Prozac TID... WHY?

[heysexylady]

I have a patient in clinic that I inherited that was started on this regimen in the 90s and still on this regimen. What would be the reasoning behind this.

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[romanticscience]

My initial thoughts: None really. Multiple day dosing could be used to mitigate initial side effects. After steady state is reached, this would have negligible effect on mean plasma level.


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[Blitz2006]

Especially since Prozac half life is like 90 hours...

 

[wolfvgang22]

Sometimes prescribers do this because the patient thinks it works better this way (placebo effect). If I have a choice between starting a benzo on an unhappy patient who is taking Prozac 20 mg PO QAM and is demanding a benzo or other quick fix medication, but I don't really think has a problem that can be solved with medication, I might prescribe Prozac 10mg TID. It's worked before, pragmatically. Ethically, it may not be ideal, but it can prevent drawn out arguments with the patient who will ultimately fire you, will report you to the patient advocate, and avoid mini investigations by administration regarding such a dysthymic patient with a personality disorder. Prozac 10mg TID in isolation is unlikely to cause harm, and if the patient actually takes it, might help.
I don't usually do this kind of thing, but sometimes is the less bad choice.
Alternatively, some prescribers just don't know how SSRIs work.

 

[PistolPete]

I have a patient in clinic that I inherited that was started on this regimen in the 90s and still on this regimen. What would be the reasoning behind this.

Was it prescribed by a psychiatrist, or some other kind of prescriber?

 

[Ψ-117]

Perhaps the patient is an ultra-fast metabolizer...

 

[heysexylady]

Was it prescribed by a psychiatrist, or some other kind of prescriber?

Perhaps the patient is an ultra-fast metabolizer...

I'm not sure if it was a psychiatrist or not. He just said it was his doctor at home (another state). Knowing him.... I'm leaning towards thinking the original prescriber being a psychiatrist.

I don't think it was because he was a rapid metabolizer because he said that he was started on three times a day and didn't think it was unusual until I commented on his regimen.

 

[Merovinge]

I don't think it was because he was a rapid metabolizer because he said that he was started on three times a day and didn't think it was unusual until I commented on his regimen.

I'm pretty sure the rapid metabolizer was a joke. Prozac and it's active metabolite has such a long half-life that its available as once weekly dosing. Would need to have the most superhuman metabolism to make TID the appropriate dosing and lord knows what the dose would need to be. Likely started that way be a bad prescriber and some chance its a placebo thing like wolf mentioned above.

 

[birchswing]

I have been until last week on Paxil 3x/day (10 mg). (I recently dropped 10 mg, which is another story. I will tell it if anyone cares, but probably not appropriate for this forum, although it might be interesting because it's a rather rare occurrence.)

I was initially on Paxil 30 mg 1x day.

When Paxil CR came out, my psychiatrist at the time wanted me to switch, in spite of the fact that it had very little half-life difference. The only thing it seemed to help with according to the research was nausea, which I did not have.

But my main reason for not wanting to switch to Paxil CR was that I had been on brand name Paxil and it had been recalled from GSK's plant in Puerto Rico, which if you look back on the FDA's report was a hot mess. They eventually sent in armed guards to raid the facility because of all the problems it had. I was on generic Paxil and did not want to go back on anything made by GSK.

My psychiatrist was miffed that I wouldn't switch to Paxil CR, and in what I think was a temper tantrum, insisted that I then agree to switch to Paxil 3x daily. I can't recall how long ago this was, maybe a decade or so, and it was then grandfathered in among several psychiatrists I've seen since then.

So, that's one explanation for an irrational use of SSRIs multiple times daily.

It probably makes *slightly* more sense with Paxil than Prozac due to the relatively short half-life of Paxil. Although even twice daily would be well more than enough to make up for any troughs.

 

[sunlioness]

Yeah. If I have a patient on a regimen like that it's because they told me it works better that way and I got tired of arguing.


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[MLT2MT2DO]

I have been until last week on Paxil 3x/day (10 mg). (I recently dropped 10 mg, which is another story. I will tell it if anyone cares, but probably not appropriate for this forum, although it might be interesting because it's a rather rare occurrence.)

I was initially on Paxil 30 mg 1x day.

When Paxil CR came out, my psychiatrist at the time wanted me to switch, in spite of the fact that it had very little half-life difference. The only thing it seemed to help with according to the research was nausea, which I did not have.

But my main reason for not wanting to switch to Paxil CR was that I had been on brand name Paxil and it had been recalled from GSK's plant in Puerto Rico, which if you look back on the FDA's report was a hot mess. They eventually sent in armed guards to raid the facility because of all the problems it had. I was on generic Paxil and did not want to go back on anything made by GSK.

My psychiatrist was miffed that I wouldn't switch to Paxil CR, and in what I think was a temper tantrum, insisted that I then agree to switch to Paxil 3x daily. I can't recall how long ago this was, maybe a decade or so, and it was then grandfathered in among several psychiatrists I've seen since then.

So, that's one explanation for an irrational use of SSRIs multiple times daily.

It probably makes *slightly* more sense with Paxil than Prozac due to the relatively short half-life of Paxil. Although even twice daily would be well more than enough to make up for any troughs.

Your odd dosing has more to do with your axis 2 disorder than your axis 1.

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[birchswing]

Your odd dosing has more to do with your axis 2 disorder than your axis 1.

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I'm open to that and have inquired about it, but no one has seen fit to ascribe such a diagnosis to me, at least not to my knowledge. I understand it's possible to see something glaring and I won't deny anyone's reality, but there's also a unique and limited context to anonymously posting online. Given the nature of this forum to not proffer medical advice, I will defer to my own understanding of my situation and the manner it's been explained to me by those who know me. I'm sorry if the vignette I shared about how a person could end up an SSRI TID was in a grey area. Calling it a temper tantrum was the fastest way I could think to convey the situation. In reality, I can only say that one event followed another. I declined Paxil CR; I was told that if I was going to not take Paxil CR that I had to take Paxil three times a day.

 

[MLT2MT2DO]

I'm open to that and have inquired about it, but no one has seen fit to ascribe such a diagnosis to me, at least not to my knowledge. I understand it's possible to see something glaring and I won't deny anyone's reality, but there's also a unique and limited context to anonymously posting online. Given the nature of this forum to not proffer medical advice, I will defer to my own understanding of my situation and the manner it's been explained to me by those who know me. I'm sorry if the vignette I shared about how a person could end up an SSRI TID was in a grey area. Calling it a temper tantrum was the fastest way I could think to convey the situation. In reality, I can only say that one event followed another. I declined Paxil CR; I was told that if I was going to not take Paxil CR that I had to take Paxil three times a day.

I apologize I thought you had actually posted an axis 2 diagnoses you carried in the past.

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[birchswing]

I apologize I thought you had actually posted an axis 2 diagnoses you carried in the past.

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No problem.

 

[thoffen]

We are getting to far into medical advice here IMO.

Paxil is a short half-life drug. Prozac is a very long half-life drug. Aside from labeling, there is some potential rationale for split dose paxil.

RE: the other, the real thing we should be understanding is not why crazy regimens sometimes work, it's why we believe that non-crazy regimens do. And I am in no way suggesting our drugs have no efficacy.

 

[DD214_DOC]

I inherit stuff like this all the time. It doesn't make sense and is totally unnecessary, but the parents swear it works better. Don't try to change it, because even if it works, it won't.

 

[666357]

Many of these folks have comorbid personality disorders (not suggesting your patient does).
Don't try to interpret someone's history by their Rx list.
I have several patients with dependent personality d/o's and cormorbid depression and anxiety/panic d/o.
I've done this on a number of occasions with antidepressants and other categories of meds as well.
These folks often are the ones that end up on some dangerous med combos, typically involving our friend Xanax.
Rather than add on more drugs, sometimes it just more effective (and safer) if you say something like, "Well maybe we'd get better daytime coverage of those symptoms if we split the dose in half..."
If it does no harm, then there oughtn't be any harm in trying it. If they respond well to the change, then so what? Leave well enough alone. If I inherit a patient from a doctor who's retiring and they're on Prozac 10mg TID and stable/euthymic, guess what? I'm refilling that Rx exactly the same. The dumbest thing I could do is try to explain why it doesn't make sense pharmacologically (not to mention waste my time).
Placebo isn't a psychological phenomena, it's one of our tools. Yeah, I get it though. From a pharmacological perspective it makes no sense, but we're not practicing psychopharmacology, we're practicing psychiatry and boy does it may your life easier when you follow up with someone who's on Prozac 10mg tid and they're telling you it's the perfect regimen for them. Your real struggle with doing things like this is overcoming your own ego for fear of ridicule/embarrassment by another colleague who understands the medication and not having the opportunity to justify or explain your medical decision making. But don't let that stop you. You're the brilliant psychiatrist who has kept their patient euthymic, stable, functional, and off of those other nasty meds.
Rx: Prozac 10 mg TID, #90, 3RF

 

[smalltownpsych]

Many of these folks have comorbid personality disorders (not suggesting your patient does).
Don't try to interpret someone's history by their Rx list.
I have several patients with dependent personality d/o's and cormorbid depression and anxiety/panic d/o.
I've done this on a number of occasions with antidepressants and other categories of meds as well.
These folks often are the ones that end up on some dangerous med combos, typically involving our friend Xanax.
Rather than add on more drugs, sometimes it just more effective (and safer) if you say something like, "Well maybe we'd get better daytime coverage of those symptoms if we split the dose in half..."
If it does no harm, then there oughtn't be any harm in trying it. If they respond well to the change, then so what? Leave well enough alone. If I inherit a patient from a doctor who's retiring and they're on Prozac 10mg TID and stable/euthymic, guess what? I'm refilling that Rx exactly the same. The dumbest thing I could do is try to explain why it doesn't make sense pharmacologically (not to mention waste my time).
Placebo isn't a psychological phenomena, it's one of our tools. Yeah, I get it though. From a pharmacological perspective it makes no sense, but we're not practicing psychopharmacology, we're practicing psychiatry and boy does it may your life easier when you follow up with someone who's on Prozac 10mg tid and they're telling you it's the perfect regimen for them. Your real struggle with doing things like this is overcoming your own ego for fear of ridicule/embarrassment by another colleague who understands the medication and not having the opportunity to justify or explain your medical decision making. But don't let that stop you. You're the brilliant psychiatrist who has kept their patient euthymic, stable, functional, and off of those other nasty meds.
Rx: Prozac 10 mg TID, #90, 3RF

I completely disagree with this. It is one thing to not argue with patients about placebo effects which many of my patients have all the time or to maximize the placebo effect by reassuring patient that this medication is effective for intended target symptom, but quite another to intentionally mislead patient to use placebo effect as a treatment. Especially with a patient with dependent personality issues, it would seem that you would just be feeding into the pathology. Saying that you need to either use the placebo or add more drugs is a false choice scenario. There are other alternatives including psychological treatments that aren't deceptive.

 

[666357]

[QUOTE="There are other alternatives including psychological treatments that aren't deceptive.[/QUOTE]


And when ALL those fail?

 

[smalltownpsych]

[QUOTE="There are other alternatives including psychological treatments that aren't deceptive.

And when ALL those fail?[/QUOTE]
Then that is ultimately the patient's choice or responsibility. I don't know about psychiatrists' ethics, but as a psychologist it is unethical for me to use deceptive practices. I used to think differently about placebos and wondered why we don't use them regularly in medicine. This was before I saw how often our society and mental health system and the control dynamics foster dependency with the "we know what is best for the patient" mentality. Not saying that is what you are doing by any means, but I do believe that it is a step down that path.

 

[birchswing]

And when ALL those fail?

Then that is ultimately the patient's choice or responsibility. I don't know about psychiatrists' ethics, but as a psychologist it is unethical for me to use deceptive practices. I used to think differently about placebos and wondered why we don't use them regularly in medicine. This was before I saw how often our society and mental health system and the control dynamics foster dependency with the "we know what is best for the patient" mentality. Not saying that is what you are doing by any means, but I do believe that it is a step down that path.

Not making a point because I don't have a real opinion on it myself, but curious what you think about motivational interviewing or neurolinguistic programming (not the efficacy of NLP but the ethics)? Both of those, to me, seem to involve a level of omission of facts.

 

[deleted343839]

Not making a point because I don't have a real opinion on it myself, but curious what you think about motivational interviewing or neurolinguistic programming (not the efficacy of NLP but the ethics)? Both of those, to me, seem to involve a level of omission of facts.

I don't see how this applies to motivational interviewing. There is no directive to withhold information in MI; how and in what sequence of events you present information is important, however. That's true of most talk interventions, though.

Since NLP is bogus then, yeah, I'd say it's ethically shady to offer as a treatment.

 

[birchswing]

I don't see how this applies to motivational interviewing. There is no directive to withhold information in MI; how and in what sequence of events you present information is important, however. That's true of most talk interventions, though.

Since NLP is bogus then, yeah, I'd say it's ethically shady to offer as a treatment.

With NLP, I was thinking along the lines of mirrored speech patterns as being equivalent to the topic of placebo. Although I suppose any therapeutic technique you don't directly tell the client about could be deceptive. With MI, I was thinking about the same thing, the techniques used, and whether the client is aware that they are being engaged in MI or not. MI goes a bit further in that I'm not even sure if the client necessarily has agreed to work on a particular issue when a therapist engages MI with them on it. But like you said, I guess that's true for a lot of psychotherapy. Although, those ones stuck out at me as being less obvious. Empathy, direct suggestions, instructions on breathing, or instructions on how to do CBT, or even hypnosis are all more obvious interventions to me, and it's more clear what the therapist's opinion and intent is. I suppose how you do any of those things could involve techniques that aren't specifically mentioned.

 

[smalltownpsych]

With NLP, I was thinking along the lines of mirrored speech patterns as being equivalent to the topic of placebo. Although I suppose any therapeutic technique you don't directly tell the client about could be deceptive. With MI, I was thinking about the same thing, the techniques used, and whether the client is aware that they are being engaged in MI or not. MI goes a bit further in that I'm not even sure if the client necessarily has agreed to work on a particular issue when a therapist engages MI with them on it. But like you said, I guess that's true for a lot of psychotherapy. Although, those ones stuck out at me as being less obvious. Empathy, direct suggestions, instructions on breathing, or instructions on how to do CBT, or even hypnosis are all more obvious interventions to me, and it's more clear what the therapist's opinion and intent is. I suppose how you do any of those things could involve techniques that aren't specifically mentioned.

I think what you are saying is when a patient is coming to me for help but they might be focusing on the wrong target. For example, patient presents with depression but I find out that substance use is probably the root cause or a major contributing factor. It is completely consistent with motivational interviewing technique for me to present that information/opinion. The patient will either agree or disagree and in MI, I wouldn't argue with them, but would work with patient to examine the evidence for and against that. I would be completely upfront during the whole process. Not sure where the deception would be. I am also upfront with all of my patients that it doesn't really matter what my opinion is as to what is causing problems in the patient's life, what matters more is their opinion. This tends to avoid the defensive pattern of intellectual debating that many patients are used to doing with everyone else in their life.

The other point of what you are saying is true, I wouldn't necessarily tell the patient from moment to moment what techniques I am doing. That would hamper the treatment as we would always be in the intellectual realm. Nevertheless, I provide a lot of psychoeducation for my patients when appropriate which is usually more often in the beginning of treatment. It has to be balanced with helping the patient obtain some symptomatic relief through some of the methods you elaborated above during first few sessions or they won't come back. To be honest, even though I probably provide more psychoeducation than the majority of the therapists out there I probably should provide even more and sometimes I take it for granted that patient knows what we are doing or understands the process when they don't.