Do Antidepressants Cause Switching or Not?

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Anasazi23

Anasazi23

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I had a situation recently that caused me to re-look at the literature, as I was pretty convinced I had switched a young businessman into a hypomanic flip.

Mid 30's, no prior psych tx. Substance use hx (crystal). Some suspicious hx of hypomanic sx. (spending, impulsivity) Med hx noncontributory. Reporting depressed mood affecting his motivation and work. After risk/benefit discussion, agrees to trial of antidepressant first.

Started low dose AD, little effect, so raised the dose at one month. Two weeks later, reporting he's showing up at work at 4am (starts at 8, and got in trouble with boss for this behavior), hyperverbal, little sleep with increased energy.

Absolutely does not want to give up the AD, saying he hasn't felt this stable or happy in his life. MSE essentially normal.

I did some re-reading on AD switching, and it seems to only get more complicated the further you dig. Then, I read this:
http://www.thecarlatreport.com/index.asp?page=wp7232008115628

Interested in other's opinions.
 
I have been really interested in this topic as this situation comes up so often when treating patients with mood disorders. Obviously, literature is really mixed but thankfully, newer ADs have a lower switch rate. Most but not all studies show that bupropion has a lower switch rate and thus is commonly recommended by some attendings. I believe it is always OK to use ADs in many of these patients. I am always relieved if somehow I can find a reason to give a small dose of seroquel or abilify for a mood stabilizing effect.

I am wondering which AD did you put this patient on and how high did you go?
 
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IIRC, this is more of an issue with AD's that act primarily on 5HT. I don't believe there is a clear answer in the research, though if there is a concern, I'd think a mood stabilizer would be a more prudent choice.

OPD makes a good pt about the CM use. I'd be curious if there is more to that.
 
Therapist4Chnge said:
IIRC, this is more of an issue with AD's that act primarily on 5HT. I don't believe there is a clear answer in the research, though if there is a concern, I'd think a mood stabilizer would be a more prudent choice.

OPD makes a good pt about the CM use. I'd be curious if there is more to that.
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The problem is when the patient is sitting in front of you, and they're just flat out depressed. Like Carlat says in that article I linked above, it's just damn hard to not prescribe an AD in that case, particulary if you're looking at bipolar II.

As far as the serotonin thing, there's no clear research to suppor that either, so the questions becomes what to do when the patient is sitting in front of you, and they're talking about suicidal thoughts.

In terms of the case I described above, there appeared to be a bipolar II flavor to the guy which predated the meth use, though that's always hard to tell. The meth use is used in the typical fashion as in most big cities that have a meth epidemic. I'll leave it at that.

The essential question is, according to some of those reports described by Carlat, the rate of baseline switching is comparable to placebo in some studies.
 
Nuts, I saw a slide on a power point presentation years ago comparing the levels of flipping into mania from antidepressants. Welbutrin did it the least, the SSRIs were the next most often, then SNRIs did it the most.

But when I look on pubmed, there's no article that cross compares it in such a clean manner.
 
Right, that's the thumbnail conventional wisdom, but what do you guys think of that Carlat summary? It basically refutes most of that.
 
I haven't ignored lithium deliberately, but I must admit...outside of an inpatient setting, the side effect profile is nearly a deal-breaker for almost every young bipolar I see. Slightly less so for VPA and its constituents.
 
I know the studies do not back this up my own experiences, but so far in long term inpatient, over 50% of the patients I've had who've been on lithium long term got a permanent thyroid problem over it.

And if I discharge a patient on lithium, I've given the patient a very good loaded gun to kill him/herself with.

For that reason, I tend to shy away from using lithium, even though it is highly efficacious.
 
"I wouldn't buy a cemetery plot yet"...I didn't expect something like that in an academic-esque article. :laugh:

As for the author's comments....I think he stretching a bit at his conclusions. Some of the first studies he cited (I just skimmed) have 10 wk durations, which may suffice for acute treatment, but I think generalizability needs to be cautious with the shorter time frame. They also used the Ham-D which is a pharma favorite, but it really isn't as good of a measure for comparative depressive symptoms.

AD + Mood Stabilizer seems like a decent way to go (per his stance), though if there is limited support for LT use, why not go with a monotherapy and avoid putting another med on board (side effects, cost, interactions, etc)? Not to be all -ology, but how about some supportive therapy and basic coping skills to use in conjunction with a mood stabilizer?

As for Lithium....I agree about the LT issues. Many people find stability on it, though if they are LT, the damage is often done already. How about Lamictal? There is some decent data on BPD-II for it, and the side effect profile is better for LT issues.
 
seems like something like lamictal (with its purported mood-elevating properties) as a mood stabilizer plus some sort of therapy might be worth trying. Granted there are a lot of lamictal horror stories about imparied memory formation and short term memory.
 
Lamictal can cause double vision according to some literature. More rarely, stevens-johnson syndrome.

I'm just a student, but I'm loathe to use lamictal or even Li much if I can use depakote/VPA. Isn't depakote cheaper than lamictal, too?
Finally, I think I'd rather generally use an AD and reduce SI more, if present, than worry about flipping a patient into hypomania. Hypomania isn't mania. Are we sure that this patient isn't actually manic? Just wondering.

I don't think there is enough evidence to support psychotherapy in lieu of AD in Bipolar disorders, am I wrong about that? I think some CBT would be great for sure in the long term, but I'm not comfortable with that for immediate stabilization of mood and alleviation of negative symptoms in this outpatient. If you wanted to use just one drug, what do you think about Abilify or, if you want to go really cheap, Geodon?
 
The biggest problem I have with Lamictal is it takes several weeks to reach the therapeutic dosage. Several patients are non-compliant as it is already. Makes it that more much difficult with a medication that takes over a month of slowly increasing its dose to reach a level where there's going to be effect.
 
whopper said:
The biggest problem I have with Lamictal is it takes several weeks to reach the therapeutic dosage. Several patients are non-compliant as it is already. Makes it that more much difficult with a medication that takes over a month of slowly increasing its dose to reach a level where there's going to be effect.
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True....though this isn't reserved just for Lamictal. I think the starting dose and titration of many of these medications is too quick, and the increased s/e causes a d/c of the medication before it is given the proper amount of time to work. In regard to SJS...sure it is a concern (in addition to other rashes/skin irritation, etc), though it has such a low incidence rate, that short of a prior adverse Hx with it, I'd think it'd still be an option. As for diplopia....mixed data IIRC about the incidence rate. I'm always skeptical to the published data on s/e's, as some seem low. I'd be curious what some of the more seasoned people think, as my musings are academic in nature and I don't have the real world experience in this area.
 
OldPsychDoc said:
Would also wonder more about that hx meth use!
Click to expand...

Anyway to get a drug screen and/or some vitals next time you see him acting like this without ruining the therapeutic alliance?

Also, don't forget the fish oil! (I'm not kidding 😀)
 
Every single patient I have in inpatient are put on fish oil. I'm not kidding. The only ones not taking it are ones that refused it after a few tries. Every single outpatient, I'd have to give the 15 minute lecture on it. I was thinking of just making a brochure & have them read it in the waiting area because it takes up a lot of my time.

Another problem with lamictal (as an outpatient) is that the dosing goes up every so often. Another thing to confuse the patient. In inpatient its not so bad because I can control the dosing & they just have to take the pills.

However I do like lamictal as a medication.
 
BobA said:
Anyway to get a drug screen and/or some vitals next time you see him acting like this without ruining the therapeutic alliance?

Also, don't forget the fish oil! (I'm not kidding 😀)
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Said patient was in a drug tx center, so they get urines every visit.

I'm not concerned about therapeutic alliance with drug addiction patients. They're well informed that random and/or routine urines are part of their onging assessment. If a patient is refusing this, they aren't completely ready for treatment. The doctor, in this case, is treating the addiction concurrently. There theoretically isn't an accusatory tone more typical of a family member or friend. In that sense, patients rarely object in my experience.
 
I've had a few cases of diplopia with lamictal. In most of those cases, however, the patient was taking VPA concurrently.

I think Lamictal was a complete game-changer in the treatment of bipolar disorder and has, according to opinions voiced in the psychopharm conferences, completely changed the way psychiatrists treat patients.

I use it a lot. But sometimes, the depressive component just breaks through, and you have to go to plan B, or wait it out, which can be dangerous depending on the patient.
 
Anasazi23 said:
I think Lamictal was a complete game-changer in the treatment of bipolar disorder and has, according to opinions voiced in the psychopharm conferences, completely changed the way psychiatrists treat patients.
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Can you elaborate on this? I've heard and read some good things about lamictal, which is why I brought it up. But I wasn't aware it had reached such an important status.
 
I'm sorry, fish oil? For the uninformed, please elaborate...
 
There's a lot of data showing a good dose of Omega 3 Fatty Acids can help with mental illness, though I got to admit, some of the data is equivocal.

A simple Google scholar search on "fish oil psychiatry" will yield the following...
http://scholar.google.com/scholar?q...=UTF-8&oe=UTF-8&sourceid=ie7&um=1&sa=N&tab=ws

Just a small sample of the hits
Addition of Omega-3 Fatty Acid to Maintenance Medication Treatment for Recurrent Unipolar Depressive … - ►psychiatryonline.org
HTML: 
B Nemets, Z Stahl, RH Belmaker - American Journal of Psychiatry, 2002 - Am Psychiatric Assoc
... J, Toft E, Moller J, Rasmussen K, Dyerberg J, Schmidt EB: Effect of fish oil on
heart ... Arch Gen Psychiatry 1999; 56:407-416[Abstract/Free Full Text]; Hamazaki T ... 
Cited by 258 - Related articles - Web Search - BL Direct - All 5 versions 

… Levels in Concentrated Over-the-Counter Fish Oil Preparations: Is Fish Oil Healthier Than Fish?
SE Foran, JG Flood, KB Lewandrowski - Archives of Pathology and Laboratory Medicine, 2003 - arpa.allenpress.com
... 6. Fish oil is a possible substitute for eating fish and has been used
pharmacologically in subjects at risk for CAD and in certain psychiatric populations. ... 
Cited by 38 - Related articles - Web Search - BL Direct - All 5 versions 

Randomised double-blind placebo-controlled trial of fish oil in the treatment of depression
KM Silvers, CC Woolley, FC Hamilton, PM Watts, RA … - Prostaglandins, Leukotrienes & Essential Fatty Acids, 2005 - Elsevier
... for a current depressive episode and no co-existing psychiatric disorder (except ...
allergies to seafood, objections to taking fish or olive oil-based products ... 
Cited by 43 - Related articles - Web Search - All 5 versions 

Randomised clinical trials of fish oil supplementation in high risk pregnancies
SF Olsen, NJ Secher, A Tabor, T Weber, JJ Walker, … - BJOG: An International Journal of Obstetrics & Gynaecology, 2000 - Blackwell Synergy
... Table 2. Secondary (a piori) hypotheses of the Fish Oil Trials In Pregnancy. ... Randomised
clinical trials of fish oil supplementation in high risk pregnancies. ... 
Cited by 170 - Related articles - Web Search - BL Direct - All 4 versions 

Omega 3 Fatty Acids in Bipolar Disorder A Preliminary Double-blind, Placebo-Controlled Trial
AL Stoll, WE Severus, MP Freeman, S Rueter, HA … - Archives of General Psychiatry, 1999 - Am Med Assoc
... the baseline visit, a detailed psychiatric and medical ... ethyl esters or placebo (olive
oil ethyl esters) were obtained from the Fish Oil Test Materials ... 
Cited by 260 - Related articles - Web Search - BL Direct - All 7 versions 

A randomised double blind placebo controlled trial of fish oil in high risk pregnancy
JL Onwude, RJ Lilford, H Hjartardottir, A Staines, … - BJOG: An International Journal of Obstetrics & Gynaecology, 1995 - Blackwell Synergy
... of Psychiatry 39:4, 274–280 ... Sjúrður F. Olsen, Niels J. Secher, Stein Björnsson, Tom
Weber and Anders Atke. (2003) The potential benefits of using fish oil ... 
Cited by 84 - Related articles - Web Search - BL Direct - All 5 versions 

Short-term administration of omega 3 fatty acids from fish oil results in increased transthyretin … - ►pnas.org [HTML] 
LG Puskas, K Kitajka, C Nyakas, G Barcelo-Coblijn, … - Proceedings of the National Academy of Sciences, 2003 - National Acad Sciences
... Fish oil was a generous gift of BLT Berg Lipidtech (Aale, Norway). Abbreviations. ...
Neurosurg. Psychiatry 63, 506-508[Abstract/Free Full Text]. 45. ... 
Cited by 69 - Related articles - Web Search - BL Direct - All 9 versions 

Omega-3 Fatty Acids in the Treatment of Psychiatric Disorders.
M Peet, C Stokes - Drugs, 2005 - drugs.adisonline.com
... Am J Psychiatry 2002; 159: 1029-34 [Context Link]. 60. Mehta D, editor. ... How
blind is double-blind? A study of fish oil versus placebo. ... 
[/QUOTE]

I figure at the least, it won't hurt.  Most Americans do not get a good amount of Omega 3's anyways.  I figure its cheap, its good for you, so even if it doesn't cause psychiatric benefit--at least it might lower their cholesterol, inflammation, loosen their joints & protect against a heart attack & stroke a bit.

I would never reccomend fish oil instead of FDA approved psychotropic medications unless the patient has minor depression or anxiety, and they tell me they do not want a medication.  I do though reccomend all my patients take it or at least some other source of Omega 3s (but the data on fish oil is stronger that flax seed oil on psychiatric benefit).  

The only cases where I would re-think this is where the patient may have a bleeding disorder or is on an anticoagulant medication such as warfarin--in which case I'd call up the IM/PCP covering that and ask if the fish oil is still appropriate with their condition & meds.
Click to expand...
 
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Yup. And as whopper has previously mentioned, the higher the EPA in the supplement, the better. This is an issue since the majority of supplements have more DHA than EPA, which while not bad, is not as good as the other way.

Omega 3s are an essential part of nerve cell membranes and myelin and all that good stuff. EPA has a rather rapid turnover. And paleonutrition studies as well as more modern stuff indicate that we are very very low in EPA consumption compared to how we were even 50 years ago.

The need for supplementation does not exist if we eat grass-fed freerange beef, drink grassfed milk, and eat freerange properly fed chickens.

Supplementation in general isn't an issue of going pill-crazy to augment your natural abilities, but rather simply making up for the inadequate nutritional value of modern food compared to its analogues even thirty or forty years ago.

There are some eye opening studies about how much teh nutritional content of various vegetables (raw) has changed in the past 40 years or so.
 
whopper said:
There's a lot of data showing a good dose of Omega 3 Fatty Acids can help with mental illness, though I got to admit, some of the data is equivocal.

A simple Google scholar search on "fish oil psychiatry" will yield the following...
http://scholar.google.com/scholar?q...=UTF-8&oe=UTF-8&sourceid=ie7&um=1&sa=N&tab=ws

Just a small sample of the hits


I figure at the least, it won't hurt. Most Americans do not get a good amount of Omega 3's anyways. I figure its cheap, its good for you, so even if it doesn't cause psychiatric benefit--at least it might lower their cholesterol, inflammation, loosen their joints & protect against a heart attack & stroke a bit.

I would never reccomend fish oil instead of FDA approved psychotropic medications unless the patient has minor depression or anxiety, and they tell me they do not want a medication. I do though reccomend all my patients take it or at least some other source of Omega 3s (but the data on fish oil is stronger that flax seed oil on psychiatric benefit).

The only cases where I would re-think this is where the patient may have a bleeding disorder or is on an anticoagulant medication such as warfarin--in which case I'd call up the IM/PCP covering that and ask if the fish oil is still appropriate with their condition & meds.
Click to expand...

I did a few years of research on Omega 3 fatty acids (O3FAs) -- am a big fan of them -- and would just make a few points.

The brain is something like 70% fat, and O3FAs are an essential and easily deficient component of fats (since O3FAs are primarily in certain foods, a limited diet can easily be deficient in O3FAs).

We showed in our preliminary data that O3FAs lowered depression for patients with heart failure (since depression is a risk for heart disease, the medications had a double benefit). There is a lot of belief in O3FAs reducing depression in general, however...

I would recommend it in a few cases:
- Mildly depressed or dysthymic patient who wants a medicine but doesn't want an antidepressant
- Pregnant woman with h/o depression -- this will help her child's brain develop better. In fact there is research (don't have references now) that pregnant women who take O3FAs will have babies with higher IQs, due to a more robust brain development in utero.

O3FAs are just excellent medications that are gaining in popularity, and I think will continue to become more popular. (full disclosure, way back in the early '90s, I would actually go to a random health food store and buy this stuff in liquid form -- it was disgusting -- but I was an early believer).

From the research lab where I worked, we considered O3FAs to be equivalent regardless of source -- fish, pills, or flax seed oil (which has a ridiculous amount of O3FAs in it).

Can't imagine that this supplement causes switching, and if so, we should be telling bipolar patients to avoid salmon!
 
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actually, I think O3FAs decrease frequency of switching.

did your lab consider only total amount of O3FA to be important, or did EPA/DHA matter?
 
masterofmonkeys said:
actually, I think O3FAs decrease frequency of switching.

did your lab consider only total amount of O3FA to be important, or did EPA/DHA matter?
Click to expand...

We had a certain ration of EPA/DHA, which I don't remember -- but all the standardized supplements had this. I can say that I remember going to GNC or the pharmacy and noticing that most of the over the counter supplements had pretty much the same ratio...

And we used a relatively high amount of O3FAs, to ensure that we would see a result -- it was about 3g. This is equivalent to about 5-10 pills -- we gave a liquid form -- and it was a problem, since people complained and occasionally dropped out due to not being able to handle the taste.
 
gotcha. Maybe things are hugely different now, but I try to look for a 1:1 or better ratio of EPA/DHA (Omacor/Lovaza is about 5:4 which is lower than I'd like). Most of the common and less expensive stuff is about 1:2 or even 1:3, which isn't terribly helpful.

The GNC triple-strength is one of the few commonly found ones that is decent enough in dose for my tastes. Another good brand (but hard to find) is the Pure Encapsulations product. The Biotest brand's Flameout product is pretty good, and since it's German, it's regulated and tested so you know that the amount on the label is actually the true amount. It's also hugely expensive.

I take the GNC stuff right now.
 
masterofmonkeys said:
gotcha. Maybe things are hugely different now, but I try to look for a 1:1 or better ratio of EPA/DHA (Omacor/Lovaza is about 5:4 which is lower than I'd like). Most of the common and less expensive stuff is about 1:2 or even 1:3, which isn't terribly helpful.

The GNC triple-strength is one of the few commonly found ones that is decent enough in dose for my tastes. Another good brand (but hard to find) is the Pure Encapsulations product. The Biotest brand's Flameout product is pretty good, and since it's German, it's regulated and tested so you know that the amount on the label is actually the true amount. It's also hugely expensive.

I take the GNC stuff right now.
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Yeah, you can see that in my interviews, how poorly I explain my old research!

Nobody seems to care, though -- Even though they tell us to "know our research," I don't think people care about the little details as long as you are positive, excited, and obviously worked on the project.
 
I was PI (and usually sole person) for all of my research. Most of it has to do with monkeys and calculus. People usually just stare at me uncomprehendingly when I get all excited about derivatives and integrals and total energy expenditure versus daily versus rate of change of energy expenditure and start doing the whole air blackboard thing and giggling while I stare fixedly at the wall.

People ask about your research but don't seem to really care unless you have a research plan and interests for the future. Then you have to get far more specific than you could possibly get before you've even started. 'No, I don't know whether I'm going to use urinary or salivary assays yet.' *frowning*'hmm, well you might want to figure that out.'
 
Thanks for writing the above data. While I was aware of it, I didn't type it down in my earlier post because I was busy at that moment & I have a bad habit of sometimes writing down a minor boo-boo technical error when I don't have the source right in front of me.

I've read dozens of articles on the mental health benefits of Omega 3s, but heck none of those articles are on me now. I pretty much recycled them after I read them.

I will say (and I can't find the article, but I jotted it down on my palm PDA) that some studies I've seen show the depression benefit of fish oil tops off at 1g per day. I have seen several articles also showing neurological benefits. I've also read reports hypothesizing that they are involved in post partum psychosis & depression since during pregnancy, the fetus depletes the mother of a lot of EPA that would've otherwise done to her brain. Our modern diet is very deficient on this nutrient. Makes sense--in several cases a mother's brain actually shrinks while pregnant.

I did however discuss this theory with a prominent expert in the field of reproductive psychiatry (will not name her), and she didn't know what I was talking about, & she didn't seem to know the benefits of Omega 3s in mental health either.

One other concern I didn't mention was that because if increasing amounts of heavy metals in the environment, pregnant females should get molecularly distilled fish oil which can be obtained from places like Vitamin Shoppe or GNC. Otherwise most adults have nothing to fear from the standard fish oil supplements.

So I figure why not? Its healthy. If it doesn't create psychiatric benefit, its still a healthy supplement to take. I still though get an occasional "oh you're one of those" in a condescending manner from a colleague (geez--are these people reading on their journals? There's plenty of data of safety & mental health benefit of fish oil), or a "hey--I should do that with my own patients, why didn't I think of that?"
 
In general our stores of DHA are very good and we have a very low turnover of it. In fact, some research indicates that some of the DHA present in our brains in adulthood is the same stuff we got from our mommies when we were feti. But that also means pregnancy is a time of DHA depletion for the mother.

EPA on the other hand is rapidly turned over, which is why I think it's so important to check your O3FA supplement not only for total amount but also for specific amounts of EPA.

I don't know why anyone would doubt the importance of nutrition and exercise in psychiatry. Most of the people I've talked to on the interview trail seemed genuinely excited that this was where I planned on focusing research efforts.
 
If I remember correctly, Columbia was doing some research on fish oil possibly preventing or slowing down the onset of Alzheimer's. I do remember from a few lectures that fish oil in vitro stops the biochemical process that causes Alzheimer's in the brain. Some studies have showed correlation with EPA/DHA & reduced incidence of Alzhiemer's.

MOM--I remember you mentioning that you were interested in some of the top tier programs. If you're interested in doing research on Omega 3s & mental health, might want to bring this up when you interivew, especially at Columbia. Darned-can't find a link to the article where I read that Columbia was doing a very large study on this.
 
I just wanted to thank 'sazi for showing me the way to such a wonderful resource!

I've been hoping to find something like the Carlat report - Thanks!
 
BobA said:
I just wanted to thank 'sazi for showing me the way to such a wonderful resource!

I've been hoping to find something like the Carlat report - Thanks!
Click to expand...

No problem. The Carlat report has been around for years. It's a nice summary of the recent pharmacological (and other) research out there in a digestable form. Oftentimes your residency will pay for a paper subscription that they'll keep in the resident library if you ask. It's relatively cheap.

The Carlat pharma influence blog, however, (and by his own admission) is quite one-sided. Though, I see where he's coming from in many respects. Sometimes, however, it reads as an all-out Crusade against the pharm companies. Without starting a whole new magilla, there's fallout from biting the hand that feeds you.
 
whopper said:
If I remember correctly, Columbia was doing some research on fish oil possibly preventing or slowing down the onset of Alzheimer's. I do remember from a few lectures that fish oil in vitro stops the biochemical process that causes Alzheimer's in the brain. Some studies have showed correlation with EPA/DHA & reduced incidence of Alzhiemer's.

MOM--I remember you mentioning that you were interested in some of the top tier programs. If you're interested in doing research on Omega 3s & mental health, might want to bring this up when you interivew, especially at Columbia. Darned-can't find a link to the article where I read that Columbia was doing a very large study on this.
Click to expand...

yes, there is also someone new at MGH and I have heard she is really into o3fa. Just something if you happen to interview there...
 
The Carlat pharma influence blog, however, (and by his own admission) is quite one-sided.
Click to expand...

On occasion, something we should all read despite it being opinion & not empirical evidence.

There is a strong subjectivity in our field, not only in perception of symptoms but also of therapeutic approaches, such as which atypical to give out first, which antidepressant. I've often times found myself questioning why certain outpatient psychiatrists or FP docs gave their patient Paxil (and would only give that one out) when the overwhelming evidence shows its pretty much the worst SSRI in terms of side effects & no more efficacious against depression, while dealing with a patient who's recently been admitted who never wanted to gain weight, gained over 50 lbs on it & was never told about its side effect profile.

However guidelines only say--start with an SSRI. It should go farther than that. There clearly are certain ones better than others in terms of side effect profile.

We should be actively debating & self checking how we practice, even if it is within the APA & standard of care guidelines.

With the exception of the opinionated sources of psychiatric information, such as when we get into intellectual discussions, debates on this board, Carlat, Op-Eds given to journals or the Last Psychiatrist, I don't see this type of needed discussion going on.
 
whopper said:
On occasion, something we should all read despite it being opinion & not empirical evidence.

There is a strong subjectivity in our field, not only in perception of symptoms but also of therapeutic approaches, such as which atypical to give out first, which antidepressant. I've often times found myself questioning why certain outpatient psychiatrists or FP docs gave their patient Paxil (and would only give that one out) when the overwhelming evidence shows its pretty much the worst SSRI in terms of side effects & no more efficacious against depression, while dealing with a patient who's recently been admitted who never wanted to gain weight, gained over 50 lbs on it & was never told about its side effect profile.

However guidelines only say--start with an SSRI. It should go farther than that. There clearly are certain ones better than others in terms of side effect profile.

We should be actively debating & self checking how we practice, even if it is within the APA & standard of care guidelines.

With the exception of the opinionated sources of psychiatric information, such as when we get into intellectual discussions, debates on this board, Carlat, Op-Eds given to journals or the Last Psychiatrist, I don't see this type of needed discussion going on.
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I would hate the guidelines to go into any great detail. I mean, they are guidelines - just to give you a rough direction to take. It is YOUR (mine, etc) responsibility as a physician to assess each individual case and make appropriate recommendations. It is unfortunate that some docs do not feel they need to keep abreast or are too lazy to tailor their mgmt to an individual patient, but it does not make the case for "detailed guidelines", imho.
 
Wow...ask and ye shall receive...thanks for the good resources everyone!
 
I would hate the guidelines to go into any great detail. I mean, they are guidelines - just to give you a rough direction to take. It is YOUR (mine, etc) responsibility as a physician to assess each individual case and make appropriate recommendations.
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True--make them too specific and that causes a problem too. Just unfortunate that there's too many lazy docs out there who aren't putting a little more brain power than to simply prescribe the same med all the time.

I don't think a patient could ever win a malpractice suit against a doctor that put them on the SSRI that causes the most amount of weight gain when they specifically told the doctor they did not want an antidepressant that causes weight.

No matter how much harm it may cause the patient--the standard is simply to put the patient on an SSRI, so by default 1 of the 4 criterion for malpractice would never be done, so long as the doc gives an SSRI--even a badly chosen one.

Sorry for the rant...just seen too many doctors practice like this, and it bugged the heck out of me.
 
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