Psychiatric Annals

EDITORIAL 

Where the Rubber Meets the Road

Jan Fawcett, MD

Abstract

Due largely to the efforts and policies of the Federal Drug Administration data concerning the efficacy of various psychotropic drugs, these drugs must show a sufficient effect compared to placebo in controlled trials in carefully selected populations of patients representative of a single diagnosis before that medication can be marketed with a specific indication. This means that we have the comfort of knowing that medications marketed in psychiatry with FDA indications have proven themselves effective at least in certain specified populations. This month's edition of Psychiatric Annals, edited by Philip G. Janicak, MD, deals with special populations in psychopharmacology. It deals with the all-toofrequent clinical situations seen by the psychiatric clinician where data from controlled studies is not available because of the existence of varying degrees of comorbidity with other psychiatric disorders or other medical disorders. While some of these disorders may eventually become available to study from a standpoint of controlled studies, in many cases we have to rely on open-label studies to understand the possible therapeutic advantages of various psychopharmacologic treatments. These are the cases that are so often seen in psychiatric practice these days where the conditions are not easily standardized because of the existence of more than one diagnosis and differing proportions.

This is truly, as the saying goes, "where the rubber meets the road" in the practice of psychiatry. The psychiatrist of today, and increasingly so of tomorrow, will be the one consulted in these cases that are just not easily pigeonholed. Managing comorbid symptoms in AIDS or stroke patients, managing comorbid disorders such as major depression with borderline personality disorder, or patients with comorbid neurological disorders or alcoholism and other drug abuse disorders are going to be the common problems psychiatrists will be called on to face. Frequently, there will not be double-blind controlled study data to guide us, but we will have to take the best available case reports, open studies, and the clinical experience of some of our peers.

For this reason, I think it is helpful to review the opinions of varying experts who review these difficult problems and bring forth the existing information to allow clinicians to make informed decisions in approaching their most difficult and complicated cases. In this issue, Dr. Janicak begins by discussing "Psychopharmacotherapy in the HIV-infected Patient."He reviews a wide range of treatments for conditions in AIDS patients such as depression and psychotic reactions. We see valuable information from open studies and information concerning drug reactions that are pitfalls in this group of patients.

The next article, "Psychopharmacotherapy of the Personality-Disordered Patient" by Dr. Janicak, John M. Davis, MD, and Frank J. Ayd, Jr, MD, presents a cogent review of the available studies and findings concerning the use of various psychopharmacologic agents in the treatment of patients with borderline personality disorder and other comorbid personality disorders mixed often with Axis I disorders. The difficult diagnostic complexity in considering outcomes in various types of therapy with these disorders is carefully laid out in this article. It doesn't surprise us that the discussion is likely to be complicated in its presentation of data in various subtypes and mixtures of personality disorders. It is very helpful to know at least what the data are from the attempts that have been made to study therapeutic results and limitations of existing pharmacologic agents with patients with primary or comorbid personality disorders. We certainly need all the help we can get in this area because these are the patients that are going to form one aspect of the residue of difficult patients we are called on to treat after all is said…

Due largely to the efforts and policies of the Federal Drug Administration data concerning the efficacy of various psychotropic drugs, these drugs must show a sufficient effect compared to placebo in controlled trials in carefully selected populations of patients representative of a single diagnosis before that medication can be marketed with a specific indication. This means that we have the comfort of knowing that medications marketed in psychiatry with FDA indications have proven themselves effective at least in certain specified populations. This month's edition of Psychiatric Annals, edited by Philip G. Janicak, MD, deals with special populations in psychopharmacology. It deals with the all-toofrequent clinical situations seen by the psychiatric clinician where data from controlled studies is not available because of the existence of varying degrees of comorbidity with other psychiatric disorders or other medical disorders. While some of these disorders may eventually become available to study from a standpoint of controlled studies, in many cases we have to rely on open-label studies to understand the possible therapeutic advantages of various psychopharmacologic treatments. These are the cases that are so often seen in psychiatric practice these days where the conditions are not easily standardized because of the existence of more than one diagnosis and differing proportions.

This is truly, as the saying goes, "where the rubber meets the road" in the practice of psychiatry. The psychiatrist of today, and increasingly so of tomorrow, will be the one consulted in these cases that are just not easily pigeonholed. Managing comorbid symptoms in AIDS or stroke patients, managing comorbid disorders such as major depression with borderline personality disorder, or patients with comorbid neurological disorders or alcoholism and other drug abuse disorders are going to be the common problems psychiatrists will be called on to face. Frequently, there will not be double-blind controlled study data to guide us, but we will have to take the best available case reports, open studies, and the clinical experience of some of our peers.

For this reason, I think it is helpful to review the opinions of varying experts who review these difficult problems and bring forth the existing information to allow clinicians to make informed decisions in approaching their most difficult and complicated cases. In this issue, Dr. Janicak begins by discussing "Psychopharmacotherapy in the HIV-infected Patient."He reviews a wide range of treatments for conditions in AIDS patients such as depression and psychotic reactions. We see valuable information from open studies and information concerning drug reactions that are pitfalls in this group of patients.

The next article, "Psychopharmacotherapy of the Personality-Disordered Patient" by Dr. Janicak, John M. Davis, MD, and Frank J. Ayd, Jr, MD, presents a cogent review of the available studies and findings concerning the use of various psychopharmacologic agents in the treatment of patients with borderline personality disorder and other comorbid personality disorders mixed often with Axis I disorders. The difficult diagnostic complexity in considering outcomes in various types of therapy with these disorders is carefully laid out in this article. It doesn't surprise us that the discussion is likely to be complicated in its presentation of data in various subtypes and mixtures of personality disorders. It is very helpful to know at least what the data are from the attempts that have been made to study therapeutic results and limitations of existing pharmacologic agents with patients with primary or comorbid personality disorders. We certainly need all the help we can get in this area because these are the patients that are going to form one aspect of the residue of difficult patients we are called on to treat after all is said and done.

The next contribution to this issue is entitled "Pharmacologic Management of Major Comorbid Psychiatric Disorders in Drug and Alcohol Addictions" by Norman S. Miller, MD. Dr. Miller discusses the limitations and caveats involved in pharmacologic management of patients with major psychiatric disorders complicated by drug or alcohol addiction. Again, we are reminded of the complexity and necessity to recognize comorbid disorders and to employ careful risk/benefit assessment in terms of using pharmacologic treatments in these patients depending on the stage of their disorders, the type of addiction, and the severity of the "major psychiatric disorder."

Next, Anne M. Leach, MD, discusses "The Psychopharmacotherapy of Eating Disorders." Dr. Leach reviews both the reported benefits and shortcomings of psychopharmacotherapy of varying subtypes of eating disorders. She points out the limitations of pharmacotherapy in certain types of anorexic patients as opposed to others with more bulimic factors

In her contribution, "Psychopharmacology of Neuropsychiatrie Disorders," Rita Shaughnessy, MD, PhD, first discusses the varying types of symptoms seen in patients with neurological disorders, then reviews a range of neurological disorders and their psychiatric manifestations such as brain tumors, cerebral vascular disorders, dementias, seizure disorders, and traumatic brain injuries, as well as discussing the use of a range of pharmacotherapeutic agents for the treatment of such disorders as anxiety disorders, aggression and violence disorders, and depression. This article provides a valuable brief survey for the practicing psychiatrist of the range of neuropsychiatrie conditions that can present with psychiatric symptoms that may require pharmacologic treatment approaches.

This issue by no means exhausts all of the difficult situations we may find ourselves approaching in our day-to-day practice, but it certainly provides useful data concerning the significant proportion of problems we are bound to encounter. Let's hope we will continue to chip away at these most complicated combinations of disorders that make our practice both challenging and in many ways interesting.

Don't forget the new beginning feature entitled "Grand Rounds." Please send in your cases if you wish to present interesting cases, treatment results, or clinical situations that you think might be interesting to your colleagues. It will take a number of months to have the volume of cases coming in to run this feature monthly, but if you're willing to write them up and reference them to some extent, I think we can all teach each other through sharing our richest and most challenging clinical experiences with one another. After all, it's keeping in touch with the most interesting and challenging cases that keeps the excitement alive in the practice of psychiatry.

10.3928/0048-5713-19951001-06

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