Psychology vs. Psychiatry

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Jon Snow said:
Yes, there are many pitfalls. I see this all the time (neurology setting). Sometimes an "error" is a subjective thing though. . . depends on your specialty, yes? A behavioral neurologist might see that some medications in the system are anti-cholinergic and want to immediately discontinue them because of potential cognitive effects, whereas as the prescribing practioner might see them as necessary for whatever condition they were treating.
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Absolutely I agree 100%. There's degrees to medical errors. The only ones that get investigated on a regular basis are those that result in a patient death. Others that cause morbidity only may skate by. Many mistakes are thankfully self-limited, where clinician error doesn't cause permanent damage and the body repairs itself. Say a patient comes in diagnosed as "psychotic" but really has delirium from a bacterial infection. If they were never worked up and no one caught the other symptoms because a coherent history couldn't be gathered and the patient couldn't be examined, they'd get admitted and treated for their psychosis. They could go on to die, or their body could fight off the infection and they'd get better. The clinician might never pick up on the missed diagnosis if they get better despite the providers best efforts.

But your anti-cholinergic point is well-taken. We all have our biases that often arise from our training. This leads to style of treatment and perhaps more of the "art" of clinical work. Do anticholinergics always as a rule cause cognitive impairment? Maybe. But it might not always be the cause of the problem for that patient. It's our failure to recognize that we have biases that is really the dangerous territory.
 
Nitemagi,

I certainly agree with many of your points. My point is similar to what you are saying about not assuming you know everything. The more you learn the more you realize what you do not yet know and we all need to stay aware of this dynamic. I see many seasoned residents who come to believe they have it all figured out when they leave residency and it leaves them at a disadvantage when they get out in the workforce for many reasons. Most come to realize there is always so much more to learn at some point, but the residents who get there before they leave tend to do much better.
 
stigmata said:
Nitemagi,

I certainly agree with many of your points. My point is similar to what you are saying about not assuming you know everything. The more you learn the more you realize what you do not yet know and we all need to stay aware of this dynamic. I see many seasoned residents who come to believe they have it all figured out when they leave residency and it leaves them at a disadvantage when they get out in the workforce for many reasons. Most come to realize there is always so much more to learn at some point, but the residents who get there before they leave tend to do much better.
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I just think that the psychologist and the resident needs more training in stats and chemistry to understand pharmacology in the first place. I did a lot of work to get to a point where I can truly read entire meta analyses and see some of what they were afraid to print in a particular research article. To effectively provide services if you want to perform psychotherapy and prescribe as either a psychiatrist or psychologist. If you cannot interpret other's work to help your clients of patients, how can you be confident in the services, psychotherapy and meds you prescribe; we can say "clinical experience" but without training and study in outside but related applications/tools how can the claim be made to be providing "quality services."
 
nitemagi said:
Absolutely I agree 100%. There's degrees to medical errors. The only ones that get investigated on a regular basis are those that result in a patient death. Others that cause morbidity only may skate by. Many mistakes are thankfully self-limited, where clinician error doesn't cause permanent damage and the body repairs itself. Say a patient comes in diagnosed as "psychotic" but really has delirium from a bacterial infection. If they were never worked up and no one caught the other symptoms because a coherent history couldn't be gathered and the patient couldn't be examined, they'd get admitted and treated for their psychosis. They could go on to die, or their body could fight off the infection and they'd get better. The clinician might never pick up on the missed diagnosis if they get better despite the providers best efforts.

But your anti-cholinergic point is well-taken. We all have our biases that often arise from our training. This leads to style of treatment and perhaps more of the "art" of clinical work. Do anticholinergics always as a rule cause cognitive impairment? Maybe. But it might not always be the cause of the problem for that patient. It's our failure to recognize that we have biases that is really the dangerous territory.
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There can be all sorts of issues the primary doc or therapist cannot account for that are not irreparable, but can hinder progress and then those that cannot be undone.
 
Many times psychiatry lacks a depth of rapport and the addressing of emotional issues that Psychologists often cover. Of course their are many many outliers to this (David Scharff comes to mind) but the majority of Psychiatrists that I have met only hold 15 -20 min meetings just to adjust medication where with many Psychologists I have met longer meetings that focus on more emotional and personal issues are addressed. Both are necessary, and like I said before, these are gross generalizations so take it with a grain of salt.
 
PsychGraduate said:
I just think that the psychologist and the resident needs more training in stats and chemistry to understand pharmacology in the first place. I did a lot of work to get to a point where I can truly read entire meta analyses and see some of what they were afraid to print in a particular research article. To effectively provide services if you want to perform psychotherapy and prescribe as either a psychiatrist or psychologist. If you cannot interpret other's work to help your clients of patients, how can you be confident in the services, psychotherapy and meds you prescribe; we can say "clinical experience" but without training and study in outside but related applications/tools how can the claim be made to be providing "quality services."
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The problem with this premise is that what is most commonly treated in psychiatry is symptoms as opposed to diagnoses, but research focuses on diagnoses over symptoms. Someone with bipolar disorder who is overweight and has primarily depressive periods would likely be treated very differently that someone with the same Dx who is primarily hypomanic and otherwise healthy.
 
stigmata said:
The problem with this premise is that what is most commonly treated in psychiatry is symptoms as opposed to diagnoses, but research focuses on diagnoses over symptoms. Someone with bipolar disorder who is overweight and has primarily depressive periods would likely be treated very differently that someone with the same Dx who is primarily hypomanic and otherwise healthy.
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Agreed. But that is why good research interpretive skills and clinical training are so important. Also that is why I at times hold a dim view of most psychiatrists, not because we do not need psychiatrists, or that no excellent ones exist, but many (>50%) seem to be giving medications without a deep understanding of the drugs they are prescribing. They read a research study biased from the manufacturer with gaps in reports on side effects and contraindications in many cases, they have forgotten basic tenets of metabolism and biochemistry and then when the patient has a severe reaction to > 1 drug prescribed due to using too high of a loading dose, not taking an adequate history and taking the time to perform an adequate holistic assessment, there are issues of competence.

Obviously some patients will be allergic to a given medication or are psychosomatic on any or most drugs and sometimes doses need to be adjusted several times. The issue I have is many psychiatrists do not have adequate medical knowledge and cannot understand a drug study they are reading. I do not mean all psychiatrists, but there needs to be better education and training for them to prepare them for the realities of practice in my opinion.
 
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ltj999 said:
Many times psychiatry lacks a depth of rapport and the addressing of emotional issues that Psychologists often cover. Of course their are many many outliers to this (David Scharff comes to mind) but the majority of Psychiatrists that I have met only hold 15 -20 min meetings just to adjust medication where with many Psychologists I have met longer meetings that focus on more emotional and personal issues are addressed. Both are necessary, and like I said before, these are gross generalizations so take it with a grain of salt.
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This is more a manifestation of managed care than of a lack of interest of psychiatrists. Most psychiatrists I know would love to spend more time with their patients, but the current reimbursement model is shoddy at best.
 
PsychGraduate said:
Agreed. But that is why good research interpretive skills and clinical training are so important. Also that is why I at times hold a dim view of most psychiatrists, not because we do not need psychiatrists, or that no excellent ones exist, but many (>50%) seem to be giving medications without a deep understanding of the drugs they are prescribing. They read a research study biased from the manufacturer with gaps in reports on side effects and contraindications in many cases, they have forgotten basic tenets of metabolism and biochemistry and then when the patient has a severe reaction to > 1 drug prescribed due to using too high of a loading dose, not taking an adequate history and taking the time to perform an adequate holistic assessment, there are issues of competence.

Obviously some patients will be allergic to a given medication or are psychosomatic on any or most drugs and sometimes doses need to be adjusted several times. The issue I have is many psychiatrists do not have adequate medical knowledge and cannot understand a drug study they are reading. I do not mean all psychiatrists, but there needs to be better education and training for them to prepare them for the realities of practice in my opinion.
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NOW who's trying to start a flame war? I generally find it inappropriate to be lectured by anyone without medical training that our medical training is insufficient. Psychologists have no medical training. I've been through 2 years of basic science courses, 4 years of medical school, and 3 years so far of residency. And I was a psychology undergrad.

As for reading studies, that largely varies on format of training. Pharmaceutical influence and tweaking of data for studies is rampant throughout all of medicine. It's probably most highly abused in primary care, since primary care doctors write for more psychotropics that psychiatrists ever will. This makes them easy targets since they're already so heavily burdened with their time.

Some of us are trained quite well to analyze studies critically. Many are not, it's true. This is likely an area of stronger training for psychologists, since Ph.D's are trained in a research model. MD's are trained in a treatment model. Hence the roots of the words -- psych-iatry (to treat), psych-ology (to study). Now of course that's a simplification. My point is that the general medical education curriculum is geared to master the massive amount of medical information, which has become an increasingly important skill. Medical schools are starting to compensate for this, but they're still grossly behind the curve. I was lucky to have a medical school that devoted several courses to biostats, epidem, and "mastering medical information." But this isn't enough of a reason to condemn the whole field. Really you'd have to chastise all of medicine, not just psychiatry. And you're free to do that. But all the better to chastise the ones writing the papers with shady data first.

If someone puts out a bad food product, do we blame the manufacturer or the consumer? Let the buyer beware, sure, but we also have a lot of regulation knowing that in reality people can't protect themselves from deceptive practices all the time. Maybe we need a Dept. of informatics within the federal government. Does it show I'm a democrat? 😀
 
nitemagi said:
NOW who's trying to start a flame war? I generally find it inappropriate to be lectured by anyone without medical training that our medical training is insufficient. Psychologists have no medical training. I've been through 2 years of basic science courses, 4 years of medical school, and 3 years so far of residency. And I was a psychology undergrad.

As for reading studies, that largely varies on format of training. Pharmaceutical influence and tweaking of data for studies is rampant throughout all of medicine. It's probably most highly abused in primary care, since primary care doctors write for more psychotropics that psychiatrists ever will. This makes them easy targets since they're already so heavily burdened with their time.

Some of us are trained quite well to analyze studies critically. Many are not, it's true. This is likely an area of stronger training for psychologists, since Ph.D's are trained in a research model. MD's are trained in a treatment model. Hence the roots of the words -- psych-iatry (to treat), psych-ology (to study). Now of course that's a simplification. My point is that the general medical education curriculum is geared to master the massive amount of medical information, which has become an increasingly important skill. Medical schools are starting to compensate for this, but they're still grossly behind the curve. I was lucky to have a medical school that devoted several courses to biostats, epidem, and "mastering medical information." But this isn't enough of a reason to condemn the whole field. Really you'd have to chastise all of medicine, not just psychiatry. And you're free to do that. But all the better to chastise the ones writing the papers with shady data first.

If someone puts out a bad food product, do we blame the manufacturer or the consumer? Let the buyer beware, sure, but we also have a lot of regulation knowing that in reality people can't protect themselves from deceptive practices all the time. Maybe we need a Dept. of informatics within the federal government. Does it show I'm a democrat? 😀
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I have formal medical training. I am not trying to flame a war. > 50% of psychologists are not fully competent in my opinion either. We do not know each other but I live and breathe Harrison's.

I have seen many programs where the attending physician did not know heart block correctly and the resident in psychiatry somehow knew about glucagon for beta blocker overdose in the psychiatric patient.

A little regulation can be a good thing.
 
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PsychGraduate said:
I have formal medical training. I am not trying to flame a war. > 50% of psychologists are not fully competent in my opinion either. We do not know each other but I live and breathe Harrison's.

I have seen many programs where the attending physician did not know heart block correctly and the resident in psychiatry somehow knew about glucagon for beta blocker overdose in the psychiatric patient.

A little regulation can be a good thing.
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That's fair. I can't defend others in my field. But I recognize it's tough if not impossible to train everybody in everything. Drug interactions should be basic bread and butter for us. Besides the pharmacists, no one else has much training in pharm at all. I believe stats are very important, and being able to analyze the literature is very important. But part of training is also hands on. A lot of the theoretical we discuss manifests quite rarely in real world practice. That has its place as well.
 
nitemagi said:
And I was a psychology undergrad.
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I've always chuckled at this, mostly because I did both psych. and pre-med for my undergraduate, and undergraduate psychology classes were little to no comparison to doctoral classes, so I'm not sure how it is relevant when talking about graduate training.
 
nitemagi said:
That's fair. I can't defend others in my field. But I recognize it's tough if not impossible to train everybody in everything. Drug interactions should be basic bread and butter for us. Besides the pharmacists, no one else has much training in pharm at all. I believe stats are very important, and being able to analyze the literature is very important. But part of training is also hands on. A lot of the theoretical we discuss manifests quite rarely in real world practice. That has its place as well.
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If an intern reads one chapter of current psychiatry a month, and a new resident reads on chapter of Harrisons a month then it is not so much added stress to their regular studies and training and they can ask pose appropriate questions and catch attending psychiatrists is real errors and thus become a competent attending as well one day.

In addition getting some mentoring from psychologists on psychotherapy is a good idea. Being psychoanalyzed helps too if at all possible.
 
Therapist4Chnge said:
I've always chuckled at this, mostly because I did both psych. and pre-med for my undergraduate, and undergraduate psychology classes were little to no comparison to doctoral classes, so I'm not sure how it is relevant when talking about graduate training.
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To have a background in psychology and to train in psychiatry is better than not having a psychology background, but you do make an excellent point.
 
PsychGraduate said:
To have a background in psychology and to train in psychiatry is better than not having a psychology background, but you do make an excellent point.
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Again, it all depends on your school. I wasn't implying undergrad has any equivalency to graduate training. I did a specialized focus on psychotherapy as an undergraduate, rather than traditional psych 101 classes.

And I don't think reading regular chapters or articles is added stress. I expecting expertise in biostats in all MD's would be nice but may come at the sacrifice of some other skill or area of training.
 
nitemagi said:
Again, it all depends on your school. I wasn't implying undergrad has any equivalency to graduate training. I did a specialized focus on psychotherapy as an undergraduate, rather than traditional psych 101 classes.
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Even so, that really isn't relevant to graduate training. I don't want to come off as needling, but my point is that your implication is that it is similar (though not equal). If the same comparison of undergraduate pre-med training and medical school were made, it'd be met with quite a bit of push back.

To get back on topic.....it really comes down to the core training: Scientist-practitioner v. physician.
 
nitemagi said:
Again, it all depends on your school. I wasn't implying undergrad has any equivalency to graduate training. I did a specialized focus on psychotherapy as an undergraduate, rather than traditional psych 101 classes.

And I don't think reading regular chapters or articles is added stress. I expecting expertise in biostats in all MD's would be nice but may come at the sacrifice of some other skill or area of training.
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I do not trust any doctor who does not understand biostats. I do not think reading articles is stress either or using the best textbooks available while training are that bad either. A psychiatrist who can competently practice and can interpret Harrisons is a true doctor who must know biostats, clinical medicine and biochemistry, and pharmacology for the book to make anysense anyways.

Psychotherapy can be learned prior to grad school, it is just not all that common is my point. Then again a psychologist who can understand Harrisons is extremely rare as well, so I am not going to delude myself into thinking most in the field put themselves through what I did.
 
Therapist4Chnge said:
Even so, that really isn't relevant to graduate training. I don't want to come off as needling, but my point is that your implication is that it is similar (though not equal). If the same comparison of undergraduate pre-med training and medical school were made, it'd be met with quite a bit of push back.

To get back on topic.....it really comes down to the core training: Scientist-practitioner v. physician.
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The former point is dead on 100%. The second is not so cut and dry.
 
PsychGraduate said:
The former point is dead on 100%. The second is not so cut and dry.
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Agreed. Many Physician Scientists exist, with or without Ph.D.'s in addition to their M.D.'s. Harrison's is a fine book for internal medicine. But it's a textbook. Training in epidemiology, biostatistics, informatics in my opinion is more important in the critique and assimilation of new literature. This also requires not only knowing the basics that a textbook like Harrison's would give you, but then being able to critically analyze new data that might challenge it. Psychiatry is not just (psychopharmacology + internal medicine). In my opinion it's the synergy of all that and a fluid understanding of medical conditions that mimic or worsen the psychiatric, psychiatric conditions that mimic or worsen the medical, and choosing the right tools for the right patient. Choosing that tool means being fluent in psychopharm as well as various psychotherapies -- if you choose to practice them great, if not, then to refer them to someone who practices the intervention you believe may be most appropriate. And through it all comes a critical mind that must compare data from the patient, from articles, from labs, from vital signs, from physical exam, from records, and putting together a coherent formulation that likely shifts from visit to visit and moment to moment, and be willing to change the plan accordingly. It's a tall order, and like other psychiatrist I'm working on it every day. 🙂
 
nitemagi said:
Agreed. Many Physician Scientists exist, with or without Ph.D.'s in addition to their M.D.'s. Harrison's is a fine book for internal medicine. But it's a textbook. Training in epidemiology, biostatistics, informatics in my opinion is more important in the critique and assimilation of new literature. This also requires not only knowing the basics that a textbook like Harrison's would give you, but then being able to critically analyze new data that might challenge it. Psychiatry is not just (psychopharmacology + internal medicine). In my opinion it's the synergy of all that and a fluid understanding of medical conditions that mimic or worsen the psychiatric, psychiatric conditions that mimic or worsen the medical, and choosing the right tools for the right patient. Choosing that tool means being fluent in psychopharm as well as various psychotherapies -- if you choose to practice them great, if not, then to refer them to someone who practices the intervention you believe may be most appropriate. And through it all comes a critical mind that must compare data from the patient, from articles, from labs, from vital signs, from physical exam, from records, and putting together a coherent formulation that likely shifts from visit to visit and moment to moment, and be willing to change the plan accordingly. It's a tall order, and like other psychiatrist I'm working on it every day. 🙂
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Again I will say it: I commend you. Here is my point: when one is truly comfortable with Harrisons and Current Psychiatry they can interpret any journal finding, do biostats, they thoroughly understand biochem, molecular biology, pharmacology, and contraindictations and mechanisms. Harrisons is a book but it is the most detailed and complex textbook of internal medicine and Oxford and Cecil are two other fine books. Harrisons is based upon the best available and accurate information from the best journals with the most weight of evidence, so when you understand it and interpret it professionally, no peer reviewed journal is off limits.


Yes it does take a critical mind, like when Current or some journal says use prozac instead of say Wellbutrin, but when one can analyze the stats and qualitative data they realize that the controls or the experimental group, in the prozac study were biased and the prozac was actually more dangerous...👎 in some real way that is statistically significant. You may want to prescribe the Prozac anyways under specific clinical conditions or in cases with an allergy and consideration of little or no cross reactivity between drugs, however, the basic knowledge of how to assess that comes from training, self study, and those very best textbooks in conjunction with peer reviewed journals. I do think that the self discipline, asking many questions, reading/understanding textbooks, the tests and training creates the foundation for everything else.

Of course we could prefer to compare drugs within classes for the benefit of the patient/client. The choice of inter class or intra class analysis is a bit subjective.
 
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nitemagi said:
This is more a manifestation of managed care than of a lack of interest of psychiatrists. Most psychiatrists I know would love to spend more time with their patients, but the current reimbursement model is shoddy at best.
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Very good point. But alas, it is still the reality of the professions, regardless of intent.
 
nitemagi said:
My perspective is that psychiatry offers more flexibility. There are outstanding psychiatrists that're therapists out there. If you're smart, dedicated, (as opposed to many people who got into psychiatry because it's less competitive or considered a lifestyle specialty), you can become great at the medical side of mental illness as well. But going into psychiatry and being excellent at therapy if that's your priority is a much longer road, involving additional training, and in some cases unlearning much of the personality structure ground into us through medical indoctrination. I'm happily self-aware and resistant to such indoctrination 😀
QUOTE]

I'm responding to this because the OP mentioned something about assessment and diagnosing. In terms of flexibility, the most common aspect of doctoral training in clinical psychology that people forget is the assessment piece. I've done research and therapy, but most of my clinical experience is in neuropsychological assessment. I'm a 3rd year in clinical psych, and the patients I have seen the most of are those with dementia, brain injury, ADHD, autism, epilepsy, learning disorders, and crazy cerebral vascular accidents. Its nice to have 2-4 hours with a patient to figure out whats going on, diagnose, make recommendations, and consult with those giving them whatever treatment (therapy, meds, both) they need. Just something to consider.
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Jon Snow said:
. . . they do work differently, buproprion has anticholinergic (nicotinic) effects, also impacts dopamine, and, in terms of behavior, can have motoric consequences. Of course, I think all of the SSRIs are kind of messy in their impacts. But, there are legitimate reasons to use wellburtin over prozac.
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Wellbutrin is a bit of a hybrid drug and is classfied as a NDRI, not an SSRI (though it can increase serontin levels in a minimal way) affecting norepinephrine and dopamine reuptake. Bupropion therefore, has some variance in its NT effects from TCA's, SSRI'S and MAOI's. Buprion does not affect serotonin levels in appreciable ways.

I like Wellbutrin better than quite a few other drugs. Proazac was actually found to be far more dangerous than was originally thought when research was re-analyzed and the control group skewed the results. It was not Wellbutrin that was being compared, though, I forget which medication it was. However, clinically speaking there are legitimate reasons for prescribing prozac anyways. The concern with Wellbutrin is the potential for lowering the seizure threshhold.

SSRI's are still better in general than tricyclics, especially when considering potential cardiac factors. NDRI's can be effective in patients for atleast 2 reasons when SSRI's fail: epineprhine/dopamine levels get higher and provide more clarity of thought and energy where higher serotonin is not needed; the NDRI has fewer or more tolerable side effects for the specific patient/client in question.
 
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PsychGraduate said:
Wellbutrin is a bit of a hybrid drug and is classfied as a NDRI, not an SSRI (though it can increase serontin levels in a minimal way) affecting norepinephrine and dopamine reuptake. Bupropion therefore, has some variance in its NT effects from TCA's, SSRI'S and MAOI's. Buprion does not affect serotonin levels in appreciable ways.

I like Wellbutrin better than quite a few other drugs. Proazac was actually found to be far more dangerous than was originally thought when research was re-analyzed and the control group skewed the results. It was not Wellbutrin that was being compared, though, I forget which medication it was. However, clinically speaking there are legitimate reasons for prescribing prozac anyways. The concern with Wellbutrin is the potential for lowering the seizure threshhold.

SSRI's are still better in general than tricyclics, especially when considering potential cardiac factors. NDRI's can be effective in patients for atleast 2 reasons when SSRI's fail: epineprhine/dopamine levels get higher and provide more clarity of thought and energy where higher serotonin is not needed; the NDRI has fewer or more tolerable side effects for the specific patient/client in question.
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Spot on. Though Wellbutrin is actually far more dopaminergic than it is noradrenergic. Therefore S/E's like hallucinations should be a real concern, one which is grossly underwarned in consents. It's also a 2D6 inhibitor which can raise blood levels of a host of medications, including prozac. And for me a big issue is that wellbutrin is heavily abused, especially in the jail population, being crushed and snorted or smoked, as it gives an amphetamine like high if abused in that way. So monitoring for secondary gain and substantiating use over something like an ssri is important. On the upside there's less concern for sexual side effects since it doesn't have any real serotonergic effects. Should also take into account the formulation, as a large amount of the population won't remember to take the IR form multiple times a day, but can't afford the XR form.
 
nitemagi said:
Spot on. Though Wellbutrin is actually far more dopaminergic than it is noradrenergic. Therefore S/E's like hallucinations should be a real concern, one which is grossly underwarned in consents. It's also a 2D6 inhibitor which can raise blood levels of a host of medications, including prozac. And for me a big issue is that wellbutrin is heavily abused, especially in the jail population, being crushed and snorted or smoked, as it gives an amphetamine like high if abused in that way. So monitoring for secondary gain and substantiating use over something like an ssri is important. On the upside there's less concern for sexual side effects since it doesn't have any real serotonergic effects. Should also take into account the formulation, as a large amount of the population won't remember to take the IR form multiple times a day, but can't afford the XR form.
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Except it is actually more selective for noradrenaline and not for the dopamine transporter and it is not a high affinity inhibitor of dopamine. Other drugs do that better in terms of dopamine reuptake inhibition. Everything else are real concerns, like with drug addicts looking for an amphetamine rush.
 
The best thing about Wellbutrin is using it to treat the sexual side-effects of SSRIs.
 
PsychGraduate said:
Except it is actually more selective for noradrenaline and not for the dopamine transporter and it is not a high affinity inhibitor of dopamine. Other drugs do that better in terms of dopamine reuptake inhibition. Everything else are real concerns, like with drug addicts looking for an amphetamine rush.
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Article(s) on this? I admit my norepi : dopamine ratio info was based on a conference I went to, so don't have the studies to substantiate it. Would love the resource if you have it handy...

As a partial aside, I don't believe occupancy of NE or DA transporters necessarily directly correlates with clinical effects. You get significant changes at <50% occupancy with those 2, whereas with serotonin transporter (SSRI's) you need >80 or 90%.

Here's a good stahl article:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC514842/
 
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You should. It is cheap as you can get the student rate, and it is very cool!
 
nitemagi said:
Article(s) on this? I admit my norepi : dopamine ratio info was based on a conference I went to, so don't have the studies to substantiate it. Would love the resource if you have it handy...

As a partial aside, I don't believe occupancy of NE or DA transporters necessarily directly correlates with clinical effects. You get significant changes at <50% occupancy with those 2, whereas with serotonin transporter (SSRI's) you need >80 or 90%.

Here's a good stahl article:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC514842/
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Lots. I will get you a comprehensive listing later in the week, but that is my point exactly; this type of working pharamcology comes from a solid understanding of Harrisons and pharmacology textbooks in general which are based in part on journals but also many years of clinical experience.

With NE and DA yes so when looking at those numbers from relevant data then they seem better to use instead of ST based drugs but often times an SSRI is the preferred drug if it has been around more than 5 years (I prefer 10) so its side effects are well known and the clinician can take a good history and factor in the client's/patient's potential susceptibility. As far as disclosure on medication risks; some patients are so psychosomatic when hearing any potential side effects they would never try anything if you sat there and told them all of risks... this is why loading doses at the low end are one preferred way to get the treatment started. Not everyone likes to start real low though and if the patient/client is very symptomatic and flucuating cycles as with Bipolar I, or, hypomanic-depressive states as in Bipolar II then you may need to rush things a bit.
 
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PsychGraduate said:
With NE and DA yes so when looking at those numbers from relevant data then they seem better to use instead of ST based drugs but often times an SSRI is the preferred drug if it has been around more than 5 years (I prefer 10) so its side effects are well known and the clinician can take a good history and factor in the client's/patient's potential susceptibility. As far as disclosure on medication risks; some patients are so psychosomatic when hearing any potential side effects they would never try anything if you sat there and told them all of risks... this is why loading doses at the low end are one preferred way to get the treatment started. Not everyone likes to start real low though and if the patient/client is very symptomatic and flucuating cycles as with Bipolar I, or, hypomanic-depressive states as in Bipolar II then you may need to rush things a bit.
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Start low, go slow. I think the 2nd biggest problem I've seen with prescribing has been the titration of multiple meds before a therapeutic dose can actually be established. It is a tough spot to be in though, because the pt. wants results, and they don't much care what the research says. It is not an enviable position.

As for research and known side effects....yes and no. Frankly, some of the best psych meds out there are 20+ years old. There are a TON of data, the efficacy is there, but yet they aren't used. Go figure. I think the reason why SSRIs are so popular are because GPs and FPs feel more comfortable with them, even though they may not be the best choice. The majority of psych prescriptions come from non-psychiatrists, and that definitely plays a role in med choice.
 
Therapist4Chnge said:
Start low, go slow. I think the 2nd biggest problem I've seen with prescribing has been the titration of multiple meds before a therapeutic dose can actually be established. It is a tough spot to be in though, because the pt. wants results, and they don't much care what the research says. It is not an enviable position.

As for research and known side effects....yes and no. Frankly, some of the best psych meds out there are 20+ years old. There are a TON of data, the efficacy is there, but yet they aren't used. Go figure. I think the reason why SSRIs are so popular are because GPs and FPs feel more comfortable with them, even though they may not be the best choice. The majority of psych prescriptions come from non-psychiatrists, and that definitely plays a role in med choice.
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Start low and go slow is the way to go:

I agree, but with all the drug patents and competition I tried to be a little more realistic with a target of 10 years old. But yeah, 20 years is great when there is a will to do so.

SSRI's beat first generation MAOI's and TCA's in terms of efficacy and general safety and the newer drugs like Abillfy I do not trust with so little data and a long side effect profile.
 
I think that waiting period depends on your prescribing style. TCA's are just poorly tolerated d/t anticholinergic effects. SSRI's we tend to choose based on side-effect profile at first. Starting low is always a good call for most anxiety patients in my experience, to get them through that initial worsening d/t pre-synaptic serotonergic activation. Once they're acclimated they can get to higher doses. That's why I always take drug trial "failures" by patients with a grain of salt. Often if you take a good history they've stopped them early because of poor tolerance. Start it out at baby doses and they can often handle it. Plus there's genetic variability with metabolism that makes certain people super-sensitive at baby doses.

The multiple dose titration is also a matter of style, but I've most often seen it in primary care. They don't really know maximal doses so they'll start them on baby doses of 3-4 meds, never maximizing any of them. Polypharmacy shouldn't be messed with if you don't know what you're doing. Unfortunately far too many people think they know what they're doing and just don't.

Most of Stahl's weekend conferences are free for me since I'm at UCSD. He's a professor here 🙂 I love how he'll periodically shout during a lecture to wake everyone up. He really knows his stuff, though.
 
nitemagi said:
The multiple dose titration is also a matter of style, but I've most often seen it in primary care. They don't really know maximal doses so they'll start them on baby doses of 3-4 meds, never maximizing any of them. Polypharmacy shouldn't be messed with if you don't know what you're doing. Unfortunately far too many people think they know what they're doing and just don't.
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Agreed.

Polypharmacy is a pet peeve of mine because 95% of it does not have supportive literature. There also tends to be an "add more" approach, instead of dc'ing things. It is definitely a balance of science and art, but there are too many prescribers who prescribe like Jackson Pollock painted.

nitemagi said:
Most of Stahl's weekend conferences are free for me since I'm at UCSD. He's a professor here 🙂 I love how he'll periodically shout during a lecture to wake everyone up. He really knows his stuff, though.
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Awesome. He is a pretty entertaining guy, and he definitely knows his stuff. He gets knocked sometimes because people can be dogmatic about his recommendations (which often lack data to back them up), but he's definitely one of the best psychopharmacologists out there.
 
This thread is becoming a very satisfying little discussion. Nice to see those of similar interests and background really contributing to this discussion... mainly I mean T4C and nitemagi in this specific case.
 
Therapist4Chnge said:
Agreed.

Polypharmacy is a pet peeve of mine because 95% of it does not have supportive literature. There also tends to be an "add more" approach, instead of dc'ing things. It is definitely a balance of science and art, but there are too many prescribers who prescribe like Jackson Pollock painted.

Agreed.



Awesome. He is a pretty entertaining guy, and he definitely knows his stuff. He gets knocked sometimes because people can be dogmatic about his recommendations (which often lack data to back them up), but he's definitely one of the best psychopharmacologists out there.

Definitely of interest.
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Psychopharm is still an art based upon science; no doubt about it.
 
PsychGraduate said:
Not to mention all those psychiatrists who do not understand psychopharmacology either. I met countless psychiatrists who did not know several potentially fatal drug interactions, undertand substance P, many real and emprically validated side effects of drugs they were prescribing, what ethyl methyl ketones were, what the signs and causes of horner syndrome were, (the anhydrosis is parasympathetic related) how to read the basic spacing in an EKG, how to interpret Harrison's at all, and certainly they did not offer any real psychotherapy... I thank you for caring about your profession, I commend you for having a psychology background, I appreciate your candor, and I hope that you help those cleints you work with.

I chose those seemingly unrelated signs and medical issues for several reasons and not just direct drug topics but I included several of those too.

Having said all of that, I must say that if one is dedicated to understanding the biochemical basis of pharmacology in general and specifically the biochemical basis of neuropharmacology, then they are off to a great start; there is no reason why a competent psychologist with focus cannot get the appropriate post-doctoral training to prescribe meds... think of it this way: most attending physicians and psychiatrists no next to nothing about the new drugs coming out now for these reasons: most cannot interpret the stats or the biochemistry in the industry provided lit, the meds are too new so there are unknown side effects not yet revealed and the doctors are usually so busy that they do not take the time to really get to know what they do not know about the drugs and instead heavily rely upon the pharmaceutical rep for information. Ofcourse the psychologist too needs undergrad biochemistry and psychopharmacology too.

Now some doctors and a small % of those who become psychiatrists do so with the care, detachment but focused passion necessary, however, the biochemistry taught in med school is not too good and so, if they do not recall undergrad biochem and little organic chem those pharmacology courses lack some context. Most first year to 3rd year attendings know less nowadays than a good resident, however, residency needs to be carefully crafted to maximize the resident's education...
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Just out of curiosity, is this correct? I thought the etiology was sympathetic. Just a first year med student here, and I remember dissecting the sympathetic trunk out. Took hours...

Sorry to bump the thread; I have some psychopathology of my own.
 
Zenfudge said:
Just out of curiosity, is this correct? I thought the etiology was sympathetic. Just a first year med student here, and I remember dissecting the sympathetic trunk out. Took hours...

Sorry to bump the thread; I have some psychopathology of my own.
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In Horner's there's compression of the sympathetic ganglia. Decreased sympathetic tone usually means increased relative parasympathetic tone. So in a manner of speaking, it is d/t parasympathetic. Another way to phrase it might be that it's ANS related.
 
nitemagi said:
In Horner's there's compression of the sympathetic ganglia. Decreased sympathetic tone usually means increased relative parasympathetic tone. So in a manner of speaking, it is d/t parasympathetic. Another way to phrase it might be that it's ANS related.
Click to expand...

Ah...gotcha, that makes sense. That is one of the problems with board review books is that they spout these great mnemonics, but there is often more than meets the eye (no ptosis pun intended). I guess I'll get into the meat of this topic in neuro. I suspect if I were pimped on this though, it would be expected that I answer sympathetic. "They" don't always want nuanced responses.

Thanks for your time!

By the way, I wish I was back in S.D.!
 
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