Education & Training

Ask the Doctor

Lewis A. Opler, M.D., Ph.D., is Professor of Clinical Psychiatry, Columbia University College of Physicians and Surgeons; Director of Adult Psychopharmacology Services and Director of the Research Division, New York State Office of Mental Health; and Attending Psychiatrist, New York Presbyterian Hospital.

What is your opinion about using Provigil (modafinil) to treat excessive daytime sleepiness in patients on clozapine or other sedating medications?

Provigil (modafinil) is an excellent medication for treating excessive daytime sleepiness, including sleepiness caused by other medications. Unfortunately, Provigil is expensive, and many plans won’t cover it for uses other than its FDA-approved indication (treatment of narcolepsy). Cephalon, the pharmaceutical company that produces the drug, has an exclusive patent until 2014, so it’s unlikely that a less expensive generic equivalent will be available before then.

For persons with bipolar disorder, what is the evidence that a gluten-free diet is helpful? How about using omega-3 fatty acids?

The data is not compelling that a gluten-free diet is helpful for persons with bipolar disorder. Some studies suggest that omega-3 fatty acids, particularly eicosopentanoic acid or EPA and docosohexanoic acid or DHA, may be helpful for some. Both EPA and DHA are found in fish, but it’s not clear if persons who eat fish several times a week gain additional benefit from ingesting fish oil capsules. If you wish to use fish oil as a dietary supplement, look for a product with high concentrations of the omega-3 fatty acids EPA and DHA that avoids toxic contaminants such as mercury. If you are taking anticoagulants like warfarin (brand name: Coumadin), discuss this with your physician before taking fish oil supplements. Omega-3 fatty acids have a mild inhibitory effect on platelet binding and, in combination with anticoagulants, could increase the risk of excessive bleeding.

For persons requiring antipsychotics, are there new medications that do not cause weight gain?

The two newest second-generation antipsychotics (SGAs)—ziprasidone (brand name: Geodon) and aripiprazole (brand name: Abilify)—cause less weight gain than the earlier SGAs clozapine, risperidone, olanzapine, and quetiapine. But they still cause some weight gain.

Older antipsychotics are also referred to as “first generation antipsychotics” (FGAs) or standard neuroleptics. The FGAs, particularly molindone, cause less weight gain than the SGAs.

Amantadine, approved to treat both naturally occurring and drug-induced Parkinsonism, was found to reverse neuroleptic-induced weight gain over 20 years ago. More recently, it has been shown to prevent or reverse weight gain caused by olanzapine (brand name: Zyprexa). Metformin may also counteract the tendency of antipsychotics to cause weight gain. This use, however, is not an FDA-approved indication for either drug.

How should someone on Medicare go about changing therapists, including psychiatrists, if they are unhappy with the services they are being provided?

Not all mental health professionals, including psychiatrists, accept Medicare; but enough do. If you are unhappy with the treatment you are receiving, you should find other professionals with whom you can form a more helpful treatment alliance.

First, get a list of doctors and other mental health professionals who accept Medicare. Find out how he or she is regarded and whether the practice is taking new patients. Second, when you make an appointment, be clear that you are looking for a new psychotherapist or psychiatrist (some mental health professionals don’t like to take over the treatment of a colleague’s patient without speaking to the treating professional first). Last, don’t rule out publicly funded clinics. Sometimes, treatment in the public sector is as good as, if not better than, treatment in the private sector.

Does homeopathic medicine have a role in treating persons with mental disorders?

While I am not an expert regarding the history or the present status of homeopathic medicine, I have never felt it has much to offer in psychiatry. Practitioners of homeopathic medicine give low doses of the believed pathogenic substance. There is controversy as to whether this approach works in general medicine. In psychiatry, we have not identified pathogens, so that it is unclear how one would even apply the principles of homeopathic medicine.

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