0:15

Aside from our body , medicines

0:17

can affect our mind, too . That's

0:20

how drugs like antidepressants or

0:22

sedatives work , after all . But

0:25

what happens when those effects on

0:27

our behaviour are unwanted ? When

0:34

the medicines we take to keep our health in check alter our personality

0:36

in odd or dangerous

0:38

ways ? My

0:41

name is Federica Santoro , and

0:43

this is Drug Safety Matters , a

0:45

podcast by Uppsala Monitoring Centre

0:48

, where we explore current issues

0:50

in pharmacovigilance and patient

0:52

safety . Joining

0:55

me today is Michele Fusaroli

0:57

, medical doctor and pharmacovigilance

0:59

scientist from the University of

1:01

Bologna in Italy . Michele

1:07

is fascinated by the area of research where medicine

1:09

and behavioural science overlap , so it's no

1:11

surprise that he chose to focus his PhD

1:14

studies on behavioural effects

1:16

of drugs and specifically

1:18

on impulsivity . He

1:21

is currently visiting UMC for a research

1:23

collaboration and

1:26

as he's also a big fan of this podcast , I just had to

1:28

invite him to the studio for a chat . He

1:32

explained how impulsivity

1:34

manifests , which drugs

1:36

cause it , how to cope with

1:38

it, and much more . I

1:41

hope you enjoy listening . Hi

1:53

, Michele , and welcome to Drug Safety

1:55

Matters . I'm

2:03

really glad you could make time for this interview and come here to talk about your research

2:05

and behavioural side effects of drugs . How are you feeling

2:07

today ?

2:08

I'm really good , I'm really excited because

2:10

of the opportunity to talk with you and

2:13

with the listeners of Drug Safety

2:15

Matters about my research . This

2:17

podcast has been always invaluable

2:19

to me because of how it allows

2:21

you to access other workers'

2:24

perspective ,

2:29

and I believe experiences like Drug Safety Matters are vital for fostering collaboration

2:31

and allow us to advance pharmacovigilance

2:34

together .

2:34

What an endorsement . Well , I'm really glad

2:37

to hear that you found the podcast

2:39

useful and

2:41

I hope listeners will find that

2:43

these episodes spark

2:45

ideas for collaboration . So,

2:48

let's get right into it

2:50

. I'm really looking forward to learning

2:52

more about behavioural side

2:54

effects , because I have the feeling

2:56

it's a topic that's not discussed

2:58

nearly enough . Even

3:00

in everyday life, right, as patients taking

3:03

medicines , we tend to think more

3:05

about how medicines affect our

3:07

body , and not so much our

3:09

mind and behaviour . So,

3:12

why is that ? Why is

3:14

there so little talk about such

3:16

side effects ?

3:18

I believe we are still entrenched into

3:20

Descartes' body-mind dualism .

3:27

Descartes was a 17th century French philosopher and scientist that theorised that the body

3:30

and the mind are two separate entities

3:32

. This way of thinking has two

3:34

effects that make behavioural

3:36

side effects some sort of invisible: under-reporting

3:40

and under-acknowledgement . First

3:42

, we , as patients , under-report

3:45

behavioural side effects due to our reluctance

3:47

to acknowledge that organic

3:49

conditions and exposure to substances

3:52

may influence our

3:54

behaviours , our thoughts , our choices

3:57

– those components of what

3:59

we define as our identity . Imagine

4:01

, after taking a medication for

4:03

Parkinson's disease , for example , we

4:06

perform an action that we would normally

4:08

not perform , that even feels

4:10

strange to us . For example , we enter

4:12

into a car shop and we spend

4:14

all our money in buying an extremely

4:17

expensive car . Well , in

4:19

this situation , we may not

4:21

report these strange

4:23

things that happen to us just because we

4:26

fear judgment , because we

4:28

feel responsible . Second

4:30

, we , as healthcare practitioners

4:32

, under-acknowledge behavioural

4:35

side effects because medical

4:37

education taught us to diagnose

4:39

and treat only organic conditions

4:42

, up to the point that psychosocial conditions

4:44

are of interest to us only

4:46

if they have a tangible and measurable substrate

4:49

. Even mild physiological drug effects

4:51

, like a small increase in blood pressure

4:53

, are more readily acknowledged than severe

4:56

behavioural changes . For example

4:58

, our patient may take a drug for

5:00

schizophrenia and just

5:02

after that, they may develop aggressivity

5:04

. In this situation, just because

5:07

we were

5:13

taught to do that, we may hurriedly think that schizophrenia may be enough to

5:15

explain this anger , to explain this episode , and maybe we

5:17

are not even thinking about a potential

5:19

role of the medication . To

5:21

sum up , the reason for so little

5:23

talk of behavioural side effects

5:26

is that there are both under-reporting

5:28

and under-acknowledgement .

5:30

And we'll try to dissect those

5:33

elements a little more in the

5:35

rest of the interview . We

5:38

advertised , as usual , the interview

5:40

on our social media channels , and

5:43

one of our listeners cited

5:45

an example of how drugs can affect

5:47

cognition . She cited

5:50

tamoxifen , which is a drug normally

5:52

used to treat breast cancer , and

5:54

how it can , on occasion , induce

5:56

brain fog . Have you heard about

5:59

that reaction ?

6:00

Indeed , there is evidence that tamoxifen

6:03

may be toxic for neural

6:05

cells and therefore may result

6:07

in a loss of focus and

6:09

even in memory impairment . Another

6:11

well-established effect of drugs on cognition

6:14

and behaviour is that of irritability

6:17

and aggressivity associated with

6:19

chronic use of corticosteroids . Well

6:21

, all drugs have adverse drug

6:23

reactions , and still we need their

6:26

beneficial effect , at least as long

6:28

as the underlying disease is worse than

6:30

the side effects themselves .

6:32

Absolutely . It's always about weighing the

6:34

benefits against the risks . But

6:36

you're more of an expert on behaviour

6:39

rather than cognition , as far as I understand

6:41

, and you specialise in

6:43

a particular kind of behavioural side

6:45

effects known as drug-induced

6:48

impulse control disorders . Now

6:50

, I know that may sound like a mouthful for our

6:52

listeners , but don't worry , we will explain

6:55

what they are . Let's start with

6:57

the basics , then . How do these disorders

6:59

manifest ?

7:01

If you have a drug-induced impulse control disorder

7:03

, it means that you have a difficulty

7:06

in resisting the urges or

7:08

temptation to behave in a certain

7:10

way , and this in turn affects

7:12

your well-being and may even harm

7:14

people around you . Four main

7:17

manifestations , termed as the

7:19

'four knights' of impulsivity , have

7:21

an apocalyptic effect on the quality of

7:24

life of patients and their families

7:26

. They are drug-induced pathological

7:28

gambling , hypersexuality

7:30

, compulsive shopping, and overeating

7:33

. However , impulse control disorders

7:35

vary widely and they

7:37

can take any form in the spectrum

7:39

of human behaviours , and they

7:42

usually align with the cultural

7:44

roles , social roles, and even life

7:47

experiences of the patient

7:49

. For instance , historically

7:51

, hypersexuality has been more prevalent

7:54

among men and compulsive shopping among

7:56

women, and these conditions are

7:58

distributed nowadays a bit more equally

8:01

, and this also reflects a change

8:03

in our society and in our culture

8:05

. In some Islamic countries , impulsivity

8:08

may affect some otherwise

8:10

completely normal religious behaviours , such

8:12

as resulting in excessive charity

8:15

or compulsive reading of the

8:17

Quran , even many hours per

8:19

day . Another example is

8:21

that of individuals with administrative

8:23

jobs , who may compulsively

8:26

organise documents , for example , and there are

8:28

also case reports in the literature

8:30

that describe some patients writing

8:32

poems or love

8:34

letters up to 12 hours per

8:36

day .

8:37

So I guess the manifestation varies

8:39

depending on who you are and what you normally

8:42

like to do or what kind of activities

8:44

you're drawn to .

8:45

Exactly .

8:46

What drugs are more likely to cause

8:49

these types of disorders , and is

8:51

it known why ?

8:53

There are two drug classes with an established

8:55

role in increasing impulsivity:

8:57

dopamine agonists , which are used in

8:59

Parkinson's disease , restless leg syndrome,

9:02

and prolactinoma; and third-

9:04

generation antipsychotics, used in

9:06

psychosis and mood disorder . The

9:08

exact mechanism , in fact , is

9:10

still underdefined . We

9:13

know that these drugs can directly enhance

9:15

dopaminergic activity in the nucleus

9:17

accumbens , that is , a region

9:19

of the brain involved in both

9:22

physiological motivation and pathologic

9:24

addiction . We also know that they may

9:27

switch off a serotonergic pathway

9:29

that normally modulates dopamine

9:31

levels in the nucleus accumbens . Given

9:34

these mechanisms' speculations

9:36

, we may also imagine that antidepressants

9:40

and psychostimulants in other situations

9:42

, in other conditions , may have

9:45

an effect on impulsivity . Anyways

9:47

, as always in science , there

9:49

are plausibly multiple mechanisms at

9:51

work , and we still have much

9:54

research to do in front of us to

9:56

really understand them .

9:58

What about frequency ? So, how

10:00

often do these side effects

10:02

manifest with these drugs ?

10:07

Exact frequencies are unknown . This is also because of

10:09

lack of a clear definition

10:11

of when impulsivity

10:13

becomes a disorder and also

10:15

because there is an extremely heterogeneous

10:17

time to onset . We can have

10:19

impulsivity days

10:21

or months or even years

10:24

after the first administration of the

10:26

medication . For this reason

10:28

, estimates range from 2 to

10:30

60% in different study

10:33

designs with different impulsivity

10:35

definitions . A plausible estimate

10:37

is that around 50% of patients

10:39

taking dopamine agonists develop

10:41

impulse control disorders within

10:44

five years . For

10:49

third-generation antipsychotics instead , the frequency

10:52

is even less clear . There is some idea , some evidence that supports

10:54

an even higher risk relative to dopamine

10:56

agonists , but these may also

10:58

be distorted by the fact that it

11:00

seems that third-generation antipsychotics may

11:02

cause impulsivity in just

11:05

days or weeks .

11:07

Are there any risk factors that can predispose

11:10

a patient to such disorders

11:12

?

11:13

Yes , there are . The main risk factors

11:15

are pre-existing depression and

11:17

impulsivity traits, for example,

11:19

if someone has novelty-seeking

11:22

personality , or it

11:24

is more common for males , for young

11:26

people, or for people

11:28

that had a history of

11:30

alcoholism , of smoking,

11:32

or even excessive coffee consumption

11:34

. Other possible risk factors

11:37

for impulsivity are higher

11:39

doses of dopamine agonists and

11:42

also certain genetic factors may

11:44

play a role .

11:45

From everything you've said, it can't be

11:47

easy to live with an impulse control

11:50

disorder , and you've mentioned a few examples

11:52

, but can you help us understand exactly

11:55

how patients are impacted . Like,

11:57

to what extent do these disorders

12:00

affect quality of life ?

12:02

The impact of impulse control disorders varies

12:05

greatly depending on their expression

12:07

and severity . Mind that the impact

12:10

of impulsivity may not

12:12

always be negative , it may also

12:14

be positive . In fact , individuals

12:16

with Parkinson's disease usually have

12:18

lower levels of dopamine in

12:20

the nucleus accumbens and therefore

12:22

also lower motivation . And

12:25

when they start getting dopamine agonists

12:27

we sort of normalise

12:29

their dopamine levels in the nucleus

12:31

accumbens , we boost motivation

12:34

and creativity . And what

12:36

the patients experience in the first months

12:38

of dopamine agonist treatment is

12:40

an actual honeymoon period in

12:42

which they start again getting involved

12:45

in activities , in which they even

12:47

develop new hobbies . However

12:49

, problems arise when impulsivity

12:51

gets out of control . In

12:53

this situation , the

12:56

pathologic behaviours consume

12:58

the entire life of the individual and

13:00

it can have a serious impact on the

13:02

financial stability , on the social relationships

13:05

, on the employment of the individual

13:07

. It can even cause legal issues . Moreover

13:10

, there are also expressions that are more

13:12

specific to the behaviour . Pathological

13:14

gambling and compulsive shopping , for example

13:17

, result more often in higher

13:19

loss of money and therefore can

13:21

have more problem in financial stability

13:24

and in the social relationships

13:26

. Hypersexuality, instead

13:28

, is usually associated with marital

13:30

problems , with sexually transmitted

13:32

diseases , depending on the age

13:34

also in unintended pregnancy

13:37

and sexual dysfunction . Overeating

13:39

instead can lead to obesity , metabolic

13:42

syndrome , sleep apnoea . And we

13:44

don't have to think that other behaviours

13:47

that are not among these four have

13:49

no impact on the quality of life . For example , even

13:51

a seemingly harmless compulsive

13:54

gardening may cause excessive

13:57

expenditure of money and may

13:59

result in the patient staying outside in

14:01

the garden and doing work , even

14:03

during a storm , for example , with serious

14:06

danger for their life .

14:07

Exactly . So, quite serious consequences

14:10

, even though they may sound as harmless

14:12

behaviours to begin with . Something

14:14

to keep in mind . Let's

14:17

move on to the diagnosis now , which

14:19

I imagine must be really

14:21

challenging , not least because

14:24

of what you said earlier , that it

14:26

can be really difficult to distinguish

14:28

compulsive actions from normal

14:30

ones . I mean, behaviour , even

14:32

in a normal situation, occurs on a spectrum

14:35

, so how do you tell what's normal

14:37

from pathological ? So, if

14:39

we go back in time

14:41

, can you tell me how these disorders were

14:44

identified in the first place ?

14:46

I think the first time was in 2003

14:49

, when Driver- Dunckley and colleagues from

14:51

the Barrow Neurological Institute in Phoenix

14:53

published a study , a case

14:55

series , with nine cases

14:58

of pathological gambling that

15:00

developed after taking dopamine agonists

15:02

. What raised a concern and

15:04

a suspicion of adverse drug reaction

15:07

was not the time to onset , because

15:09

the average was around 20

15:11

months . It wasn't even the frequency

15:13

, because it wasn't really significantly

15:16

higher than what expected based on the entire

15:18

population . What raised

15:20

a concern was the

15:23

seriousness of the event . These

15:25

patients started gambling without

15:28

any control . They started losing more

15:30

and more money and even one

15:32

patient committed suicide after

15:34

an extremely severe episode of gambling

15:41

. Interestingly , reducing the dose or switching to alternative

15:43

medication showed promise in mitigating this condition and also

15:45

, as we said before , subsequent

15:48

research highlighted that there

15:50

is an extreme difference between the low

15:52

motivational drive that is implicit

15:55

in Parkinson's disease and

15:57

the extreme motivational drive that we observe

15:59

when patients take dopamine agonists

16:01

.

16:03

And what about the

16:06

other class of drugs you mentioned at

16:08

the beginning , so these third- generation

16:10

antipsychotics ? Was it even

16:12

trickier to associate abnormal

16:15

behaviours to those types of drugs

16:17

, since they are used in conditions

16:20

like psychosis or bipolar

16:22

disorder that are already marked

16:25

by impulsivity ? How did it work

16:27

out for those drugs ?

16:29

Yeah , it was more challenging . In

16:31

fact , third-generation antipsychotics- induced

16:33

impulsivity may be considered that

16:36

sort of 'black swan' that

16:38

François Montastruc spoke about in

16:40

the last episode: therefore , an event

16:42

, a reaction that is completely

16:45

unexpected and also particularly

16:48

serious . Healthcare providers

16:50

initially blamed the disease and

16:53

not the drug . For example , they attributed

16:55

the impulsivity episode to schizophrenia

16:57

or to a bipolar disease

16:59

. Consequently , when in 2014

17:03

a disproportionality analysis on the FDA

17:05

adverse event reporting system found

17:08

a signal of potential

17:10

adverse drug reaction between aripiprazole and

17:13

impulse control disorders , most

17:16

of the reports were from patients , not

17:18

from doctors . Doctors

17:20

, in fact , started to report only

17:22

after 2016

17:24

, when an FDA warning came out . The

17:27

key factor aiding in the detection

17:30

of this signal was the

17:32

patient's experience , just a few

17:34

days after taking the first

17:36

dose of aripiprazole , of

17:38

an extreme loss of

17:40

control . Also , behaviours

17:43

that they may have shown before the

17:45

first administration of the drug, for example , they

17:48

are patients that may be more susceptible

17:50

to gambling and to compulsive

17:52

shopping and hypersexuality because of the

17:54

underlying disease, started

17:56

spiralling down and

17:59

they completely resolved

18:01

after the discontinuation of the drug

18:03

. I think that

18:05

the journey of discovery of impulse control

18:08

disorders induced by third- generation

18:10

antipsychotics has an important

18:12

message for us . That is to

18:14

listen to the patients . Patients

18:17

should be acknowledged as the main expert

18:19

of their disease , of their experience

18:22

of disease , and they should

18:24

be actively involved

18:26

as primary

18:28

stakeholders in clinical

18:30

practice , but also in signal detection

18:33

and signal refinement .

18:35

And that message truly resonates with us

18:37

. We have at least two

18:39

episodes in the archives on patient

18:42

engagement and patient

18:44

voices in pharmacovigilance , but

18:46

you raise so many important points . It's

18:48

also so fascinating to hear what

18:50

sparks that initial

18:52

suspicion . I think that's what makes the

18:55

job of pharmacovigilance professionals so

18:57

interesting . So,

19:00

we've looked at the past and how

19:02

these conditions were first

19:04

identified . Back to

19:06

present day: so, how are

19:09

drug-induced impulse control

19:11

disorders diagnosed

19:13

nowadays ?

19:15

If you listen to the recent episode on drug-induced

19:18

liver injury by Rita Baião

19:20

, you know that diagnosis

19:22

in medicine is usually based on

19:24

well-defined diagnostic criteria , and

19:27

the problem here is that we really

19:29

don't have those diagnostic criteria . There

19:32

are some scales that can

19:34

be used to diagnose and stage

19:36

impulsivity in Parkinson's disease

19:38

, like QUIP and Ardouin

19:41

, but they have

19:43

extremely well-recognised limitations

19:45

. For example , they consider only a

19:48

few possible behaviours

19:50

as manifestation . They don't include , for example

19:52

, kleptomania that may be one

19:54

of the manifestations of drug-induced impulsivity

19:57

. Timely diagnosis should

19:59

therefore rely on two

20:01

main factors . The first is

20:03

education of patients

20:06

and their caregivers on what

20:08

is the risk of impulse control disorder

20:10

, how they manifest, and even

20:12

their impact on quality of life . Second

20:15

, a timely diagnosis also

20:17

has to rely on frequent interviews

20:20

with both the patient and the caregiver

20:22

, because the patient may

20:24

sometimes be shy

20:26

or even reluctant to

20:28

report something because

20:30

they feel ashamed .

20:32

Of course . So that's a really important message

20:34

for patients , their carers, and

20:36

healthcare professionals . Be vigilant and

20:39

raise an alarm if you have

20:41

a suspicion that there might be something at

20:43

play here . We've talked about

20:46

then the diagnosis , complicated as

20:48

it may be . Once that has been

20:50

made , what strategies

20:52

can doctors or patients

20:54

themselves adopt to deal

20:56

with such behaviours and potentially

20:59

counteract them ?

21:01

As soon as there is an even mild impairment

21:03

of the biopsychosocial function

21:05

of the patient or the caregivers

21:07

, that is the time when

21:10

an intervention is needed, before

21:12

any severe or even irreversible

21:15

deterioration of quality of life happens

21:17

, such as those related with loss

21:19

of employment , divorce, or

21:22

legal issues . There isn't abundant

21:24

evidence on how to manage these conditions

21:27

. Here at UMC , I am

21:29

using individual case safety reports

21:31

to try to map how people

21:34

are already managing these

21:36

reactions in the real world , to

21:38

identify some pitfalls and some

21:40

good practices . Discontinuing

21:42

the drug may suffice for third-generation

21:45

antipsychotics . For dopamine

21:47

agonists it is more challenging . A

21:50

year after discontinuation , still

21:52

50% of the patients hasn't

21:54

resolved . A consensus

21:57

group for managing impulsivity in Parkinson's

21:59

disorders recently published

22:01

an expert opinion-based guideline . They

22:04

recognize the pivotal role of

22:06

involved caregivers and of

22:08

psychosocial interventions . For

22:10

example , for pathological gambling and compulsive

22:12

shopping , it may be extremely useful to

22:14

restrict access to credit cards and

22:17

to casinos and shops . For

22:19

example, it can also be useful to restrict access

22:21

to the internet , since many

22:24

of these behaviours are enacted

22:26

also online today , both gambling

22:28

, compulsive shopping , hypersexuality,

22:30

and so on . Sometimes

22:32

it may also be necessary to seek legal

22:34

support or even social support

22:36

. Concerning the pharmaceutical

22:39

management instead , these experts

22:41

could only agree on the need for closely

22:43

monitoring and tapering down dopamine

22:46

agonists at the first sign of

22:48

impairment . In fact , cautiously

22:50

, because there are some risks of

22:52

withdrawal syndrome , of

22:54

a long-term apathy and

22:56

of worsening of the motor symptoms

22:59

of Parkinson's disease itself as

23:01

soon as we discontinue the

23:03

drug . When this is

23:05

not sufficient , then the management

23:07

relies more on trial and error . There

23:09

are some strategies that received

23:12

more than 50% agreement

23:14

in this expert opinion . That is still low

23:17

as an agreement , but they

23:19

are , for example , cognitive behavioural

23:21

therapy, they are quetiapine

23:24

, clozapine, or even deep brain

23:26

stimulation that consists in surgically

23:29

placing some electrodes

23:31

in the brain to modulate its activity

23:33

.

23:34

So, it is complicated , but there are

23:36

ways to alleviate these

23:39

conditions and I

23:41

guess the general advice, as with any side

23:43

effect, just never stop taking

23:45

the drug unless you consult your physician,

23:48

right ? There's a reason why you've been put on it in

23:50

the first place . Back

23:52

to our social media

23:54

questions . We have another query

23:57

that came in from one of our listeners . Sudarshan

24:00

in India asked something

24:02

that is related to one of

24:04

the projects you are working on here

24:06

at UMC . He asks, how

24:09

does pharmacovigilance work

24:11

in these complicated scenarios

24:14

? As we've said , it's not always easy

24:16

to differentiate the adverse

24:18

event from the underlying disease

24:20

. So, can you tell us , as

24:23

a pharmacovigilance professional , how do you

24:25

think when approaching both

24:27

the identification but also the assessment

24:30

of reports in these conditions ?

24:33

At the UMC , I am now investigating methylphenidate-related

24:36

impulsivity . Methylphenidate

24:39

is a psychostimulant drug that is used

24:41

in ADHD to treat inattention

24:43

and impulsivity , but its effects

24:46

seem to be dependent on the baseline condition

24:49

, for example , of neurotransmitter of

24:51

the patient . There is some

24:53

evidence that, in some cases

24:55

, methylphenidate may aggravate or

24:57

even cause impulsivity , and

25:00

this is a 'black swan' , even more than antipsychotics

25:02

. A drug used to treat a condition

25:04

that , in certain situations , may

25:06

cause it . How to deal with

25:08

such a difficult situation ? Well , the first

25:11

thing we need to do is

25:13

to make sure that the reports we are

25:15

looking at are actually of a suspected

25:17

adverse drug reaction . We may also

25:19

have , sometimes , a report , for example

25:22

, of inefficacy: that is

25:24

, the drug was taken to treat

25:26

impulsivity but it

25:29

didn't work and therefore impulsivity is still

25:31

there . Another report that we may

25:33

observe is a resurgence of

25:35

impulsivity because of a drug shortage

25:37

. Therefore , like in the apothecary

25:39

there wasn't any more methylphenidate

25:42

, the patient stopped

25:44

to take it and impulsivity came back

25:46

. And narratives , when available

25:48

, are extremely useful to

25:51

differentiate between these different kinds

25:53

of reports . When we have identified

25:56

reports of suspected methylphenidate-induced

25:59

impulsivity , then we

26:01

can apply the usual causal indicators

26:03

that we use in causality

26:06

assessment . For example , we can look

26:08

into the temporal relationship , into

26:10

the exclusion of alternative causes . Yes

26:13

, we know that there is always ADHD

26:15

there as an underlying possible

26:17

cause . We can look at the relation

26:19

with the dose , at the challenge

26:21

and re-challenge . So, what happened when we stopped

26:23

the drug and we administered again

26:25

the drug ? And , particularly

26:28

important , as we have learned

26:30

from the case of impulse control disorder

26:33

, we can also look into the

26:35

experience of the patient, that

26:37

something happened , that something is different

26:39

from before .

26:46

This is such a complicated topic . I think we've described so many aspects of

26:48

it as challenging and difficult to approach . So, if you were

26:50

to wrap up on an encouraging note

26:53

, what would you say to patients

26:55

who are dealing with such difficult

26:57

conditions , or to healthcare

26:59

and pharmacovigilance staff who are trying

27:01

to help those patients ?

27:04

I often draw parallels between drug-induced

27:06

impulse control disorders and

27:08

Herman Melville's "Moby Dick"

27:10

. At first , the great white whale

27:12

serves as a driving force , even

27:15

a purpose , for Captain Ahab . It

27:17

is something positive that gives meaning

27:19

to their life . Yet it

27:21

evolves into an overwhelming obsession

27:23

, a compulsion that ultimately

27:25

drags Ahab into the depths of

27:27

the sea . Similarly , impulsivity

27:29

may start innocently and may

27:31

even be positive , as we said for the

27:34

honeymoon period in Parkinson's

27:36

disease , but it can also escalate

27:38

into a serious issue . Recognising

27:46

when we are losing control and seeking help is therefore crucial . We have to remember that

27:48

a diagnosis is not a conviction

27:50

. It is not a

27:53

stigmatising label . A

28:00

diagnosis is instead a tool to identify and address some needs that we have . To regain control

28:02

, we must lean on the people that surround us

28:04

. Caregiver involvement is still

28:06

the best predictor of recovery

28:09

from dopamine agonist-induced impulsivity

28:11

. The message is that we

28:13

don't have to face these battles alone . By

28:21

relying on our loved ones , we can receive the treatment that we actually need while keeping control

28:23

of our impulses . We can together navigate

28:25

the depths while keeping our vessel

28:27

steady and avoid being dragged into the

28:29

abyss by our own personal

28:32

white whale .

28:33

And I think we'll end on that encouraging note

28:35

. Don't be afraid to speak up . If

28:37

you have a suspicion that something's wrong

28:39

, do talk with your loved ones or

28:42

your healthcare professional . Well

28:44

, thank you very much for taking the time to

28:46

come on the show . Thanks . That's

29:07

all for now , but we'll be back soon with more conversations on medicines safety . If you'd like

29:09

to know more about drug-induced impulsivity

29:11

and Michele's research , check

29:13

out the episode show notes for useful

29:16

links . If you like our

29:18

podcast , subscribe to

29:20

it in your favourite player so you won't

29:22

miss an episode , and spread

29:24

the word on social media so other listeners

29:26

can find us . Apart

29:29

from these in-depth conversations with experts

29:31

, we host a series called

29:33

Uppsala Reports Long Reads

29:35

, a selection of audio stories

29:38

from UMC's pharmacovigilance news

29:40

site , so do check

29:42

that out, too . Uppsala

29:44

Monitoring Centre is on Facebook , LinkedIn

29:47

and X, and we'd love

29:49

to hear from you . Send us

29:51

comments or suggestions for the show

29:53

or send in questions

29:55

for our guests next time we open

29:58

up for that . For

30:00

Drug Safety Matters, I'm Federica

30:02

Santoro . I'd like to thank

30:04

Michele Fusaroli for his time , our

30:07

listeners Nur Azra and Sudarshan

30:09

for submitting questions , Matthew

30:12

Barwick for production support, and

30:15

of course you for tuning

30:17

in . Till next time .