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Psychiatry Proposes New Drug Classification System: From Symptom to Target-Based

What would you think if the classification of your psychiatric medications changed? Well, a new conference is taking place to address whether drug classification “names” should be changed. Currently, many psychiatric organizations believe there are advantages associated with changing from a “symptom-based” classification to a “pharmacological-based” classification system.  This new system will be discussed at the European College of  Neuropsychopharmacology conference in Berlin.

The proposal of this change is met with a degree of controversy. Psychiatrists aim to reclassify drugs based on how they work, rather than based on what they treat. They want to push this reclassification agenda because patients often get confused as to why they are prescribed a particular medication. For example, Cymbalta can be prescribed for the treatment of chronic pain – yet when people see it is classified as an “antidepressant” they may become confused and/or reluctant to take it.

Psychiatrists Want Drug Classification Names to Change

Many psychiatric organizations are apparently pushing for names of drugs to change so that people aren’t confused about taking an antidepressant or antipsychotic for other conditions. These organizations are pushing for name changes to take place based on their primary “components” rather than “purpose.”

Professor Josef Zohar of Israel stated that, “As an example the drug fluoxetine (also known as Prozac, etc.) is currently classified as an antidepressant, but is also used for bulimia and other indications. Obviously, suffering from bulimia and being given an antidepressant is potentially confusing.” He went on to further discuss other drugs that commonly confuse people such as the prescription of antipsychotics as an antidepressant augmentation strategy.

Zohar continued with:

This is more than just a name change. This will change the way we talk about medications, the way we use medications and the way we explain to our patients why we are selecting the specific medications for them. We can also use the new naming system to help a clinician make informed decisions. We are proposing that the naming system will have 4 components or 4 axes.”

4 Axes: Pharmacological-Based Classification

Zohar proposes a system involving four axes describing the drugs including:

  • Axis 1: Pharmacological target / mode of action
  • Axis 2: Approved indications
  • Axis 3: Efficacy and major side effects
  • Axis 4: Neurobiological description

As an example of the drug Cymbalta (also known as Duloxetine) is currently classified as an antidepressant. However, it is also used for peripheral neuropathy, chronic pain, and other conditions. Following the new classification system, the drug would be listed as:

  • Class: Serotonin-Norepinephrine, reuptake inhibitor
  • Indications: Major depression, generalized anxiety disorder, diabetic peripheral neuropathy, fibromyalgia, chronic pain, stress urinary incontinence
  • Efficacy: Improves symptoms of depression, anxiety, and reduces physical pain
  • Side effects: Nausea, sleepiness, insomnia, dizziness
  • Neurobiological description: Neurotransmitter changes, Physiological effects, Brain circuitry activity

Note: The above is simply an example that I came up with and may not be completely accurate in regards to Duloxetine.

Advantages of the new pharmacological-based classification system

There are some advantages that this new system has to offer. The biggest would likely be patient compliance, an issue that is difficult for psychiatrists to address. The new system would likely be more informative, and result in more organized classifications of various drugs. The stigma associated with getting a psychotropic medication such as an antidepressant for a condition other than depression would also be reduced.

  • App-Supported: A benefit from the new system is that it will be supported by an “app.”  This app is designed to help psychiatrists make the proper treatment choices for a particular condition.  Many like this idea because if guidelines are properly followed, it may promote acceptable prescription choices by psychiatrists.  The app that supports this new system is currently in a “beta” version, but will also be presented at the conference.
  • Compliance: Since drugs would not be categorized as “antidepressant” or “antipsychotic,” patients would be less likely to question why they are prescribed a certain chemical. They would be able to see that the particular chemical they’ve been prescribed is approved for their particular condition and would be more likely to comply. Someone who receives an SNRI like Cymbalta for chronic pain may initially become confused under the old system that they received an “antidepressant.” However, under the new system, they will just see that they have been prescribed an “SNRI” that is effective for pain management. This won’t cause them to think twice based on the logical fact that “antidepressant” doesn’t sound like it should help with pain.
  • Informative: Everyone likes a system that’s new and updated to fit current trends. Not that this new system will necessarily be an improvement over the old system, but proponents have argued that updates are needed in the way drugs are classified.
  • Organized classifications: The new system could easily help psychiatrists optimize treatment to fit a particular patient. Let’s say they try various drugs that act on histamine receptors. A psychiatrist would have an easier time knowing which drug to prescribe based on the described pharmacological action. Although they are already knowledgeable enough to figure things out with trial and error, on paper, the classifications would be more organized.
  • Paradigm shift: In regards to the proposal of name alterations, Professor David Kupfer (University of Pittsburgh), said: “This change in terminology represents a major shift in the way which clinicians, and their patients, will think about the drugs they use. This new system is being launched at the ECNP in Berlin, so there is a long period of negotiation and discussion to come before we get complete agreement. Nevertheless, this will mean a real change in the way we talk about the drugs used in psychiatry and neuroscience.”
  • Stigma reduction: The argument is that the names of certain drugs make patients stop taking the drug for fear of being associated with a specific disease. Certain medications like Adderall are commonly talked about in positive social context, whereas a person may be afraid to bring up a drug like Abilify in conversation. Therefore another argument could be that certain drugs carry social stigma associated with their names.

Disadvantages of the newly proposed system

There are several disadvantages associated with this newly proposed classification system. Not only would it make it more difficult to distinguish treatment hierarchy for a particular condition, but may result in increased number of off-label prescriptions. The new system seems completely unnecessary in part because there’s nothing inherently wrong with the current system.

  • Current system is fine: Many would argue that the current system is fine. Although certain individuals may be less likely to take their medication based on the class of drug that they receive, in many cases, showing them a study or providing an explanation would increase compliance. The current system in place is easy to follow, and is no different from other classes of drugs. Why should psychotropic drugs be reclassified?
  • Difficulty distinguishing treatment hierarchy: A striking disadvantage of the newly proposed system would be that it undermines the primary purpose of various medications. If a drug is classified as an “antipsychotic” yet gets classified as a D2 dopamine antagonist, people may not realize that it’s not a first-line treatment for depression. This may make it tougher for patients to understand whether they are receiving proper hierarchy of treatment options.
  • Fear of certain drugs is sometimes justified: Patients may stop taking a drug prescribed for off-label purposes for fear of being associated with a certain condition. However, in many cases these fears may be warranted. Especially considering the fact that drugs like antipsychotics are being used for depression, without much evidence to support their efficacy.
  • Non-Universal: If the system was universal and applied to all types of medications (including non-psychiatric drugs) it would be fine. Why haven’t other medications been reclassified? One could argue that since other classes of drugs haven’t been reclassified, there is no need for this new system.
  • Overcomplicated: The new system classifies a drug based on four particular “components.” Some would argue that this is overcomplicated because as long as we understand the symptoms that the drug addresses, the other details aren’t even needed. The new system attempts to shift focus away from what symptoms the drug treats and more towards how it works, which may be confusing to the average person.
  • Prevents questioning: Some would argue that the goal of psychiatrists is to essentially stop people from wondering why they are being prescribed an off-label treatment for their particular condition. For example, someone may wonder why they are being prescribed an antipsychotic for their anxiety. Instead of questioning why they are receiving an off-label option, people will be more inclined to accept it as a favorable treatment because the classification will be less obvious.
  • Off-label prescription increase: Psychiatry is essentially attempting to switch from symptom-based drug classifications to pharmacological-based drugs and method of action. Sure the argument could be made that this is a more “scientific system” but in general, it will further serve the agenda of prescribing medications for conditions that do not warrant their usage. For example, the majority of individuals should never take an antipsychotic for depression as the potential negatives outweigh the positives. Patients will be lead to believe that the drug they’ve been prescribed is a first-line treatment for their particular condition. They will become more obedient and will be less likely to question any off-label (unnecessary) treatment options.
  • Poor justification: Professor Josef Zohar (Tel Aviv, Israel) stated: “As in many fields, what we know about drugs has evolved enormously since the 1960s, but the names we use to describe these drugs have not evolved in 50 years. As an analogy, I mostly use my smartphone to type SMS text messages, yet I would not call it a “typewriter.” This is a very poor analogy in attempt to justify the name changes. In reality, a smartphone is completely different than a typewriter. A smartphone is newer technology and clearly isn’t the same thing as a typewriter, therefore the name change is justified – it allows people to distinguish between two different objects. In regards to medications, Zohar is suggesting that we modify the names of antidepressants and antipsychotics even though they would be the same chemical that they’ve always been. The problem is that none of the components have been altered to justify a name change.
  • Unnecessary: The reality is that we don’t need to rename drugs based on these “axes” – this renaming is unnecessary. Most of the information about these drugs is widely available, reclassification won’t accomplish much of anything. In general, people are able to do a little research and understand the class of the drug, its side effects, as well as the conditions for which is was approved. Also, it is commonly known that certain medications can be used to treat a variety of conditions. Not only is this reclassification completely unnecessary, but it is a waste of time. Someone will have to write up the new system.

Alternative Proposal: Psychiatric drugs should be ranked with composite scores

Instead of wasting time changing drug class, why not do something that may be beneficial? It would be nice if psychiatrists came up with a rating scale that ranked medications based on severity of side effects, long-term effects, and other health dangers. There should be a weighted system that conducts a cost-benefit analysis on each psychiatric medication and then assigns them each a numeric score or rating.

This ranking system would allow people to see the truth about which drugs (and which classes of drugs) are recommended and which should be avoided based off of a consensus hierarchy. This cost-benefit analysis wouldn’t even need to be reflected in the name of the drug. A composite score for each psychiatric medication should be derived based on the following factors:

  • Efficacy: This factor would involve assessing how well a drug works for a specific condition. Double-blind, placebo-controlled studies would need to be conducted and results open to the public.
  • Side effects: Severity of side effects and presence of unwanted side effects. Unfortunately many side effects aren’t well-documented until the medication has been on the market for years.
  • Long-term safety: This would include potential for effects such as increased weight gain, high blood pressure, development of diabetes, tardive dyskinesia, etc. The long-term effects are why you commonly see lawyers on commercials asking if you’ve taken “X” drug. They then say to call if you suffered (insert horrible condition) as a result. Long-term safety and effects need to be better investigated.
  • Adverse reactions: This would involve analyzing the potential for adverse reactions as well as the degree to which they are dangerous.
  • Withdrawal: How difficult is the medication to withdraw from? Certain drugs are thought to carry significantly longer withdrawal periods compared to others. Considering the high degree of ignorance regarding medication withdrawal, maybe psychiatric organizations can start by investigating withdrawal symptoms more thoroughly.

In regards to the newly proposed system, I would propose one that includes the information above. This would work with the new or the old system – each drug should be assigned an overall ranking score in regards to the combined factors. Additionally each “classification” of drugs should be given an average score and each sub-classification such as “SSRI” within the class of “antidepressants” should be given an average composite score based on all medications within the class.

How some psychiatrists treat depression…

Some psychiatrists throw different SSRIs at the problem and hope that they work. If they don’t, they may try another class of antidepressants, but some may be quicker than they should to augment an antipsychotic. Ultimately a person becomes swamped with their medication cocktail and ends up worse over the long-term than when they started treatment.

  1. Try SSRIs
  2. Add an antipsychotic
  3. Throw more random meds into the mix
  4. Patients end up on a large cocktail of drugs

Does anyone fail to see the problem with this? In this particular scenario, not only did the psychiatrist fail to prescribe other classes of antidepressants, but they jumped immediately to adding an antipsychotic drug. The antipsychotic drug may help some, but the long-term effects of using an antipsychotic as an augmentation strategy are considered troubling. Before a person knows it, they end up religiously taking a combination of many medications to treat something as simple as “depression.”

Yes the argument can be made that everyone is different and therefore certain agents like antipsychotics may provide some people with more benefit for depression. However, this undermines the primary purpose of antipsychotics while simultaneously neglects the severity of side effects and dangerous long-term effects of this medication class.

Although most psychiatrists are supposed to follow a code of conduct protocol for prescribing medications, many simply freelance after several antidepressants fail to treat depression. This same “freelancing” occurs when someone needs a medication for anxiety and they get prescribed an SSRI before a safer medication like Buspar. The psychiatric profession isn’t easy, but in many cases patients are taking off-label treatments prior to more established, safer options.

Concerns about the classification name changes

Since psychiatrists are already prescribing certain drugs “off-label” for conditions that they shouldn’t, this new system may make the practice more common and acceptable. It’s no coincidence that antipsychotic medications make drug companies the most money (allowing for greater kickbacks to psychiatrists). If the perception of antipsychotics changes to medications that can be used for depression and anxiety, this will end up doing far more harm than good.

Many non-psychiatric drugs are used for conditions beyond the scope of their primary purpose. In these cases, we have not resorted to name changing in order to skew the public perception of these drugs. The question remains: Why do it in psychiatry? After all, it’s just a matter of time before people figure out that a newly classified version of “paroxetine” is still “Paxil.”

Another major problem is that we don’t even know that psychiatric drugs are correcting the problem they are attempting to treat – especially over the long-term. Many experts believe that serotonin and other neurotransmitters play a role in depression, but the causes are likely far more complex with significant individual variation (based on genetic and environmental factors). Think of a common antidepressant that works to increase serotonin such as Paxil.

How will the classification change help improve the way it is administered? It probably won’t.  Most doctors and psychiatrists still are unable to explain why one drug works for Patient A, yet fails miserably in Patient B. Additionally, Patient C may not get any benefit from taking drugs and a natural therapy may work best.  It should also be mentioned that effects of drugs can often differ based on dosage.

For example, when taken at lower doses, Nortriptyline can be sedating due to its anti-histamine properties. However, at higher doses, it tends to be stimulating and have more action on norepinephrine – promoting CNS stimulation. To properly describe the mode of action would be highly difficult and likely subject to inaccuracies based on dosage.  With the new system, the mode of action will need to be described on Axis 1.

Are the classification name changes really necessary?

There are more significant problems with psychiatry than those who fail to comply with treatment because they are afraid of a particular drug classification. Changing the classification isn’t going to make people any less likely to research the chemical that they’ve been prescribed. And in many cases, a person should take extra precaution and have concerns if they are prescribed an off-label unapproved chemical for their particular condition.

People have a right to question why they are being prescribed their medication and to think for themselves. After all, psychiatrists usually aren’t the ones that have first-hand experience ingesting the drugs. They do their best to prescribe treatment based off of their years of education, but the problem is that they lack insight regarding the power of many medications.  Psychiatrists typically have a difficult time understanding how certain drugs affect people on a personal level in terms of side effects, withdrawal symptoms, and how they may create additional chemical imbalances.

The bottom line is that the classification name changes aren’t really necessary and any changes typically involve benefits and drawbacks. In large part, this “new system” seems to be a waste of time and effort. If implemented there will may be some positives, but is the systematic change really necessary? Probably not. In my opinion, the new system seems no better than the old. Only time will tell whether moving in this direction was a smart move.

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