Accutane and depression

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doctalaughs

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Wondering how other practicing dermatologists handle this?

I'm well aware of the studies showing little connection; however given legal environment (and case reports of reversible suicidality) how do you handle this? Especially since it seems like 1/3 of the teenage population is now diagnosed with depression.

I used to ask clearance from their psychiatrist (or PCP) but I don't think that provides much protection and they often don't know much about Accutane anyway.

Similar questions could be asked about Inflammatory bowel patients asking to start accutane.


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Wondering how other practicing dermatologists handle this?

I'm well aware of the studies showing little connection; however given legal environment (and case reports of reversible suicidality) how do you handle this? Especially since it seems like 1/3 of the teenage population is now diagnosed with depression.

I used to ask clearance from their psychiatrist (or PCP) but I don't think that provides much protection and they often don't know much about Accutane anyway.

Similar questions could be asked about Inflammatory bowel patients asking to start accutane.


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Pretty much what you've been doing. I will ask for clearance from psychiatry and may even have them follow along with once monthly appointments to provide two sets of screening eyes.

Documentation is obviously key and in rare cases, I bring the patient back every 2 weeks for followup and insist on the parents being in the room so I can hopefully get a better idea of how the patient is truly doing. I have used lower doses to start for these patients (although I am unconvinced that does anything and will prolong their treatment duration)

In rare cases, I will take the patient off Accutane if I truly feel uncomfortable with their mental state.

I agree it is a shame that while the research shows little to no connection between Accutane and depression, the medicolegal ramifications still make me think twice. It's unfortunate as I had no problems prescribing it as a resident but I will confess I do hesitate now as an attending.
 
If they have a psychiatrist I will ask that they run it by them if they have a history of suicidal ideation. If they are on an antidepressant but no history of suicidal ideation I treat without many qualms. I do discuss the reported risk and find that most people with history of suicidal ideation don't want to take it anyway. I don't alter the dose, do discuss the need for communication. I also have rarely stopped if someone has reported a severe mood change.

As for inflammatory bowel disease, I think the data are sufficient now to push that link aside. Also, if someone already has inflammatory bowel disease the cat is out of the bag so I would just treat.
 
If they have a psychiatrist I will ask that they run it by them if they have a history of suicidal ideation. If they are on an antidepressant but no history of suicidal ideation I treat without many qualms. I do discuss the reported risk and find that most people with history of suicidal ideation don't want to take it anyway. I don't alter the dose, do discuss the need for communication. I also have rarely stopped if someone has reported a severe mood change.

As for inflammatory bowel disease, I think the data are sufficient now to push that link aside. Also, if someone already has inflammatory bowel disease the cat is out of the bag so I would just treat.

I like your approach. Getting clearance for every teenager labeled with depression or on meds is too hard (and often the response from psychiatry or pcp is unhelpful or excludes patients that would benefit from accutane alot).

I do sometimes worry about honesty in that population. I've had patient/parent deny any mood changes only to get ahold of pcp notes describing active suicidal ideation. Not much you can do about that.

I've usually asked GI about clearance for IBD patients but maybe I'll stop.




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