Five Questions With: Dr. Mark Zimmerman

"While these medications have demonstrated efficacy, that does not mean that they are effective for all, or even most, patients. "

Dr. Mark Zimmerman is the director of outpatient psychiatry at Rhode Island Hospital and professor of psychiatry and human behavior at the Warren Alpert Medical School of Brown University. He recently published an opinion piece in The Journal of Clinical Psychiatry in which he said that “prescription medicine and therapy are effective for a wide range of psychiatric disorders, thus the need for precise diagnosis is often unnecessary.”

PBN: Is one of the conclusions for clinicians to draw from your opinion piece about the relative importance of diagnoses and treatment that if they are careful about treatment they do not necessarily need to be caught up in a precise diagnosis?
ZIMMERMAN
: I believe that diagnosis is important, and that comprehensive diagnostic assessments should be the standard of care. However, the data does not support this belief because the studies have not been done to examine this issue. While there is no data to suggest otherwise, the lack of such data is noteworthy. The purpose of the commentary was to highlight the lack of such data. While there are replicated studies demonstrating that clinical interviews miss diagnoses, there is no research demonstrating that this impacts upon outcome.

PBN: You write that most serotonin reuptake inhibitors are “effective for depression, almost all anxiety disorders, eating disorders, impulse-control disorders, substance use disorders, attention deficit disorder and some somatoform disorders.” That almost makes it sound as if medication has solved most mental health issues – is that your view?
ZIMMERMAN:
Of course not. While these medications have demonstrated efficacy, that does not mean that they are effective for all, or even most, patients. Moreover, even when patients improve on medication that does not mean that they are completely recovered.

PBN: What is the average length of a prescription for a serotonin reuptake inhibitor – and should it be longer or shorter than that?
ZIMMERMAN:
The chronic nature of many psychiatric disorders has resulted in increasing recommendations that medication be used for longer periods of time than they had been used in the past. On the other hand, a number of individuals are overtreated with medication. It is noteworthy than in the list of conditions that are SSRI-responsive, I did not include adjustment disorder. There is no evidence that medication is effective for adjustment disorder, and it is therefore critical to distinguish between adjustment disorder and major depressive disorder. In primary care, it is highly likely that adjustment disorder and major depressive disorder are not distinguished and many patients are likely treated with medication when it is not indicated.

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PBN: What is the current level of adherence when it comes to medications prescribed for mental health issues, and how could adherence be improved?
ZIMMERMAN:
The level of adherence is modest at best with up to half of patients stopping their medication within 3 months. Adherence can be improved by scheduling patients for a return visit sooner after initiating treatment. There is research to suggest that more frequent visits early in the course of treatment are associated with better outcome. I recommend that patients be seen at least twice within the first month of starting an

PBN: Is there one mental health condition that leads to the highest number of serotonin reuptake inhibitor prescriptions, and, if so, what is it?
ZIMMERMAN:
More antidepressant medications are prescribed by primary care physicians than psychiatrists. During the past 20 years drug companies have expended considerable effort in getting primary care physicians to better recognize depression, and to prescribe antidepressants. No comparable effort has been extended to improve the recognition of other psychiatric disorders. Consequently, antidepressant medications such as serotonin reuptake inhibitors are most frequently prescribed for depression.

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