The Journal of Clinical Psychopharmacology Podcast

We have all seen the television commercials imploring viewers to "ask your doctor" about Drug X, Y, or Z. The authors of a study in the Journal of Clinical Psychopharmacology were interested in finding out how such advertising might affect the prescribing of psychotropic medicines. In this podcast, the authors discuss their research with Dr. Julia A. Koretski, Digital Editor for JCP.

The authors of the study are Drs. Bennett Wechsler, Richard Balon, Richard Shader; and Anthony Rothschild. Dr. Balon is an Associate Editor of JCP and Dr. Rothschild is Editor-in-Chief. Dr. Shader is the Founding Editor-in-Chief Emeritus.

The researchers surveyed psychiatrists to ask how challenging it was for them to convince patients that a medication was not needed, despite what the advertising might suggest. The results of their survey showed that psychiatrists who were newer to their profession (less than 10 years since they completed training) had a more challenging time than those who were more experienced in changing patients' minds.

In this podcast, the authors discuss how their study came about and the thorny issues raised by the commercial promotion of psychiatric medications.

The article titled "Direct-to-Consumer Advertising Survey of Psychiatrists in Massachusetts and Michigan" is published in the January-February 2024 issue of the Journal of Clinical Psychopharmacology.

Replacement therapy is a key tool in the treatment of individuals who abuse opioids. The idea is to replace heroin or morphine with less euphoric and longer-acting substances, such as methadone, under a medication management protocol. The goals of medical-assisted replacement treatment include reducing an individual's craving for abused opioids, preventing medical complications, decreasing criminal behavior and its consequences, and utimately, hopefully, helping the individual become opioid-free. In this podcast, Dr. Richard Balon discusses the potential for replacement therapy for abuse of other types of substances, including cocaine and methamphetamines. In the podcast and in an editorial in the Journal of Clinical Psychopharmacology (JCP), he notes promising but preliminary studies of lisdexamfetamine as a possible replacement agent. Dr. Balon is an Associate Editor of JCP and Professor of Psychiatry at Wayne State University School of Medicine in Detroit, Michigan. In this podcast, he is interviewed by Dr. Julia Koretski, Digital Editor for JCP and a psychiatrist at Mass General Brigham Newton Wellesley Hospital in Newton, Massachusetts. Dr. Balon's editorial is published in the November–December 2023 issue of the Journal of Clinical Psychopharmacology, in an article titled "The Need for Examining the Role of Psychostimulants in Treatment of Methamphetamine Use/Dependence."

Clozapine is an important drug in the treatment of schizophrenia, and adherence is generally thought to be as good as, if not better than, other antipsychotics. Nonadherence, however, is difficult to detect and potentially dangerous. Tolerance to the cardiovascular effects of the drug is easily lost; restarting at a "normal" dose can prove fatal after a period of abstinence. Nonadherence also increases the risk of self-harm.

In this podcast, Dr. Robert Flanagan, a now-retired clinical scientist at Kings College Hospital in London, discusses his study of nonadherence, as measured by plasma levels of clozapine, in samples submitted to a clozapine therapeutic drug monitoring service from 1993–2017. In thousands of submitted samples, nonadherence was 1.1% for men and 1% for women.

Dr. Flanagan discusses both the implications of his research as well its limits.

The research is published in the September–October 2023 issue of the Journal of Clinical Psychopharmacology, in an article titled "Assessing Adherence to Clozapine: Practical Considerations." Dr. Flanagan's coauthors are Samora Hunter and Stephen J. Obee, also of Kings College Hospital.

Much has been written in recent months regarding the growing use of artificial intelligence (AI) in medicine and the potential benefits and risks of its use. In this podcast, Anthony J. Rothschild, MD, Editor-in-Chief of the Journal of Clinical Psychopharmacology, highlights a paper in the journal by Drs. Jose de Leon and Carlos De Las Cuevas that reports their experiment to see how ChatGPT3 would respond to various questions about clozapine metabolism. The generated text proved to be profoundly unreliable. Dr. Rothschild also discusses his editorial about the journal's policies regarding use of generative AI by authors and reviewers. Authors must disclose any such use; peer reviewers are prohibited from using AI in conducting their reviews.

Dr. Rothschild's editorial and the commentary by Drs. De Leon and de Las Cuevas both appear in the September–October 2023 issue of the Journal of Clinical Psychopharmacology.

The COVID-19 pandemic and associated public health measures shifted the way people access health care. In this podcast, Dr. Christine Leong, Associate Professor at the University of Manitoba College of Pharmacy, discusses the research she and her colleagues conducted to study the effects of the pandemic on psychotropic medication adherence. The data were drawn from a claims repository that contains information on health service and medication use for almost all Manitoba residents.

The study showed improved adherence to most psychotropic medications in the 9 months after public health restrictions were enacted. Patients who were already adherent to their psychotropic medications were less likely to discontinue them during the pandemic. Findings in this study highlight that, although there were concerns about public health measures restricting access to in-person care, access to medications in Manitoba did not seem to be restricted.

The article "Adherence to Psychotropic Medication Before and During COVID-19: A Population-Wide Retrospective Observational Study" is published in the July-August 2023 issue of the Journal of Clinical Psychopharmacology.

The July-August 2023 issue of the Journal of Clinical Psychopharmacology features a helpful tutorial written by Drs. Eric G. Smith and Hannah L. Grigorian. Their article is titled "A System for Rapidly Yet Rigorously Evaluating the Quality of Randomized Controlled Trials." The article should be of particular interest to busy clinicians, researchers, and trainees, who must grapple with the never-ending task of keeping up with the medical literature.

In this podcast accompanying the article, Dr. Smith provides an overview of criteria that can be used to assess various aspects of trials, including blinding of participants and study personnel, sample size, follow-up, analysis plans, and effect sizes.

Dr. Smith is a psychiatrist and clinical and health services researcher at the VA Bedford Healthcare System, Bedford, Massachusetts, and Assistant Professor of Psychiatry and Population and Quantitative Health Sciences at the University of Massachusetts Chan Medical School. Dr. Grigorian is a psychology research fellow at the VA Bedford Healthcare System.

Hyperammonemia is an adverse effect that poses clinical uncertainty regarding the prescription of valproic acid (VPA) use. The prevalence of symptomatic and asymptomatic hyperammonemia and its relationship to VPA concentration is not well established. In this podcast, clinical pharmacists Michelle Gnrya and Yiu-Ching Jennifer Wong of St. Paul's Hospital in Vancouver discuss their systematic review that summarizes evidence available regarding VPA-associated hyperammonemia and its prevalence, clinical outcomes, and management. Their review is published in the May-June 2023 issue of the Journal of Clinical Psychopharmacology. The review found various risk factors for this common adverse effect, including concomitant medications, liver injury, and defects in carnitine metabolism. With VPA discontinued, most symptomatic patients returned to baseline mental status with normalized ammonia level. Further studies are required to determine the benefit of routine ammonia level monitoring and to guide the management of VPA-associated hyperammonemia.

Among individuals with schizophrenia, an estimated 50% to 80% have a partial or even total lack of insight into the presence of their mental disorder. This condition, known as anosognosia, has also been observed in people with other diagnoses, such as bipolar disorder, major depression with psychotic features, obsessive-compulsive disorder, and eating disorders. The May-June 2023 issue of the Journal of Clinical Psychopharmacology features two articles on this topic, a commentary by Rachel Streiff, titled "Institutional Neglect of Anosognosia Is a Critical Barrier in the Treatment of Psychosis Related Disorders" and an editorial by Editor-in-Chief Anthony Rothschild, MD, titled "Can Psychopharmacology Do More for Our Patients With Anosognosia?"

In this podcast, Ms. Streiff, who as cared for a family member with anosognosia, and Dr. Rothschild discuss their articles with Dr. Julia Koretski, Digital Editor of the journal. The articles and podcast are designed to heighten awareness of the scant research on medication treatments for people with serious mental illness who also experience anosognosia.

For individuals with treatment-resistant depression, ketamine can be an effective fast-acting alternative to conventional antidepressants. It has been hypothesized that it partly exerts its antidepressant effects by modulating the opioid system. In this podcast, Dr. Brandi Quintanilla discusses her study that explored baseline plasma levels of κ-opioid and dynorphin peptides and changes after ketamine infusion. Participants in this randomized trial included individuals with major depressive disorder and healthy volunteers.

The results suggest that κ-opioid and dynorphin levels in plasma may not be a major underlying mechanisms of ketamine's therapeutic effects or its dissociative adverse effects. The study, however, may have been underpowered to detect effects, and additional research is needed.

Dr. Quintanilla is a psychiatry resident at the University of Texas Health Science Center at Houston and a special research volunteer in the Experimental Therapeutics and Pathophysiology Branch of the National Institute of mental health.

The article by Dr. Quintanilla and colleagues is published in the March-April 2023 issue of the Journal of Clinical Psychopharmacology.

Clozapine is a unique antipsychotic with superior efficacy in treatment-resistant schizophrenia (TRS). Unfortunately, approximately 40% to 70% of patients on clozapine continue to experience psychotic symptoms. Nevertheless, there is a concern about how high of a dose to prescribe because adverse effects are related to plasma levels of the drug. In this podcast, Dr. Jan Bogers discusses his research involving stepwise increases in clozapine doses in severely ill, long-stay patients with TRS.

The study, conducted at Rivierduinen Mental Health Organization in the Netherlands, concludes that most patients older than 60 years could not tolerate high clozapine levels and so this should not be attempted in older or otherwise physically vulnerable patients. Increasing clozapine levels to approximately 750 ng/mL in middle-aged patients with longstanding TRS may modestly reduce the severity of positive symptoms and improve the response rate.

The article appears in the March-April 2023 issue of the Journal of Clinical Psychopharmacology.