Commentary

I generally like drug reps. Some doctors don’t want to deal with them, but I don’t mind. Most are people just trying to support their families, like me. I don’t do lunches anymore, but I never mind briefly chatting and signing for samples.

I’ve fired a few, though. Obviously, I can’t get them tossed from their jobs, but I tell them to never set foot in my office again.

What sort of things really tick me off?

1. Excessive pushiness. Yes, I know you have to sell a product. But endlessly emphasizing it and asking for my support is irritating. I signed for your samples.

2. Not respecting time constraints. Most reps know that doctors only have a few seconds to sign and exchange a few words and respect that, but some will chatter on about their drug at length, even when I’m obviously trying to run to see a patient. My responsibility is to those who need my help, not to those trying to show me a slick iPad graphic.

3. Stalking me. I’ve had reps follow me over to the hospital and out to my car while still talking. Don’t make me get a restraining order.

4. Wasting my staff’s time. My awesome receptionist is very busy. She also is not the one prescribing your product. Do not interfere with her job by rambling about your drug’s dosing, mechanism of action, plan coverage, or pretty much anything. I am paying her. You aren’t. She has a patient to check out, 12 things to fax, an MRI to schedule, and two calls on hold. When you are done talking to me, you are done here. Pack up your bag and move on.

5. Overt rudeness to me and my staff. Believe it or not, I’ve had reps blatantly accuse my secretary of lying to them about such things as not scheduling lunches or not needing samples. Telling her to just “get the doctor” won’t get you anywhere. She runs the office up front, and if you cross her you won’t get to me, either. I will back her up every time.

6. Trespassing. Back before we installed a lock on the door between the lobby and office, I had a rep just walk on back without checking in with the staff. He came to my office and interrupted me with a patient. If your company encourages this, you should work somewhere else. This is a fast way to be told to get out and never come back.

7. Discuss politics. You are welcome to your viewpoints. So am I. They have no place in the interaction between a doctor and a rep. Around the 2012 election, one rep expressed viewpoints that were extreme to the point of being delusional. When she discovered that none of us agreed with her, she became quite angry and confrontational. I told her to never come back.

8. Whip out my prescribing data. Allegedly, mine is shielded, but some reps still seem to be able to access it. Quoting to me (or showing me graphs) as to how much of your product I’m writing vs. another company’s is rude. I will make my decisions based on my patients’ needs, not your sales figures.

9. Selling to my patients. They see enough direct-to-consumer advertising on TV. And magazines. And online. If they ask you questions, I have no problem with you answering them, but don’t start randomly handing them your sales brochures and telling them your drug is better than whatever I have them on.

10. Telling me that my prescribing your drug can help improve your salary or bonus. Like I don’t know that. But, again, that doesn’t and shouldn’t ever factor in to how I manage a patient. Their health, not your car payments, is my concern.

I don’t think I’m unreasonable. Like them, I have a job to do. And, at my office, the patients will always be my priority. As it should be.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I generally like drug reps. Some doctors don’t want to deal with them, but I don’t mind. Most are people just trying to support their families, like me. I don’t do lunches anymore, but I never mind briefly chatting and signing for samples.

I’ve fired a few, though. Obviously, I can’t get them tossed from their jobs, but I tell them to never set foot in my office again.

What sort of things really tick me off?

1. Excessive pushiness. Yes, I know you have to sell a product. But endlessly emphasizing it and asking for my support is irritating. I signed for your samples.

2. Not respecting time constraints. Most reps know that doctors only have a few seconds to sign and exchange a few words and respect that, but some will chatter on about their drug at length, even when I’m obviously trying to run to see a patient. My responsibility is to those who need my help, not to those trying to show me a slick iPad graphic.

3. Stalking me. I’ve had reps follow me over to the hospital and out to my car while still talking. Don’t make me get a restraining order.

4. Wasting my staff’s time. My awesome receptionist is very busy. She also is not the one prescribing your product. Do not interfere with her job by rambling about your drug’s dosing, mechanism of action, plan coverage, or pretty much anything. I am paying her. You aren’t. She has a patient to check out, 12 things to fax, an MRI to schedule, and two calls on hold. When you are done talking to me, you are done here. Pack up your bag and move on.

5. Overt rudeness to me and my staff. Believe it or not, I’ve had reps blatantly accuse my secretary of lying to them about such things as not scheduling lunches or not needing samples. Telling her to just “get the doctor” won’t get you anywhere. She runs the office up front, and if you cross her you won’t get to me, either. I will back her up every time.

6. Trespassing. Back before we installed a lock on the door between the lobby and office, I had a rep just walk on back without checking in with the staff. He came to my office and interrupted me with a patient. If your company encourages this, you should work somewhere else. This is a fast way to be told to get out and never come back.

7. Discuss politics. You are welcome to your viewpoints. So am I. They have no place in the interaction between a doctor and a rep. Around the 2012 election, one rep expressed viewpoints that were extreme to the point of being delusional. When she discovered that none of us agreed with her, she became quite angry and confrontational. I told her to never come back.

8. Whip out my prescribing data. Allegedly, mine is shielded, but some reps still seem to be able to access it. Quoting to me (or showing me graphs) as to how much of your product I’m writing vs. another company’s is rude. I will make my decisions based on my patients’ needs, not your sales figures.

9. Selling to my patients. They see enough direct-to-consumer advertising on TV. And magazines. And online. If they ask you questions, I have no problem with you answering them, but don’t start randomly handing them your sales brochures and telling them your drug is better than whatever I have them on.

10. Telling me that my prescribing your drug can help improve your salary or bonus. Like I don’t know that. But, again, that doesn’t and shouldn’t ever factor in to how I manage a patient. Their health, not your car payments, is my concern.

I don’t think I’m unreasonable. Like them, I have a job to do. And, at my office, the patients will always be my priority. As it should be.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I generally like drug reps. Some doctors don’t want to deal with them, but I don’t mind. Most are people just trying to support their families, like me. I don’t do lunches anymore, but I never mind briefly chatting and signing for samples.

I’ve fired a few, though. Obviously, I can’t get them tossed from their jobs, but I tell them to never set foot in my office again.

What sort of things really tick me off?

1. Excessive pushiness. Yes, I know you have to sell a product. But endlessly emphasizing it and asking for my support is irritating. I signed for your samples.

2. Not respecting time constraints. Most reps know that doctors only have a few seconds to sign and exchange a few words and respect that, but some will chatter on about their drug at length, even when I’m obviously trying to run to see a patient. My responsibility is to those who need my help, not to those trying to show me a slick iPad graphic.

3. Stalking me. I’ve had reps follow me over to the hospital and out to my car while still talking. Don’t make me get a restraining order.

4. Wasting my staff’s time. My awesome receptionist is very busy. She also is not the one prescribing your product. Do not interfere with her job by rambling about your drug’s dosing, mechanism of action, plan coverage, or pretty much anything. I am paying her. You aren’t. She has a patient to check out, 12 things to fax, an MRI to schedule, and two calls on hold. When you are done talking to me, you are done here. Pack up your bag and move on.

5. Overt rudeness to me and my staff. Believe it or not, I’ve had reps blatantly accuse my secretary of lying to them about such things as not scheduling lunches or not needing samples. Telling her to just “get the doctor” won’t get you anywhere. She runs the office up front, and if you cross her you won’t get to me, either. I will back her up every time.

6. Trespassing. Back before we installed a lock on the door between the lobby and office, I had a rep just walk on back without checking in with the staff. He came to my office and interrupted me with a patient. If your company encourages this, you should work somewhere else. This is a fast way to be told to get out and never come back.

7. Discuss politics. You are welcome to your viewpoints. So am I. They have no place in the interaction between a doctor and a rep. Around the 2012 election, one rep expressed viewpoints that were extreme to the point of being delusional. When she discovered that none of us agreed with her, she became quite angry and confrontational. I told her to never come back.

8. Whip out my prescribing data. Allegedly, mine is shielded, but some reps still seem to be able to access it. Quoting to me (or showing me graphs) as to how much of your product I’m writing vs. another company’s is rude. I will make my decisions based on my patients’ needs, not your sales figures.

9. Selling to my patients. They see enough direct-to-consumer advertising on TV. And magazines. And online. If they ask you questions, I have no problem with you answering them, but don’t start randomly handing them your sales brochures and telling them your drug is better than whatever I have them on.

10. Telling me that my prescribing your drug can help improve your salary or bonus. Like I don’t know that. But, again, that doesn’t and shouldn’t ever factor in to how I manage a patient. Their health, not your car payments, is my concern.

I don’t think I’m unreasonable. Like them, I have a job to do. And, at my office, the patients will always be my priority. As it should be.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

While reading the “Opportunities to partner with clinical pharma­cists in ambulatory care” (Current Psychiatry, Evidence-Based Reviews, July 2014, p. 23-29 [http://bit.ly/1s3yqmh], I became puzzled. Several times, I asked myself, “As a psychiatrist reasonably well-trained in psychophar­macology, why would I need or want to partner with a clinical pharmacist in this fashion?” Indeed, I was under the impression that this is what I trained to do. It called to mind a bumper sticker from the feminist movement of the 1960s that read, “A woman without a man is like a fish without a bicycle.” It then occurred to me that a psychiatrist without a clinical pharmacist would find himself or herself in that same lamentable position.


Scott D. Mendelson, MD, PhD
Roseburg, Oregon

While reading the “Opportunities to partner with clinical pharma­cists in ambulatory care” (Current Psychiatry, Evidence-Based Reviews, July 2014, p. 23-29 [http://bit.ly/1s3yqmh], I became puzzled. Several times, I asked myself, “As a psychiatrist reasonably well-trained in psychophar­macology, why would I need or want to partner with a clinical pharmacist in this fashion?” Indeed, I was under the impression that this is what I trained to do. It called to mind a bumper sticker from the feminist movement of the 1960s that read, “A woman without a man is like a fish without a bicycle.” It then occurred to me that a psychiatrist without a clinical pharmacist would find himself or herself in that same lamentable position.


Scott D. Mendelson, MD, PhD
Roseburg, Oregon

While reading the “Opportunities to partner with clinical pharma­cists in ambulatory care” (Current Psychiatry, Evidence-Based Reviews, July 2014, p. 23-29 [http://bit.ly/1s3yqmh], I became puzzled. Several times, I asked myself, “As a psychiatrist reasonably well-trained in psychophar­macology, why would I need or want to partner with a clinical pharmacist in this fashion?” Indeed, I was under the impression that this is what I trained to do. It called to mind a bumper sticker from the feminist movement of the 1960s that read, “A woman without a man is like a fish without a bicycle.” It then occurred to me that a psychiatrist without a clinical pharmacist would find himself or herself in that same lamentable position.


Scott D. Mendelson, MD, PhD
Roseburg, Oregon

There are many interesting aspects of Dr. Nasrallah’s review of the changes in psychiatry in recent decades (Post-World War II psychiatry: 70 years of momentous change, Current Psychiatry, From the Editor, July 2014, p. 21-22, 49-50 [http://bit.ly/1m8HcdC]). There is no doubt that great strides have been made, particu­larly in the care of the more seriously ill, and that those accomplishments owe a good deal to the introduction of psychoactive agents.

However, his reference to the “decline” of psychoanalysis was unfortunate and a gratuitous insult to those of us who continue to prac­tice psychoanalysis and who rec­ognize how much psychoanalytic thinking has contributed to the psychotherapeutic practices of non-analyst psychiatrists. If by decline he means that patients who once were in analysis now are being treated with medication alone, he is cor­rect. That might not always be in the best interest of patients, but it is a fact. If by decline he means that in all instances all patients benefit more from pills than they would from analysis, his viewpoint is derived from misinformation.

Since academic psychiatry and psy­chiatric publications became wholly owned subsidiaries of the pharmaceu­tical industry, this dismissive attitude about psychoanalysis has attained the status of established wisdom. Psychoanalysts understand that one size does not fit all, no single treatment is the best choice for all patients, and medications can be of great value. Why can’t psychopharmacologists show a similar respect for psychoanalysis?

Charles Goodstein, MD
Tenafly, New Jersey

Dr. Nasrallah responds
Thank you, Dr. Goodstein, for expressing your view about my editorial. However, it is unfair to describe the editorial as being dismissive and insulting toward psycho­analysts. I was simply stating undeniable historical facts about the evolution of psychiatry—one aspect was the reduced prevalence and influence of psychoanaly­sis over the past few decades, which was partially because of the advent of phar­macotherapy. The other reason was the emergence of other psychotherapies, such as cognitive-behavioral therapy, interpersonal psychotherapy, and dia­lectical behavior therapy, which are evidence-based, shorter in duration, and more cost effective.

Psychoanalysis remains an important component of contemporary psychiatry, albeit limited to a smaller subgroup of patients.

In my residency, I was heavily trained in psychodynamic therapy, and many of my supervisors were psychoanalysts. I developed my neuroscience skills in a post-residency fellowship at the National Institutes of Health. Nowadays, residency programs must provide both psychother­apeutic and psychopharmacologic train­ing to psychiatric residents.

Your statement that medications have replaced psychotherapy is inaccurate. We train our residents to provide each out­patient with both pharmacotherapy (when indicated) side-by-side with psychotherapy—whether supportive, psychoeducational, psychodynamic, or cognitive-behavioral therapy, or a combi­nation thereof. I continually warn residents about reducing psychiatric care to giving pills, which would be a travesty.

In addition, I regard psychotherapy as a neurobiological intervention because it modifies brain connectivity and neuro­plasticity (see my December 2013 Editorial, “Repositioning psychotherapy as neu­robiological intervention,” available at CurrentPsychiatry.com).

Last, I wish you would not insult aca­demic psychiatry as being a “wholly owned subsidiary of the pharmaceuti­cal industry.” Someone must develop new and better treatments for serious psychiatric brain disorders. The only entities dedicated to doing that, in the United States, are the pharmaceutical industry and the academic psychophar­macology experts. Together, they gener­ate new ideas and develop innovative mechanisms of action and test them in controlled clinical trials to treat disabling mental disorders. It is not fair to impugn the integrity of academic psychiatrists when they are doing what they were trained to do. They have the integrity and objectivity to criticize the industry when necessary. (See page 50 of my editorial under the subheading “Pharmaceutical industry debacle.”)

Henry A. Nasrallah, MD
Professor and Chairman
Department of Neurology & Psychiatry
Saint Louis University School of Medicine
St. Louis, Missouri

There are many interesting aspects of Dr. Nasrallah’s review of the changes in psychiatry in recent decades (Post-World War II psychiatry: 70 years of momentous change, Current Psychiatry, From the Editor, July 2014, p. 21-22, 49-50 [http://bit.ly/1m8HcdC]). There is no doubt that great strides have been made, particu­larly in the care of the more seriously ill, and that those accomplishments owe a good deal to the introduction of psychoactive agents.

However, his reference to the “decline” of psychoanalysis was unfortunate and a gratuitous insult to those of us who continue to prac­tice psychoanalysis and who rec­ognize how much psychoanalytic thinking has contributed to the psychotherapeutic practices of non-analyst psychiatrists. If by decline he means that patients who once were in analysis now are being treated with medication alone, he is cor­rect. That might not always be in the best interest of patients, but it is a fact. If by decline he means that in all instances all patients benefit more from pills than they would from analysis, his viewpoint is derived from misinformation.

Since academic psychiatry and psy­chiatric publications became wholly owned subsidiaries of the pharmaceu­tical industry, this dismissive attitude about psychoanalysis has attained the status of established wisdom. Psychoanalysts understand that one size does not fit all, no single treatment is the best choice for all patients, and medications can be of great value. Why can’t psychopharmacologists show a similar respect for psychoanalysis?

Charles Goodstein, MD
Tenafly, New Jersey

Dr. Nasrallah responds
Thank you, Dr. Goodstein, for expressing your view about my editorial. However, it is unfair to describe the editorial as being dismissive and insulting toward psycho­analysts. I was simply stating undeniable historical facts about the evolution of psychiatry—one aspect was the reduced prevalence and influence of psychoanaly­sis over the past few decades, which was partially because of the advent of phar­macotherapy. The other reason was the emergence of other psychotherapies, such as cognitive-behavioral therapy, interpersonal psychotherapy, and dia­lectical behavior therapy, which are evidence-based, shorter in duration, and more cost effective.

Psychoanalysis remains an important component of contemporary psychiatry, albeit limited to a smaller subgroup of patients.

In my residency, I was heavily trained in psychodynamic therapy, and many of my supervisors were psychoanalysts. I developed my neuroscience skills in a post-residency fellowship at the National Institutes of Health. Nowadays, residency programs must provide both psychother­apeutic and psychopharmacologic train­ing to psychiatric residents.

Your statement that medications have replaced psychotherapy is inaccurate. We train our residents to provide each out­patient with both pharmacotherapy (when indicated) side-by-side with psychotherapy—whether supportive, psychoeducational, psychodynamic, or cognitive-behavioral therapy, or a combi­nation thereof. I continually warn residents about reducing psychiatric care to giving pills, which would be a travesty.

In addition, I regard psychotherapy as a neurobiological intervention because it modifies brain connectivity and neuro­plasticity (see my December 2013 Editorial, “Repositioning psychotherapy as neu­robiological intervention,” available at CurrentPsychiatry.com).

Last, I wish you would not insult aca­demic psychiatry as being a “wholly owned subsidiary of the pharmaceuti­cal industry.” Someone must develop new and better treatments for serious psychiatric brain disorders. The only entities dedicated to doing that, in the United States, are the pharmaceutical industry and the academic psychophar­macology experts. Together, they gener­ate new ideas and develop innovative mechanisms of action and test them in controlled clinical trials to treat disabling mental disorders. It is not fair to impugn the integrity of academic psychiatrists when they are doing what they were trained to do. They have the integrity and objectivity to criticize the industry when necessary. (See page 50 of my editorial under the subheading “Pharmaceutical industry debacle.”)

Henry A. Nasrallah, MD
Professor and Chairman
Department of Neurology & Psychiatry
Saint Louis University School of Medicine
St. Louis, Missouri

There are many interesting aspects of Dr. Nasrallah’s review of the changes in psychiatry in recent decades (Post-World War II psychiatry: 70 years of momentous change, Current Psychiatry, From the Editor, July 2014, p. 21-22, 49-50 [http://bit.ly/1m8HcdC]). There is no doubt that great strides have been made, particu­larly in the care of the more seriously ill, and that those accomplishments owe a good deal to the introduction of psychoactive agents.

However, his reference to the “decline” of psychoanalysis was unfortunate and a gratuitous insult to those of us who continue to prac­tice psychoanalysis and who rec­ognize how much psychoanalytic thinking has contributed to the psychotherapeutic practices of non-analyst psychiatrists. If by decline he means that patients who once were in analysis now are being treated with medication alone, he is cor­rect. That might not always be in the best interest of patients, but it is a fact. If by decline he means that in all instances all patients benefit more from pills than they would from analysis, his viewpoint is derived from misinformation.

Since academic psychiatry and psy­chiatric publications became wholly owned subsidiaries of the pharmaceu­tical industry, this dismissive attitude about psychoanalysis has attained the status of established wisdom. Psychoanalysts understand that one size does not fit all, no single treatment is the best choice for all patients, and medications can be of great value. Why can’t psychopharmacologists show a similar respect for psychoanalysis?

Charles Goodstein, MD
Tenafly, New Jersey

Dr. Nasrallah responds
Thank you, Dr. Goodstein, for expressing your view about my editorial. However, it is unfair to describe the editorial as being dismissive and insulting toward psycho­analysts. I was simply stating undeniable historical facts about the evolution of psychiatry—one aspect was the reduced prevalence and influence of psychoanaly­sis over the past few decades, which was partially because of the advent of phar­macotherapy. The other reason was the emergence of other psychotherapies, such as cognitive-behavioral therapy, interpersonal psychotherapy, and dia­lectical behavior therapy, which are evidence-based, shorter in duration, and more cost effective.

Psychoanalysis remains an important component of contemporary psychiatry, albeit limited to a smaller subgroup of patients.

In my residency, I was heavily trained in psychodynamic therapy, and many of my supervisors were psychoanalysts. I developed my neuroscience skills in a post-residency fellowship at the National Institutes of Health. Nowadays, residency programs must provide both psychother­apeutic and psychopharmacologic train­ing to psychiatric residents.

Your statement that medications have replaced psychotherapy is inaccurate. We train our residents to provide each out­patient with both pharmacotherapy (when indicated) side-by-side with psychotherapy—whether supportive, psychoeducational, psychodynamic, or cognitive-behavioral therapy, or a combi­nation thereof. I continually warn residents about reducing psychiatric care to giving pills, which would be a travesty.

In addition, I regard psychotherapy as a neurobiological intervention because it modifies brain connectivity and neuro­plasticity (see my December 2013 Editorial, “Repositioning psychotherapy as neu­robiological intervention,” available at CurrentPsychiatry.com).

Last, I wish you would not insult aca­demic psychiatry as being a “wholly owned subsidiary of the pharmaceuti­cal industry.” Someone must develop new and better treatments for serious psychiatric brain disorders. The only entities dedicated to doing that, in the United States, are the pharmaceutical industry and the academic psychophar­macology experts. Together, they gener­ate new ideas and develop innovative mechanisms of action and test them in controlled clinical trials to treat disabling mental disorders. It is not fair to impugn the integrity of academic psychiatrists when they are doing what they were trained to do. They have the integrity and objectivity to criticize the industry when necessary. (See page 50 of my editorial under the subheading “Pharmaceutical industry debacle.”)

Henry A. Nasrallah, MD
Professor and Chairman
Department of Neurology & Psychiatry
Saint Louis University School of Medicine
St. Louis, Missouri

Cannabis abuse and THC content are on the rise
The authors of the July 2014 Residents’ Voices article (What we ought to talk about when we’re talking about decriminalizing Cannabis, Current Psychiatry, July 2014, p. 45-46 [http://bit.ly/1uAb7iK]) highlight the mental health complications of Cannabis and mention that, when Cannabis is juxta­posed with other illicit substances, it appears innocuous.

On the contrary: Data from the 2011 Drug Abuse Warning Network highlighted the rising involvement of Cannabis in emergency department (ED) visits. The report indicated that of the 1,252,500 ED visits involving illicit drugs in 2011, the most com­mon illicit drug involved was cocaine, which accounted for 505,224 ED vis­its, with Cannabis a close second at 455,668 visits—not including syn­thetic cannabinoids, which came in fifth, with 28,531 ED visits.¹

Another useful point to but­tress the concerns raised by the authors is that the potency of delta-9-tetrahydrocannabinol (THC), the primary psychoactive ingredient in Cannabis, has increased gradu­ally over the years. The University of Mississippi Potency Monitoring Project, a National Institute on Drug Abuse–funded landmark project that studied samples of Cannabis confiscated by law enforcement in the United States between 1993 and 2008, revealed that the mean THC content increased from 3.4% in 1993, to 8.8% in 2008.² The THC content of Cannabis is responsible for most of its psychoactive effects, so that the higher the THC content, the greater the adverse effects on mental health.

A major phytocannabinoid, canna­bidiol (CBD), also present in Cannabis, appears to counteract the adverse effects of THC, particularly by means of its antipsychotic property. Compared with the rising mean THC content of Cannabis from 1993 to 2008, CBD content has remained relatively the same: a mean of 0.3% in 1993 and 0.4% in 2008.^3,4

Several factors have been pos­tulated for the trend toward a high THC–low CBD profile in recent years: cultivation methods, the pref­erence for cultivating seedless female plants (sinsemilla) that tend to have a high THC content, and global avail­ability of seeds over the Internet. The high THC–low CBD profile has been linked to an increased risk of Cannabis dependence and increased treatment-seeking for Cannabis-related problems.³

Adegboyega Oyemade
Addiction Psychiatrist
Maryland Treatment Centers, Inc.
Attending Psychiatrist
Sinai Hospital
Baltimore, Maryland


-------------------------------------------------------------------

Research for 'Rx: Cannabis' is needed
Regarding the essay by Drs. Gershan and Gangahar on decriminalization of Cannabis, I want to comment on issues surrounding prescription Cannabis.

It is clear that Cannabis can exacer­bate psychosis, among other risks, but its potential benefits remain relatively unexplored. The authors correctly point out that, among indications for Cannabis, none are FDA-approved. Yet, off-label prescribing is pervasive and accepted in psychiatry, lack of FDA approval of indications for Cannabis is not an especially compelling argument against such prescribing.*

Lack of research and funding ham­pers efforts to conduct trials of the therapeutic value of Cannabis, as does its Schedule I status (ie, “no currently accepted medical use and a high potential for abuse” [language of the Controlled Substances Act]). There are reports of benefit in intractable epilepsy and posttraumatic stress dis­order (PTSD) that merit further inves­tigation; however, such research is hampered, I believe, by bureaucracy.

For example, an approved study at the University of Arizona of the use of Cannabis to treat PTSD has remained in regulatory limbo for longer than 4 years because of the immense hur­dles involved in performing research on this substance—despite how press­ing such research is, given the large number of veterans returning from active duty with this diagnosis and the paucity of treatment options.

Perhaps, there also is something “missing” in the debate about research into Cannabis.

Wesley Ryan, MD
PGY-5 Addiction Psychiatry Fellow
University of Washington
Seattle, Washington

*Editor's Note: An earlier version of this article stated, "Yet, off-labeling prescribing of Cannabis is pervasive, and I've found, accepted in psychiatry," which does not reflect the author's opinion or intended meaning. The sentence has been corrected to read, "Yet, because off-label prescribing is pervasive and accepted in psychiatry, lack of FDA approval of indications for Cannabis is not an especially compelling argument against such prescribing."

Cannabis abuse and THC content are on the rise
The authors of the July 2014 Residents’ Voices article (What we ought to talk about when we’re talking about decriminalizing Cannabis, Current Psychiatry, July 2014, p. 45-46 [http://bit.ly/1uAb7iK]) highlight the mental health complications of Cannabis and mention that, when Cannabis is juxta­posed with other illicit substances, it appears innocuous.

On the contrary: Data from the 2011 Drug Abuse Warning Network highlighted the rising involvement of Cannabis in emergency department (ED) visits. The report indicated that of the 1,252,500 ED visits involving illicit drugs in 2011, the most com­mon illicit drug involved was cocaine, which accounted for 505,224 ED vis­its, with Cannabis a close second at 455,668 visits—not including syn­thetic cannabinoids, which came in fifth, with 28,531 ED visits.¹

Another useful point to but­tress the concerns raised by the authors is that the potency of delta-9-tetrahydrocannabinol (THC), the primary psychoactive ingredient in Cannabis, has increased gradu­ally over the years. The University of Mississippi Potency Monitoring Project, a National Institute on Drug Abuse–funded landmark project that studied samples of Cannabis confiscated by law enforcement in the United States between 1993 and 2008, revealed that the mean THC content increased from 3.4% in 1993, to 8.8% in 2008.² The THC content of Cannabis is responsible for most of its psychoactive effects, so that the higher the THC content, the greater the adverse effects on mental health.

A major phytocannabinoid, canna­bidiol (CBD), also present in Cannabis, appears to counteract the adverse effects of THC, particularly by means of its antipsychotic property. Compared with the rising mean THC content of Cannabis from 1993 to 2008, CBD content has remained relatively the same: a mean of 0.3% in 1993 and 0.4% in 2008.^3,4

Several factors have been pos­tulated for the trend toward a high THC–low CBD profile in recent years: cultivation methods, the pref­erence for cultivating seedless female plants (sinsemilla) that tend to have a high THC content, and global avail­ability of seeds over the Internet. The high THC–low CBD profile has been linked to an increased risk of Cannabis dependence and increased treatment-seeking for Cannabis-related problems.³

Adegboyega Oyemade
Addiction Psychiatrist
Maryland Treatment Centers, Inc.
Attending Psychiatrist
Sinai Hospital
Baltimore, Maryland


-------------------------------------------------------------------

Research for 'Rx: Cannabis' is needed
Regarding the essay by Drs. Gershan and Gangahar on decriminalization of Cannabis, I want to comment on issues surrounding prescription Cannabis.

It is clear that Cannabis can exacer­bate psychosis, among other risks, but its potential benefits remain relatively unexplored. The authors correctly point out that, among indications for Cannabis, none are FDA-approved. Yet, off-label prescribing is pervasive and accepted in psychiatry, lack of FDA approval of indications for Cannabis is not an especially compelling argument against such prescribing.*

Lack of research and funding ham­pers efforts to conduct trials of the therapeutic value of Cannabis, as does its Schedule I status (ie, “no currently accepted medical use and a high potential for abuse” [language of the Controlled Substances Act]). There are reports of benefit in intractable epilepsy and posttraumatic stress dis­order (PTSD) that merit further inves­tigation; however, such research is hampered, I believe, by bureaucracy.

For example, an approved study at the University of Arizona of the use of Cannabis to treat PTSD has remained in regulatory limbo for longer than 4 years because of the immense hur­dles involved in performing research on this substance—despite how press­ing such research is, given the large number of veterans returning from active duty with this diagnosis and the paucity of treatment options.

Perhaps, there also is something “missing” in the debate about research into Cannabis.

Wesley Ryan, MD
PGY-5 Addiction Psychiatry Fellow
University of Washington
Seattle, Washington

*Editor's Note: An earlier version of this article stated, "Yet, off-labeling prescribing of Cannabis is pervasive, and I've found, accepted in psychiatry," which does not reflect the author's opinion or intended meaning. The sentence has been corrected to read, "Yet, because off-label prescribing is pervasive and accepted in psychiatry, lack of FDA approval of indications for Cannabis is not an especially compelling argument against such prescribing."

Cannabis abuse and THC content are on the rise
The authors of the July 2014 Residents’ Voices article (What we ought to talk about when we’re talking about decriminalizing Cannabis, Current Psychiatry, July 2014, p. 45-46 [http://bit.ly/1uAb7iK]) highlight the mental health complications of Cannabis and mention that, when Cannabis is juxta­posed with other illicit substances, it appears innocuous.

On the contrary: Data from the 2011 Drug Abuse Warning Network highlighted the rising involvement of Cannabis in emergency department (ED) visits. The report indicated that of the 1,252,500 ED visits involving illicit drugs in 2011, the most com­mon illicit drug involved was cocaine, which accounted for 505,224 ED vis­its, with Cannabis a close second at 455,668 visits—not including syn­thetic cannabinoids, which came in fifth, with 28,531 ED visits.¹

Another useful point to but­tress the concerns raised by the authors is that the potency of delta-9-tetrahydrocannabinol (THC), the primary psychoactive ingredient in Cannabis, has increased gradu­ally over the years. The University of Mississippi Potency Monitoring Project, a National Institute on Drug Abuse–funded landmark project that studied samples of Cannabis confiscated by law enforcement in the United States between 1993 and 2008, revealed that the mean THC content increased from 3.4% in 1993, to 8.8% in 2008.² The THC content of Cannabis is responsible for most of its psychoactive effects, so that the higher the THC content, the greater the adverse effects on mental health.

A major phytocannabinoid, canna­bidiol (CBD), also present in Cannabis, appears to counteract the adverse effects of THC, particularly by means of its antipsychotic property. Compared with the rising mean THC content of Cannabis from 1993 to 2008, CBD content has remained relatively the same: a mean of 0.3% in 1993 and 0.4% in 2008.^3,4

Several factors have been pos­tulated for the trend toward a high THC–low CBD profile in recent years: cultivation methods, the pref­erence for cultivating seedless female plants (sinsemilla) that tend to have a high THC content, and global avail­ability of seeds over the Internet. The high THC–low CBD profile has been linked to an increased risk of Cannabis dependence and increased treatment-seeking for Cannabis-related problems.³

Adegboyega Oyemade
Addiction Psychiatrist
Maryland Treatment Centers, Inc.
Attending Psychiatrist
Sinai Hospital
Baltimore, Maryland


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Research for 'Rx: Cannabis' is needed
Regarding the essay by Drs. Gershan and Gangahar on decriminalization of Cannabis, I want to comment on issues surrounding prescription Cannabis.

It is clear that Cannabis can exacer­bate psychosis, among other risks, but its potential benefits remain relatively unexplored. The authors correctly point out that, among indications for Cannabis, none are FDA-approved. Yet, off-label prescribing is pervasive and accepted in psychiatry, lack of FDA approval of indications for Cannabis is not an especially compelling argument against such prescribing.*

Lack of research and funding ham­pers efforts to conduct trials of the therapeutic value of Cannabis, as does its Schedule I status (ie, “no currently accepted medical use and a high potential for abuse” [language of the Controlled Substances Act]). There are reports of benefit in intractable epilepsy and posttraumatic stress dis­order (PTSD) that merit further inves­tigation; however, such research is hampered, I believe, by bureaucracy.

For example, an approved study at the University of Arizona of the use of Cannabis to treat PTSD has remained in regulatory limbo for longer than 4 years because of the immense hur­dles involved in performing research on this substance—despite how press­ing such research is, given the large number of veterans returning from active duty with this diagnosis and the paucity of treatment options.

Perhaps, there also is something “missing” in the debate about research into Cannabis.

Wesley Ryan, MD
PGY-5 Addiction Psychiatry Fellow
University of Washington
Seattle, Washington

*Editor's Note: An earlier version of this article stated, "Yet, off-labeling prescribing of Cannabis is pervasive, and I've found, accepted in psychiatry," which does not reflect the author's opinion or intended meaning. The sentence has been corrected to read, "Yet, because off-label prescribing is pervasive and accepted in psychiatry, lack of FDA approval of indications for Cannabis is not an especially compelling argument against such prescribing."

The more we learn about Ebola, the more it is becoming apparent that overcoming the psychosocial reactions to this deadly virus comes down to one word: education.

Education that is tailored to the audience has been most successful, as has maintaining a focus on the psychosocial impact of the disease on patients (here and abroad), their families, and their health care workers. Take the case of Nigeria, which the World Health Organization (WHO) declared free of Ebola virus transmission on Oct. 20. Nigeria used contact tracing to physically monitor all identified contacts daily for 21 days. In addition to allocating government funds and disbursing that money quickly, the private sector reportedly contributed resources aimed at scaling up control measures.

Perhaps most importantly, according to the WHO, “house-to-house information campaigns and messages on local radio stations, in local dialects, were used to explain the level of risk, effective personal preventive measures, and the actions being taken for control. The full range of media opportunities was exploited – from social media to televised facts about the disease delivered by well-known ‘Nollywood’ movie stars.”

I cannot overemphasize the importance of tailoring our educational messages about the virus to specific audiences. The sort of information needed to help allay the anxiety of an administrative assistant who asks, “Why didn’t the vaccine those nurses took before treating the patient work?”) is different from the information required of a front-line nurse at a public sector hospital, who might ask “Will our gowns protect us if we have a patient?” or a hospitalist at a tertiary care pediatrics hospital who might wonder “Is our isolation unit appropriate for treating this disorder?”

Regarding the disease’s potential victims – patients, family, health care workers – we should be mindful of the psychosocial impact that even the possibility of contact with the virus has. Potential contacts with the virus face destruction of all of their belongings, an inability to work while bills mount, and even the stress of the unwelcome spotlight.

Indeed, while there is a dearth of information available on mental health aspects of Ebola, specifically, there are powerful stories out there (here and here, for example) on the persistent stigma associated with this terrible disease.

Several other community mental health perspectives need to be considered, as well:

• What if a potential victim is a transient homeless man known to the community mental health system who is not inclined to accept a voluntary quarantine?

• What if he slept the night before at a homeless shelter for 300 people, all of whom are required to leave the shelter each morning?

• What if the potential victim is an intravenous drug abuser not inclined to accept an offer of methadone as a substitute while in quarantine?

• What if the potential victim is actively psychotic, not committable under your particular state’s law, but refusing all assistance because of paranoia?

• What if a call comes from a school principal stating that an elementary student, the child of a health care worker involved in an Ebola case, is distraught over marginalization in class and in the cafeteria by fellow students?

• What if a community of first-generation immigrants, historically dependent upon the psychosocial support of a robust group of community volunteers, suddenly finds itself without those supports when one member of the community is diagnosed with the disease?

• What if some members of the community also have the challenge of a severe mental illness?

As physicians and mental health experts, we can take the lead in tamping down anxiety tied to Ebola. How do we do it? By fostering education and preparedness, advocating for minimizing the risk of more victims of this disease, and supporting efforts to end its spread in West Africa.

Here in the United States, we must help our communities maintain their empathy for the suffering of Ebola’s victims and their families, as well as the suffering of the health care workers (and their families, too) who bravely care for these unfortunate patients.

Dr. Baker is medical director for behavioral health in the Texas Department of State Health Services, Austin.

The more we learn about Ebola, the more it is becoming apparent that overcoming the psychosocial reactions to this deadly virus comes down to one word: education.

Education that is tailored to the audience has been most successful, as has maintaining a focus on the psychosocial impact of the disease on patients (here and abroad), their families, and their health care workers. Take the case of Nigeria, which the World Health Organization (WHO) declared free of Ebola virus transmission on Oct. 20. Nigeria used contact tracing to physically monitor all identified contacts daily for 21 days. In addition to allocating government funds and disbursing that money quickly, the private sector reportedly contributed resources aimed at scaling up control measures.

Perhaps most importantly, according to the WHO, “house-to-house information campaigns and messages on local radio stations, in local dialects, were used to explain the level of risk, effective personal preventive measures, and the actions being taken for control. The full range of media opportunities was exploited – from social media to televised facts about the disease delivered by well-known ‘Nollywood’ movie stars.”

I cannot overemphasize the importance of tailoring our educational messages about the virus to specific audiences. The sort of information needed to help allay the anxiety of an administrative assistant who asks, “Why didn’t the vaccine those nurses took before treating the patient work?”) is different from the information required of a front-line nurse at a public sector hospital, who might ask “Will our gowns protect us if we have a patient?” or a hospitalist at a tertiary care pediatrics hospital who might wonder “Is our isolation unit appropriate for treating this disorder?”

Regarding the disease’s potential victims – patients, family, health care workers – we should be mindful of the psychosocial impact that even the possibility of contact with the virus has. Potential contacts with the virus face destruction of all of their belongings, an inability to work while bills mount, and even the stress of the unwelcome spotlight.

Indeed, while there is a dearth of information available on mental health aspects of Ebola, specifically, there are powerful stories out there (here and here, for example) on the persistent stigma associated with this terrible disease.

Several other community mental health perspectives need to be considered, as well:

• What if a potential victim is a transient homeless man known to the community mental health system who is not inclined to accept a voluntary quarantine?

• What if he slept the night before at a homeless shelter for 300 people, all of whom are required to leave the shelter each morning?

• What if the potential victim is an intravenous drug abuser not inclined to accept an offer of methadone as a substitute while in quarantine?

• What if the potential victim is actively psychotic, not committable under your particular state’s law, but refusing all assistance because of paranoia?

• What if a call comes from a school principal stating that an elementary student, the child of a health care worker involved in an Ebola case, is distraught over marginalization in class and in the cafeteria by fellow students?

• What if a community of first-generation immigrants, historically dependent upon the psychosocial support of a robust group of community volunteers, suddenly finds itself without those supports when one member of the community is diagnosed with the disease?

• What if some members of the community also have the challenge of a severe mental illness?

As physicians and mental health experts, we can take the lead in tamping down anxiety tied to Ebola. How do we do it? By fostering education and preparedness, advocating for minimizing the risk of more victims of this disease, and supporting efforts to end its spread in West Africa.

Here in the United States, we must help our communities maintain their empathy for the suffering of Ebola’s victims and their families, as well as the suffering of the health care workers (and their families, too) who bravely care for these unfortunate patients.

Dr. Baker is medical director for behavioral health in the Texas Department of State Health Services, Austin.

The more we learn about Ebola, the more it is becoming apparent that overcoming the psychosocial reactions to this deadly virus comes down to one word: education.

Education that is tailored to the audience has been most successful, as has maintaining a focus on the psychosocial impact of the disease on patients (here and abroad), their families, and their health care workers. Take the case of Nigeria, which the World Health Organization (WHO) declared free of Ebola virus transmission on Oct. 20. Nigeria used contact tracing to physically monitor all identified contacts daily for 21 days. In addition to allocating government funds and disbursing that money quickly, the private sector reportedly contributed resources aimed at scaling up control measures.

Perhaps most importantly, according to the WHO, “house-to-house information campaigns and messages on local radio stations, in local dialects, were used to explain the level of risk, effective personal preventive measures, and the actions being taken for control. The full range of media opportunities was exploited – from social media to televised facts about the disease delivered by well-known ‘Nollywood’ movie stars.”

I cannot overemphasize the importance of tailoring our educational messages about the virus to specific audiences. The sort of information needed to help allay the anxiety of an administrative assistant who asks, “Why didn’t the vaccine those nurses took before treating the patient work?”) is different from the information required of a front-line nurse at a public sector hospital, who might ask “Will our gowns protect us if we have a patient?” or a hospitalist at a tertiary care pediatrics hospital who might wonder “Is our isolation unit appropriate for treating this disorder?”

Regarding the disease’s potential victims – patients, family, health care workers – we should be mindful of the psychosocial impact that even the possibility of contact with the virus has. Potential contacts with the virus face destruction of all of their belongings, an inability to work while bills mount, and even the stress of the unwelcome spotlight.

Indeed, while there is a dearth of information available on mental health aspects of Ebola, specifically, there are powerful stories out there (here and here, for example) on the persistent stigma associated with this terrible disease.

Several other community mental health perspectives need to be considered, as well:

• What if a potential victim is a transient homeless man known to the community mental health system who is not inclined to accept a voluntary quarantine?

• What if he slept the night before at a homeless shelter for 300 people, all of whom are required to leave the shelter each morning?

• What if the potential victim is an intravenous drug abuser not inclined to accept an offer of methadone as a substitute while in quarantine?

• What if the potential victim is actively psychotic, not committable under your particular state’s law, but refusing all assistance because of paranoia?

• What if a call comes from a school principal stating that an elementary student, the child of a health care worker involved in an Ebola case, is distraught over marginalization in class and in the cafeteria by fellow students?

• What if a community of first-generation immigrants, historically dependent upon the psychosocial support of a robust group of community volunteers, suddenly finds itself without those supports when one member of the community is diagnosed with the disease?

• What if some members of the community also have the challenge of a severe mental illness?

As physicians and mental health experts, we can take the lead in tamping down anxiety tied to Ebola. How do we do it? By fostering education and preparedness, advocating for minimizing the risk of more victims of this disease, and supporting efforts to end its spread in West Africa.

Here in the United States, we must help our communities maintain their empathy for the suffering of Ebola’s victims and their families, as well as the suffering of the health care workers (and their families, too) who bravely care for these unfortunate patients.

Dr. Baker is medical director for behavioral health in the Texas Department of State Health Services, Austin.

The Greek word apnea literally translates to “without breath.” More than 18 million American adults experience several moments “without breath” every night, according to the National Sleep Foundation. These pauses in breathing can last from a few seconds to minutes and can occur up to 30 times per hour or more. There are three types of apnea: obstructive, central, and mixed. Of the three, obstructive sleep apnea (OSA) is the most common. If left untreated, sleep apnea can have serious or life-threatening consequences, such as high blood pressure, heart disease, and day-time sleepiness that can lead to car accidents, depression, and headaches.

The significance of this condition has led the American College of Physicians (ACP) to publish guidelines regarding the management of OSA in adults. These guidelines are intended to provide clinicians with evidence-based recommendations that will have positive, long-term effects on patients’ cardiovascular risk, as well overall health and quality of life.

Recommendation 1: Encourage weight loss in all overweight and obese patients diagnosed with OSA.

There is strong evidence that shows how weight loss interventions can reduce the apnea/hypopnea index (AHI) and improve symptoms. The apnea/hypopnea index is a measure of the number of apnea and hypopnea episodes per hour of monitored sleep. According to the American Academy of Sleep Medicine, an OSA diagnosis is defined by ≥ 15 events/hr (with or without OSA symptoms) or ≥ 5 events/hr with OSA symptoms. Severity of OSA is classified as:

• Mild: 5-14 events/hr

• Moderate: 15-30 events/hr

• Severe: >30 events/hr

In patients with mild OSA, weight loss alone can be sufficient to normalize the apnea/hypopnea index, thereby reducing the need for continuous positive airway pressure (CPAP). In those with persistent OSA, weight loss can reduce the amount of PAP pressure required, which can increase tolerance of and adherence to CPAP. However, weight loss alone may not be sufficient to reduce OSA in all patients. In obese patients, weight loss must be encouraged with another primary treatment. In a meta-analysis of 342 patients in 12 published trials, weight loss produced substantial reductions in apnea/hypopnea index; however, the majority of patients continued to have persistent OSA after significant weight reduction. So, while weight loss should always be encouraged in patients with OSA, it should not be assumed that this intervention alone will be sufficient; patients need to be reassessed to determine whether OSA persists and if so, CPAP should be continued.

Recommendation 2: Prescribe CPAP as the initial therapy for patients diagnosed with OSA.

©David Cannings-Bushell/iStockphoto.com

CPAP is as critical as it is effective not only in reducing the AHI but also in improving sleep continuity and architecture and decreasing the sleep hypoxia that is associated with OSA. Because of the lack of adherence to CPAP, many new features have been added including heated humidification, broad pressure adjustments, and expiratory pressure relief; while many of these features mildly improve patients’ preferences, there is no evidence to suggest that these changes improve efficacy or adherence. Again, it is critical that each patient’s needs be taken into consideration. Some patients, particularly those with mild forms of OSA, may not need CPAP and instead, may benefit from positional therapy or weight loss. Other therapy such as surgery or mandibular advancement devices (MADs) may be better suited for some patients despite their lessor effectiveness when compared with CPAP.

Recommendation 3: Consider MAD as an alternate therapy to CPAP for patients diagnosed with OSA who prefer MAD or for those with adverse effects associated with CPAP.

MADs have been recommended for patients with moderate to severe OSA, those with apnea/hypopnea index values between 18-40 events/hour, and for individuals who experienced adverse events on CPAP or who can’t tolerate using it. While CPAP still is considered to be primary therapy, for those who must use a mandibular advancement device, it can often be very effective. Patients may find it easier to be compliant with MAD than with CPAP. One group of researchers observed that MADs were able to provide appropriate decrease in obstructive events in 70% of patients with mild OSA, 48% of those with moderate OSA, and 42% of those with severe OSA (Chest 2011:139:1331-9). The ACP concluded that, without sufficient evidence, it is unclear which patients will benefit from MADs. Data from several studies show that patients who are younger and thinner, with less severe OSA, may benefit more from the use of MADs. Although the ACP does not recommend surgery or pharmaceutical therapy for OSA, the ACP does acknowledge that it may work for certain patients. However, the documented efficacy rate ranges from 20%-100%, thereby making it challenging to determine its true effect.

Bottom Line

The ACP recommends weight loss for all overweight patients with OSA. CPAP is first-line therapy, particularly if weight loss cannot be sustained or does not sufficiently lessen symptoms. For selected patients who are younger and thinner, with less severe OSA, or for those patients who are unable to tolerate CPAP, MADs can be used as an alternative first-line therapy with moderate success.

Reference

Qaseem A., Holty J.C., Owens D. et al. Diagnosis of obstructive sleep apnea in adults: a Clinical Practice Guideline from the American College of Physicians. Ann. Intern. Med. 2014;161:210-20.

Dr. Grover is a second-year resident in the family medicine residency program at Abington Memorial Hospital. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

The Greek word apnea literally translates to “without breath.” More than 18 million American adults experience several moments “without breath” every night, according to the National Sleep Foundation. These pauses in breathing can last from a few seconds to minutes and can occur up to 30 times per hour or more. There are three types of apnea: obstructive, central, and mixed. Of the three, obstructive sleep apnea (OSA) is the most common. If left untreated, sleep apnea can have serious or life-threatening consequences, such as high blood pressure, heart disease, and day-time sleepiness that can lead to car accidents, depression, and headaches.

The significance of this condition has led the American College of Physicians (ACP) to publish guidelines regarding the management of OSA in adults. These guidelines are intended to provide clinicians with evidence-based recommendations that will have positive, long-term effects on patients’ cardiovascular risk, as well overall health and quality of life.

Recommendation 1: Encourage weight loss in all overweight and obese patients diagnosed with OSA.

There is strong evidence that shows how weight loss interventions can reduce the apnea/hypopnea index (AHI) and improve symptoms. The apnea/hypopnea index is a measure of the number of apnea and hypopnea episodes per hour of monitored sleep. According to the American Academy of Sleep Medicine, an OSA diagnosis is defined by ≥ 15 events/hr (with or without OSA symptoms) or ≥ 5 events/hr with OSA symptoms. Severity of OSA is classified as:

• Mild: 5-14 events/hr

• Moderate: 15-30 events/hr

• Severe: >30 events/hr

In patients with mild OSA, weight loss alone can be sufficient to normalize the apnea/hypopnea index, thereby reducing the need for continuous positive airway pressure (CPAP). In those with persistent OSA, weight loss can reduce the amount of PAP pressure required, which can increase tolerance of and adherence to CPAP. However, weight loss alone may not be sufficient to reduce OSA in all patients. In obese patients, weight loss must be encouraged with another primary treatment. In a meta-analysis of 342 patients in 12 published trials, weight loss produced substantial reductions in apnea/hypopnea index; however, the majority of patients continued to have persistent OSA after significant weight reduction. So, while weight loss should always be encouraged in patients with OSA, it should not be assumed that this intervention alone will be sufficient; patients need to be reassessed to determine whether OSA persists and if so, CPAP should be continued.

Recommendation 2: Prescribe CPAP as the initial therapy for patients diagnosed with OSA.

©David Cannings-Bushell/iStockphoto.com

CPAP is as critical as it is effective not only in reducing the AHI but also in improving sleep continuity and architecture and decreasing the sleep hypoxia that is associated with OSA. Because of the lack of adherence to CPAP, many new features have been added including heated humidification, broad pressure adjustments, and expiratory pressure relief; while many of these features mildly improve patients’ preferences, there is no evidence to suggest that these changes improve efficacy or adherence. Again, it is critical that each patient’s needs be taken into consideration. Some patients, particularly those with mild forms of OSA, may not need CPAP and instead, may benefit from positional therapy or weight loss. Other therapy such as surgery or mandibular advancement devices (MADs) may be better suited for some patients despite their lessor effectiveness when compared with CPAP.

Recommendation 3: Consider MAD as an alternate therapy to CPAP for patients diagnosed with OSA who prefer MAD or for those with adverse effects associated with CPAP.

MADs have been recommended for patients with moderate to severe OSA, those with apnea/hypopnea index values between 18-40 events/hour, and for individuals who experienced adverse events on CPAP or who can’t tolerate using it. While CPAP still is considered to be primary therapy, for those who must use a mandibular advancement device, it can often be very effective. Patients may find it easier to be compliant with MAD than with CPAP. One group of researchers observed that MADs were able to provide appropriate decrease in obstructive events in 70% of patients with mild OSA, 48% of those with moderate OSA, and 42% of those with severe OSA (Chest 2011:139:1331-9). The ACP concluded that, without sufficient evidence, it is unclear which patients will benefit from MADs. Data from several studies show that patients who are younger and thinner, with less severe OSA, may benefit more from the use of MADs. Although the ACP does not recommend surgery or pharmaceutical therapy for OSA, the ACP does acknowledge that it may work for certain patients. However, the documented efficacy rate ranges from 20%-100%, thereby making it challenging to determine its true effect.

Bottom Line

The ACP recommends weight loss for all overweight patients with OSA. CPAP is first-line therapy, particularly if weight loss cannot be sustained or does not sufficiently lessen symptoms. For selected patients who are younger and thinner, with less severe OSA, or for those patients who are unable to tolerate CPAP, MADs can be used as an alternative first-line therapy with moderate success.

Reference

Qaseem A., Holty J.C., Owens D. et al. Diagnosis of obstructive sleep apnea in adults: a Clinical Practice Guideline from the American College of Physicians. Ann. Intern. Med. 2014;161:210-20.

Dr. Grover is a second-year resident in the family medicine residency program at Abington Memorial Hospital. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

The Greek word apnea literally translates to “without breath.” More than 18 million American adults experience several moments “without breath” every night, according to the National Sleep Foundation. These pauses in breathing can last from a few seconds to minutes and can occur up to 30 times per hour or more. There are three types of apnea: obstructive, central, and mixed. Of the three, obstructive sleep apnea (OSA) is the most common. If left untreated, sleep apnea can have serious or life-threatening consequences, such as high blood pressure, heart disease, and day-time sleepiness that can lead to car accidents, depression, and headaches.

The significance of this condition has led the American College of Physicians (ACP) to publish guidelines regarding the management of OSA in adults. These guidelines are intended to provide clinicians with evidence-based recommendations that will have positive, long-term effects on patients’ cardiovascular risk, as well overall health and quality of life.

Recommendation 1: Encourage weight loss in all overweight and obese patients diagnosed with OSA.

There is strong evidence that shows how weight loss interventions can reduce the apnea/hypopnea index (AHI) and improve symptoms. The apnea/hypopnea index is a measure of the number of apnea and hypopnea episodes per hour of monitored sleep. According to the American Academy of Sleep Medicine, an OSA diagnosis is defined by ≥ 15 events/hr (with or without OSA symptoms) or ≥ 5 events/hr with OSA symptoms. Severity of OSA is classified as:

• Mild: 5-14 events/hr

• Moderate: 15-30 events/hr

• Severe: >30 events/hr

In patients with mild OSA, weight loss alone can be sufficient to normalize the apnea/hypopnea index, thereby reducing the need for continuous positive airway pressure (CPAP). In those with persistent OSA, weight loss can reduce the amount of PAP pressure required, which can increase tolerance of and adherence to CPAP. However, weight loss alone may not be sufficient to reduce OSA in all patients. In obese patients, weight loss must be encouraged with another primary treatment. In a meta-analysis of 342 patients in 12 published trials, weight loss produced substantial reductions in apnea/hypopnea index; however, the majority of patients continued to have persistent OSA after significant weight reduction. So, while weight loss should always be encouraged in patients with OSA, it should not be assumed that this intervention alone will be sufficient; patients need to be reassessed to determine whether OSA persists and if so, CPAP should be continued.

Recommendation 2: Prescribe CPAP as the initial therapy for patients diagnosed with OSA.

©David Cannings-Bushell/iStockphoto.com

CPAP is as critical as it is effective not only in reducing the AHI but also in improving sleep continuity and architecture and decreasing the sleep hypoxia that is associated with OSA. Because of the lack of adherence to CPAP, many new features have been added including heated humidification, broad pressure adjustments, and expiratory pressure relief; while many of these features mildly improve patients’ preferences, there is no evidence to suggest that these changes improve efficacy or adherence. Again, it is critical that each patient’s needs be taken into consideration. Some patients, particularly those with mild forms of OSA, may not need CPAP and instead, may benefit from positional therapy or weight loss. Other therapy such as surgery or mandibular advancement devices (MADs) may be better suited for some patients despite their lessor effectiveness when compared with CPAP.

Recommendation 3: Consider MAD as an alternate therapy to CPAP for patients diagnosed with OSA who prefer MAD or for those with adverse effects associated with CPAP.

MADs have been recommended for patients with moderate to severe OSA, those with apnea/hypopnea index values between 18-40 events/hour, and for individuals who experienced adverse events on CPAP or who can’t tolerate using it. While CPAP still is considered to be primary therapy, for those who must use a mandibular advancement device, it can often be very effective. Patients may find it easier to be compliant with MAD than with CPAP. One group of researchers observed that MADs were able to provide appropriate decrease in obstructive events in 70% of patients with mild OSA, 48% of those with moderate OSA, and 42% of those with severe OSA (Chest 2011:139:1331-9). The ACP concluded that, without sufficient evidence, it is unclear which patients will benefit from MADs. Data from several studies show that patients who are younger and thinner, with less severe OSA, may benefit more from the use of MADs. Although the ACP does not recommend surgery or pharmaceutical therapy for OSA, the ACP does acknowledge that it may work for certain patients. However, the documented efficacy rate ranges from 20%-100%, thereby making it challenging to determine its true effect.

Bottom Line

The ACP recommends weight loss for all overweight patients with OSA. CPAP is first-line therapy, particularly if weight loss cannot be sustained or does not sufficiently lessen symptoms. For selected patients who are younger and thinner, with less severe OSA, or for those patients who are unable to tolerate CPAP, MADs can be used as an alternative first-line therapy with moderate success.

Reference

Qaseem A., Holty J.C., Owens D. et al. Diagnosis of obstructive sleep apnea in adults: a Clinical Practice Guideline from the American College of Physicians. Ann. Intern. Med. 2014;161:210-20.

Dr. Grover is a second-year resident in the family medicine residency program at Abington Memorial Hospital. Dr. Skolnik is associate director of the family medicine residency program at Abington Memorial Hospital and professor of family and community medicine at Temple University in Philadelphia.

I have been privileged to spend over one half of my 70 years on this planet as a surgeon. Even considering the innumerable highly stressful moments and the occasional failures in patient care that continue to haunt me, I cannot conceive of a more satisfying and enjoyable vocation. It saddens me to know that a significant percentage of those in our profession have not been able to gain a similar level of fulfillment from their lives in surgery as I have.

There is no doubt that a pall of negativity has descended upon the medical profession in recent years. The factors that have caused it are real – declining compensation in face of an increased workload, less autonomy in practice with a steadily increasing number of physicians and surgeons being employees rather than independent practitioners, an oppressive regulatory environment necessitating a seemingly endless amount of paperwork, and finally the uncertainty of what our profession will look like once health care reform settles into its final form.

These issues – along with the always-present stresses that accompany caring for sick patients and the challenge of balancing a too-busy professional life with a meaningful personal existence – have led to a shocking number of our colleagues experiencing the symptoms of burnout; emotional exhaustion, depersonalization, and a sense of low personal accomplishment.

It would be inappropriate for me to in any way minimize the effect that burnout is having on medical professionals. It is now a greater threat to surgeon wellness than any other dynamic, including alcoholism and drug abuse. I will deal with it in some detail in a future editorial. But here I would like to consider some of the unique and positive features that, in my opinion, still make surgery the most noble of professions and a career that we can highly recommend to our children and grandchildren. I sincerely hope that emphasizing the more upbeat and constructive aspects of our profession, most of which are obvious but are unfortunately obscured by the cloud of negativity, will provide at least a small beacon of light for those having difficulty seeing their way forward.

I feel compelled to admit to some important disclaimers. While I do not consider myself a Pollyanna, ever since reading a Dutch study (Giltay et al., Arch. Gen. Psychiatry 2004;61:1126-35) that showed an impressive difference in longevity between optimists and pessimists, I have solidly placed myself in the optimist camp. Additionally, I have spent my entire surgical career within the ivy-covered walls of academe. Finally, I fully realize that what brings joy to one person may not do so to another.

My basic assertion is that, while many aspects of our profession have changed, the basic core – the opportunity to make positive changes in the lives of others – remains solidly intact. As a surgical academician, this was not limited to just patients, but extended to medical students, surgical residents, and surgical faculty. I suspect in the private setting there are also numerous opportunities to mentor young colleagues and lend support to surgeons who are experiencing burnout or other issues that compromise the quality of their lives and their effectiveness as surgeons.

The most satisfying aspect of my practice was the nonmonetary rewards I received from grateful patients. The patient-doctor relationship that surgeons enjoy with their patients is particularly special. We alone among medical professionals have the opportunity to suddenly and dramatically alter the course of patients’ pain, suffering, and prognosis. We alone invade the sacred spaces of their bodies. Although what we do is based on science and anatomy, to many patients, it is almost in the realm of the supernatural. I have always thought that the designing and construction of a complex building is a more challenging feat than removing a diseased gallbladder, but patients don’t see it that way. If we are willing to simply maintain meaningful and kind communication with them, they freely and liberally express their gratitude for even minimal surgical achievements. When a life-threatening situation has been suddenly erased by a surgical operation, many consider it in the domain of the heroic.

Especially amazing to me is the generosity of patients and their families even when complications or death compromise the outcome. Occasionally, gratitude comes in the guise of a gift. The most memorable for me was an envelope labeled “Pennies from Heaven” that contained $2.83 designated for bile duct cancer research given to me by the grandchildren of a woman with that dread disease on whom I had operated. The sum may have been insufficient to have any scientific impact but was more than enough to brighten my day after I observed this lovely woman enduring a long, difficult, and eventually unsuccessful postoperative course (“Pennies from Heaven,” ACS Surgery News, December 2011, p. 18).

Aside from the privilege of caring for patients, the most rewarding element of my professional life has been the opportunity to mentor others. Nearly all of us who have had success in our profession have had one or more valuable mentors. Performing this function for others is not only appropriate, but, in a sense, represents a giving back for what others have done for us. An effective mentor provides a nurturing environment in which the mentee can reach his/her full potential. Whether you are helping a resident or junior associate better adjust to life as a surgeon or find their best career path, assisting them in achieving their goals is nearly as satisfying as successfully seeing a patient through a challenging operation and complicated postoperative course.

As difficult as life in surgery can often be, focusing on the unique positives – the appreciative patient cured of a life-threatening tumor, the skilled and accomplished senior resident who you helped train, the young associate who seeks your wisdom on difficult cases and becomes a better surgeon because of it – rather than the negative background of uncertainty and loss of control may help to confirm that what you are doing is worthwhile and most likely making the world a  better place.  

Dr. Rikkers is the editor in chief of ACS Surgery News. 

I have been privileged to spend over one half of my 70 years on this planet as a surgeon. Even considering the innumerable highly stressful moments and the occasional failures in patient care that continue to haunt me, I cannot conceive of a more satisfying and enjoyable vocation. It saddens me to know that a significant percentage of those in our profession have not been able to gain a similar level of fulfillment from their lives in surgery as I have.

There is no doubt that a pall of negativity has descended upon the medical profession in recent years. The factors that have caused it are real – declining compensation in face of an increased workload, less autonomy in practice with a steadily increasing number of physicians and surgeons being employees rather than independent practitioners, an oppressive regulatory environment necessitating a seemingly endless amount of paperwork, and finally the uncertainty of what our profession will look like once health care reform settles into its final form.

These issues – along with the always-present stresses that accompany caring for sick patients and the challenge of balancing a too-busy professional life with a meaningful personal existence – have led to a shocking number of our colleagues experiencing the symptoms of burnout; emotional exhaustion, depersonalization, and a sense of low personal accomplishment.

It would be inappropriate for me to in any way minimize the effect that burnout is having on medical professionals. It is now a greater threat to surgeon wellness than any other dynamic, including alcoholism and drug abuse. I will deal with it in some detail in a future editorial. But here I would like to consider some of the unique and positive features that, in my opinion, still make surgery the most noble of professions and a career that we can highly recommend to our children and grandchildren. I sincerely hope that emphasizing the more upbeat and constructive aspects of our profession, most of which are obvious but are unfortunately obscured by the cloud of negativity, will provide at least a small beacon of light for those having difficulty seeing their way forward.

I feel compelled to admit to some important disclaimers. While I do not consider myself a Pollyanna, ever since reading a Dutch study (Giltay et al., Arch. Gen. Psychiatry 2004;61:1126-35) that showed an impressive difference in longevity between optimists and pessimists, I have solidly placed myself in the optimist camp. Additionally, I have spent my entire surgical career within the ivy-covered walls of academe. Finally, I fully realize that what brings joy to one person may not do so to another.

My basic assertion is that, while many aspects of our profession have changed, the basic core – the opportunity to make positive changes in the lives of others – remains solidly intact. As a surgical academician, this was not limited to just patients, but extended to medical students, surgical residents, and surgical faculty. I suspect in the private setting there are also numerous opportunities to mentor young colleagues and lend support to surgeons who are experiencing burnout or other issues that compromise the quality of their lives and their effectiveness as surgeons.

The most satisfying aspect of my practice was the nonmonetary rewards I received from grateful patients. The patient-doctor relationship that surgeons enjoy with their patients is particularly special. We alone among medical professionals have the opportunity to suddenly and dramatically alter the course of patients’ pain, suffering, and prognosis. We alone invade the sacred spaces of their bodies. Although what we do is based on science and anatomy, to many patients, it is almost in the realm of the supernatural. I have always thought that the designing and construction of a complex building is a more challenging feat than removing a diseased gallbladder, but patients don’t see it that way. If we are willing to simply maintain meaningful and kind communication with them, they freely and liberally express their gratitude for even minimal surgical achievements. When a life-threatening situation has been suddenly erased by a surgical operation, many consider it in the domain of the heroic.

Especially amazing to me is the generosity of patients and their families even when complications or death compromise the outcome. Occasionally, gratitude comes in the guise of a gift. The most memorable for me was an envelope labeled “Pennies from Heaven” that contained $2.83 designated for bile duct cancer research given to me by the grandchildren of a woman with that dread disease on whom I had operated. The sum may have been insufficient to have any scientific impact but was more than enough to brighten my day after I observed this lovely woman enduring a long, difficult, and eventually unsuccessful postoperative course (“Pennies from Heaven,” ACS Surgery News, December 2011, p. 18).

Aside from the privilege of caring for patients, the most rewarding element of my professional life has been the opportunity to mentor others. Nearly all of us who have had success in our profession have had one or more valuable mentors. Performing this function for others is not only appropriate, but, in a sense, represents a giving back for what others have done for us. An effective mentor provides a nurturing environment in which the mentee can reach his/her full potential. Whether you are helping a resident or junior associate better adjust to life as a surgeon or find their best career path, assisting them in achieving their goals is nearly as satisfying as successfully seeing a patient through a challenging operation and complicated postoperative course.

As difficult as life in surgery can often be, focusing on the unique positives – the appreciative patient cured of a life-threatening tumor, the skilled and accomplished senior resident who you helped train, the young associate who seeks your wisdom on difficult cases and becomes a better surgeon because of it – rather than the negative background of uncertainty and loss of control may help to confirm that what you are doing is worthwhile and most likely making the world a  better place.  

Dr. Rikkers is the editor in chief of ACS Surgery News. 

I have been privileged to spend over one half of my 70 years on this planet as a surgeon. Even considering the innumerable highly stressful moments and the occasional failures in patient care that continue to haunt me, I cannot conceive of a more satisfying and enjoyable vocation. It saddens me to know that a significant percentage of those in our profession have not been able to gain a similar level of fulfillment from their lives in surgery as I have.

There is no doubt that a pall of negativity has descended upon the medical profession in recent years. The factors that have caused it are real – declining compensation in face of an increased workload, less autonomy in practice with a steadily increasing number of physicians and surgeons being employees rather than independent practitioners, an oppressive regulatory environment necessitating a seemingly endless amount of paperwork, and finally the uncertainty of what our profession will look like once health care reform settles into its final form.

These issues – along with the always-present stresses that accompany caring for sick patients and the challenge of balancing a too-busy professional life with a meaningful personal existence – have led to a shocking number of our colleagues experiencing the symptoms of burnout; emotional exhaustion, depersonalization, and a sense of low personal accomplishment.

It would be inappropriate for me to in any way minimize the effect that burnout is having on medical professionals. It is now a greater threat to surgeon wellness than any other dynamic, including alcoholism and drug abuse. I will deal with it in some detail in a future editorial. But here I would like to consider some of the unique and positive features that, in my opinion, still make surgery the most noble of professions and a career that we can highly recommend to our children and grandchildren. I sincerely hope that emphasizing the more upbeat and constructive aspects of our profession, most of which are obvious but are unfortunately obscured by the cloud of negativity, will provide at least a small beacon of light for those having difficulty seeing their way forward.

I feel compelled to admit to some important disclaimers. While I do not consider myself a Pollyanna, ever since reading a Dutch study (Giltay et al., Arch. Gen. Psychiatry 2004;61:1126-35) that showed an impressive difference in longevity between optimists and pessimists, I have solidly placed myself in the optimist camp. Additionally, I have spent my entire surgical career within the ivy-covered walls of academe. Finally, I fully realize that what brings joy to one person may not do so to another.

My basic assertion is that, while many aspects of our profession have changed, the basic core – the opportunity to make positive changes in the lives of others – remains solidly intact. As a surgical academician, this was not limited to just patients, but extended to medical students, surgical residents, and surgical faculty. I suspect in the private setting there are also numerous opportunities to mentor young colleagues and lend support to surgeons who are experiencing burnout or other issues that compromise the quality of their lives and their effectiveness as surgeons.

The most satisfying aspect of my practice was the nonmonetary rewards I received from grateful patients. The patient-doctor relationship that surgeons enjoy with their patients is particularly special. We alone among medical professionals have the opportunity to suddenly and dramatically alter the course of patients’ pain, suffering, and prognosis. We alone invade the sacred spaces of their bodies. Although what we do is based on science and anatomy, to many patients, it is almost in the realm of the supernatural. I have always thought that the designing and construction of a complex building is a more challenging feat than removing a diseased gallbladder, but patients don’t see it that way. If we are willing to simply maintain meaningful and kind communication with them, they freely and liberally express their gratitude for even minimal surgical achievements. When a life-threatening situation has been suddenly erased by a surgical operation, many consider it in the domain of the heroic.

Especially amazing to me is the generosity of patients and their families even when complications or death compromise the outcome. Occasionally, gratitude comes in the guise of a gift. The most memorable for me was an envelope labeled “Pennies from Heaven” that contained $2.83 designated for bile duct cancer research given to me by the grandchildren of a woman with that dread disease on whom I had operated. The sum may have been insufficient to have any scientific impact but was more than enough to brighten my day after I observed this lovely woman enduring a long, difficult, and eventually unsuccessful postoperative course (“Pennies from Heaven,” ACS Surgery News, December 2011, p. 18).

Aside from the privilege of caring for patients, the most rewarding element of my professional life has been the opportunity to mentor others. Nearly all of us who have had success in our profession have had one or more valuable mentors. Performing this function for others is not only appropriate, but, in a sense, represents a giving back for what others have done for us. An effective mentor provides a nurturing environment in which the mentee can reach his/her full potential. Whether you are helping a resident or junior associate better adjust to life as a surgeon or find their best career path, assisting them in achieving their goals is nearly as satisfying as successfully seeing a patient through a challenging operation and complicated postoperative course.

As difficult as life in surgery can often be, focusing on the unique positives – the appreciative patient cured of a life-threatening tumor, the skilled and accomplished senior resident who you helped train, the young associate who seeks your wisdom on difficult cases and becomes a better surgeon because of it – rather than the negative background of uncertainty and loss of control may help to confirm that what you are doing is worthwhile and most likely making the world a  better place.  

Dr. Rikkers is the editor in chief of ACS Surgery News.