Rethinking Atypicals

When the new "atypical" antipsychotics came out we were excited to see the problem of Tardive Dyskinesia was no longer the great worry. We became comfortable and complascent with prescribing the medications and we found them extremely helpful for not only psychosis but bipolar symptoms including mood lability, anger and insomnia. They, indeed, have been enormously helpful and a far cry from the older, side effect laden "typicals", but at what costs?

We have been aware of the risk of diabetes with these medications but we attributed it to the weight gain that fostered insulin resistance, as anyone who gains weight elevates their risk. We have been feeling secure in monitoring fasting blood sugars and Hemaglobin A1c as markers of a problem. This, however, as it turns out, may not be adequate or even helpful It appears that what the body does to compensate for the insulin resistance is increase the amount of insulin production from of the pancreas. Unfortunately, what we know of pancreatic functioning is that insulin production over time diminishes naturally with age. If we over tax the pancreas (with obesity, poor dietary habits, atypical anti-psychotic medications, etc) the risk of developing diabetes is much higher.

Given the above, we, as a profession, need to adapt our prescribing habits to what we are learning. We will need to go back to the old mentality of using anti-psychotic, whether typical or atypical, with caution. We certainly need to use them as necessary but maybe for shorter periods of time and with the expectation that if we can replace them with other medications (eg, mood stabilizers in the case of bipolar), we should plan on doing so. Perhaps adding adjunctive medications (though the fewer medications the better) or natural supplements (such as cinnamon) may be worth considering. The atypical antipsychotic medications are exceptionally good treatments and far better than the other older options and hopefully, the pharmaceutical companies can work further on identifying new medications with at least equal efficacy and less risk. In the meantime, we keep trying to understand what best to do to help our patients.

Autism, Aspergers and medications

Risperdal was recently approved for treatment of aggression and mood lability with Autism. Unfortunately, for the psychiatric community it was nothing new. We have been using antipsychotics for treatment of the symptoms of autism for years. There is one positve however, there is hope that this might mean more pharmaceutical monies directed toward treatment of autism spectrum disorders.

Autism is a complex disorder that is confusing and poorly understood at the present. So far we know there are some complex genetics involved, there may be a predisposition that is triggered by something, (eg like MMR vaccine), there is a bowel connection with inflammatory bowel wall and frequent bowel issue like chronic constipation and there may be nutritional issues with casein, gluten intolerances and magnesium ?deficiency. At this point we have to address as many issues as we identify: sensory, dietary, bowel, communication, social, need for supplements, etc. Hopefully, in 5-10 years we'll look back and wonder why we had it all wrong and were grabbing at straws. We have to do the best we can with what we have.