Vortioxetine/Trintellix

I was privileged to attend an educational session at Black and Blue Restaurant hosted by Lundbeck the company that brings us Trintellix.  The Black and Blue Restaurant was an excellent setting for a small group meeting with superb food and service.  At the end of an often 12 hour day full of surprises and emergencies the last thing I want to do is get more education, given I’m already educated beyond my intelligence.
Yet, I was impressed with this latest of antidepressants and glad that it plugged a true gap in the much needed armentarium that doctors bring to fight disease.  Patients often complain of neurocognitive effects of depression. Many have had excellent mood relief and sleep benefits and reduced anxiety but still complained that they didn’t ‘think’ as ‘clearly’ as before. Often the effect  of their depression on concentration, memory, especially focus is an early symptom of depression but not as recognized as the low mood, thoughts of worthlessness and even suicidal ideation and the panic.  Yet when those symptoms are relieved there is really too often this lingering sense most noted subjectively that they’re not in the game, that their brain is sluggish or they’re not as ‘bright’ as they were.
Along comes Trintellix.  The students in my practice loved it.  Afraid of taking anything that would effect their studies I was able to offer this newest of antidepressants and hear the positive reports that yes it worked for depression and anxiety but most importantly it helped them get back the edge on their studies.
So when I’ve tried a medication clinically and seen it work I’m glad to have dinner bought for me to find out more about the medication and how others are finding it.
That’s how clinically medications are used.  I’ve learned of Truvada a medication that prevents people from getting HIV having unprotected sex with people who have HIV.  I’ve not had the opportunity to prescribe it as the medication after millions of research dollars is only available at approximately $50 a pill. Yet I would prescribe it first chance because there is a need and the cost benefit is most positive.  However after I started using it I ‘d be glad to learn what others were finding clinically.  As a researcher clinician I study the journals and studies mostly put out by university departments and those put out by the industry before using a medication.
Pharmaceutical companies, like car companies like Ford  or Toyota and any other big manufacturing company, keep good stats and monitor the experience of the medications., their product.   Because people were finding the 10 mg tablet of Trintellix was triggering GI symptoms even when it was taken with the largest meal at dinner, the 5 mg tablet was released which didn’t cause the GI symptoms.  After 2 weeks I’ve increased my patients to 10 mg even though 5 mg is actually an effective dose, while most of my patients are on 10 to 20 mg.
I’ve given samples which I received very thankfully as well as prescriptions. The samples are a god send for patients starting a new medication. They’re like a ‘test drive’.  They don’t really tell if a medication is going to work because you usually need to be on the medication for a couple of weeks and the samples are usually only for a week. However 90% of all side effects with medications especially the worst allergic reactions happen right away. This allows a patient to save spending $100 or so on a month supply of medication if there is a problem as well as saving them the cost of the first weeks of treatment.
I liked that there were maybe 10 clinical psychiatrists there that night. Several had academic appointments and most were affiliated with a hospital but several like me were solely in private clinical practice doing the work of actually seeing patients.  I knew a couple personally and several by their excellent reputation so it was pleasant to be there. A couple of the young guys impressed me too.  Women and men and a half dozen ethnic backgrounds so typical of Vancouver were present.  Almost all were parents too, so were giving up time with families to learn, which is so typical of the healing profession still.
These are the notes I took.It really was a great presentation by Dr. Dianne Macintosh, a self proclaimed ‘soccer mom’.  I really appreciated learning of it’s safety in the elderly.
Trintellix 

vortioxetine

Lunbeck

Eileen Sutchuck

Dr. Dianne McIntosh

Multi-dimensional disorder

1 in 5 mental illness

51billion cost of mental illness

Ssri

Snri

Multimodal -5ht1a

5ht3

5ht7

Sert

Montgomery - Asberg Depression Rating Scale

- proven efficacy

Hamilton Anxiety and depression

Broad efficacy 

Nausea side effect best start 5 mg or 5 mg eod

No difference in weight gain from placebo so very much appreciated

Sexual side effects not much similar copra led

Tests of cognitive function

Sheehan Disability Scale (SDS)

Digit Symbol Substitution Test (DSST)

PDQ-D6

RAVLT acquisition - 

RAVLT delayed recall

Memory tests

Vortioxetine well replicated

Objective performance data improved

Katona et al - elderly study

Lundbeck provided some of these cognitive assessment tests that were specifically made for brief clinical use in a busy office. I’d not used them though I started using clinical tests in my practice way before the mainstream trend.  Hamilton and Beck Depression scales have been around for a long time but I only just started using the PDQ’s a few years back. I’d not used the SDS so really was thankful to be given a copy. One worries about copyright so it’s great when there’s freeware that can enhance one’s practice.  

All round a very good evening and worthwhile. My patients will benefit from the practical insights I gained and the discussions I had with colleagues.    I really prefer eating take out at home on the couch with the dog in front of the tv after a long day of work after what now is looking like a life time of  clinical service.  The Black and Blue, Eileen and Dianne made the whole experience enjoyable.

I really am thankful to Lundbeck for their work in providing a new medication which really fills a need. I think the speed of society and the increased need for neurocognitive function with computers and cell phones, increased time pressures and more complex intellectual problem solving in the workplace brought the need for Trintellix to the forefront.  In the old days people were just glad to no longer be wanting to kill themselves and not having panic attacks where they thought they were going to die.  Now they and their bosses want people back at work with the capacity to think sharp and focus so Trintellix was needed.  Now it’s here.  

DSMV

Hoorah!
I just received my new American Psychiatric Assocation, Diagnostic and Statistical Manual of Mental Disorders - DSM5 - 5th edition.  It's been a long awaited highly controversial text. I've just done the overview and really it's looking overall very good. The devil's in the details but first glance this is a great book.  A whole lot of terrific work.  Well done! 
July3, 2013
I got to read some more of DSM5
PTSD criteria has been broadened over all but has some more specific subcategories. I think it is more in line with the way it has been used clinically though I can see problems arising. Overall it's clear that some serious thinking has gone into this area of trauma related illness and it's well reflected in the clinical thinking inherrent in the changes since DSMIV. This is an area I work alot with and can see myself enjoying using the DSM5 without any overt concerns.
Bipolar Disorder II - the Bipolar Disorder I has remained much the same and hasn't had any controversy attached to it over the years.  Mania is a pretty drastic presentation so it's not one that gets overly misdiagnosed.  Bipolar II however has had serious flaws in diagnostic thinking lacking any real 'exclusion' criteria surrounding the term hypomania.  The idea that 'hypomania is irritability' is where the major crux is. If you're 'irritable' for 4 days now you can be diagnosed with a 'major' mental illness which can reflect on you 'freedom', 'work', 'income' and reputation.  However, a psychiatrist can safely prescribe a wide variety of medications that are likely to improve your mood.  Bipolar II and Bipolar Spectrum Disorders has been where drug companies have had their recent greatest influence as well reported in the book Unhinged, among other sources. That said there's really clear evidence that while the DSM folk might have still been overly influenced by the industry in this regard, there's an attempt to tighten up the diagnosis in specific areas. Therefore I'd say that the prescription pad psychiatrist won't be changed by this but a more concerned clinician with some diagnostic conscience will find this a better diagnosis than was available previously. 
Cyclothymia is well detailed in DSMV.
Substance Abuse - this was a very controversial area and it leaves a lot to be desired.  But it's far from as bad as some of us Addiction Psychiatry/Addiction Medicine sort thought.  It's only about 10years outdated in conceptualization but it's not 50 years out of date or on another planet like some feared.  It's really not changed much from DSMIV on first sight . Again the details will count.  There's some improvement in language. What I do like is that substance use depression is under depression. There was obviously a need for the Substance Use Disorder like this to be categorized under the headings and this has been done with Substance Use Psychotic disorder listed in the grouping for
Schizophrenia and Psychotic Disorders.  When all the chameleon colours of substance abuse disorders was listed separately novice practitioners and especially counsellors routinely misdiagnosed substance abuse psychosis and mood disorder and anxiety disorders because they were not listed under psychosis, mood or anxiety.  This is an improvement I think. The category of substance abuse itself in he desk reference is just fine, broad and specific as needed. Consistent with ICD9and 10 and not much different from DSMIV and probably easier to use clinically in the desk reference because the presentations of this category are often messy and overlapping. The specificity of the previous DSMIV was fairly academic and there's evidence this is more user friendly
The specific substance abuse areas are well documented too
Obviously I'll have more to say about this category when I go through the big book in detail but really it's not as crazy as people feared. I think everyone can work with it but appreciate that Addiction folk feel short changed as the opportunity for DSM5 to reflect the scientific advances in the field, as evidence by MRI, PET, blood urine, end organ damage etc and all the advanced knowleded now available in genetics and neurochemistry isn't clearly evidenced but that's possibly not the job of DSMV. 
Schizophrenia and Psychosis - I think this section is pretty damn good.  It's really well described schizophrenia, brief psychotic episodes, schizophreniform illness, schizoaffective disorder and substance induced psychosis. Can't see anything with first overview I'd disagree with.
 Personality Disorders- I'm really pleased that  the original Jungian categories of essentially odd, extrovert and introvert have been maintained.  There's been major advances in this field which are represented by more dimentionality but frankly I was concerned with clinically having to learn a whole new way of thinking about personality even if it's more scientific. I can see doctors working in this field being very disappointed but again I'm kind of happy it's not going to change the whole Axis II thinking radically. I suspect others that don't work in my areas of interest will like the conservative elements that have influenced DSM5 because while I individually as an addiction psychiatrist who works with trauma have specific concerns I'm pleased when I see that others broad areas have retained their overall basis.  DSM5 is a major undertaiking as much political as scientific, just getting all the doctors with competing agendas to sit at the table.
And this is looking overall like a really worthwhile undertaking.  An amazing contribution like a new encyclopedia Britanica.
The Neurocognitive Domains is a great section that really is an advance and reflects much of the new knowledge in traumatic and degenerative brain changes. Well done DSM5
The Sexual Dysfunction section in DSMIV was really well established and there's more of the same good thinking and work in this DSM5.
Eating disorders seems good too. No surprises, nothing off the wall. Just what we're concerned about clinically.
The Dissociative disorders were highly controversy but seem to be here in a very usable form. 
Somatic Sympton and related disorders seems on first glance to be better conceptualized overall and a very useful set of categories laid out the way clinicians think./
The sleep disorders are well established also with clear definitions and criteria. 

I''m going to say that again with first and second go round at this book, the DSM5 is a truly great work overall with naturally some areas of controversy. It's been a long time coming and a whole lot of very dedicated folk have done an overall amazing job at categorizing mental illness in a way that is clearly going to be useful to clinicians.  Having seen some 10 thousand psychiatric cases over a quarter century or so I think this new DSM5 is going to serve me well.  I'm looking forward to to the courses and controversy and discussions that will flow from this book and result in development of a likely even better DSMV.  It's only too bad that DSMV doesn't have a 'spiritual psychiatry" section.  A V code would have been nice. That would be asking the APA to raise the bar higher than it's usually used too though. Other V codes have been improved on in a major way with the addition of 'suspected and confirmed categories" in the case of 'abuse' which previously was 'assumed true' when indeed it's turned out that there's a real place in the world for the legal term 'alleged' and it's apparent that psychiatric diagnosis are demanding some 'boundaries' in this regard. 

There's a lot of little category changes and additions which will need specific review but again overall it's really an admirable work.

 I know DSMIII is a whole other animal than this DSMV. I'm looking at the advances in my life time a bit like the Star Trek series of enterprises over the centuries of that show and this is only in a matter of decades. The advances made in science and the clinical progression is truly amazing. 

The American Psychiatric Association deserves to be highly applauded for this major and extraordinary contribution to our collective medical knowledge.  Thank you to all involved in the production of DSM5.