Medication "stew" for typical MDE

[ghost dog]

Figure this one out. I dare you.

I saw a patient recently on the following meds:

Cipralex, Celexa, Trazodone, Amitriptyline , Seroquel , Librium , Propranolol PRN, and Clonazepam.

Her PHQ-9 score was : 8 / minimally depressed.

While I don't see a ton of psych patients, I did think this was very ******ed. I should add this patient had a hx of CHF / CAD and HTN.

The scripting practioner in question was older than Methuselah.

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[heyjack70]

the cipralex (escitalopram, I had to look it up) and citalopram combo, and librium/clonazepam are the real the deal breakers for me. Each essentially has the same MOA as the other so why combine them. Add to that my assumption that this pt is older given the heart disease and HTN, and you would want to limit bzd's and anticholinergics which is not being done. that being said, I don't know anything about the patient so take my comments with a very small grain of salt.

 

[ghost dog]

the cipralex (escitalopram, I had to look it up) and citalopram combo, and librium/clonazepam are the real the deal breakers for me. Each essentially has the same MOA as the other so why combine them. Add to that my assumption that this pt is older given the heart disease and HTN, and you would want to limit bzd's and anticholinergics which is not being done. that being said, I don't know anything about the patient so take my comments with a very small grain of salt.

Note: Lexapro = Cipralex

 

[ghost dog]

the cipralex (escitalopram, I had to look it up) and citalopram combo, and librium/clonazepam are the real the deal breakers for me. Each essentially has the same MOA as the other so why combine them. Add to that my assumption that this pt is older given the heart disease and HTN, and you would want to limit bzd's and anticholinergics which is not being done. that being said, I don't know anything about the patient so take my comments with a very small grain of salt.

When I put this laundry list of meds into my epocrates interaction checker, a lawyer icon popped up and said , "Have you been harmed by a doctor? Please call the law firm of Sokolov and associates today"

Operators are standing by.

 

[atsai3]

figure this one out. I dare you.

I saw a patient recently on the following meds:

Cipralex, celexa, trazodone, amitriptyline , seroquel , librium , propranolol prn, and clonazepam.

Her phq-9 score was : 8 / minimally depressed.

While i don't see a ton of psych patients, i did think this was very ******ed. I should add this patient had a hx of chf / cad and htn.

The scripting practioner in question was older than methuselah.

phq-9 = 8
gcs = 3

 

[billypilgrim37]

phq-9 = 8
gcs = 3

I think I just heard a rimshot behind me...

 

[whopper]

Citalopram should be to the maximum dosage possible for this patient before other medications are added. Again no need to be on two forms of it.

I've seen some doctors give out more than one antidepressant but neither was at the max dosage. This should only be done if there's a known benefit with both, but not with either to the same degree at the max dosage. (Max dosage meaning manufacturer's max or the max dosage where a patient gets side effects they can tolerate.) A recent study in the AJP showed that polypharmacy with antidepressants, in more cases than not, is not needed. (Although another article in the same issue also suggested that antipsychotics more often than not could have more benefit with polypharmacy, but IMHO polypharm should still be avoided unless there's an actual demonstrated benefit in the specific patient.)

The only thing that justifies Amitriptyline, IMHO is if somehow again this combo works and the other meds don't work alone, or if there's chronic pain.

Trazodone: helps with sleep, it could, in theory, augment the current antidepressants. Problem here is the sleep benefit over time will likely subside because this medication usually causes sleep tolerance. It also might not have been needed in the first place.

Seroquel: it does work as an antidepressant adjunct, but was it needed in the first place? Out of all the atypicals, it worsens QT prolongation the most per the CATIE trial (which did not take in account the newer atypicals such as Fanapt). I'm also suspecting if this patient has CHF and HTN, he likely has a poor metabolic profile. Seroquel, as we all know, is not the best choice in this regard for such a patient unless it's known to work and work well where other meds have failed.

Clonazepam and Librium: long-term benzo use is always a bad idea.

I hope the good aged doctor documented the benefit each med caused and why he put this poor patient on this medication gumbo. I'd bet the farm he didn't.

 

[billypilgrim37]

Probably needed all the benzos to treat the agitation from the serotonin syndrome the other drugs were causing.

 

[Bartelby]

Looking at that list makes me feel a little depressed.

 

[Doctor Bagel]

Maybe the trazodone and amitriptyline were prescribed a while ago for stuff other than depression and never got discontinued. Trazodone for sleep and amitriptyline for neuropathy? Then clonazepam for restless legs. Seroquel for sleep with the provider forgetting about the trazodone.

 

[whopper]

I was thinking the same. Not that it excuses the problem. If it's all from one doctor that's even worse.

I got a patient with complex regional pain syndrome and IMHO the pain is causing the depression. The primary doctor hasn't done much to treat it. I called his office to inform him that I think the chronic pain is the root of the problem given that she had no psychiatric problems whatsoever until her CRPS started.

I checked up the disorder on UpToDate and it turned out there's a heck of a lot of stuff that could've been done that hasn't been done. I gave her a printout of the findings.

Aside from that the guy isn't returning my calls, she told me she saw him last week and he didn't remember anything he did with her before. He walked into the office visit as if he didn't know her.

Point being that outpatient doctor communication blows, and several doctors aren't that good. When patients get caught between a multi-doctor problem this might not be solvable if the other doctors refuse to cooperate with each other as a team.

 

[Sneezing]

Patient collected all these meds over the years from different sources and no primary care doctor (or specialist) has taken ownership of the patient to do a legitimate medication reconcilliation. As a result the patient take some here, takes some there, and ultimately thinks they are taking them all...

 

[ghost dog]

Patient collected all these meds over the years from different sources and no primary care doctor (or specialist) has taken ownership of the patient to do a legitimate medication reconcilliation. As a result the patient take some here, takes some there, and ultimately thinks they are taking them all...

Nope, this isn't a case of "medication snowball."

In this scenario, I'm pretty sure this patient had received all her psych meds from 1 practioner (who graduated in 1949).

Needless to say, I diplomatically recommended that the majority of them be tapered and stopped.

 

[Manicsleep]

Nope, this isn't a case of "medication snowball."

In this scenario, I'm pretty sure this patient had received all her psych meds from 1 practioner (who graduated in 1949).

Needless to say, I diplomatically recommended that the majority of them be tapered and stopped.

Unfortunately, you are right about older physicians and its true in almost all specialties. Although I hate the idea of MOC, I think its a good thing because if you go to a board certified physician you know they have been tested in the past decade or are about to be tested. The whole grandfathering out loophole is just nonsense.

When you say you 'diplomatically' recommended they be tapered, what did you say and how did the patient take it? We are seeing a lot of patients from a physician who was older and his practice was a benzo bash so he attracted a lot of drug seekers but also a lot of legit patients who were actively offered benzos with ever increasing doses to treat all manner of disease. This doc was very personable and so very trusted (unfortunately) and a lot of the PCPs and now my psychiatrists are having a hell of a time with his patients.

 

[ghost dog]

Unfortunately, you are right about older physicians and its true in almost all specialties. Although I hate the idea of MOC, I think its a good thing because if you go to a board certified physician you know they have been tested in the past decade or are about to be tested. The whole grandfathering out loophole is just nonsense.

When you say you 'diplomatically' recommended they be tapered, what did you say and how did the patient take it? We are seeing a lot of patients from a physician who was older and his practice was a benzo bash so he attracted a lot of drug seekers but also a lot of legit patients who were actively offered benzos with ever increasing doses to treat all manner of disease. This doc was very personable and so very trusted (unfortunately) and a lot of the PCPs and now my psychiatrists are having a hell of a time with his patients.

The patient was sent to me for chronic pain management, and I will be seeing her in follow up. I sent a 5 page consult note to the scripting /
" Pyschiatrist " (who is actually an internist / biochemist by training - don't ask I have no idea).

I'll see what happens with all these psychoactive meds. My guess will be that he will chose to do the easiest thing - nothing. In this case, I will be picking up the phone and giving him a jingle.