Understanding psychosis

This post has the same title as the latest post from the Healthy Minds. Health Lives blog, my favourite for commenting on because it is published under the auspices of the American Psychiatric Association (APA) (see previous post). The APA blogger suggests that it helps to understand psychosis by recognising its connection with the brain. Does it really? It's merely tautologous. Of course it's something to do with the brain. So what? Knowledge of the brain doesn't give any understanding about personal and social factors.

Actually understanding the irrational may require more than being logical. What makes us think that someone is mentally ill may be that what they are saying is difficult to follow and understand. It makes us think there is something wrong mentally. It doesn't help to wishfully speculate about brain processes when what is required is considerable effort to understand why someone may have crazy experiences and express themselves in a mad way. We don't live in the real world for all sorts of reasons, including our own convenience about understanding the world. And it suits the APA blogger to have her biomedical belief about psychosis.

Menacing cloud hovering near prospective patients

Seroquel is the best-selling psychiatric medication in the US and, as pointed out in a feature in Medical Marketing and Media (MM&M), its patent is due to expire in 2012. Its manufacturers, AstraZeneca, last year reached an agreement to settle US product liability litigation over Seroquel for about $198 million (see Wall Street Journal article). Earlier in the year it also paid $520 million to resolve allegations that it marketed regular Seroquel for off-label uses between 2001 and 2006.

However, this doesn't seem to matter to Astrazeneca financially with global Seroquel sales of $4.9 billion in 2009. And it is MM&M's Large Pharma Marketing Team of the Year. It has approval for an XR formulation which extends the use of the drug under patent. This formulation has been approved as an add-on to antidepressants for the treatment of major depressive disorder. 

There's a full page advert for it on the back of this week's BMA News, which does not use the cloud as in the US campaign. The image of the depressed woman curled up in her kitchen unable to do her washing, which is used to advertise seroquel XL (it's called XL, not XR, in the UK) to UK doctors, for some reason seems to be different from that used for direct-to-consumer US advertising.

Off-label use of atypical antipsychotics

A Reuters report based on an article in Pharmacoepidemiology and Drug Safety suggests atypical antipsychotics are overused. The article looked at trends in outpatient prescribing in the US. Antipsychotic use for indications without FDA approval increased between 1995 and 2008 with an estimated cost associated with off-label use in 2008 of US$6.0 billion. Atypical use has grown far beyond substitution for the now infrequently used typical agents.

(With thanks to Vince Boehm)

Opportunities and threats for psychiatry

In an e-interview in The Psychiatrist, John G. Csernansky was asked what he saw as the most promising opportunity facing the psychiatric profession and what he saw as the greatest threat. He said the most promising opportunity was the introduction of new knowledge about neuroscience into the practice of psychiatry. The greatest threat was that the public has become impatient with the lack of progress of biomedical research and may begin to withdraw its support for it.

Psychiatry has seen itself on the verge of neuroscientific breakthrough ever since its modern origins over 150 years ago. We are no nearer being "finally on the threshold of knowing enough to develop reasonable models of the pathophysiology of neuropsychiatric diseases and how to treat them", as Csernansky believes, than we were then. It's not so much that the public has become impatient with the lack of progress but that there needs to be a conceptual shift in understanding. The reason progress hasn't been made in biomedical research is that it is "barking up the wrong tree". The sorts of neurobiological processes underlying mental disorder may be no different from the basis of our "normal" thinking, feelings and behaviour.

By the way, when Csernansky was asked what single change would substantially improve quality of care, he said simplification of how we pay for mental healthcare. This is just at the time when the UK government is reforming health care (eg. see my personal blog entry), which will lead to the introduction of a mental health tariff based on clusters of patients which people don't, at least currently, understand. Still, it will be possible to undercut the national tariff, so maybe the new clustering system will never get off the ground. Anyway, the introduction of a tariff complicates block contract arrangements which we have got used to in the NHS and there is a lack of evidence that this change will lead to an improvement in services.

A cute little video about a visit to a psychiatrist

(With thanks to Adinah's post on ICSPP Discussion Group giving the link. See also her comment on another blog.)