Benefit of rapidly titrating an SSRI during an inpatient stay?

[ryerica22]

I'm doing a moonlighting job where I'm seeing a ton of patient's who have been hospitalized for only 4-5 days, yet are on pretty high doses of SSRI's (Zoloft 150mg, Prozac 60mg, etc.). I'm imagining that the inpatient psychiatrists do this so that insurance authorizes the stay when its for depression/SI, however, I don't know if it really makes that much of a difference in such a short stay in terms of resolving ones suicidality, especially when it takes at least 2 weeks for these meds to kick in.

Is there something I'm missing? Does rapidly titrating in such a few days cause depression to dramatically get better? I always thought it was the effect of inpatient Milieu (social work, therapy, groups, etc).

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[splik]

No it doesn't but the best arguments for doing so is your patients in the inpatient hospital are different than outpatients by virtue of needing hospitalization and thus a more aggressive titration is warranted. for many patients, especially with more severe mental states, they will need higher doses of medications, and while these are unlikely to make big differences during the inpatient stay (except for the not to be discounted placebo effects), it does confer an advantage when they leave of not having to wait weeks to get up to a more therapeutic dose when a patient is in crisis. So it does potentially confer a major advantage on discharge. I was skeptical about this before hand but on the occasions where I cover the inpatient now, I will be fairly aggressive with titrating antidepressants. What I am much less a fan of is aggressive titration of antipsychotics to much higher than necessary doses, where all you are going to do is give the patient more adverse effects that will lead to poor adherence. That is much more of a problem in inpatient settings - inappropriately high doses of antipsychotics - and an unwillingness to wait for the antipsychotics to kick in at a lower dose, or wait to start meds in the first place, which is often insurance driven.

Here is a little article by david feifel who used to work at ucsd where he outlines and makes a compelling case for more aggressive pharmacotherapy in the inpatient setting: Transforming the Psychiatric Inpatient Unit from Short-term Pseudo-asylum Care to State-of-the-art Treatment Setting

 

[futuredo32]

No it doesn't but the best arguments for doing so is your patients in the inpatient hospital are different than outpatients by virtue of needing hospitalization and thus a more aggressive titration is warranted. for many patients, especially with more severe mental states, they will need higher doses of medications, and while these are unlikely to make big differences during the inpatient stay (except for the not to be discounted placebo effects), it does confer an advantage when they leave of not having to wait weeks to get up to a more therapeutic dose when a patient is in crisis. So it does potentially confer a major advantage on discharge. I was skeptical about this before hand but on the occasions where I cover the inpatient now, I will be fairly aggressive with titrating antidepressants. What I am much less a fan of is aggressive titration of antipsychotics to much higher than necessary doses, where all you are going to do is give the patient more adverse effects that will lead to poor adherence. That is much more of a problem in inpatient settings - inappropriately high doses of antipsychotics - and an unwillingness to wait for the antipsychotics to kick in at a lower dose, or wait to start meds in the first place, which is often insurance driven.

Here is a little article by david feifel who used to work at ucsd where he outlines and makes a compelling case for more aggressive pharmacotherapy in the inpatient setting: Transforming the Psychiatric Inpatient Unit from Short-term Pseudo-asylum Care to State-of-the-art Treatment Setting

How do you know they will even need a higher dose of an antidepressant? Maybe 50 mg of Zoloft will end up being therapeutic for them? I have a fair number of patients doing well on low doses of antidepressants. I get so many new patients just discharged from the hospital not only on a high dose of an antidepressant but also something for sleep and Ativan tid neither of which they were taking prior. The standard of care in the hospitals seem to be either 50 mg of Trazodone or Seroquel for sleep plus Ativan .5-1 mg tid.

 

[Liquid8]

You can be more aggressive with inpatients, in part due to a greater degree of medical and nursing monitoring and capacity to alter and adjust things if needed. If I am switching antidepressants with an outpatient, I will do so gradually with a washout period. This might not be suitable for an inpatient, but in that setting I have more flexibility to change things quicker and can implement short term PRNs to cover withdrawals when needed.

As Splik points out, the other obvious thing is that any one determined to need inpatient care is likely to be more unwell, thus anticipating a higher dose. However, as I followup most of my inpatients in my outpatient clinic, I tend not to max things out and leave some room to play with doses without having to bring someone back in for a subsequent change.

 

[hamstergang]

What I've seen and don't understand at all is after starting and rapidly titrating an antidepressant, switching to a new agent if the patient is just as depressed after 5-7 days.

 

[Liquid8]

What I've seen and don't understand at all is after starting and rapidly titrating an antidepressant, switching to a new agent if the patient is just as depressed after 5-7 days.

Can't say I've seen that, but if I had I probably wouldn't understand it either. One possible explanation would be if the patient was having intolerable side effects, but that would be a reason for leaving medications at a lower dose for longer and slower increases.

 

[clausewitz2]

What I've seen and don't understand at all is after starting and rapidly titrating an antidepressant, switching to a new agent if the patient is just as depressed after 5-7 days.

Possibly a belief that constant change in medications is the only way to justify inpatient hospitalization to insurance?

 

[whopper]

STAR*D showed that higher dosages of antidepressants (of course up to the FDA max) for most patients usually does increase efficacy of the antidepressant. If a patient has severe depression and I start then on an antidepressant, while in inpatient, I tended to increase it faster than the 1 week-norm for pretty much all of them. I never raised it faster than every 4 days. As mentioned above you risk serotinergic syndrome. Warn the patient of what you're doing and offer then the choice to do the norm or go faster with higher risks but hopefully (but possibly not) faster improvement (but higher risk of side effects).

What I've seen and don't understand at all is after starting and rapidly titrating an antidepressant, switching to a new agent if the patient is just as depressed after 5-7 days.

Likewise I don't get the psychiatrists (or really any other doctor treating any disorder) that don't well-catalog what's already been tried and the dosages. E.g. pt tried on Wellbutrin, they were stopped but the doctor didn't write down in the notes why, the effects good or bad, and the duration the patient was on it.

So often times I get a new patient and even if I have the prior doctor's notes I tell the patient I can't make heads or tails if they really had an adequate trial.

On my own notes I keep a section in the patient's history of "Psychotropic Medication Trials" that I don't write into the history section until the pt's had an adequate trial (e.g. Antidepressant-1 month of med at the highest FDA dosage of highest tolerable dosage for the patient.

Here's a cut and paste from one of my patients.
Belsomra: Helped with sleep at 15 mg. Denied side effects.
Buspirone: "made me sick." even at low dosages first few days.
Carbamazepine: "sick to my stomach, bad no appetite, numbness, muscle aches, nausea, not being able to sleep."
Desvenlafaxine: "Worked great," denied side effects at maximum dosage.
Duloxetine at 60 mg by mouth: some improvement. Doctor that prescribed it moved out of the area so she wasn't able to continue it.
L-Methylfolate: Improved depression. Worked better at 30 mg daily vs 15 mg daily. No side effects.
Methylphenidate: Made XXX more anxious
Melatonin 30 mg in one night: No benefit.
Olanzapine: 20 mg-IBS sx are gone, appetite is up but so far this is what she wants.
Paroxetine: Worked but only until she became an adult then it stopped working.
Propranolol: Didn't help at lower dosages but at higher dosages it lowered her BP too much.
SAM-E: no benefit with mood or joints despite being on 1500 mg daily for 1.5 months.
Viibryd: Felt no difference on the starter pack 2 week trial
Wellbutrin: "Made me go completely panic attack." even at small dosage first few days.

 

[ryerica22]

Thanks for the responses. I wonder if the improvements noted in depression within an inpatient setting are due to rapid titration or other factors (i.e. individual therapy)? I remember getting a lot of pushback from parents during my child inpatient rotation as a 2nd year where they questioned why I would want to increase Prozac only after a couple of days if the effect will take a couple of weeks.

 

[st2205]

Thanks for the responses. I wonder if the improvements noted in depression within an inpatient setting are due to rapid titration or other factors (i.e. individual therapy)? I remember getting a lot of pushback from parents during my child inpatient rotation as a 2nd year where they questioned why I would want to increase Prozac only after a couple of days if the effect will take a couple of weeks.

There are lots of non-medical things transpiring that are much larger variables in the equation. Being on an inpatient unit allows time to sit down and think about life, think about what got you where you are, think about what you want to do different, etc. People feel more optimistic and hopeful about the future when making New Year’s resolutions, for instance. Also, people on an inpatient unit are more likely to end up their as a result of affective instability, and that door swings both ways.

 

[whopper]

Thanks for the responses. I wonder if the improvements noted in depression within an inpatient setting are due to rapid titration or other factors (i.e. individual therapy)? I remember getting a lot of pushback from parents during my child inpatient rotation as a 2nd year where they questioned why I would want to increase Prozac only after a couple of days if the effect will take a couple of weeks.

Just my opinion, quick improvement (specifically meaning less than 7 days) with depression in inpatient likely isn't the medication even with quick titration. Lots of things go on in a psych unit such as group therapy, simply having hope the new treatment will work, placebo effect....and wanting to get the heck out of there cause the patient realizes that it's not going to be like the hotel stay they thought it'd be.

 

[NickNaylor]

For patients in the inpatient setting, my initial goal is almost always a moderate-high dose of antidepressant irrespective of what's going on. For example, my goal prior to discharge might be 100-150 mg of sertraline, 15-20 mg of escitalopram, 150-225 mg of venlafaxine, etc.. This is primarily to ensure that they leave the unit on an adequate dose which, as mentioned, is evidence-based - i.e., patients are more likely to respond at higher doses and aggressive treatment than lower doses. There is further evidence that a longer duration of untreated or inadequately treated symptoms portends a poorer outcome; since I don't necessarily know what's going to happen once the patient leaves the hospital, I want to do everything that I can to maximize the chances that they continue to improve after discharge.

Based on what we know about the pharmacology of antidepressants, it is very unlikely that the medication itself is responsible for any improvement during a 5-7 day admission, as mentioned by @whopper. This is where psychotherapeutic and psychosocial interventions are helpful.