A View from the Trenches: Why Psychiatry needs CES – Part 3

Depression

There is considerable controversy involving the efficacy of antidepressant medications.
The controversy also involves the risk/benefit analyses of currently approved interventions For example, Time magazine recently cited Kirsch’s meta-analysis in PLoS Medicine that found little benefit of antidepressants for most patients as well as Dr. John Krystal’s findings that about 25% of patients did worse on antidepressants than on placebo”.

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There are also many non-pharmacologic interventions for reducing anxiety. Some of these include dietary supplements, acupuncture, meditation, yoga, and exercise. These interventions, however, are not employed by a large segment of society that suffers from anxiety.

These persons instead seek medication from their physician to alleviate their suffering. Typical classes of medications for anxiety include the SSRI’s, benzodiazepines as well as the off label use of antihistamines and atypical antipsychotic medications and antiepileptic medications.

In addition to the inherent problems with SSRI’s, there are also serious problems with the other classes of medications. A serious side effect of benzodiazepines includes their potential for inducing physical and psychological dependence. In addition, withdrawal symptoms can prove life threatening, especially with the shorter acting benzodiazepines like alprazolam. When taken as directed, which is often not the case; this class can result in compromised coordination and slowed reaction, falls, disinhibition, delirium, and anterograde amnesia.

It is not uncommon to see suicide attempts using a combination of a benzodiazepine together with alcohol and/or another sedative hypnotic. While buspirone is relatively well tolerated, it has poor efficacy for many anxiety disorders and 3 to 4 week lag time to effect often leads to premature discontinuation.

Medications such as gabapentin are used off label for anxiety disorders but there is no research to support its efficacy. Unfortunately, physicians have begun using the atypical antipsychotic medications to treat anxiety. This class of medications has a large and increasing number of very serious side effects. Recent attention has been focused on their causing metabolic syndrome.

They frequently cause extra pyramidal side effects, sedation, elevated prolactin levels and drug/drug interactions. All of these medications should be avoided during pregnancy and used with caution in the elderly. In short, the side effect profile of current pharmacologic treatments for anxiety limits their safe use. CES is a safe, initial alternative to such medications.

Insomnia
Many patients benefit from improving sleep hygiene as a treatment for insomnia. Others may improve using a sleep phase changes or treating the underlying problem such as sleep apnea, medical conditions, alcohol abuse, etc.

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For many others, recent pharmacologic treatments prove effective and have minimal side effects. Targeting melatonin receptors is a novel and promising approach. For many persons, however, existing treatments are ineffective, too expensive, result in side effects or conflict with their desire to avoid medications.

Some side effects from medications are very disturbing, such as sleep associated behaviors that result in harm to self or others. For others, there is morning sedation, drug/drug interactions or rebound insomnia. When behavioral interventions are not effective, CES could be considered prior to initiating medications.

By Jason Worchel, M.D., a noted psychiatrist and Director of the Hilo Mental Health Center in Hilo, HI. This post is from a paper written by Dr. Worchel in his testimony before the F.D.A. concerning the effectiveness and safety of CES from the perspective of a practicing psychiatrist.

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