Antipsychotics for depression?

[Abider]

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So I'm presenting an ischemic colitis patient to surgery conference tomorrow and am digging through the chart and see Risperdal indicated as Tx for her depression.

After looking around in the drug manuals I can't find anything indicating a use of risperdal for depression. And the patient doesn't have any record of psychosis.

Any thought of why this might be on her med list? Or in a broader sense how common is it to use anti-psychotics outside of indicated uses?

 

[Iwillheal]

Low dose antipsychotics are sometimes used to augment the effects of SSRIs (like T3 augmentation, that kind of thing). It's more of a clinical judgement and it's mostly used in treatment resistant depressions (especially when combined with agitation, aggression, etc) though some professionals really do go overboard with the antipsychotics in my opinion.

Disclaimer: I'm not a psychiatrist, but a psych grad student working in a medical setting.

 

[whopper]

There are studies showing that atypicals at low dosages could augment an antidepressant. There is no FDA indication for any antipsychotic to treat depression though a few have an indication for antidepressant augmentation.

That said, atypicals are more expensive than other antidepressant augmentation agents. E.g. Buspirone is $4 a month, Abilify 5 mg is a few hundred a month.

 

[BobA]

So I'm presenting an ischemic colitis patient to surgery conference tomorrow and am digging through the chart and see Risperdal indicated as Tx for her depression.

After looking around in the drug manuals I can't find anything indicating a use of risperdal for depression. And the patient doesn't have any record of psychosis.

Any thought of why this might be on her med list? Or in a broader sense how common is it to use anti-psychotics outside of indicated uses?

This is an unfortunately common practice. There are many more treatments that have a stronger evidence base with less evidence of harm.

How old is the patient? do they have dementia? risperdal is (again unfortunate) commonly used for agitation in dementia as well.

 

[Abider]

This is an unfortunately common practice. There are many more treatments that have a stronger evidence base with less evidence of harm.

How old is the patient? do they have dementia? risperdal is (again unfortunate) commonly used for agitation in dementia as well.

(Thanks for the consult all.)

InterestiIng questions. 58 F. Protracted course of depression that isn't well characterized in the chart. No dementia. I would have liked to dig further when she was in the hospital, but I'm rolling with surgeons and they don't care much for such questions or discussion.

As and aside she hasn't read any of the books and doesn't know her lines as an ischemic bowel pt--no hypo perfusion, no cardiac stasis or thromboemboli, no systemic arterial disease. Just a healthy cocaine habit. I'm presenting the cocaine habit as an important possible etiology.

I'm curious who wrote the order. But continuity of care and detailed health records are nearly nonexistent in the population we're serving. It just came listed on the admit med list.

 

[OldPsychDoc]

(Thanks for the consult all.)

InterestiIng questions. 58 F. Protracted course of depression that isn't well characterized in the chart. No dementia. I would have liked to dig further when she was in the hospital, but I'm rolling with surgeons and they don't care much for such questions or discussion.

As and aside she hasn't read any of the books and doesn't know her lines as an ischemic bowel pt--no hypo perfusion, no cardiac stasis or thromboemboli, no systemic arterial disease. Just a healthy cocaine habit. I'm presenting the cocaine habit as an important possible etiology.

I'm curious who wrote the order. But continuity of care and detailed health records are nearly nonexistent in the population we're serving. It just came listed on the admit med list.

And I presume that the "depression" diagnosis came on the same med list?
And surgeons being surgeons, there is no particular need to figure out what exactly is meant by "depression"?

I can concoct certain scenarios for this ("based on true stories") that might make sense--an admission to an outside hospital with substance-induced psychosis and depression due to cocaine withdrawal perhaps...reported out to a nurse at residential rehab as "for my depression, I guess"...reordered at the halfway house because "she's still moody, and it seems to help"...and (apologies to BillyPilgrim) So It Goes.

(And actually, that's just one possible scenario--one with some actual rationality to it. I can think of LOTS of just plain stupid reasons this would have occured!)

 

[whopper]

Forgot the mention. The theory behind atypical antipsychotics benefiting is based on their 5-HT2A interactions.

http://www.psychiatrist.com/pcc/pccpdf/v05s03/v05s0306.pdf

Unfortunately, due to the drug rep infiltration, I've noticed several residents giving out Abilify 5 mg as augmentation. While it works, again, as mentioned above, why go with it first when it's hundreds of dollars a month? Lamictal, Buspirone, an antidepressant of a different mechanism (E.g. Wellbutrin with SSRIs, Trazodone with an SSRI), synthroid, all work are much cheaper and usually have less side effects.

I'd consider an atypical first-line for antidepressant augmentation if the patient had depression with psychotic features, but all things being equal, Risperdal is $30 a month if taken from the right source, Abilify is hundreds.

 

[billypilgrim37]

and (apologies to BillyPilgrim) So It Goes.

Poo-tee-weet?

 

[vistaril]

And I presume that the "depression" diagnosis came on the same med list?
And surgeons being surgeons, there is no particular need to figure out what exactly is meant by "depression"?
QUOTE]

?? Of course there is no need to figure out "what is meant by it". They are there to fix her bowel.

the sad thing is the surgeons probably would have probably done a better job than her outside psychiatrist at treating her depression in the sense that they wouldnt have put her on risperdal based on data that sucks.

 

[vistaril]

So I'm presenting an ischemic colitis patient to surgery conference tomorrow and am digging through the chart and see Risperdal indicated as Tx for her depression.

After looking around in the drug manuals I can't find anything indicating a use of risperdal for depression. And the patient doesn't have any record of psychosis.

Any thought of why this might be on her med list? Or in a broader sense how common is it to use anti-psychotics outside of indicated uses?

you havent done your psych rotation yet have you?

After that you will learn that literally any class of a psychotropic drug can be used to treat any type of psych dx....there are literally 5 million different combinations of antidepressants, mood stabilizers, benzos, stimulants, and antipsychotics we can use to treat depression, anxiety, bipolar, and psychotic d/os.........and there is a sorta study/paper/something somewhere that sorta supports it too!!

 

[twright]

So I'm presenting an ischemic colitis patient to surgery conference tomorrow and am digging through the chart and see Risperdal indicated as Tx for her depression.

After looking around in the drug manuals I can't find anything indicating a use of risperdal for depression. And the patient doesn't have any record of psychosis.

Any thought of why this might be on her med list? Or in a broader sense how common is it to use anti-psychotics outside of indicated uses?

This is very common practice, unfortunately.
A few of the atypical antipsychotics have received an FDA indication for adjunctive treatment of depression. The efficacy estimates are rather flimsy, and these should be weighed against the substantive potential harms.

 

[deleted103644]

you havent done your psych rotation yet have you?

After that you will learn that literally any class of a psychotropic drug can be used to treat any type of psych dx....there are literally 5 million different combinations of antidepressants, mood stabilizers, benzos, stimulants, and antipsychotics we can use to treat depression, anxiety, bipolar, and psychotic d/os.........and there is a sorta study/paper/something somewhere that sorta supports it too!!

😆

 

[whopper]

After that you will learn that literally any class of a psychotropic drug can be used to treat any type of psych dx....there are literally 5 million different combinations of antidepressants, mood stabilizers, benzos, stimulants, and antipsychotics we can use to treat depression, anxiety, bipolar, and psychotic d/os.........and there is a sorta study/paper/something somewhere that sorta supports it too!!

True which is why it takes an intelligent and astute clinician to make sense out of the sea of data and results. Unfortunately several psychiatrist don't, but as with any field there's good ones and bad ones out there. A thing that helps to separate the good from the bad in this example is the use of a coherent decision making algorithm concerning meds.

As a general rule, augmentation should only be added to patients that have already reached a maximum dosage of an antidepressant (determined by recommended max dosage guidelines or the patient cannot tolerate it at a higher dosage) that needs further improvement. IMHO if the patient got no benefit whatsoever from the antidepressant and they've been on it for at least 1 month, it's better to just start them on another one. Augmentation works by improving an already existing med's effects. If the antidepressant had no benefit whatsoever, it's like mulitplying it's effect by 0. You can add as much augmentation as you want, anything times 0 is 0.

 

[Abider]

And I presume that the "depression" diagnosis came on the same med list?
And surgeons being surgeons, there is no particular need to figure out what exactly is meant by "depression"?

I can concoct certain scenarios for this ("based on true stories") that might make sense--an admission to an outside hospital with substance-induced psychosis and depression due to cocaine withdrawal perhaps...reported out to a nurse at residential rehab as "for my depression, I guess"...reordered at the halfway house because "she's still moody, and it seems to help"...and (apologies to BillyPilgrim) So It Goes.

(And actually, that's just one possible scenario--one with some actual rationality to it. I can think of LOTS of just plain stupid reasons this would have occured!)

I see.

I finished. But am still interested in what I learned about how psychiatric care is regarded by other services....

Yes the depression dx seem to have been addressed merely by each consulting team asking about suicidal ideation, noting the negative in their notes, and moving on.

As I begin to probe psychiatry as my primary interest, I have to say, I find this troubling. That a proper dx and tx plan for my patient's psychiatric problems could be so uniformly disregarded and ignored. As if it never mattered to her overall health to be to be casually imprecise and almost flippant with our aspect of her care.

 

[whopper]

Abider you're seeing a truth that happens in the medical politics of the general hospital. Each field of medicine is perceived in a specific manner by other branches of medicine. E.g. IM docs don't like ER docs because those docs do the admissions. Further ER doctors are in a paradigm of either admit or not, and when they treat, doing so in a spot-manner ignoring long-term treatment objectives.

Surgeons are often seen as "plumbers" that know how to stop a leak or sew things up but not much else. It's quite common to get a patient from surgery to medicine with all the meds completely screwed up even though all the surgeon had to do was put them on the same meds they were on before the surgery.

Now these perceptions are based on stereotypes, but stereotypes with some truth. These arise IMHO out of the personalities that are drawn to the specific fields, the personalities that are created by being in the field for years, the environment of the hospital of simply wanting to do your specific "box" and nothing more (without seeing the patient as a whole), and being a small cog in a big and sometimes uncaring machine.

As for psychiatrists, most perceive us as the medical doctors that forgot their medicine and often times they simply try to dump a patient onto us claiming them to be suicidal when they weren't. Like I said, it's a stereotype but unfortunately I've seen truth in it. While in residency almost all my attendings would ask for an IM consult when a person had a BP of 135/89 thinking that in and of itself was HTN. Further, as you've seen, several docs ignore psychiatric problems in their patients.

There are of course exceptions when basing characterizations on stereotypes.

 

[Abider]

Abider you're seeing a truth that happens in the medical politics of the general hospital. Each field of medicine is perceived in a specific manner by other branches of medicine. E.g. IM docs don't like ER docs because those docs do the admissions. Further ER doctors are in a paradigm of either admit or not, and when they treat, doing so in a spot-manner ignoring long-term treatment objectives.

Surgeons are often seen as "plumbers" that know how to stop a leak or sew things up but not much else. It's quite common to get a patient from surgery to medicine with all the meds completely screwed up even though all the surgeon had to do was put them on the same meds they were on before the surgery.

Now these perceptions are based on stereotypes, but stereotypes with some truth. These arise IMHO out of the personalities that are drawn to the specific fields, the personalities that are created by being in the field for years, the environment of the hospital of simply wanting to do your specific "box" and nothing more (without seeing the patient as a whole), and being a small cog in a big and sometimes uncaring machine.

As for psychiatrists, most perceive us as the medical doctors that forgot their medicine and often times they simply try to dump a patient onto us claiming them to be suicidal when they weren't. Like I said, it's a stereotype but unfortunately I've seen truth in it. While in residency almost all my attendings would ask for an IM consult when a person had a BP of 135/89 thinking that in and of itself was HTN. Further, as you've seen, several docs ignore psychiatric problems in their patients.

There are of course exceptions when basing characterizations on stereotypes.

I'll keep it in mind, thanks.

 

[BobA]

you havent done your psych rotation yet have you?

After that you will learn that literally any class of a psychotropic drug can be used to treat any type of psych dx....there are literally 5 million different combinations of antidepressants, mood stabilizers, benzos, stimulants, and antipsychotics we can use to treat depression, anxiety, bipolar, and psychotic d/os.........and there is a sorta study/paper/something somewhere that sorta supports it too!!

What you are saying is absolutely true -that there are many studies out that justifying many treatments. However, most of those studies are low quality. There are very very few QUALITY studies on which to base treatment (relative to a field like cardiology where studies have huge numbers of patients and high quality study design). So if one limits themselves to using quality evidence then there really aren't many treatment options with strong evidence

 

[strangeglove]

It turns out that Seroquel XR is FDA-approved for monotherapy of MDD and GAD. Not saying it makes it right to prescribe it for these indications, but this seemed relevant to the present discussion.

 

[billypilgrim37]

It turns out that Seroquel XR is FDA-approved for monotherapy of MDD and GAD.

I thought there used to be a smiley where the little guy's mouth dropped open really far in disbelief. I couldn't find it.

 

[OldPsychDoc]

I thought there used to be a smiley where the little guy's mouth dropped open really far in disbelief. I couldn't find it.

Here ya go--

 

[strangeglove]

Sorry. I think this was approved for add on, not monotherapy. There were studies showing efficacy for monotherapy and they were applying for FDA approval for monotherapy. I guess I have succumbed to AZ propaganda.

 

[OldPsychDoc]

Sorry. I think this was approved for add on, not monotherapy. There were studies showing efficacy for monotherapy and they were applying for FDA approval for monotherapy. I guess I have succumbed to AZ propaganda.

"No drug lunch for you! 3 months!"

 

[whopper]

Just double checked Epocrates...

schizophrenia
[400-800 mg PO qpm]
Start: 300 mg PO qpm, then incr. up to 300 mg/day prn; start 50 mg PO qpm in elderly or debilitated pts, then incr. by 50 mg/day; Max: 800 mg/day; Info: do not cut/crush/chew; give on empty stomach or w/ light meal; periodically reassess need for tx; D/C if ANC <1000; consider D/C if unexplained decr. in WBC
bipolar disorder, manic/mixed
[400-800 mg PO qpm]
Start: 300 mg PO qpm x1, then 600 mg PO qpm x1, then may adjust by 200 mg/day prn; start 50 mg PO qpm in elderly or debilitated pts, then incr. by 50 mg/day; Max: 800 mg/day; Info: do not cut/crush/chew; give on empty stomach or w/ light meal; for acute monotherapy or acute or maint. lithium or valproate adjunct; periodically reassess need for tx; D/C if ANC <1000; consider D/C if unexplained decr. in WBC
bipolar disorder, depressive
[300 mg PO qpm]
Start: 50 mg PO qpm x1, then 100 mg PO qpm x1, then 200 mg PO qpm x1, then 300 mg PO qpm; start 50 mg PO qpm in elderly or debilitated pts, then incr. by 50 mg/day; Max: 600 mg/day; Info: do not cut/crush/chew; give on empty stomach or w/ light meal; doses >300 mg rarely more effective; for acute tx; D/C if ANC <1000; consider D/C if unexplained decr. in WBC
major depressive disorder, adjunct tx
[150-300 mg PO qpm]
Start: 50 mg PO qpm x2 days, then 150 mg PO qpm x2 days; Max: 300 mg/day; Info: do not cut/crush/chew; give on empty stomach or w/ light meal; periodically reassess need for tx; D/C if ANC <1000; consider D/C if unexplained decr. in WBC

Could Seroquel work for monodepression? Possibly. Norquietapine is an SNRI. A problem with using it first line is it has a hell of a lot of side effects and it's expensive.

Of course if it did get a depression approval, I wouldn't be surprised if it started being prescribed even more than it already is because of some drug rep giving out nice dinners.

 

[Encephalopathy]

With cocaine dependence and a probable substance-induced depression, I'm pretty sure she endorsed psychotic features at one point or another.

 

[Abider]

With cocaine dependence and a probable substance-induced depression, I'm pretty sure she endorsed psychotic features at one point or another.

Yeah I wondered about that too. If so, however, how common is it for some temporary psychiatric dx to follow a patient, even through an entire hospital stay without any verification of dx or concern for conscientious psychopharmacological tx.?

My hospital takes care of the very poor. I am curious if it's an under served issue or just an interspecialty "not my problem thing" coupled with poor continuity of care. And also is a script like this one the mark of a psychiatrist or would a non-specialist venture into off label psychopharm?

 

[OldPsychDoc]

Yeah I wondered about that too. If so, however, how common is it for some temporary psychiatric dx to follow a patient, even through an entire hospital stay without any verification of dx or concern for conscientious psychopharmacological tx.?

All. The. Time. You'll see this more and more as you get to take care of complicated patients of all stripes on all rotations. It's called a "chart weed" and it's not just psych. I heard tell once of a pt that was being presented at the bedside with a past medical hx of "BKA (below knee amputation) x 2". The attending observed that the patient had feet. Further chart review indicated that several admissions previously, 2 episodes of DKA (diabetic ketoacidosis) had occured. The transcription error had been perpetuated through several readmissions without being noted. Face it. We're ALL lazy.

My hospital takes care of the very poor. I am curious if it's an under served issue or just an interspecialty "not my problem thing" coupled with poor continuity of care. And also is a script like this one the mark of a psychiatrist or would a non-specialist venture into off label psychopharm?

Yes, yes, yes, and not necessarily--especially if it had been started, as I suggested, to temporize a drug induced psychosis, and a patient with less well-developed historical recall skills just kept saying it was for "my depression" or something. I've seen it all the time...

 

[Abider]

All. The. Time. You'll see this more and more as you get to take care of complicated patients of all stripes on all rotations. It's called a "chart weed" and it's not just psych. I heard tell once of a pt that was being presented at the bedside with a past medical hx of "BKA (below knee amputation) x 2". The attending observed that the patient had feet. Further chart review indicated that several admissions previously, 2 episodes of DKA (diabetic ketoacidosis) had occured. The transcription error had been perpetuated through several readmissions without being noted. Face it. We're ALL lazy.



Yes, yes, yes, and not necessarily--especially if it had been started, as I suggested, to temporize a drug induced psychosis, and a patient with less well-developed historical recall skills just kept saying it was for "my depression" or something. I've seen it all the time...

Hmmm. Ok, thanks for teaching, appreciate it.

 

[digitlnoize]

?? Of course there is no need to figure out "what is meant by it". They are there to fix her bowel.

This, to me, speaks to exactly what is wrong with modern medicine. There is a distinct attitude of "that's not MY problem" going around. The surgeons are there to fix her bowel and to hell with everything else. That is not good medicine, and it is not how we should be practicing.

I'm not expecting every surgeon to understand advanced psychiatric med management, but they should recognize depression in a patient and at least attempt to address it. Likewise, if we see a hospitalized schizophrenic with a BP of 180/110, we should attempt to address that. Burying out heads in the sand and saying, "That's not MY problem," is just a terrible way to treat people.

 

[Tripolar]

I think everyone is missing the problem. This is a surgery note or non-psychiatric record I assume. What they call "depression" could be anything from bipolar, schizophrenia, anxiety etc. I see depression slapped down for almost any psych complaint. Its almost used interchangeably with some docs as psychiatric history.

My bet is she has bipolar disorder or another psychotic illness that is not mentioned.

 

[whopper]

True,

I remember a schizophrenic patient being labelled as depression by an IM doc, surgeons tend to be even worse in diagnosing.

 

[Abider]

Point taken all. And thanks for the teaching points.

But this was a surgery consult only if the ischemic ulcerations became transmural and the colon unviable.

The chart was for her inpatient stay and internal medicine was doing the bulk of her management. IM, GI, and surgery all seamed to rubber stamp the admitting dx of depression, honestly I'm not certain if the antipsychotic was given throughout her stay, we're using paper charts and I neglected to note it--this being a surgical presentation afterall. It was listed as one her regular meds which she was instructed to continue as directed by primary care...which meant, in her case I'm afraid, some occasional visit to a local clinic and regular use of her dealer.

I sort of thought of these questions as I was finished and thinking about what it meant for my field of interest and how our aspect of care gets carried out. Unfortunately it didn't occur to me in real time. I'm still preoccupied with learning to present without getting my butt chewed for cluelessness.

 

[OldPsychDoc]

...
I sort of thought of these questions as I was finished and thinking about what it meant for my field of interest and how our aspect of care gets carried out. Unfortunately it didn't occur to me in real time. I'm still preoccupied with learning to present without getting my butt chewed for cluelessness.

The most important part of this presentation was your willingness to question a report of "risperdal for depression" instead of taking it at face value. This is what you are supposed to be learning from presenting patients at this stage of the game, vs it being some sort of performance art of displaying knowledge as entertainment to others.

 

[aphenomenon]

With this talk of augmentation and relative cost, etc....I wonder does it matter on the "type" of depression? Like would you choose risperdal to augment for a depression with hint of psychotic features but buspirone to augment for depression in a patient with baseline anxiety or something of the sort, right?

 

[whopper]

I remember doing consult a few times and having no to little confidence in the diagnosis given to us by surgery or IM, then asking the patient who gave us contradictory information.

As far as IM was concerned, they didn't care if the history was all wrong.

 

[kugel]

With this talk of augmentation and relative cost, etc....I wonder does it matter on the "type" of depression? Like would you choose risperdal to augment for a depression with hint of psychotic features but buspirone to augment for depression in a patient with baseline anxiety or something of the sort, right?

For me, sure it matters. If the pt has psychosis, i'll probably use an antipsychotic as my adjunct. If the pt has lots of anxiety, why not use the buspirone? If the pt has bad anergy, I'm more likely to try synthroid or try adding bupropion. I'm a fan of using lithium as adjunct unless there's a better alternative for some specific reason like those above.