Louis B. Cady, MD – CEO & Founder – Cady Louis B. Cady, MD – CEO & Founder – Cady Wellness Institute Wellness Institute Adjunct Assoc. Professor –

Indiana University School of Medicine Department of Psychiatry

Child, Adolescent, Adult & Forensic Psychiatry – Evansville, Indiana

SCRATCHING YOUR HEAD PSYCHIATRY II: How to Think INSIDE the Allopathic Box… [and Practice Precisely, Effectively, and to

Maximum Benefit]

(c) 2012 Louis B. Cady, M.D. - all rights reserved

“Slumber not in the tents of your fathers. The world is advancing. Advance with it.”

- Giuseppe Mazzine

Relevance for your practice• ALL PRESCRIBERS - don’t kill your patient

with a drug-drug interaction.

• ALL PARTICIPANTS - Know bad/stupid psychopharmacology when you see it.– Be able to DO SOMETHING about it.

• Don’t diagnose someone as having “drug problems” when they DON’T.

• Better “MOA” understanding

A quick look back in history

The Interpretation of Dreams – 1885 - 1890

Ugo Cerletti 1935Prozac - 1987

The Therapeutic Trifecta of Psychiatry:ShrinkingShocking

or Drugging

[Supposedly the only three things you could do to a patient’s

brain…]

Dangers with Psychiatry/psychotropics

• Failure to diagnose– (E.g “head case” and then they die of a medical problem)

• Failure to adequately treat• Failure to prescribe accurately (Rx-rx interaction)• Giving people side effects• Using the wrong drug• Ignorance about best options because “I always did it that

way.” • Getting people addicted• Practicing beyond your ability and expertise• Violating black box warnings

Depression & Anxiety & a malpractice suit in 1 Easy Lesson

DEPRESSIONSIG: E- CAPS!

• Sleep• Sadness • Interest loss• Guilt• *Energy• Concentration• Appetite• Psychomotor Sx• Suicidal thinking

Gen. ANXIETY D.O.•Somatic Sx (“energy”,etc.)•WORRY•Irritability•Concentration•Keyed up•Insomnia (“sleep”)•Restlessness

SWICKIR is Quicker:

Worry + 3 = GAD (Baughman)5of 9 with 1 of 2 x 2 weeks

*ACCURATE MEDICAL diagnosis “mood disorder due to a general medical condition” AND r/o bipolar disorder

BEWARE BEWARE – “too much” energy

Lifetime Prevalence of Common Psychiatric Disorders

Kessler 1994; Kessler 1995; DSM-IV-TR™ 2000.*In menstruating women.

Lifetime prevalence (%)0 2 4 6 8 10 12 14

7.8%PTSD

5.1%Generalized anxiety d.o

3.5%Panic disorder

2.5%OCD

16 18

Alcohol dependence 14.1%

Major depressive disorder 17.1%

13.3%Social anxiety disorder

5%*PMDD

Epidemiology of DepressionPrevalence of Major Depression

Regier et al., 1988; Blazer et al., 1994

0

5

10

15

20

EpidemiologicCatchment Area (ECA)

National ComorbiditySurvey (NCS)

Percentof Patients

point prevalence (30 day)

lifetime prevalence

PHQ-9 Symptom Checklist

1. Over the last 2 weeks, how often have youbeen bothered by the following problems?

Notat all

0

Severaldays

1

More than half the days

2

Nearly every day

3

a. Little interest or pleasure in doing things

b. Feeling down, depressed, or hopeless

c. Trouble falling or staying asleep, or sleeping too much

d. Feeling tired or having little energy

e. Poor appetite or overeating

f. Feeling bad about yourself, or that you are a failure…

g. Trouble concentrating on things, such as reading…

h. Moving or speaking so slowly…

i. Thoughts that you would be better off dead… Subtotals: 3 4 9

TOTAL: 16

Kroenke 2001.

Depression—Impact on the Healthcare System

• Compared with those without depression, depressed individuals: – Utilize all types of healthcare services more

often

– Incur 1½ to 2 times greater healthcare costs

– increased length of hospital stay

– significant worsening of physical, social, and role functioning

Simon 1995; Luber 2000; Verbosky 1993; Wells 1989.

% Patients Disabled 3+ Days

33.7%

19.45%

16.9%

3.1%

Comorbidity of Depression and Anxiety

Disability

Wittchen, Depress Anxiety, 2002

Percent of Patients With ≥1 Disability Day in Past Month

GAD + MDD

MDD/no GAD

GAD/no MDD

no GAD/no MDD

Where does ADHD come from?

Kids and Adults – Differences in HYPERACTIVE domain

AS A CHILD:• Squirming, fidgeting• Cannot stay seated• Cannot wait turn • Runs/climbs excessively• Cannot play quietly• On the go/driven by motor• Talks excessively• Blurts out answers• Intrudes, interrupts others

AS AN ADULT:• Work inefficiencies• Can’t sit through meetings• Cannot wait in line• Drives too fast• Self-selects very active job• Cannot tolerate frustration• Talks excessively• Makes inappropriate

comments• Interrupts others

Sources: DSM-IV (TR). APA 2000:85-93)Weiss MD, Weiss JR. J Clin Psychiatry 2004;65(Suppl 3):27-37.

Horrigan J, et al. Presented at 47th Annual AACAP Meeting: October 24-29, 2000. New York, NY.

Persistence of ADHD Into Adulthood• ADHD is a heterogeneous disorder associated with

considerable disability and comorbidity that, in many cases, persists into adulthood1

– Some studies have found persistence as high as 36.3%2

• Mood, anxiety, and substance use disorders are the most common comorbid disorders in adults with ADHD3

• Current prevalence of ADHD persistent into adulthood 4.4%4 (5% by new study – Willcut – Neurotherapeutics 2012

• Much of the treatment of adult ADHD can be based on experience in treating children/adolescents5

1. Barkley et al. J Abnorm Psychol. 2002;111:279-289.2. Kessler RC et al. Biol Psychiatry 2005 June;57(11):1442-51. [retrospective review of 3,197 14-44 yo

respondents in NCS-R]3. Biederman et al. Am J Psychiatry. 1993;150:1792-1798. 4. Kessler et al. Am J Psychiatry. 2006;163(4):716-

23. 5. Dodson WW. J Clin Psychol. 2005;61:589-606.

Diagnostic Pearls - Cady• How’s work?

– How has your employment history been?

• How’s your mood? Your marriage (relationship)?• How was school for you?• Are people nervous driving with you?• Are there periods of time when you have too much

energy for no particular reason?• Do you ever have to have a beer at the end of the day to

relax?– [gently lead in to other substances, especially stimulants that

may have a CALMING effect]– “Have you ever taken any of your child’s ADD Rx?” [or other

stimulants, energy drinks, diet pills, or cocaine]

Pharmacology Failures…

1. “Begin with the end in mind.” (Covey)

2. Start LOW – (rule of thumb – ½ what the drug rep and package insert says!)

3. Go up to the maximum tolerated dosage, with finesse.

– Tell them about “Goldilocks”

4. If it doesn’t work, add something complimentary (that makes sense).

THE FACTS• SSRI’s treat depression AND/OR anxiety• Patients may INITIALLY need something else for daytime

anxiety or sleep.• BZD’s of choice:

– clonazepam 1 mg tablets – ½ to 1 twice daily to three times daily

– Diazepam – 5 mg =- ½ - 1 ½ twice daily to three times daily

• (first pass and second pass effects)• ANTIANXIETY RX (non BZD) – Buspirone, per package

insert. Push to 20 mg THREE TIMES DAILY or to the point of maximum tolerability for 4 – 6 weeks AT THAT DOSE. – Start with 5 mg. Can use WITH SSRI’s

AVOID Alprazolam (Xanax ®)

• Addicting (and rapidly so)

• Can have seizures if rapidly withdrawn (structurally similar to carbamazepine)

• MD’s shot over it.

• NOT an “anti-anxiety” medication

• NOT a sleeper.

• Even if they need a BZD for anxiety, it doesn’t have to be Xanax.

Sleepers – my preferences• Rozerem (brand) (a melatonin analog) – 8 (up to 16* mg) at

bedtime. VASTLY under-rated. May need to take 2 weeks before adequate effect. (* off-label dose)– Dual acting agent – homeostatic and circadian effects. 70x as

potent as melatonin. – Melatonin SR may also be a good agent.

• Trazodone (50 – 150mg ½ - 2 hrs before HS. (Note, off label “unapproved.” Warn on priapism).

• Lunesta (brand) – 2 – 3 mg. Try samples. Have mouthwash on hand. (Probably most predictable agent)

• Ambien 12.5 mg CR (brand) – legitimately lasts longer than zolpidem. Probably not as effective as Lunesta.

• Zolpidem – generic. People get hooked on it.• Paradigm: SYMPTOMATIC treatment – after depression is stabilized, fade

out the sleeper

Why treatment failures occur: too much or too little…The REAL mechanism of action of SSRI’s

Animation © NEI, Inc. (Neuroscience Institute) and is used specifically with permission from Stephen Stahl, MD, Ph.D.

Drug, drug... who's got the

drug?

Depression/anxiety Rx:

• TCA

• Venlafaxine (Effexor)

• Duloxetine (Cymbalta)

• Mirtazapine (alpha 2)

• Desmethylvenlafaxine (Pristiq)

& others….

Side Effects & Drug Interactions: The Doc Cady “Can’t s” of the TCA’s

PeePoop

SpitSpurtFocusThink

Stand up Stay awake

Stay thin

ANTICHOLINERGIC/ ANTIMUSCARINIC EFFECTS

Alpha-adrenergic blockade

"Antihistamine" effects

“Drug-drug interactions” clinically relevant?!

Drug-drug interactions: chum for legal “sharks”

“Strattera [coupled with Prozac or Paxil] has been great for our admissions.”

-Dr. William Beute, MD

Pine Rest Campus Clinic

Grand Rapids, MI

April 21, 2004

[quoted with permission]

Cytochrome p-450 2D6 inhibition measured as % increase in “Desipramine AUC” – in vivo data

Preskhorn, Alderman, et al. Pharmacokinetics of desipramine coadministered with sertraline or fluoxetine. J. Clin Psychopharmacol 1994;14:90-98;

Escitalopram package insert - note – different source of data, but same method

Critically important when combining with other Rx metabolized through 2D6

pathways

SomeSome drugs metabolized through drugs metabolized through cytochrome P-450 IID6 systemcytochrome P-450 IID6 system

ADHDADHDAmphetaminesAmphetaminesSTRATTERASTRATTERA

AnalgesicsAnalgesics•AcetaminophenAcetaminophen•AspirinAspirin

AntacidsAntacids

AntiarrthymicsAntiarrthymics•Procainamide, Procainamide, •QuinidineQuinidine•EncainideEncainide•FlecainideFlecainide

AnticonvulsantAnticonvulsant•carbamazepinecarbamazepine

ANTI-PAINANTI-PAINCODEINE!CODEINE!

BronchodilatorsBronchodilators•TheophyllineTheophylline

CardiacCardiac•Digoxin; digitalisDigoxin; digitalis

CoughCough•DextromethorphanDextromethorphan

DiureticsDiuretics•ChlorthalidoneChlorthalidone•FurosemideFurosemide•HCTZHCTZ•TriamterineTriamterine

AntibioticsAntibiotics•TMP & SMXTMP & SMX•AmpicillinAmpicillin•ErythromycinErythromycin•PenicillinPenicillin•TetracyclineTetracycline

AntidepressantsAntidepressants•TCATCA’’s & s & ““2P2P’’ss””

AntihistaminesAntihistaminesAntihypertensivesAntihypertensivesAntipsychoticsAntipsychotics•ClozarilClozaril•RisperdalRisperdal•ZyprexaZyprexa

The “not so selective” SSRI’s; how to “Do yourself a favor.”

drug SSRI? 2nd order effects Side effects possible

Escitalopram (Lexapro) now generic

Yes NOTHING (excess serotonin side effects only)

Sertraline (Zoloft) Yes Dopamine (1/3 as potent as amphetamine)

Agitation, nervousness; improved [ ]

Citalopram (Celexa)

Yes AntiH1 Sedation (note- FDA lowered max dose to 40mg)

Paroxetine (Paxil) Yes Ach NOT “NRI”

Doped up, TCA effects, neurocognitive problems, withdrawal. Sexual, Prostate sxs

Fluoxetine (Prozac)

Yes 5HT2C Agitation, appetite suppression

New Agents, New Mechanisms(agent) (MOA) Differentiating points

Venlafaxine (“IR” and XR) (Effexor)

SSRI, NRI Nausea, GI side effects, sxl dysfunction

Duloxetine (Cymbalta) SSRI, NRI Same. Better tolerated. For pain w/ dep.

Desvenlafaxine (Pristiq) – “son of Effexor”

SSRI, NRI Better tolerated

Trazodone XR with Contramid® (OLEPTRO)

5HT2a/c BLOCKER, mild SSRI

Legitimate effect on depression/anxiety without doping up.

Vilazodone (Viibryd) SPA, SSRI ONLY SPARI. Weaker “SSRI.” Targets 5HT1A. Less sexual side effects.

Bupropion (“XL” – not “SR”) (Wellbutrin)

“NDRI” Possibility of anxiety & “wound up.” Improved concentration. Push to 450 mg. SZ warning..

Duloxetine (Cymbalta) Versus Escitalopram (Lexapro) and Placebo: An 8-month, Double-Blind Trial in Patients With Major Depressive

DisorderPigott et al., Curr Med Res Opin, 2007

An illustrative study on picking your antidepressant…

Total Score

*

Anxiety/Somatization Sleep Maier Retardation

SubscalesHAMD17 (MMRM)

*p<0.05

Comparison of Escitalopram and Duloxetine: 8-Month Trial

Pigott et al., Curr Med Res Opin, 2007

Significantly Different Adverse Events (p<0.05 Duloxetine vs Escitalopram)

Comparison of Escitalopram and Duloxetine: 8-Month Trial

Percent of Patients

Pigott et al., Curr Med Res Opin, 2007

• Remission rates for both escitalopram and duloxetine continued to improve over time

• Significantly more escitalopram-treated patients continued treatment compared to duloxetine-treated patients

• Escitalopram showed significant improvement vs duloxetine on the HAMD17 sleep subscale

• Compared to escitalopram, duloxetine significantly increased pulse and systolic blood pressure

Conclusions: they both worked the same; side effects were worse with duloxetine

Comparison of Escitalopram and Duloxetine: 8-Month Trial

Pigott et al., Curr Med Res Opin, 2007

Two New Agents You Need to Know• Extended release Trazodone

– NOT “son of Trazodone”– Possibility of legitimate antidepressant effect with anti-anxiety

effect WITHOUT doping patient up.– A “SARI” – serotonin antagonist reuptake inhibitor

• Vilazodone – the only SPARI available. • How to appreciate:

– 5HT1A is receptor for antidepressant effect of serotonin– 5HT2A and 5HT2 C: anxiety, sleep disruption, sexual side

effects.– ANYTHING which works preferentially on 5HT1A is GOOD!

XR Trazodone steady state dosing study

• (Levels done after 7 days steady state)

• 300 mg XR Traz AUC comparable to 100 mg IR Traz tid

• Cmax 42% lower than IR Trazodone– Translation – it

doesn’t dope the patient up.

Kramer, WG et al. Once-daily Trazodone: Overview of Pharmacokinetic Properties. Poster – ACCP 38th Annual Meeting, San Antonio, TX 2005

XR Trazodone Food Effect Study

• PI says “take at night”

• CMax increase by 86% (!!!) under fed conditions. Peak is at 7 hours post dose (with feeding).

• Note – this may lead the enlightened prescriber to vary the time of dosing.

Kramer, WG et al. Once-daily Trazodone: Overview of Pharmacokinetic Properties. Poster – ACCP 38th Annual Meeting, San Antonio, TX 2005

Vilazodone – a SPARI (per Stephen Stahl, MD, Ph.D.) – Serotonin Partial Agonist Reuptake Inhibitor

• Highly serotonergic. START LOW (5 mg).• Because of 5HT1A agonism, LESS “SSRI” effect is required.

ADHD Rx for frontline medicine• Desiderata – get control, and keep it consistent for predictable

period of time

• Rules of thumb: don’t be guided on SIZE. START LOW. “Know the Biederman max” for MPH and amphetamine.

• Recommendations (for children and adult):– Focalin XR (Dexmethylphenidate XR) 5,10,15,20,30 and 40 mg capsules)

• Rationale: MPH based. FAST. 8 – 10 hours. Can dose twice daily (off-label), a.m. >pm. (can also start with ½ capsule)

– Vyvanse – (lisdexamfetamine [sic]) – 20,30,40,50,60,70 mg [= 7.5 – 30 mg] amphetamine equivalents. Lasts 12 – 14 hours. (Can dissolve in water – per PI!).

– Kapvay/Intuniv – FDA approved in kids. • Kapvay easier to use, better tolerated.

• Intuniv more potent, but more side effects (sedation)

Practicing beyond your ability (and knowledge) – the second generation antipsychotics

• Definitions:– Mood stabilizer – something that stabilizes mood

(Lithium, carbamazepine, VPA)– Antipsychotic – something you give someone who is

PSYCHOTIC to get them UNPSYCHOTIC.– Antidepressant – something for depression.– “2nd generation antipsychotic (“SGA’s”) = S2/D2

blockers.”• Can “stabilize mood” as well as function as antipsychotics• Now some FDA approved for either add-on use or single agents

for “bipolar depression” (e.g., quietapine XR)

Know who you’re playing with• SGA’s and WEIGHT GAIN (Cady experience)

– olanzapine/risperidone > quietapine> aripiprazole/arsenapine> lurasidone/ziprasidone

• (Zyprexa/Risperdal>Seroquel> Abilify/Saphris> Latuda/Geodon)

• EXPENSIVE: $400 – $600 /per month

• All will work for mania. NONE are pure “mood stabilizers.” Some make you fat.

• Some will work for depression but dope you up.

• Much less risky than 1st generation for tardive dyskinesia.

• Axiom: refine your psychopharmacology before going to look for an SGA.

• If you have to use one (for bipolar or psychosis, Lurasidone is probably most benign – 40 – 80 mg twice daily (or 160 mg HS)

Cady recommendation for SGA’s in primary care

• As little as possible.

• Do NOT use as primary mood stabilizers for bipolar disorder. Use lithium (Type I) VPA (Type I/II) or Lamotrigine – which is a real option. Check levels and labs as needed

• Can use if single, or better yet, DOUBLE mood stabilizers don’t work.

• Abilify (only “dopaminergic” SGA) probably best for antidepressant augmentation at LOW DOSE.

– 2 – 4 or 5 mg is optimum dose for this. (Start with ½ of a 2 mg and go up)

– Onset is FAST when it happens.

• Olanzapine is most dependable for rapid onset and control of manic episode, or agitation, or EXTREME PANIC & anxiety (off label).. Lurasidone may be best tolerated.

A quick look back in psychiatric tx:

The Interpretation of Dreams – 1885 - 1890

Ugo Cerletti 1935Prozac - 1987

The Therapeutic Trifecta of Psychiatry:ShrinkingShocking

or Drugging

[Supposedly] the only three things you could do to a patient’s

brain…]

STAR*D Study demonstrates that current treatment has limited effectiveness

Trivedi (2006) Am J Psychiatry; Rush (2006) Am J Psychiatry; Fava (2006) Am J Psychiatry; McGrath (2006) Am J Psychiatry47

Likelihood of discontinuing treatment increases with each new medication attempt

Systemic Drug Side Effects

Weight Gain

Constipation

Diarrhea

Nausea

Drowsiness

Insomnia

Decreased Libido

Nervous Anxiety

Increased Appetite

Decreased Appetite

Fatigue

Headache/Migraine

Abnormal Ejaculation

Impotence

Sweating

Tremor

Treatment Discontinuation Side Effects

Weakness

Dry Mouth

DizzinessTrivedi (2006) Am J Psychiatry; Rush (2006) Am J Psychiatry; Fava (2006) Am J Psychiatry; McGrath (2006) Am J Psychiatry; Neuronetics, Inc. (data on file)

ECT – origins• Origin in 1700’s – Middlesex Hospital

– machine with weak electrical current used for range of illnesses.– John Birch, English neurosurgeon, used it to shock the brains of

depressed patients– Benjamin Franklin, after shocked, recommended electric shock for

tx of mental illness

• Ugo Cerletti – 1935 – noted (incorrectly) that epilepsy and schizophrenia didn’t occur in same patient

• Problems with ECT – memory loss, anesthesia risk• Cost of $6400 for eight treatments• 80% improvement • 33,000 hospitalized Americans – ECT in 1980, last year for

NIMH figures– http://www.faqs.org/health/topics/19/Electroconvulsive-therapy.html

But even before Freud…

• Electromagneitc induction – 1831 (Michael Faraday & Joseph Henry)

• 1st demonstrated by Faraday August 29, 1831

Faraday’s Law of Induction

TMS Magnetic

field

Induced neuronal current

From electricity to magnetism

• Bartholow, R (1874)– Stimulation of human brain

(exposed cortex) of patient with cranial defect.

• d’Arsonval – “Phosphenes and vertigo” induced inside powerful magnetic coil

• Silvanus P. Thomson, Ph.D. – new type of magnetic stimulation (1910)

Thompson, SP. “A Physiological Effect of an Alternating Magnetic Field.” Proceedings of the Royal Society of London B82:396-399, 1910

First patent application for magnetic therapy:

• 1902 Adrian Pollacsek and Berthold Beer – Vienna, Austria for a “therapeutical apparatus”

• Electromagnetic coil, placed over the skull was noted to “pass vibrations into the skull” and “treat depression and neuroses.”

A quick look back in psychiatric history - redux

Freud: The Interpretation of Dreams – 1885 - 1890

Ugo Cerletti 1935 Prozac - 1987

ShockingShrinking Drugging

Silvanus P. Thompson, Ph.D. (1910)

Zapping

First modern TMS:

• Barker AT, et al. “Non-invasive magnetic stimulation of the human motor cortex. The Lancet 1:1106-1107, 1985.

• 1st device – designed by Barker – Univ. of Sheffield, England.– 100 microsecond, 2 T

pulse

Coil types and rationale

From Matt Edwardson, MD – Research Fellow and Acting Instructor, Dept. of Neurology, Univ. of WA 10/16/2011

An unusual side effect of imaging (2004)…

• CONCLUSIONS: “These preliminary data suggest that the EP-MRSI scan induces electric field that are associated with reported mood improvement in subjects with bipolar disorder.”

Neuron

NeuroStar TMS Directly Depolarizes Cortical Neurons

Pulsed magnetic fields from NeuroStar: •induce a local electric current in the cortex which depolarizes neurons •eliciting action potentials•causing the release of chemical neurotransmitters

Neurons are “electrochemical

cells” and respond to either electrical or

chemical stimulation

NeuroStar Releases Neurotransmitters in the Brain

Depolarization of neurons in the DLPFC causes local neurotransmitter release

Depolarization of pyramidal neurons in the DLPFC also

causes neurotransmitter release in deeper brain neurons

Activation of deeper brain neurons then exerts secondary effects on remaining portions of

targeted mood circuits

Dorsolateral prefrontal

cortex

Anterior cingulate

cortex

Kito (2008) J Neuropsychiatry Clin Neurosci

These effects These effects are associated are associated

with with improvements in improvements in

depressive depressive symptomssymptoms

ECT vs. TMSECT TMS

Anesthesia, LOC Yes No

Induction of seizure Yes No

Systemic effects Anesthetic drugs, increase HR

none

Treatment schedule 3X/ week (8 -15 tx) Daily, M-F, six weeks (30 tx)

Rapidity of onset 2 – 3 treatments 2 – 3 weeks

Mechanism of action SEIZURE. Massive NT release; rise in sz threshold

Precise, LOCAL release of NT’s. Reactivation of neural circuits.

Side effects Memory loss, confusion Essentially none (mild HA 1st week)

Psychosocial impact can’t work Drive to and from tx’s, work improved

After-effects Mild (usually transient) memory loss

None. Pro-cognitive

Insurance coverage Almost always Rare. Improving

From Michael Farraday to today

Does it work?• Original registration trial

– 307 major depressed patients• 67% women

• 93% recurrent depressives

• 43% had been hospitalized already

– 42 sites– Treatment per label

• Results: ½ patients responded; 1/3 of patients remitted.

• 80% patients completed the treatment.

Who Was Studied?• Primary diagnosis: DSM-IV Major Depressive Disorder

– Unipolar type, non-psychotic– Moderate to severe symptoms at baseline– Approximately one-third of patients had a co-morbid anxiety

disorder (OCD excluded)

• Antidepressant Treatment History:– Average number of antidepressant medication trials in current

episode = 4 (range: 1 to 23 attempts)• Majority of treatment attempts were unable to achieve adequate

dose and duration of treatment due to intolerance

– In the indicated patient population, all patients failed to achieve satisfactory benefit from one antidepressant medication at an adequate dose and duration in current episode

Demitrack and Thase (2009) Psychopharm Bulletin

65

O’Reardon, JP, et al. (2007) Efficacy and Safety of Transcranial Magnetic Stimulation in the Acute Treatment of Major Depression: A Multi-Site Randomized Controlled Trial. Biol Psychiatry 62:1208-1216.

Optimization of TMS (‘OPT-TMS’) Study

• NIMH-funded, independent of industry • N=190 patients, 4 premier academic sites • Primary outcome measure: % Remission - Active 15% vs Sham 4% (P =

0.015); Odds Ratio of achieving remission: 4.2 (95%CI, 1.3-13.2)

Major Findings:• MADRS total score decreased:16.6%

(Active) vs 6.9% (Sham) p=0.01 (Effect size: 0.51)

• 30% of patients achieved remission in open-label extension phase

• Excellent safety and adherence

Conclusion: “Daily left prefrontal rTMS as monotherapy produced statistically significant and clinically meaningful antidepressant therapeutic effects greater than sham.”

Mark S. George, MD; Sarah H. Lisanby, MD; David Avery, MD; William M. McDonald, MD; Valerie Durkalski, PhD; Martina Pavlicova, Phd; Berry Anderson, Phd, RN; Ziad Nahas, MD; Peter Bulow, MD; Paul Zarkowski, MD;Paul E. Holtzheimer III, MD; Theresa Schwartz, MS; Harold A. Sackeim, PHD

Recent TMS Literature Review• Roughly 30 controlled clinical research studies to date• Most recent meta-analysis (Slotema, et al, 2010):

– Included analysis of 34 studies involving 1,383 patients– Estimated standardized effect size = 0.55 (P < 0.001)

Conclusion: “…rTMS deserves a place in the standard toolbox of psychiatric treatment methods, as it is effective for depression…and has a mild side effect profile….”

1.Slotema, CW, Blom, JD, Hoek, HW, Sommer, IEC. (2010) Should we expand the toolbox of psychiatric treatment methods to include repetitive transcranial magnetic stimulation (rTMS)J Clin Psych 71(7):873-84.

2.Schutter, DJLG. (2009) Antidepressant Efficacy of High-Frequency Transcranial Magnetic Stimulation Over the Left Dorsolateral Prefrontal Cortex in Double-Blind Sham-Controlled Designs: A Meta-Analysis. Psychol Medicine, 39:65-75.

• No systemic side effects

• No adverse effect on cognition

• Most common adverse event associated with treatment was scalp pain or discomfort– < 5% of patients discontinued due to adverse events

• No seizures with NeuroStar device during clinical studies (over 10,000 treatments)

• Rare risk of seizure with NeuroStar TMS in post-market use (0.003% per treatment, <0.1% per acute treatment course) (>150,000 treatments in post-marketing experience to date)

• Long term safety demonstrated in 6 months follow-up

NeuroStar TMS Therapy: Safety Overview

Janicak, et al. J Clin Psychiatry, 2008; Janicak, et al. Brain Stimulation, 2010.

No Evidence of Emergent Suicidal Ideation

* Shift Score indicates the percent of subjects who experienced a change in HAMD Item 3 score from 0 or 1 at baseline to 3 or 4 at later point in time.

HA

MD

Ite

m 3

Su

icid

al I

dea

tio

nS

hif

t S

core

(%

)*

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

Baseline Week 2 Week 4 Week 6

NeuroStar TMS Therapy (n=155)

Sham TMS (n=146)

Janicak (2008) J Clinical Psychiatry.

Long Term Follow Up After Acute Treatment

ACUTE BENEFIT(6 Weeks)

TAPER(3 Weeks)

LONG TERM OUTCOME ASSESSMENT

(6 Months)

RCT or Open-Label Extension Study Long-Term Follow-Up Study

Transition from TMS to

pharmacotherapy

Antidepressant medication monotherapy w/TMS rescue as

add-on if needed through 6 Months

Janicak, et al. Brain Stimulation, 2010.

Long Term Follow Up After Acute Treatment

Janicak, et al. Brain Stimulation, 2010.

• Safety confirmed during long term, open-label 6 month follow up period

• During open-label follow up on antidepressant medication monotherapy,– ~37% of patients required TMS reintroduction– ~85% of patients who received TMS reintroduction benefited

• Net incidence of illness relapse under these open-label follow up conditions: 11%– Six-month relapse with antidepressant treatment alone in

STAR*D study was 35-50% (Level 2 and 3 range)

The story of Geraldine…

Photos used with patient’s permission

IDS-SR

CGI -S

Learning points I hope we have achieved…

• Precise diagnosis.

• Improved concepts of ADHD presentation in children and adults.

• Avoid obvious drug-drug interactions.

• Avoid excess/inappropriate BZD’s.

• Avoid over-use of SGA’s.

• Understand TMS and where it fits into current psychiatric treatments

Contact information:Louis B. Cady, M.D.

www.cadywellness.com

www.indianaTMS-cadywellness.com

Office: 812-429-0772E-mail: lcady@cadywellness.com

4727 Rosebud Lane – Suite FInterstate Office Park

Newburgh, IN 47630 (USA)