Archive for the ‘HIGHLIGHTS’ Category

“Badge of delusion”

 

Most people who read the editorial in the Friday March 27th Dallas Morning News will totally relate to the indignation toward the abusive behavior of a Dallas police officer, Robert Powell.  He showed such a lack of empathic understanding and social intelligence that it challenges our faith in mankind.

 

Most people will also feel at least some comfort as the editor did in the conclusion that although he will probably keep his job at least he will have to live forever with the self-knowledge “that in a matter of life and death, he screwed over a fellow human being just because he could.”

 

Unfortunately, this is living in a fantasy world where deep down everybody is a good person.  In my 42 years of practicing psychiatry I have never had an abusive person come in and say, “I am an insensitive, self-absorbed, abusive person and I really feel bad about it.  I suffer from guilt and shame and I want to do whatever I can do to atone for my bad behavior.  I know it’s wrong to get high on power trips and watching people squirm – I know it’s wrong to feel smug and righteous using the letter of the law to ignore extenuating circumstances, while jacking people around.”  And they also don’t say, “I know I should care what other people think of me, I should be able to put myself in other people’s shoes and be able to see things from their perspective.  I know I should have at least some spiritual connections and values outside of myself.  I shouldn’t rationalize and blame the victim when there’s a bad outcome.  I have to be true to myself – I was doing my job – the dude broke the law – everybody has an excuse.”

 

Reality is that it’s only those that are abused and victimized that live with the memory and pain forever.  

 See editorial http://www.dallasnews.com/sharedcontent/dws/dn/opinion/editorials/stories/DN-cop_0327edi.7341749c.html

 

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Pristiq vs Effexor

Question: Now that Pristiq has been out for awhile, what has been the clinical response with your patients compared with the Effexor XR formulation? Rumors have said it is more tolerable and less sexual side effects, although I have tried some samples, and it doesn’t seem to be as calming as Effexor, and I am unsure what the Pristiq 50mg dose is compare to a similar Effexor XR dosage?

Also what SSRI/SNRI tends to have the fewest sexual side effects?

Thanks


Answer:

Pristiq and Cymbalta seem to have less sexual side-effects than Effexor
and if Pristiq at 50mg is an adequate dose it should have the least
sexual effects. 90% of the first 570,000 treated with Pristiq have
stayed with a 50mg dose. This dose has the same efficacy in control
studies as 75-150 of Effexor with better tolerability. The drop out
rate due to side-effects is essentially the same as placebo.

When most people (normal metabolizers) take Effexor – 70% of the benefit
comes from Effexor being metabolized so the effects are very similar.
Pristiq does have a slightly higher ratio of norepinephrine effect
relative to serotonin than Effexor and this could account for your
impression that it’s not as calming – that is most likely a temporary
effect.

Because Pristiq doesn’t require the same liver metabolism as Effexor
there are less issues with drug drug interactions and tolerability for
those people (7-10% of Caucasians) who are poor metabolizers. Poor
metabolizers don’t usually do as well on Effexor and don’t usually
tolerate doses above 75mg. Some people do better on 100mg of Pristiq.

Pristiq is also more cost-effective, especially at 100mg dose – since
there is a 100mg tablet – whereas Effexor frequently requires 225mg or
more necessitating multiple capsules.

Wyeth is also getting ready to launch a program where they will pay 1/2
of your cost (copay or cash) as long as you take it on a continual
basis for life if necessary.

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Panic and traveling

Question: Dear Dr. Jones, I treated with you about 15 years ago for agoraphobia–and was helped very much by your keen insight into this condition. Would you have time for a quick question? I’ve had a problem traveling long distances from home for most of my adult life. I’ve had periods of remission, lived well despite the condition, working as television reporter, etc. But the problem is, in short, I’ve always limited my travel fearing “the big one.” Now, I want to go to Europe before I’m too old to enjoy! Klonopin works well for me. Do you think if I just plain old up and flew off to Italy, I would not have a “breakdown” if I brought Klonopin?— even if when I got there, I became extremely panicked by facing such a long trip after a life time of fearing it? In case you advise to “work up to it” with smaller trips first–I do note that whenever I force myself to take a trip I always have some degree of panic/pain (although also enjoy the trip!) and one time I had violent panic one week driving 30 miles away–then, flew 1000 miles the next week with less fear! Then, came back and panicked again going 30 miles! For me, sucessive approximation doesn’t seem useful. Thanks so much for any information! Best,
Kate


Answer:

Dear Kate,

Congratulations for not letting Agoraphobia/panic attacks control your life
to any large extent. Although I can’t make specific treatment
recommendations, there are several general principles that apply to your
situation.

First, panic attacks associated with travel in cars, planes, etc., are the
claustrophobic kind which are related to hypersensitivity to increasing
levels of CO2 in your blood – conditioned fear responses and anticipatory
anxiety results in shallow breathing and a build up of co2. The best way to
prevent this is to breathe properly – out first…see my website section on
panic attacks for the full technique. http://test.askdrjones.com/wp-content/uploads/handouts/HO%20Anxiety%20Handout.pdf. Practice this periodically and always use this technique when you
start to get anxious or panicky.

Klonopin is the strongest panic preventer but like most medications needs to
be taken in the right dose. Panic patients tend to take as little as they
can get by with instead of as much as they need. Usual daily dose is 2-3mg
but can be higher. It’s ok to sedate yourself on long flights if necessary.

Desensitization is situation specific – so that being able to fly 1000 miles
doesn’t mean you can necessarily drive long distances. Avoidance or using
escape makes you worse, as does hanging in there but having a horrible
experience. Using proper breathing and or adequate medication to get
through it makes you better. Some people need to add an SSRI or SNRI to
facilitate full desensitization. Positive self-talk and having distractions
can also help.

Good luck!
Dr. Jones

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Can stimulants permanently stunt growth in children?

I have not seen previous reports of permanent growth suppression from long-term use of stimulants during childhood.  Expert consensus and my clinical experience is that height may be slightly delayed but is genetically determined (assuming adequate nutrition).

The package insert for methylphenidate products (Ritalin, Concerta, Focalin, Daytrana, Metadate), cautions that daily use in a controlled study versus a controlled group did show on average 2cm less height after 3 years – but it is assumed to eventually catch up.

Kids who don’t take medication on weekends or during summer don’t show this delay.  The presumed mechanism of the delay is that norepinephrine (increased by methylphenidate) leads to a decreased release of growth hormone during deep sleep, (normally in the first 3 hours).  This suppression of growth hormone can probably be prevented by use of Clonidine or possibly Guanfacine  taken at bedtime.

In the reader’s comment amphetamines were referenced but the statement was also made that the person referred to was treated with methylphenidate.  Of course both are stimulants but are significantly different.

The package insert on amphetamines (including Adderall and Vyvanse) cautions about below average weight gain over a one year period of daily use.  In the Vyvanse study the evidence was that at the beginning of the study the average child was at the 62nd percentile of body weight – since food is a natural booster of dopamine in the nucleus accumbens, patients on amphetamines are less likely to eat out of boredom and they usually lose weight.

In fairness, we do have more studies using methylphenidate in kids than amphetamines.  The longest controlled study ever, the MTA study was also predominantly methylphenidate.  Intuitively it would make sense that amphetamines would raise norepinephrine levels even more since they increase release in addition to blocking reuptake.  Empirically however, methylphenidate is associated with increased excretion of norepinephrine and amphetamines are associated with a decrease.  Presumably amphetamines are more likely to down regulate, ie, modulate norepinephrine levels.

The hardcore science for all of this is in its infancy.  We will undoubtedly find that there are “outliers”, but at this time with all the evidence I know of the long-term benefits outweigh potential risks for the spectrum of Attention Deficit Hyperactivity Disorder.

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Best Medications Revisited

In December 2006 I participated in a survey of psychiatrists by a pharmaceutical company.  They asked me if I could have only five medications to prescribe which ones would I choose?  Since I have a cash only practice I have to go with the most effective medications long term.

Most medication studies are to meet FDA requirements, which means short studies (6-8 weeks), and they only have to show 50% improvement in symptoms and be statistically better than placebo (that may be associated with only 30-40% improvement).  These studies do not represent real world treatment – patients can’t be given any counseling and can only be on one medication. 

It is only through extensive clinical experience that we can learn which medications are best.

I think of the best medications as the ones that patients come back and say are great….that they have changed their life – side effects are minimal, and the highest standard is that they are still saying it after 6 months, 1 year, 5 years, etc.  If the medication starts working on day one that is a bonus. 

Great medications help you feel better, function better, be less stressed and help protect your overall health.  Great medications also enable you to focus on your life – career, relationships, hobbies, and not be constantly preoccupied by symptoms and survival.  You think – I wish I had this medication a long time ago. 

The main problem with the best meds is cost – especially if you don’t have good insurance – but usually there’s a way to get the medications you need or at least to find generics that are close to the best branded meds.

In my experience stimulants as a group have the highest batting average (the highest percent of the time a particular med works great).  I have patients that have taken them for over three decades.  I haven’t seen any long term problems from taking them.

I was initially trained in the 60’s.  One of the most helpful things I was taught – “if what you are doing isn’t working, do something else.  Even if it is wrong it will get you unstuck.”  This led me to trial and error and eventually to appreciate the value and relative safety of stimulants.

Amphetamines have been available for over 70 years and methylphenidate over 50 years so we have more experience with them than any other medication that we currently use in psychiatry.  Ironically, stimulants aren’t included in the top 10 most often prescribed meds by psychiatrists in the first quarter of 2008.  Despite the fact we have much safer delivery systems the FDA still regulates all the stimulants at a higher level – requiring a written prescription and maintaining a record of each prescription. This creates practical problems, inconvenience, etc.,  not to mention a certain intimidation is felt by doctors.  By contrast, the most abused prescription medications – pain meds – such as Hydrocodone – are much less regulated.

My top 5 list has changed some since 12/06 and hopefully will keep changing as we get even better medications.  For now it consists of the following:

#1     Stimulants – Vyvanse (preferred by 3/4’s of my patients who prefer amphetamines) and Adderall XR (preferred by 1/4 of my patients who prefer amphetamines).  15% of patients prefer one of the methylphenidates such as Concerta, Focalin XR, or Daytrana.

#2     Benzodiazepines – Alprazolam (Xanax and Niravam are my first choice).  Clonazepam, especially Klonopin wafers are a  close second.  

Alprazolam, in a recent study was the #1 med prescribed for stress symptoms by primary care physicians.  Psychiatrists in 2008 used Clonazepam #1, then Seroquel #2, and Alprazolam #3 for stress symptoms.   

#3     Sleeping medication – Ambien CR/Lunesta (I rated Ambien CR first in 06 only because 15-20% of patients have a bad taste the next day from Lunesta – but using a mouthwash with whitener morning and night usually prevents significant taste problems).  Both of these meds work great for most people.  They are both approved for long term use and provide normal sleep.  Short acting Ambien is still preferred by some patients and some take it because it is in generic and they can’t afford CR or Lunesta.  Short acting may not keep you asleep more than 5 hours and has some risk of side effect issues.

No sleep medications were in the top 10 meds prescribed by doctors in 2008.

#4     Antidepressants – Pristiq/Effexor XR – I don’t have enough experience with Pristiq (son of Effexor) to be confident that the majority of patients will end up preferring it to Effexor XR, but in theory it’s better, safer to use, easier to dose, easier to combine with other meds, especially Wellbutrin.  Wellbutrin is the only antidepressant that almost never has weight gain or sexual side effect issues (except for infrequent uses of MAOI’s like Emsam patch).  But Wellbutrin doesn’t have efficacy for the whole range of anxiety and depression symptoms so it would not be the preferred med if you could only use one antidepressant.

Cymbalta is the other antidepressant in this category.  It has more FDA approved uses including fibromyalgia, and generalized anxiety disorder and is very similar to Pristiq in its ratio of effect on serotonin and norepinephrine.  I rank Pristiq first because it has much lower protein binding and therefore gets into the brain faster and works faster.  Prestiq has essentially no drug drug interactions whereas Cymbalta inhibits metabolism of certain medications that can either result in unexpected side-effects or interfere with the activation of pain medications like codeine or hydrocodone. 

#5     Mood stabilizers – Abilify/Seroquel.  There is no perfect choice in this category.  I use these two the most but I also use a lot of Lamictal, Zyprexa (Symbyax) and Lithium.

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I have had chronic sleeping problems for 10 years. I am a 58 yo woman going through menopause. My mother is 90 and still on sleeping pills. Could my condition be hereditary? Which pill will give me 7 hours of sleep leaving me refreshed the next day?

See the Do’s and Don’ts of sleeping habits on my site:   

 http://askdrjones.com/wp-content/uploads/2006/06/sleep_dos_and_donts1.pdf

Make sure you are doing all the cognitive and behavioral things you can do to optimize sleep. 

You are in a high risk group for insomnia.  Sleep problems are more common in women than men, increase with age, and are aggravated by menopause.  The onset of your insomnia coincides with perimenopause.

Estrogen has many more potential benefits than risks for most women – especially brain benefits.  Unfortunately, if you still have your uterus you have to take some progesterone.  There are options like long acting intrauterine forms of progesterone that can minimize side-effects.  I am totally opposed to oral estradiol such as Estrace.  http://test.askdrjones.com/2007/04/28/say-goodbye-to-the-pill-ladies/

  Premarin or synthetic Cenestin by mouth and or estradiol cream/gel or patch is the best form.  The WHE study 5 years ago scared a lot of women about estrogen replacement therapy but the women in the study were on average 10 years post menopause and never used estrogen – that puts women at greater risk and may apply to you especially if you smoke.

One milder option is prescription DHEA which in women mainly turns to testosterone (good for bone and muscle) but then in the brain is converted to estrogen – avoiding the increased risk of estrogen related breast cancer.  

There are occasional women who benefit from natural progesterone (Prometrium) at bedtime since it has a natural benzodiazepine like sedative effect.  I recommend that you don’t take synthetic progesterone like Provera.  

Any form of alcohol can contribute to sleep problems because it causes arousal as it wears off.  If you do drink alcohol make sure it is not within 3-4 hours of going to bed.

We are fortunate to have very effective sleep medications that provide normal sleep.  The mildest, shortest acting is Sonata, usually 10mg-20mg lasts 4-5 hours.  Benzodiazepines such as Xanax, Klonodine, Ativan, etc., shouldn’t be used at bedtime because they decrease stage 4 sleep (the most important type of sleep), but they can be used for early awakening with inability to get back to sleep – since we get all our deep sleep in the first three hours.

Lunesta (2-4mg is needed) for sleep but may cause a bad taste in 15-20% of people (less likely if taken with orange juice).

In general, Ambien CR is better than Ambien tablets because they frequently don’t last long enough.  The generic form is probably weaker.  The CR form is not as strong as the tablets for inducing sleep but lasts longer.  Some people have to combine CR with the short acting tablets to get to sleep.

All of these sleep medications work better on an empty stomach – combined with good sleep habits as I stated earlier.

Circadian rhythm problems can also contribute to the problem.  Morning bright light and or evening melatonin or prescription Rozerum may also help. 

Adding Tenex or Clonidine, or occasionally Prozosin can be helpful.  Trazodone, Seroquel, or low dose Doxepin may help.  Neurontin (up to 800mg) or Lyrica also induce normal sleep.

Chronic insomnia can be very resistant because of all the anxiety and conditioned negative expectations.  It is harder to treat initially and gets easier as fear of insomnia subsides.  When problems persist a sleep study can help identify problems such as restless legs, myoclonus, or sleep apnea.

When all else fails there is a medication that usually works, Xyrem.  It is highly regulated because of previous misuse of it as GHB.

Because good sleep is so essential you have to persist until you find what works for you.  Don’t give up until you find the right medication at the right dose.    

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How can I prevent recurrence of depression and what do I do if the depression does come back?

Depression runs in my family and I’ve been on the same medicine for a while with no episodes of depression.  About two weeks ago I woke up feeling not myself and contributed it to getting my period on top of coming down with a respiratory infection.  Still not feeling well after two weeks I think it might be depression because I feel tired, confused thinking, can’t focus, etc.  I’ve called my doctor and he told me to up my medicine 100mgs.  My question:  

Since I have not had an episode of depression in quite some time could it have been brought on by me not feeling well?

 


 

Dr. Jones’ reply:

I’m not sure what antidepressant you are on – but it was possibly Zoloft or Luvox since they can be increased by 100mg increments, but not SNRI’s (Effexor, Cymbalta) or other SSRI’s (Prozac, Celexa, Lexapro, Paxil).

Women with a family history and or prior history of depression who respond to an SSRI or SNRI can have return of symptoms if their serotonin level is reduced (as it is premenstrually, post partum, or during perimenopause).  Being ill can also contribute to relapse by disrupting sleep or normal thyroid function.

Previous studies have shown that:  "the dose that gets you well keeps you well", but even then the relapse rates are:  20% of patients have recurrence within 3 years,  50% relapse if the dose is lowered, or 80% relapse if medication is stopped.

Recurrent depression not only causes distress and possible short term impairment, it can also increase your vulnerability to future episodes and decrease your responsiveness to treatment.

There are several things that can help prevent recurrence:

  1. Good sleep – 7-8 hours every night (Lunesta, Ambien provide normal sleep)
  2. Physical activity – daily vigorous activity for at least 30 minutes (a 2 mile walk or equivalent)
  3. Omega 3 fatty acids – take twice daily.  (I trust Cooper brand the most)
  4. Bright light daily 
  5. Thyroid – make sure thyroid levels are good  test.askdrjones.com/ 
  6. Cognitive behavioral therapy – if needed
  7. Other medications – other medications may help such as alprazolam, atypicals, stimulants
  8.  L Methylfolate – (Deplin,  Cerefolin, or Cerefolin NAC)  – these contain a form of folic acid that gets into the brain cells.  Deplin was recently approved by the FDA as an add-on treatment for depression.  Cerefolin also contains B12 and Cerefolin NAC has a third ingredient that increases glutathione (a powerful brain cell antioxidant).  These medications not only can improve mood, but improve cognition and energy.  Caution:  taking Deplin if your B12 level is low can be harmful.  It is safer to either check your B12 levels or take Cerefolin. 
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Only 1/3 of ADHD Kids are Being Consistently Treated: Why are we not taking better care of our greatest resource?

A study of 3,000 randomly selected kids ages 8-15 was funded by the National Institute of Health (with no pharmaceutical company support).  The main author was Tanya Froehlich, a developmental behavior pediatrician.   The study was published in Archives of Pediatric & Adolescent Medicine Sept 07.

Originally the objective was to see if ADHD in kids was being over diagnosed and over treated.  Actual findings showed only 3% of those without ADHD were receiving medical treatment – and they could have represented kids who had improved so no longer met criteria.  They also found that 9% of the 3,000 kids had ADHD of which only 1/3 were consistently being treated.

That finding or worse has been repeatedly found – the question is, WHY?

I believe the most common reason is that the patient has not taken “the right medication at the right dose”.

 In consulting with physicians in their offices a frequently mentioned problem is getting kids to take their meds.  My approach is to first redefine the problem for kids and their families.

ADHD is a type of personality that makes it difficult to focus on things that aren’t interesting.

Like what?  Like school mostly.  The cause is genetic (polymorphism).  Mother Nature doesn’t want ADHD kids or adults spending time with boring, repetitive stuff.  ADHD people are the explorers, challengers, and changers of the world.

One of the problems with being ADHD is that in order for us to go to the best schools and get the best jobs, starting with the 9th grade we need to perform well in school and keep up with boring details (and at work boring reports, etc.)

The GOOD news is that medication – especially stimulants make our lives better by giving us the ability to do well on the boring stuff.  It also helps us stay calm and still when appropriate, and in control.

THE GOAL

The goal is to find a medication that kids, teens, and adults like.  Their lives are easier – they’re getting things done effectively and side-effects from the meds if any, are minimal.  HINT:  The medication probably isn’t Strattera.

If medication makes kids feel bad they shouldn’t take it.  I worry more about kids/teens who take meds that make them feel bad or detached or flat or racy.  I worry about parents who keep giving kids the wrong medication or the wrong dose.

Another reason for poor consistent compliance with treatment is that usually at least one of the parents is also ADHD.  Only 10% of ADHD adults are being treated.  So the parents forget, lose the med, are running late, or don’t have time.  They can’t stay organized to keep up with getting refills, scheduling and keeping follow-up appointments, much less filing insurance forms, etc.

Again this year at the American Psychiatric Association annual meeting a group of loud marchers picketed the main conference center.  “Stop poisoning our children” and other banners were being waved.  They were mostly Scientologists who are a blend of idiocy and nuttiness.  They should be sentenced for life to be locked up with a hyperactive kid like our son was in childhood.

Unfortunately, some patients give up too quickly on one or more meds because they don’t understand all the nuances of dosing and side-effects.  But, fortunately, we keep getting better and better medications that are more effective and last all day and are safer with less side-effects.

 Newest med:test.askdrjones.com/2007/07/16/vyvanse-new-treatment-for-adhd/

     

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What Is ADHD and What Causes It?

ADHD is a personality type that is determined mainly by genetics.  Survival of the group is enhanced by variability of its members.  We wouldn’t want everyone to be the same.   Ancient tribes for example, needed a look-out person who could patiently maintain watch in case something happened.  That wouldn’t be an ADD person.  The ADD person needs much more stimulation.

The diagram shows the range of stimulation within which everyone functions.  You are excited at the higher end and relaxed at the lower end.  Everyone also has a level of stimulation below which they are bored and above which they are overstressed.  People with ADHD tend to have a problem at both ends.  They need higher stimulation than normal people and are stressed more easily.  They have trouble separating important from unimportant and tend to have too much on their mind.

Stimulants help both problems.  They turn on the brain to enable concentration on the lower level stimuli.  They also allow focus on one thing at a time, which helps the ADD person to be less hyper and more relaxed.

If a kid with ADD is playing baseball and you put him in the outfield, when the ball is hit to him you may ask – where is he?  The kid with ADD can’t pay attention in case something happens.  He may be digging a hole, or playing with stuff in his pocket or visiting with someone on the side-lines.  This inability to focus and separate the important from the unimportant is also seen in schoolwork (and in the case of adults, paperwork).

Boredom with routine is related to inadequate dopamine levels in the part of the brain that controls drive and motivation.  Easy distractibility is related to inadequate norepinephrine in the brain cortex.  Impulsivity is related to inadequate dopamine in the cortex.

ADD people focus on things that are interesting rather than things that are important.  They need action.  They are often the explorers, innovators and challengers in our world.

test.askdrjones.com/2007/07/16/vyvanse-new-treatment-for-adhd/

 

 

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What Is Psychopharmacology?

Psychopharmacology is the study of the use of medications in treating mental disorders. The complexity of this field requires continuous study in order to keep current with new advances. Psychopharmacologists need to understand all the clinically relevant principles of pharmacokinetics (what the body does to medication) and pharmacodynamics (what the medications do to the body). This includes an understanding of

  • Protein binding (how available the medication is to the body)
  • Half-life (how long the medication stays in the body)
  • Polymorphic genes (genes which vary widely from person to person)
  • Drug-drug interactions (how medications affect one another)

Since the use of these medications is to treat mental disorders, an extensive understanding of basic neuroscience, basic psychopharmacology, clinical medicine, the differential diagnosis of mental disorders, and treatment options is required. Psychopharmacologists also must be skilled in building and utilizing a therapeutic alliance with the patient.

Who Qualifies as a Psychopharmacologist?

In a generic sense, any physician who treats patients with psychotropic medication is a psychopharmacologist. Physicians who have completed residency training after medical school have a high level of understanding and expertise in pharmacology, including psychopharmacology. Psychiatrists (who have completed four years of advanced training after medical school) have an even higher level of understanding and expertise in psychopharmacology.

The term “psychopharmacologist”, however, may also be used in a more specific sense to mean a physician with training in advanced psychopharmacology. That is, some psychiatrists specialize even further in psychopharmacology through academic education, Continuing Medical Education (CME), or self-study.

Physicians who are certified by the American Board of Medical Specialties have demonstrated a high level of understanding and expertise in pharmacology and other areas of medicine. Only board certified medical specialists are eligible to take the ASCP’s Examination in Advanced Psychopharmacology. This rigorous exam covers all areas of psychopharmacology and requires a thorough understanding of the latest science that has relevance to clinical practice. The exam must be taken every 5 years.

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