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Back to the Pharmacological Future

The Carlat Psychiatry Blog, Volume , Number ,

Doc, I need to give you a hug. I hope COVID rules don’t prevent me from doing so. I just haven’t seen Ms. A this stable in 13 years . . . until you put her on this new medication. I need to thank you properly!

Those words of gratitude from Jackie, Ms. A’s caregiver of said 13 years, touched me in a way that few have during the pandemic. Assembled during that visit were Ms. A seated quietly in front of me, Jackie her caregiver to the left, and Ms. A’s brother/guardian to the right, all beaming with appreciation—or so I imagined since all parties were masked. I hesitated for a few quick seconds but then as we all stood to depart, I opened my arms wide. After all, I thought, this was a medication management visit, not psychotherapy, and since I am fully vaccinated against SARS-CoV-2 (and perhaps needed the hug just as much as she did), it was all systems go.

I might have overstepped my bounds from an infection control standpoint but the mental health consequences of the absence of human touch during the pandemic has emerged as a significant concern. I believe that during this time in history when “inappropriate” touch in a variety of workplace settings (including my own) continues to dominate headlines, we in psychiatry must remain open to the power of nonsexual human touch—especially when the request comes from a grateful patient or members of their care team outside of the context of psychotherapy.

When we as mental health experts are able to free a patient from the chains of behavioral dyscontrol and agitation due to a combination of schizoaffective disorder, bipolar type, and developmental delay, the emancipation it brings is absolutely worthy of celebration.

When we as mental health experts are able to free a patient from the chains of, in this case, behavioral dyscontrol and agitation due to a combination of schizoaffective disorder, bipolar type, and developmental delay, the emancipation it brings is absolutely worthy of celebration. As an internist-psychiatrist, I find it ironic that we line hospital corridors with applause to celebrate the recovery of a patient who discharges following a battle with COVID-19 but there is often little fanfare when a patient with severe and persistent mental illness (SPMI) discharges from hospital after months (or even years) on an inpatient psychiatry unit. Cakes on birthdays are usually the most noteworthy indulgence for psychiatric patients during their inpatient stays.

In outpatient psychiatry, the acknowledgment of recovery can be more muted still, which is why when I started a partial hospitalization program (PHP) program several years ago, one of the first orders of business was to create a certificate of completion from our program, signed by the therapist and psychiatric provider. The impact of this intervention was best captured when one of our “graduates” told me that she had framed her certificate and valued it more than her college diploma hanging juxtaposed. In the case of Ms. A, I believe that simple hug served as a proper punctuation mark to our visit, bucking the “no physical contact is the general rule in psychiatry” textbook stance.

Yet, the value of touch is not the primary subject of this thought piece. You might be wondering which medication change was so instrumental in Ms. A’s recovery—the one that demanded the hug. I recently delivered a well-received continuing medical education (CME) talk on behalf of my institution entitled Newest Antidepressants and Antipsychotic Mood Stabilizers. The title likely leaves you contemplating which novel psychotropic medication I used to stabilize Ms. A’s symptoms. I will divulge that secret shortly but the reason that CME is so important is that learning new treatment options for our patients often allows us to harness the power of novel mechanisms of action to better control symptoms, typically with fewer adverse effects. Simply put, newer is usually better—whether it comes to technology or pharmacotherapy. It has to be—otherwise nobody would use the new stuff. Learning about the newer treatment options is important since none of us would ever want gaps in our fund of knowledge to be a stumbling block in our patients’ recovery. Yet, what of the older options?

One of my most impactful teaching cases to date has been Ms. B, a retired nurse who struggled with major depressive disorder for decades. She was trialed on a litany of the latest and greatest pharmacological and psychotherapeutic treatment options up through the mid-2000s when I met her. It wasn’t until we took a step back in time (cue Huey Lewis and the News’ Back in Time)—specifically to the 1950s when the tuberculosis drug, iproniazid, made its debut as the first monoamine oxidase inhibitor to treat depression—that we found success. Ms. B responded to isocarboxazid, iproniazid’s less hepatotoxic cousin introduced in 1959. She found remission life-altering—and I found it unforgettable.

We both panicked several years later when her insurance company stopped covering isocarboxazid and pharmacies had a hard time procuring it. Fortunately, she has continued to do well even after a hasty substitution with the “newer” option, tranylcypromine, introduced two whole years later in 1961. Ms. B remains one of my few remaining cases where I introduce my residents to the ubiquitous board question involving MAOIs and the threat of hypertensive crisis with tyramine-containing foods. Ultimately, our gamble to make the old new again paid dividends. Which brings us back to Ms. A.

Ms. A was not sleeping through the night and decompensating. Despite our best efforts with several second-generation antipsychotic (SGA) mood stabilizers, including most recently olanzapine and quetiapine, which theoretically lowered her risk of movement disorders, etc., we were not finding success. I typically think in “threes” when offering treatment options and during our index visit, I offered Ms. A’s team two newer agents—cariprazine and asenapine—as options along with the original SGA, risperidone. In the spirit of shared decision-making, we reviewed each option carefully and ultimately settled on the 1993 offering. Not new but with a higher degree of D2 blockade, risperidone proved the correct choice. After a brief titration, Ms. A calmed down—better than she ever had according to those who know her best. Old had become new again.

Great care must be exercised whenever we go back to the future with pharmacotherapy. Higher rates of adverse effects for the prescribed and greater vigilance by the prescriber are typically incumbent. Yet, when it works out, sometimes even beyond all expectation, the best problem in the world for us to have at the end, pandemic or no: “Doc, I need to give you a hug!”

Y. Pritham Raj, MD

Associate Professor, Departments of Internal Medicine and Psychiatry, Oregon Health & Science University. The author reports no conflicts of interest concerning the subject matter of this article


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