Antidepressant for parkinsons patient?

[futuredo32]

So I got a patient who has had long standing depression. She has been on 60 mg of Cymbalta and was weaning down to 40 because it stopped working. She wants med management and therapy, I like therapy and will be seeing her every other week for therapy- she can only come every other week for therapy due to transportation issues. The first step was easy, titrate down to 20 mg of Cymbalta. NO antidepressant works with her parkinsons meds because they are all a risk for serotonin syndrome. She was depressed prior to her Parkinson's diagnosis 7 years ago, now more so. What to give her????????? She is severely depressed opposed to ECT.

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[slappy]

So I got a patient who has had long standing depression. She has been on 60 mg of Cymbalta and was weaning down to 40 because it stopped working. She wants med management and therapy, I like therapy and will be seeing her every other week for therapy- she can only come every other week for therapy due to transportation issues. The first step was easy, titrate down to 20 mg of Cymbalta. NO antidepressant works with her parkinsons meds because they are all a risk for serotonin syndrome. She was depressed prior to her Parkinson's diagnosis 7 years ago, now more so. What to give her????????? She is severely depressed opposed to ECT.

You need to be more specific. Is she on selegiline? I routinely treat PD patients with depression with SSRIs and TCAs.

 

[splik]

as above, we rx antidepressants all the time to patients with PD including those taking MAOIs like rasagaline or selegiline. MAO-B is not really involved in the breakdown of serotonin, thus there is not really a risk of serotonin syndrome, and the doses neurologists use for these drugs are low. You can even rx MAOIs like nardil to pts on sinemet! you can always discuss with pt's neurologist if any concerns.

also bear in mind pts with a long hx of depression or treatment-resistant depression are unlikely to respond to antidepressant monotherapy.

 

[WisNeuro]

Recent meta-analyses are not promising for any particular medication in this group. Although, most analyses also do a poor job (of a very hard task) in differentiating very long-standing depression from depression likely related to degenerative processes in the population, so who knows. CBT treatment consistently returns large positive effect sizes. I'd just emphasize that, maybe troubleshoot with her to step up to every week. Any med transport available? Many county Council of Aging agencies have transportation resources as well. Also, check with social work if you have them available, they usually have a handy list of such resources.

 

[HarryMTieboutMD]

ECT!

 

[futuredo32]

She said NO Ect. She was on The combo med for Levadopa/carbidopa and "one other med" she couldn't recall. I am applying to FP next year to be honest. I am really good at therapy- not to sound obnoxious at all, my therapy supervisor said I don't need supervision- I got a new supervisor and was told the same thing, I feel weak in psychpharm with patients like this when it says don't use xyz with patients on abc because it could cause serotonin syndrome. I go by what it says in Stahls. My first training program was new and I left when our program director left but it was actually better than the second one. The outpatient training was awesome, the inpatient was awful but I think it is better now. We did outpatient first due to the ACGME rules. The second one was established and had a good reputation but we really had no say in what meds the patients were on and the attendings would change the meds and not tell us.

 

[futuredo32]

Recent meta-analyses are not promising for any particular medication in this group. Although, most analyses also do a poor job (of a very hard task) in differentiating very long-standing depression from depression likely related to degenerative processes in the population, so who knows. CBT treatment consistently returns large positive effect sizes. I'd just emphasize that, maybe troubleshoot with her to step up to every week. Any med transport available? Many county Council of Aging agencies have transportation resources as well. Also, check with social work if you have them available, they usually have a handy list of such resources.

She did well on Cymbalta until recently. I am a solo practioner there is no social worker . There is a great bus system but even I find it confusing. I work in a college town, how the students figure out the bus system I have no clue . We discussed different types of therapy and she wants a combination of supportive and psychodynamic. I LOVE CBT but find most patients don't want CBT. And even when I have only presented CBT , if a patient doesn't want CBT they don't do the homework. Most patients just want to talk. CBT has a great reputation but even I tried it for a year and a half for test anxiety (way too long) and got nothing out of it. I still have extreme test anxiety

 

[slappy]

She said NO Ect. She was on The combo med for Levadopa/carbidopa and "one other med" she couldn't recall. I am applying to FP next year to be honest. I am really good at therapy- not to sound obnoxious at all, my therapy supervisor said I don't need supervision- I got a new supervisor and was told the same thing, I feel weak in psychpharm with patients like this when it says don't use xyz with patients on abc because it could cause serotonin syndrome. I go by what it says in Stahls. My first training program was new and I left when our program director left but it was actually better than the second one. The outpatient training was awesome, the inpatient was awful but I think it is better now. We did outpatient first due to the ACGME rules. The second one was established and had a good reputation but we really had no say in what meds the patients were on and the attendings would change the meds and not tell us.

Good luck with FP.

If you decide to stay in psychiatry, 1) throw that Stahl out, get a Maudsley and read it several times before using it as a reference, 2) hire a therapy and psychopharm supervisor. Based on what you've said about your two residency programs, you seem to have gotten pretty awful training.

 

[WisNeuro]

She did well on Cymbalta until recently. I am a solo practioner there is no social worker . There is a great bus system but even I find it confusing. I work in a college town, how the students figure out the bus system I have no clue . We discussed different types of therapy and she wants a combination of supportive and psychodynamic. I LOVE CBT but find most patients don't want CBT. And even when I have only presented CBT , if a patient doesn't want CBT they don't do the homework. Most patients just want to talk. CBT has a great reputation but even I tried it for a year and a half for test anxiety (way too long) and got nothing out of it. I still have extreme test anxiety

If someone was doing CBT for 1.5 years with you for text anxiety, they were doing it wrong. I'd work on the pitch for the different types of therapy. Half the battle is how you present what you're doing. I've generally not had a problem getting patients to buy in to CBT after having a lengthy discussion about options, expectations, and the general literature about what we're trying to treat.

 

[futuredo32]

Good luck with FP.

If you decide to stay in psychiatry, 1) throw that Stahl out, get a Maudsley and read it several times before using it as a reference, 2) hire a therapy and psychopharm supervisor. Based on what you've said about your two residency programs, you seem to have gotten pretty awful training.

I REALLY hope to be able to switch to FP. I thought everyone used Stahl's like a Bible. I have had 2 therapy supervisors and they both said I didn't need them, a psychopharm supervisor isn't a bad idea and yeah, my training did suck. But I REALLY hope to leave psychiatry and flip to fp. That is the only reason I am taking the board exam. I LOVE FP. I knew my first year of psych residency I wanted to switch but kinda got "persuaded" to stay. I had a patient suicide my second year of residency and that has never left. I have tried all "flavors of psych inpatient, c/l , cmh, private practice, prison, I prefer outpatient private practice with psychotherapy the most but I just miss medicine with the variety but you still get to have the bond with the patient though not to the same degree. I just miss the variety. Thank you for your input.

 

[futuredo32]

If someone was doing CBT for 1.5 years with you for text anxiety, they were doing it wrong. I'd work on the pitch for the different types of therapy. Half the battle is how you present what you're doing. I've generally not had a problem getting patients to buy in to CBT after having a lengthy discussion about options, expectations, and the general literature about what we're trying to treat.

I had a patient suicide my second year of psych residency, actually three of us did. It didn't seem to phase the other two residents, but I pretty much fell apart. We were doing outpatient first before inpatient because it was a new program and the ACGME rules had changed that year where you couldn't be without an attending or PGY-2. I wouldn't see a patient without an attending in the room the whole visit (which was quite a change because prior I wasn't even staffing with anyone), I was afraid to suggest treatment plans, I wanted to send everyone to the hospital, I was crying all the time and wanted to call all my outpatients multiple times a day to make sure they were ok. I really took it hard. The attendings and my PD were amazing and very supportive. The patient's mom was also a patient at the clinic and it turned out she was selling her meds for spending money (She had a TBI and lost her case for disability). The program director said that in order to remain at the program I needed to seek therapy and could leave during work hours to do so. I was pretty much hanging by a thread and knew of an amazing psychiatrist who did psychoanalysis. I saw him and he did a combination of supportive and psychodynamic therapy. Gradually my attendings spent less and less time in the room with my patients and I regained confidence. I'm still seeing this psychiatrist for therapy and I have learned more about therapy being in therapy than I have from residency, conferences or books. I did mainly CBT in residency. But based on my experience personally and after residency, despite the literature, I think psychodynamic therapy is really more helpful, JMO.

 

[OldPsychDoc]

She said NO Ect. ...

Use those therapy skills to help her change her mind.

 

[WisNeuro]

I had a patient suicide my second year of psych residency, actually three of us did. It didn't seem to phase the other two residents, but I pretty much fell apart. We were doing outpatient first before inpatient because it was a new program and the ACGME rules had changed that year where you couldn't be without an attending or PGY-2. I wouldn't see a patient without an attending in the room the whole visit (which was quite a change because prior I wasn't even staffing with anyone), I was afraid to suggest treatment plans, I wanted to send everyone to the hospital, I was crying all the time and wanted to call all my outpatients multiple times a day to make sure they were ok. I really took it hard. The attendings and my PD were amazing and very supportive. The patient's mom was also a patient at the clinic and it turned out she was selling her meds for spending money (She had a TBI and lost her case for disability). The program director said that in order to remain at the program I needed to seek therapy and could leave during work hours to do so. I was pretty much hanging by a thread and knew of an amazing psychiatrist who did psychoanalysis. I saw him and he did a combination of supportive and psychodynamic therapy. Gradually my attendings spent less and less time in the room with my patients and I regained confidence. I'm still seeing this psychiatrist for therapy and I have learned more about therapy being in therapy than I have from residency, conferences or books. I did mainly CBT in residency. But based on my experience personally and after residency, despite the literature, I think psychodynamic therapy is really more helpful, JMO.

For some things, like what you describe, dynamic oriented therapy can be similarly efficacious as CBT. But, for most anxiety disorders, CBT is far and away the treatment of choice. Good to be competent delivering both. It's nice to be able to treat panic disorder in as little as 8 sessions with some follow up booster sessions for a couple of months, as well as treating some long term depression/comorbid cluster B long-term using dynamic and CBT techniques. It's about what is best for the patient, not what we like better. Glad to hear you had a positive experience in the end, though.

 

[slappy]

For some things, like what you describe, dynamic oriented therapy can be similarly efficacious as CBT. But, for most anxiety disorders, CBT is far and away the treatment of choice. Good to be competent delivering both. It's nice to be able to treat panic disorder in as little as 8 sessions with some follow up booster sessions for a couple of months, as well as treating some long term depression/comorbid cluster B long-term using dynamic and CBT techniques. It's about what is best for the patient, not what we like better. Glad to hear you had a positive experience in the end, though.

References? Therapy isn't a strong point for me, but the reviews I've read doesn't support CBT's superiority over PDT here (well, the better reviews, ones that aren't written with an obvious bias).

 

[HarryMTieboutMD]

Good luck with FP.

If you decide to stay in psychiatry, 1) throw that Stahl out, get a Maudsley and read it several times before using it as a reference, 2) hire a therapy and psychopharm supervisor. Based on what you've said about your two residency programs, you seem to have gotten pretty awful training.

What's the advantage of Maudsley to Stahl's prescribers guide (most people know not to trust essential psychopharm)? Seems like they are more complimentary than anything...

 

[WisNeuro]

References? Therapy isn't a strong point for me, but the reviews I've read doesn't support CBT's superiority over PDT here (well, the better reviews, ones that aren't written with an obvious bias).

References for which disorders? Therapy efficacy is not a constant across every disorder. They respond differently to different modalities. In cases of fairly straightforward anxiety disorders, it's really not controversial, CBT is consistently more efficacious than other treatments. A quick lit search for RCTs for something like panic disorder will net you plenty to look at.

 

[slappy]

What's the advantage of Maudsley to Stahl's prescribers guide (most people know not to trust essential psychopharm)? Seems like they are more complimentary than anything...

Despite the title, Maudsley's is more of a complete textbook and not just a series of truncated drug monographs. It gives you a much better understanding of psychopharmacology, and if one's going to read only one psychopharm book, Maudlsey's is head and shoulders above Stahl's prescriber's guide. Maudsley's also provides references that you can use to look up the actual data, and is not one man's opinion/work that Stahl's is, giving it much more legitimacy.

 

[slappy]

References for which disorders? Therapy efficacy is not a constant across every disorder. They respond differently to different modalities. In cases of fairly straightforward anxiety disorders, it's really not controversial, CBT is consistently more efficacious than other treatments. A quick lit search for RCTs for something like panic disorder will net you plenty to look at.

References for your second sentence here: "For some things, like what you describe, dynamic oriented therapy can be similarly efficacious as CBT. But, for most anxiety disorders, CBT is far and away the treatment of choice."

According to the most reliable review on the efficacy of PDT by Peter Fonagy, that isn't the case: The effectiveness of psychodynamic psychotherapies: An update

 

[futuredo32]

In residency I had a very different patient population. They had a very specific problem and CBT worked. In private practice I am getting patients who have mostly never tried therapy and have a lifetime of problems that they have never shared with anyone. I have done a few CBT cases in private practice that worked well for specific phobias or social anxiety and tried a few for depression but those for depression said honestly, I would just rather talk and I have so much to say and I don't want to do homework. I feel like it is their 45 minutes to use how they want and if they don't want to do CBT they don't have to. When my PD "made" me go to therapy (and yes I did need to go ,I was not handling the suicide of my patient well at all) I was so resentful and after the initial eval, sat there for 18 sessions and stared at his carpet for 45 minutes and then for several more weeks would leave after a short time and he is a psychoanalyst but I finally said I didn't want analysis and he adjusted and it's eclectic. He really kinda sucked at first, and later told me that since residency he had done nothing but psychoanalysis . But I seriously credit myself for helping him improve in other modalities of therapy and it works. It's definitely not psychoanalysis, it's more supportive and psychodynamic but I have learned way more about therapy by being a patient than through any book or anything else and I have learned so much about me and that is so awesome. And NOW I am so glad my PD made me go

 

[WisNeuro]

References for your second sentence here: "For some things, like what you describe, dynamic oriented therapy can be similarly efficacious as CBT. But, for most anxiety disorders, CBT is far and away the treatment of choice."

According to the most reliable review on the efficacy of PDT by Peter Fonagy, that isn't the case: The effectiveness of psychodynamic psychotherapies: An update

You have to dig a little deeper than that. The Fonagy review is one of the biased reviews you derided earlier. The studies he cites for panic disorder are two very small studies with barely adequate methodology. The real problem is actually the lack of good studies for dynamic oriented therapies in anxiety disorders. You can run a meta-analysis looking at the two, but have dozens of RCT on the CBT side and a handful if you are lucky on the dynamic side for the most part. Additionally, the several studies looking at economic differences favor the CBT, due to the time limited nature (E.g, PCT is generally a 12-week treatment for the most part). I'm all about having a variety of treatments, but if a treatment can easily treat something in 8-12 weeks with the same efficacy as another treatment that takes a year or longer, we should probably be good doctors and efficiently treat their disorder, maximizing QOL changes.

 

[slappy]

You have to dig a little deeper than that. The Fonagy review is one of the biased reviews you derided earlier. The studies he cites for panic disorder are two very small studies with barely adequate methodology. The real problem is actually the lack of good studies for dynamic oriented therapies in anxiety disorders. You can run a meta-analysis looking at the two, but have dozens of RCT on the CBT side and a handful if you are lucky on the dynamic side for the most part. Additionally, the several studies looking at economic differences favor the CBT, due to the time limited nature (E.g, PCT is generally a 12-week treatment for the most part). I'm all about having a variety of treatments, but if a treatment can easily treat something in 8-12 weeks with the same efficacy as another treatment that takes a year or longer, we should probably be good doctors and efficiently treat their disorder, maximizing QOL changes.

That's fair.

That review read pretty fair to me though, and he also has nothing to gain by touting PDT. But I'll look into this more soon.

 

[WisNeuro]

That's fair. That review read pretty fair to me, and he also has nothing to gain by touting PDT. But I'll look into it more soon.

Here are a few excerpts from the anxiety disorders section of the paper for some of my specific problems with you using it to justify your belief.

"There are no studies of PDT against inactive controls in generalized anxiety disorder, except a study of Internet-based PDT, which yielded no evidence of superiority to waitlist control on anxiety ratings"
"Two small studies of panic disorder have been reported."
"There is no evidence that PDT is helpful for obsessive-compulsive disorder"
"There is only one study of PDT as an approach to post-traumatic stress disorder (PTSD)"

I'm just curious what about this review was suggestive of good evidence of efficacy across the board. To me, the review reads more as "we really have no idea in the anxiety realm due to the dearth of literature for PDT, but we're going to make some claims based on some really small studies, if there are any at all, that aren't all that much supported by quality data." Don't get me wrong, there are some things for which PDTs, like IPT, work wonders, but there really isn't enough evidence, for the most part, on many things in the anxiety disorder spectrum.

 

[splik]

That review read pretty fair to me, and he also has nothing to gain by touting PDT. But I'll look into it more soon.

yes the freud memorial professor of psychoanalysis and CEO of the Anna Freud Centre would have nothing to gain by touting PDT...

 

[slappy]

Here are a few excerpts from the anxiety disorders section of the paper for some of my specific problems with you using it to justify your belief.

"There are no studies of PDT against inactive controls in generalized anxiety disorder, except a study of Internet-based PDT, which yielded no evidence of superiority to waitlist control on anxiety ratings"
"Two small studies of panic disorder have been reported."
"There is no evidence that PDT is helpful for obsessive-compulsive disorder"
"There is only one study of PDT as an approach to post-traumatic stress disorder (PTSD)"

I'm just curious what about this review was suggestive of good evidence of efficacy across the board. To me, the review reads more as "we really have no idea in the anxiety realm due to the dearth of literature for PDT, but we're going to make some claims based on some really small studies, if there are any at all, that aren't all that much supported by quality data." Don't get me wrong, there are some things for which PDTs, like IPT, work wonders, but there really isn't enough evidence, for the most part, on many things in the anxiety disorder spectrum.

Nope, no belief at all. I don't do any psychotherapy work. I was merely curious where you got your (paraphrasing) CBT is far and away the treatment of choice for most anxiety disorders, over PDT, because that's not what I've been taught, seen in practice or read. If anything, they were comparable for some, and there aren't enough RCTs to make conclusions for the others. I also didn't say PDT had better efficacy across the board. And you missed some sections of the review (like the efficacy being equivalent in social anxiety - those studies were certainly powered to prove the null), but it's a testament to its fairness that you were able to get all the negative studies from there too.

 

[WisNeuro]

Nope, no belief at all. I don't do any psychotherapy work. I was merely curious where you got your (paraphrasing) CBT is far and away the treatment of choice for most anxiety disorders, over PDT,

I got that, because there is ample evidence for CBT for anxiety disorders, while PDT simply does not have the evidence base for many things within the anxiety spectrum.

 

[slappy]

yes the freud memorial professor of psychoanalysis and CEO of the Anna Freud Centre would have nothing to gain by touting PDT...

Where he teaches MBT and IPT, not genericised PDT.

 

[slappy]

I got that, because there is ample evidence for CBT for anxiety disorders, while PDT simply does not have the evidence base for many things within the anxiety spectrum.

Fair enough!