Gary S. Sachs

Massachusetts General Hospital, Boston, Massachusetts, United States

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Publications (4)4.24 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: The original Expert Consensus Guidelines on the Treatment of Bipolar Disorder were published in 1996. Since that time, a variety of new treatments for bipolar disorder have been reported; however, evidence for these treatments varies widely, with data especially limited regarding comparisons between treatments and how to sequence them. For this reason, a new survey of expert opinion was undertaken to bridge gaps between the research evidence and key clinical decisions. The results of this new survey, which was completed by 58 experts, are presented in The Expert Consensus Guideline Series: Medication Treatment of Bipolar Disorder 2000, which was published in April 2000 as a Postgraduate Medicine Special Report. In this article, the authors describe the methodology used in the survey and summarize the clinical recommendations given in the resulting guidelines. The expert panel reached consensus on many key strategies, including acute and preventive treatment of mania (euphoric, mixed, and dysphoric subtypes), depression, rapid cycling, and approaches to managing treatment resistance and comorbid psychiatric conditions. Use of a mood stabilizer is recommended in all phases of treatment. Divalproex (especially for mixed or dysphoric subtypes) and lithium are the primary mood stabilizers for both acute and preventive treatment of mania. If monotherapy with these agents fails, the next recommended intervention is to combine them. This combination of lithium and divalproex can then serve as the foundation to which other medications are added if needed. Carbamazepine is the leading alternative mood stabilizer for mania. The experts rated the other new anticonvulsants as second-line options (i.e., their use is recommended if lithium, divalproex, and carbamazepine fail or are contraindicated). For milder depression, a mood stabilizer, especially lithium, may be used as monotherapy. Divalproex and lamotrigine are other first-line choices. For more severe depression, the experts recommend combining a standard antidepressant with lithium or divalproex. Bupropion, selective serotonin reuptake inhibitors (SSRIs), and venlafaxine are preferred antidepressants. The antidepressants should usually be tapered 2-6 months after remission. Monotherapy with divalproex is recommended for the initial treatment of either depression or mania in rapid-cycling bipolar disorder. Antipsychotics are recommended for use in combination with the above regimens for mania or depression with psychosis, and as potential adjuncts in nonpsychotic episodes. Atypical antipsychotics, especially olanzapine and risperidone, were generally preferred over conventional antipsychotics. The guidelines also include recommendations concerning the use of electroconvulsive therapy (ECT), clozapine, thyroid hormone, stimulants, and various novel agents for patients with treatment-refractory bipolar illness. The experts reached high levels of consensus on key steps in treating bipolar disorder despite obvious gaps in high-quality data. To evaluate many of the treatment options in this survey, the experts had to extrapolate beyond controlled data; however, their recommendations are generally conservative. Experts give their strongest support to initial strategies and medications for which high-quality research data or longstanding patterns of clinical usage exist. Within the limits of expert opinion and with the understanding that new research data may take precedence, these guidelines provide clear pathways for addressing common clinical questions and can be used to inform clinicians and educate patients about the relative merits of a variety of interventions.
    Journal of Psychiatric Practice 08/2000; 6(4):197-211. · 1.35 Impact Factor
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    ABSTRACT: Chronic unemployment is a major problem faced by many persons with schizophrenia. In this article, the author first reviews reasons why employment is an important goal for patients with schizophrenia. Employment appears to improve the clinical symptoms of schizophrenia. Employment also reduces the economic costs of the illness to society. The author then discusses predictors of positive employment outcomes in schizophrenia. Clinical symptoms, especially positive symptoms, do not appear to play a large role in predicting occupational functioning in schizophrenia. The author than reviews the evidence for the role of cognitive impairment in unemployment in patients with schizophrenia. In seven of the eight studies reviewed, significant relationships between cognitive functioning and work status/work behaviors were reported. These studies provide the basis for identifying those patients most at risk for the poorest occupational outcomes as well as those most likely to benefit from focused intervention.
    Journal of Psychiatric Practice 07/2000; 6(4):197-211. DOI:10.1097/00131746-200007000-00003 · 1.35 Impact Factor
  • Source
    G S Sachs · D J Printz · DA Kahn · D Carpenter · J P Docherty
    [Show abstract] [Hide abstract]
    ABSTRACT: New treatments for bipolar disorder have been reported since we first published survey-based expert consensus guidelines in 1996. The evidence for these treatments varies widely; data are especially limited regarding comparisons between treatments and how to sequence them. We therefore undertook a new survey of expert opinion in order to bridge gaps between the research evidence and key clinical decisions. Based on a literature review, a written survey was prepared which asked about 1,276 options for psychopharmacologic interventions in 48 specific clinical situations. Most options were scored using a modified version of the RAND Corporation 9-point scale for rating appropriateness of medical decisions. We contacted 65 national experts, 58 of whom (89%) completed the survey. Consensus on each option was defined as a non-random distribution of scores by chi-square test. We assigned a categorical rank (first-line/preferred choice, second-line/alternate choice, third-line/usually inappropriate) to each option based on the confidence interval of its mean rating. Guideline tables indicating preferred treatment strategies were then developed for key clinical situations. The expert panel reached consensus on many key strategies, including acute and preventive treatment for mania (euphoric, mixed, and dysphoric subtypes), depression, and rapid cycling, and approaches to managing the complications of treatment resistance and comorbidity. Use of a mood stabilizer is recommended in all phases of treatment. Divalproex (especially for mixed or dysphoric subtypes) and lithium are the cornerstone choices among this class for both acute and preventive treatment of mania. Regardless of which is selected first, if monotherapy fails, the next recommended intervention is to use these agents in combination. The combination can then serve as the foundation on which other medications are added, if needed. Carbamazepine is the leading alternative mood stabilizer for mania. Expert opinion regards other new anticonvulsants as second-line options (e.g., if the previously mentioned mood stabilizers fail or are contraindicated). For milder depression, a mood stabilizer, especially lithium, may be used as monotherapy. Divalproex and lamotrigine are other first-line choices. For more severe depression, a standard antidepressant should be combined with lithium or divalproex. Bupropion, selective serotonin reuptake inhibitors (SSRIs), and venlafaxine are preferred antidepressants, and should be tapered 2 to 6 months after remission. Divalproex monotherapy is recommended for initial treatment of either depression or mania with rapid cycling. Antipsychotics are recommended for use with the above regimens for mania or depression with psychosis, and as potential adjuncts in non-psychotic episodes. Atypical antipsychotics, especially olanzapine and risperidone, were generally preferred over conventional antipsychotics. Recommendations are also given concerning the use of electroconvulsive therapy (ECT), clozapine, thyroid hormone, stimulants, and various novel agents for patients with treatment-refractory illness. The experts reached high levels of consensus on key steps in treating bipolar disorder despite obvious gaps in high-quality data. To evaluate many of the treatment options in this survey, the experts had to extrapolate beyond controlled data; however, their recommendations are generally conservative. Experts reserve strongest support for initial strategies and individual medications for which there are high-quality research data, or for which there are longstanding patterns of clinical usage. Within the limits of expert opinion and with the understanding that new research data may take precedence, these guidelines provide clear pathways for addressing common clinical questions in a manner that can be used to inform clinicians and educate patients regarding the relative merits of a variety of interventions.
    Postgraduate Medicine 05/2000; Spec No:1-104. · 1.54 Impact Factor
  • Source
    David A. Kahn · Ruth Ross · David J. Printz · Gary S. Sachs
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    ABSTRACT: Bipolar disorder (also known as manic-depressive illness) is a severe biological disorder that affects slightly more than 1% of the adult population (more than 2.2 million people in the United States). Although symptoms and severity vary, bipolar disorder almost always has a powerful impact on those who have the illness and on their family, partners, and friends. If you or someone you care about has been diagnosed with bipolar disorder, you proba- bly have many questions about the illness, its causes, and treat- ments that are available. This guide is intended to answer commonly asked questions about bipolar disorder. The treatment information given here is based on research findings and a recent survey of approximately 50 leading experts on bipolar disorder.* WHAT IS BIPOLAR DISORDER? As human beings, we all experience a variety of moods—hap- piness, sadness, anger, to name a few. Unpleasant moods and changes in mood are normal reactions to everyday life, and we can often identify events that caused our mood to change. However, when we experience mood changes—or extremes—that are out of proportion to events or come "out of the blue" and make it hard to function, these changes may be due to a mood disorder. Mood disorders are medical illnesses that affect our moods and how we feel. There are 2 main types of mood disorders. In unipolar (1 pole) disorders, such as major depressive disorder, the mood changes all involve a lowering of mood. In bipolar (2 pole) disor- ders, at least some of the changes involve an excessive elevation in mood. All mood disorders are associated with changes in brain chemistry. They are not the fault of the person suffering from them. Mood disorders are treatable medical illnesses for which there are specific interventions that help.