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smithy

drug awards!!

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Consider the number of new drugs coming out in psychiatry each year. I think most of them are completely useless. But let face it some are greeeeeat.

Anyone got any suggestions on the best and/or worst drugs to come out in the past 100 years?

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Can't beat a bit of clozapine, olanzapine, trifluoperazine, pipothiazine, clopixol depot, depixol and good old haloperidol. Pimozide's not too bad either!

Risperdal consta! What does it do, how long does it take to work...and how much? Any ideas what quetiapine does - no side effects, but any effects?

Am I too old fashioned!?

With antidepressants, nothing like amitriptyline or nortreiptyline (can do levels). Quite a fan of SSRIs too and mirtazepine.

I'm most impressed with depakote and litium has got thousands of years of evidence.

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MAOIs would go on my not so good list. Anything that's based on the same chemicals that went into hydrazine and doesn't allow you to eat cheese and wine, (and banana skins if you wanted to) is not a drug I'd want.

Chlorpromazine I think would be top of the list of best drugs. As the first antipsychotic to be used in general psychiatric populations I think it has done more for people with mental illness than many others. It treated the previously untreatable, and gave many people a chance at life outside of an asylum for the first time in history.

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Best: Clozapine

Worst: Buspirone

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I too think that CPZ and the tricyclics have stood the test of time and have been genrally efficacious.

clozapine has made a difference to a significant number too.

it would be great if an anti-depressant can be discovered which starts working within the first week!

how abt ECT?

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Clozapine and Lithium r the best, no doubt- and ECT as well

Worst? Aripirpazole and Duloxetine!

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Clozapine and Lithium r the best, no doubt- and ECT as well

Worst? Aripirpazole and Duloxetine!

same for me ! :)

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I'm not a fan of aripiprazole - nausea and agitation. Chlorpromazine is good, although hypotension and dizziness is a problem

I've never prescribed an MAOI.

Interesting to see how a lot us like the oldies!

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I had a chance to stop MAOI's in one of my patients and

put her on SSRI no use, we had to give her ECT-

I have seen wonderful improvements in almost all (seen many relapses after long remissions as well)

Appreciate the Lithium and depakote.

Yet to sense anything positive in Ari*****zole.

Haloperidol and CPM very handy.

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Chlorpromazine and Haloperidol are the best

Benzos are the worst ( because of itz abuse potential)

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I feel the question of which is the best & worst drugs slightly puzzling.For a neurotic Antianxiolytic & antidepressants are best.For a Psychotic antipsychotic is best & so on & so forth.

Every Drug is called ' Molecule' in trade parlance. Every Molecule from the stage of Concept to actual Phase -3 trials ( using in pure disease populations for a limited periods) takes hundreds ofmillions of pounds.

Believe you, Me Pharmaceutical Companies dont take it easy.

Even with all their efforts they some times cant detect certain things, which is why Phase-4 of drug monitoring is important.These catch for example Agranulocytosis in Clozapine(it was originally introduced in the 80's & stopped due agranulocytosis),QT Interval prolongation in Sertindole or Impaired Glucose Tolerance or whatever legally correct term to describe this phenomenon with Olanzapine etc...

Thalidomide which was an antileprosy drug caused phocomelia & then post marketing surveillance(phase-4) was introduced(around the 2nd world war period).More recently concerns over COX-2 Inhibitors was also highlighted.

There are 2 factors which ultimately decide whether a drug is good or bad Efficacy & Tolerability.More Efficacious 7 tolerable the drug the better.Add to this convinience of dosing plans & routes of administration & you have the perfect 'MOLECULE'.

For example the 2 Holy Grails of Modern Psychopharmacology are:-

1) Clozapine with no side effects in intramuscular form.

2) A Mood stabiliser which efficacious & tolerale in intramuscular form

They are difficult, almost impossible, but they are worth Billions of dollars & Pharmaceutical majors are on the look out for them.

Finally what was a wonder drug in this era will be a relic in the next era.For example Chlorpromazine which changed the way mentally ill were treated and eventually heralded community treatment of these illnesses was considered a major mile stone in Psychiatry(My 1st Boss used to introduce me to his patients as the next best thing since chlorpromazine!LOL!).Today when I describe Chlorpromazine to my patients, I talk about it as being an old drug with many side effects compared to the newer ones.See my drift.

The best is an utopian dream we all want to realise.......... only in our dream aspirations, As a Great Poet once said.

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Thanks for a great post,

I agree with your view of the perfect molecule.

I am not convinced at all though by your view of how drugs companies fit into the picture. You'll find that if you scratch the surface they do very little indeed in terms of R&amp:lol:, whats more most phase IV trials are done for no other reason other than to extend patents, and you'll find many examples of where they have with held inportant side effect data inorder to boost profits. (I could say lots more)

ooo they make me angry!!!!!!!

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drug companies do very little cutting edge research.they make sure that docs keep prescribing branded drugs and this is where a lot of their money goes into,when generic ones are cheaper and equally effective.well known drugs are changed slightly and millions made from them.

their money and policies does cause poverty and hardships,especially to patients who do not have insurance and those vulnerable.this is more a north american problem but does occur in many countries.

here in the uk their persuasion of the medics prescribing habits eats into ths nhs funds.

read 'the truth about the drug companies:how they deceive us and what to do about it by marcia angell, former editor in chief of the new england journal of medicine,available on amazon.

they do contribute to the prostitution of the profession.i am equally guilty having free lunches and pens,meetings etc.where do i draw a line.am i strong enough to say we do not need any freebies at all and need to take a policy stand.the drug companies just gets the money back from the patients and govt.

reading marcia's book has given me a different perception and hopefully a principeled stand soon.i guess that things have to change and are changing and the profession should become what it shoud be i.e professional .

i guess this is a sensitive issue but for a start becomming aware will be useful.

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other good books are :

selling sickness:how drug companies are turning us all into patients

by ray monihan

big pharma by jacky law

let the tide start changing, lets be a little poorer but decent honourable docs.i know i should start with myself.

i discussion will be most welcome as i feel this is a major silent issue which has a major impact in our patients lives and the funding of the health service.as doctors we have to be the leaders in difficult issues like these however unwilling and uncomfortable we feel.

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Smithy,Aron ;

I am no conduit for the Pharmaceutical industry. Far From it, I have over the years ammassed a wealth of information about the unhealthy interaction between the Industry & the Profession.

Here is an essay I scribbled after a recent editorial in the British Journal of Psychiatry this year.It is a rough draft Only, but the references in the essay are accurate , to the best of my knowledge..

There are also interesting websites to browse(if you have time and wish to, ofcourse)

'

“Psychiatric Drug Promotion & The Politics of Neoliberalism”

-Joanna Moncrieff

Nazi- era Psychiatry’s Operation T4, after the headquarters of the Program Tiergartenstrasse 4 & Soviet era Psychiatry’s Serbsky Institute & its “latent” Schizophrenia & their disastrous consequences are well known. More recently In China, “Akangs”(Secure Special Hospitals) have detained “Falungong” dissidents and are being treated for the mysterious “quijong related mental disorder”. Psychologist Hendrik Verwoerd, a Psychologist & a one time leader of South Africa &used psychiatric grounds to craft apartheid regime.(Getting through MRCPsych Parts 1 &2,1001 EMQ’S Albert Michael , 2004,page 8)

The first Nobel Laureate for his work in the mentally ill was Wagner Von Jauregg in 1927 for malarial treatment of Neurosyphilis, now would be considered Barbaric! Subsequently Egas Moniz got the second Nobel Prize for work in Mental health in 1949 for prefrontal leucotomy in Schizophrenia, would be considered by many to be unethical in today’s practice.(Use of Drugs in Psychiatry,5th Edition, Page 12)

With the above Notorities, We can Understand why Psychiatry has such a bad name & Psychiatrists feared.

Britain,along with most developed nations has now less than a third of the Psychiatric inpatient beds than it had in the 1950’s(In place of Fear,11thBiennial report,Mental Health Act Commisiion,2005,page 113). The discovery of Chlorpromazine by Delay &amp:lol:eniker in 1952 & Sociologist Erving Goffman’s Asylums published in 1961 which recognised “Institutionalisation” & its negative consequences on patients, both played a part in the reduction of bed provision.

Dr.Hamish Mcallister Williams in his Critical Appraisal Lecture at the One Day Basic Psychopharmacology Course by the British Association of Psychopharmacology in 2005

Eloquently describes how Antipsychotic trials have disproportionately increased since 1990 & skyrocket in 1997, the year of introduction of Olanzapine, How approximately more than 80% of trials in Psychiatry have less than 100 patients & Last less than 6 months in duration.He also describes 531 Interventions in the first 2000 antipsychotic trials & 640 different outcome scales in the first 2000 antipsychotic (Marshall et al,2000,BJPsych). The Loss to Follow up by 6-12 weeks in trials of newer antipsychotics is Clozapine about 15%,Risperidone 30%, Olanzapine 40%, & Quetiapine over 50%.. In the period between 1966- 1995 mean quality scores have remained fairly static despite the hype of the industry.

Over 650 Million Prescriptions are written by GP’s alone(House of Commons health committee “Influence of Pharmaceutical Industry” 4th Report of session 2004-2005).Medicines cost the NHS 7 Billion every year, 80% of which is spent on branded patented products.It is the 3rd most Profitable Economic Activity after Tourism & Finance in the UK. While the US is the Industry’s Largest Market & is the site of most drug research & development, The UK accounts for 10% of the global R&amp:lol: expenditure & is estimated to fund approximately 65% of all health related R&amp:lol: in the UK.

According to the ABPI(Association of British Pharmaceutical Industry), Improved treatments in 12 areas of serious illness since the 1950’s has saved the NHS an equivalent of 11 Billion per year,4 Billions saving taking into account 7 Billion NHS expenditure annually on medication.. The estimated cost of drug development has gone up from 54 Million Dollars in 1979 to 897 Million Dollars in 2003(Tufts,SDD,Lehmann Brothers). The Industry Funds Over half of all post graduate education & training in the UK.In the US Major Pharmaceutical Companies spend of the order of 24% to 33% of sales on marketing, about twice as much as on R&amp:lol:. About 8000 drug company representatives operate in the UK.

Over 75% of Clinical Trials Published in the Lancet,The New England Journal of Medicine are industry funded. & one of witnesses to the parliamentary select committee claimed over 50% of the articles written in the journals may have been Ghost Written!

(Continued in next Post)

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All the mental health research is in my view being done to suit the centre right political agenda of low taxation(whether New Labour or New Conservative party) & the Political agenda is:-

The Current Drive to reduce Incapacity Benefit Claimants is also to be seen in a different light. In the 1970’s it was low back ache, today it is depression. Trends in sickness benefits in Great Britain and the contribution of mental disorders

Please Google Richard Layard,an economist from the London School of Economics who states that by 2040 or something we have to get 2 out of the following 3 groups into work(Children,The sick & the Old). Otherwise the welfare state as we know it will be doomed.(that is my understanding of it after reading a few articles he wrote)

J Moncrieff0,z

J Pomerleau1

People with mental health problems have the highest rate of unemployment amongst disabled peopleAbout 80 million working days are lost every year in the UK due to mental illness, with the cost to employers amounting to £1.2 billion. An average of 3000 British people move onto incapacity benefits each week and the leading causes of this are musculo-skeletal problems (28%) and psychiatric disorders (20%). In 1993, 1 in 5 days of certified work incapacity in the UK was due to mental ill health, which accounted for 92 million lost working days.

The estimated annual total cost of mental illness in England at 1996/1997 prices is £32.1 billion; the component costs include £11.8 billion in lost employment, £7.6 billion in Department of Social Security payments and £4.1 billion in National Health Service costs (Patel & Knapp, 1998).

best websites I for looking at the other side of the Pharmaceutical industry(which they don’t want us to know)

ALLIANCE FOR HUMAN RESEARCH PROTECTION (AHRP)

Promoting Openness, Full Disclosure, and Accountability

http://www.ahrp.org

Parliamentary select Committee report on the Industry & the profession:-

http://www.publications.parliament.uk/pa/cm200405/cmselect/cmhealth/42/42.pdf

Interesting article:-

http://www.obgynsurvey.com/pt/re/obgynsurv/abstract.00006254-200008000-00012.htm;jsessionid=G2sHSbwgyGKBjhVypr46bpw4J2pjN5T1xD6WNkB7dTNLyJT8Qvpw!1941873617!-949856145!8091!-1

Interesting site:-

http://www.nofreelunch-uk.org/'

I am not saying that drug companies are evil or that there should be no contact between the Industry & the Profession. But there needs to be an open debate about the whole interaction.

Hope the evidence I am presenting will atleast partly convince you to this view of mine.

I have tried to make the references as accurate as possible, but some mistakes might be there, but they are not intentional

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I However Recognise that despite all the nasty things that drug companies do(they are the flavour of the moment as it suits goverment agenda of cutting costs of employing personnel by giving medication), I equally understand that they have huge reservoirs of cash to do research if it had financial gains.

What we need for the moment is not stopping the Industry as it would be detrimental to all of us but REGULATION of the industry like tighter controls on the Industry-profession interaction, High standards & more transperancy for studies to be published in journals & fighting for our right to have scientific freedom( to say that if a drug is causing concern, then we should state the obvious).For example SSRI's & Suicide, Olanzapine & weight gain/diabetes etc.... without fear of recrimination from the industry with law suits & litigation.

However it is my firm view that if we can get our act together(Profession & Industry), then the public at large will benefit immensely.

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hi maram

thanks for your views.yes we do need regulations,but we seem not to be the best people to regulate ourselves.the pharm industry has changed subtly and the current relationship with medics is not healthy at all.just being doctors does not make us saints and honourable people.the industry plays on our greed,and ego and after a while it seems the norm.the treats and the obligations just get bigger.we are lucky here that the nhs is still free and their is less pressure on doctors to be businessmen and women.but in countries where it is not ,doctors have become businessmen/women to the detriment of patients using expensive medicines and equipment.i guess being aware that we are not saints and how we are behaving is a start.

my father who is diabetic lives in north america.i can see the amount of expensive repeated investigations,numerous consultations, and branded expensive medicines he gets.his treatment would have been more sensible and cheaper here.as he has insurance it doesn't affect him.

it is an individual choice but our decision/s will have repurcussions.a good start is to see how weak,cowardly and greedy we are and can become.this insight will be the best protection.

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Hi Aron,

Sorry to hear about your old man. Hope things will be okay with him.

I am not saying that Doctors are saints. far from it ! Shipman,Van Velzen(Alderhey organ scandal), Bristol Heart Scandal, Prof Sir Roy Meadows & loads of GP's caught for suspected inappropriate behaviour etc.. prove we are as good or as bad as anybody. no different.

I am calling for tighter regulation of the interaction between the Profession and the Industry, More Transperancy about any data the companies hold, more ethical standards in publishing articles for example letting us know if they are ghost written etc.........

How ? it is up for debate,may be a parliament select committee and a few honest representatives from the profession and the industry, but done in a transperent mannner.

Thats worth a thought

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All the consultants in the country should be given a form to fill at the end of the year stating which is the antidepressant of 1st,2nd and 3rd choice , same for antipsychotics,mood stabilisers etc.

all of them must be pooled and the views emerging from that sample should be given weight before making guidelines.Just an idea.

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hi maram

thanks and i agree with your points.my only concern is that doctors who hold ultimate power and responsibility in prescribing can be subtly affected.the industry spends millions in studying human behaviour and especially docs behaviour,and how to use and change us.i know a number of docs who travel abroad on sponsered trips,lecture and prescribe mainly one or two favoured drugs.this is not the norm but is a dangerous trend.

the bottom line is not to fool ourselves as being immune and above any persuasion.a clear awareness of what we are doing now and how much we should deal with drug companies is important.it is a personal perception and choice.i don't have any clear answers yet.

anyway thanks maram, project m and smithy for your refs and thoughts.

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Worst? Aripirpazole and Duloxetine!

I completely agree. Aripriprazole is so bad, and most patients experience a WORSENING of psychotic symptoms after taking it!

Duloxetine causes too much headache in patients that I won't prescribe it anymore.

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My experience is not good with buspirone. It is very slow to act and I haven't seen any of its effects.

Duloxetine 50:50 I would say.

Aripiprazole 50:50 !!!

One case did very well on aripiprazole , another had to be shifted to clozapine though there was a partial response on aripiprazole. Some of them develop severe anxiety with aripiprazole and have to be shifted to clozapine. Anyone aware of a combination of olanzapine and aripiprazole?

Duloxetine is almost equal to venlafaxine in efficacy. Many patients did respond , but one or two developed hypertension.

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Have anyone reviewed the CATIE trial - published in the NEJM.

It was not sponsored by any drug company and is the largest trial ever done in chronic schizophrenia.

It conluded that after 18 months 73 % of patients did not take any of the atypicals presribed at the start of the trial !

Also that Olanzapine worked the quickest but overall results were similar. Perphenazine was the typical drug used and at lower doses caused even less EPSE than some of the newer drugs!

Olanzapine made you put on the most weight and Risperidone caused increased prolactin.

It was actually depressing to realise that these drugs had a lot of side-effects and were in the end were more or less efually efficacious.

The conclusion of the paper was that no ONE drug is really that much superior to another and that just because you didn't respond to one drug that didn't mean you might not respond to another - makes me think that having tried only two drugs (of which one has to be atypical) might be too quick before you put someone on Clozapine (NICE guidelines).

Recently read that Although Clozapine would save 493 suicides in 10 000 population will cause about 436 deaths due to physical complications.

The truth is that these drugs can change people's lives in terms of symptoms but untill we minimise side-effects better patients just won't take them.

Would you?

And which one would you take?

Aripirazole - INSOMNIA/NAUSEA

Olanzapine - OBESITY

Risperidone - IMPOTENCE/LIBIDO

Clozapine - DIABETES

Haloperidol - EPSE

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