little hill. And he did it with eight pounds. Cool. And he's worked up from zero pounds, you know, doing five or six sprints to now doing four sprints up this hill with eight pounds.

And he loves it, right? Because then when he sprints without it, he notices how he just flies up it, you know? And he's six years old. With my daughter, it's like, you know, you know, know, getting to walk around on her hands or, you know, we do, we've done cold plunges together. We, we try to make it fun. And I also talk about the importance of courage, the importance of of doing things that are hard, doing things, being okay with a little uncomfort, discomfort. Talk about how we get stronger in the mind. You know, how do we, practice doesn't make perfect. Practice makes progress. So whether we're doing like, intellectual challenging things or physically challenging things.

I try to sort of instill some of the wisdom of the ages as well. So me and my daughter are reading a graphic novel version of the Iliad, which is a lot of fun. Yes. Awesome. And eventually I want to read her the Iliad itself. But I want to read her the classics. And by classics, I mean like this culture read this book and they talked about it.

and it changed the way that they behaved with one another. Those are the classics in my mind. So every culture has those classics, and I would like to slowly go through them, and the primary texts as well. And so that's kind of intellectually what I'm slowly trying to bring them up in. May your children grow with that heroic view of life and existence. You're also reading The Hobbit, right?

The Hobbit, yeah. So helpful. I'm glad that you like that book. Oh, my, I had never read it. I just saw some of the movies. My son tolerates the Hobbit. We got through the Hobbit. We're on the Lord of the Rings.

And for one, for the parents out there, it's a free lecture and basic Western values that your kids will actually listen to. They'll listen to Gandalf if they don't listen to you. That helps. Describe Western values, because some people hear that and they'll be like, what? It's talking about capitalism?

Oh, Western value. So I'll just list a couple of them. The Western view of power and its ability to corrupt. So, you know, when people think of Western values, I think they'll often think of how Western culture often falls victim to power and the worst of it. But Tolkien is a huge advocate of the corruptive ability of power. That's the whole deal with the rings. Everyone that touches the rings is corrupted, ultimately.

And the whole story is about managing that corruption and dealing with it. There's a lot of quiet heroism. So in the Lord of the Rings, there's a lot of humble people who get to choose whether they're going to collaborate with evil and do what's easy or if they're going to say no and do what's hard. And it is a most excellent thing to just have those stories for our children. And that's just off the top of my head. You know, I can, if I sat down, I could probably think of a hundred examples of how some of the the bedrock values that you would want your kids to have that maybe you don't see in Paw Patrol or whatever else, you know, is available to our children that you will get from

reading great literature, whether it's the Elliott or the Odyssey or something, maybe a little more accessible in Tolkien. Yeah, I would say the Hobbit is accessible, like both my eight and my nine-year-old. sorry, six and eight year old. We're able to understand The Hobbit. And sometimes I would have to like sort of explain things. And I think there's value in actually physically reading it to your kids, not just listening to the audiobook.

The value in actually reading it is they're so used to hearing your voice. And so they've heard your voice for years and now they hear you. And plus it shows that what you're giving attention to has value. So if you decide, for example, I am only going to give attention to football. Your kids will overvalue football. And if they're not good at it, that will hurt their egos, you know? And so giving your attention to good things like a book like this, I think has incredible value. The Hobbit, the biggest takeaway for me that I saw my kids really walk away with

was the idea of money and greed and how greed corrupts. So in this story, it shows how like both the dragon was corrupted by the horde of gold and then subsequently other characters. And how the hero, Bilbo Baggins, you know, Hobbit, was actually not easily as corrupted. And money seemed very unimportant to him. And he kind of became the hero because of that, despite his small size. and inability to, you know, fight in ways that other characters could, his ability to sort of withstand or sort of see things clearly in the midst of lots of money. And every day I'm reminded how money blinds people.

You know, it's like it only takes one of your relatives dying with a lot of money to realize how the whole family can be completely, you know, destroyed fighting for that money. You know, it's like, some... It just goes on, right? So it's like... Which literally happened in The Hobbit. You know, as soon as those dwarves set sight on that gold, you almost have a catastrophic war between allies.

Yeah, and so you have a great story that talks about bravery, that talks about courage, that talks about sort of how greed corrupts and how money is not important. And my kids walked away with like, they talk differently about money now. They see that like, oh, life is not about money. You know, like that's not the end goal. So one thing I would add, and this dovetails with sort of the Jungian view of life, is he's a hobbit, you know, he's not Achilles.

He's not some great, amazing hero is one of the more humble creatures in that world. And the hobbits have a choice between a very comfortable lifestyle, which they love. So not only do they have a comfortable lifestyle, but constitutionally, and this really speaks to me. You know, I'm part Hobbit myself. They just, they love, they love their meals, they love their rest, they love their comfort and their safety. Gardens. Yep, yep. And throughout the whole, you know, every time something bad happens, you know, Bilbo is saying,

man, I really wish I was just in my Hobbit hole, eating my second dinner by a warm fire. And he has to contend with the sort of humble, heroic task of always choosing adventure and expanding out into the world and growing rather than trudging back to Hobbiton and being comfortable and putting up his feet. Or, you know, like, at times he could have turned around, but he cared more about the people he was with and they're finding an escape plan for them or finding a way out for them it was like it was his love of his comrades that led to him not paying attention to the blaring desire of his heart to be in his hobbit hole and so it's like we have we could have multiple motivations going on at

once and we could pay attention and magnify maybe a quietly voice that's inside of us, maybe the voice of courage, coming back to like how I think about parenting, it's like, how do we get our kids to access the voice of courage more than the voice of fear? How do we ourselves? You know, whether it's, you know, in our, in our professional roles, we all have points where we have to like access that to do what is right or to push through or to you know, or to explore when we're not sure what is right. And in the Lord of the Rings, you know, spoilers are fair after a century, I think, right?

Yeah. So, you know, in the Lord of the Rings, when this burden of the ring passes on to Frodo, the best guide Frodo has is Gandalf. And he says, you know, I'm not really sure what you have to do, but you have to do something. Take this ring and go. And Frodo has to be adventurous enough to say,

okay, I'm going to go out there. There's other elements in the story that push them forward. But that's one of my favorite parts of it is these hobbits could be so comfortable, but they choose adventure and they choose the right thing. And like you said, when under pressure, they will consistently choose a higher value. At least these specific hobbits with Tokish blood, or at least Bill, though, has Tokish blood. Right. And bringing this back to Polypharmacy, at times it's easier to just cater to adding more meds and to not having difficult conversations about decreasing clonopin decrease not giving Xanax not trying to get patients off of you know things like marijuana it's like it's easier to not have those conversations those conversations can

elicit very you know strong emotional reactions from patients right not only is it easier, but you could have great wealth if you avoid that. If you're writing for medical marijuana and other easier things, you would have great to use in a full practice in no time. Or like the opiate epidemic was partially built on physicians who decided, I'm going to do five-minute opiate prescribing and see 100 patients a day and make, you know, two plus million dollars a year or more. unfortunately that has led to you know an epidemic and decay in our society and so you know what we want to do is not we want to fight against that conspiracy of decay mediocrity i think that heroic aspect obviously

am biased but i think that's heightened for psychiatrists because there's so much lassitude in what you can do. The evidence does not often point us towards a treatment. So it is a bit of an adventure when we make our treatment decisions. And we have a greater responsibility to be good stewards of that. It's not the case that an algorithm is going to get you through your patient encounters. You have to figure it out. Yep. And like every hero's journey, you need mentors. So as you go through psychiatry residency, for example, build relationships with your attendings. You know, those people could be people you could ask questions of in the years to come, you know, and if you're in town with Jake McBride, I think we think in very similar lines, a lot of these things. And so,

connect with him if you're a newer psychiatrist or a therapist, having questions about difficult patients who are on multiple medications, wondering if they are impacting the work that you are doing. And, yeah, we'll leave it there for today. How about that? Sounds good, David. All right. Good to see you, man. Likewise.