Blitz2006

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On call today, and saw a patient on Brintellix in the ER. We don't even talk about it in our residency program, but was wondering if its a drug I should consider in outpatient world or just a waste of time?

Thanks,
 

Shikima

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Waste of time IMO. Use as a 3rd option after all the others have been tried due to expense and difficulty in obtaining samples.
 

thoffen

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No one uses Brintellix in the US anymore.
Some use Trintellix. I haven't.
 

northernpsy

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I have seen like one patient on Brintellix. The patient I saw was put on it by an NP who was basically trying to run through every antidepressant to treat a patient with very poor coping skills and histrionic personality traits. It...didn't seem very effective. :)

So far, I have not encountered a patient where Brintellix seemed like a necessary step in their treatment.
My general philosophy is that if you've got a patient who has had a decent trial (not just "I tried it for a few days and then stopped taking it") of a couple SSRIs, the SNRIs, mirtazapine, bupropion, the usual augmentation strategies, etc. and the patient still isn't doing well...then you need to re-evaluate the diagnosis rather than throwing the latest variation on the same theme at them.
 

PistolPete

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I have seen like one patient on Brintellix. The patient I saw was put on it by an NP who was basically trying to run through every antidepressant to treat a patient with very poor coping skills and histrionic personality traits. It...didn't seem very effective. :)

So far, I have not encountered a patient where Brintellix seemed like a necessary step in their treatment.
My general philosophy is that if you've got a patient who has had a decent trial (not just "I tried it for a few days and then stopped taking it") of a couple SSRIs, the SNRIs, mirtazapine, bupropion, the usual augmentation strategies, etc. and the patient still isn't doing well...then you need to re-evaluate the diagnosis rather than throwing the latest variation on the same theme at them.
Agreed. They either have an underlying personality disorder as the likely cause of their symptoms. Otherwise you go to ECT if it's truly treatment resistant depression.
 
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SeniorWrangler

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Pharmacologically fascinating drug, but I don't see it being used much clinically.
Nice overview here, but it doesn't shed light on whether any of these in vitro receptor affinities have any practical significance: Stephen M. Stahl (2015). Modes and nodes explain the mechanism of action of vortioxetine, a multimodal agent (MMA): enhancing serotonin release by combining serotonin (5HT) transporter inhibition with actions at 5HT receptors (5HT1A, 5HT1B, 5HT1D, 5HT7 receptors). CNS Spectrums, 20, pp 93-97 doi:10.1017/S1092852915000139
 
H

HarryMTieboutMD

A lot of the private practice psychiatrists in my city use it... probably because they can. I guess you can justify it if someone has sexual dysfunction and can't tolerate Wellbutrin or Remeron
 

jettavr6

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Waste of time IMO. Use as a 3rd option after all the others have been tried due to expense and difficulty in obtaining samples.
Felt the same way for a long time, but have found it useful in many situations where other medications hadn't worked. Long half life. LOT of nausea in the first few days. Insurance coverage seems to be getting better.
 
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MLT2MT2DO

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A lot of the private practice psychiatrists in my city use it... probably because they can. I guess you can justify it if someone has sexual dysfunction and can't tolerate Wellbutrin or Remeron
I can see it...

I've heard nothing fixes sexual dysfunction in a 60 year old private practice doctor quicker than a scantily clad 20 year old drug rep.

Sent from my SM-G900V using SDN mobile
 

splik

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I have seen like one patient on Brintellix. The patient I saw was put on it by an NP who was basically trying to run through every antidepressant to treat a patient with very poor coping skills and histrionic personality traits. It...didn't seem very effective. :)

So far, I have not encountered a patient where Brintellix seemed like a necessary step in their treatment.
My general philosophy is that if you've got a patient who has had a decent trial (not just "I tried it for a few days and then stopped taking it") of a couple SSRIs, the SNRIs, mirtazapine, bupropion, the usual augmentation strategies, etc. and the patient still isn't doing well...then you need to re-evaluate the diagnosis rather than throwing the latest variation on the same theme at them.
Trintillex as it's now called is not going to be your first line treatment, nor are you going to use it for better efficacy. The main benefits are 1) much lower rate of sexual dysfunction compared with SRIs. This is a big deal for a lot of patients; 2) it is well tolerated in elderly patients and might boost cognitive function (supposedly does so on a neuropsychological test, what this means it practice remains to be seen); and 3) doesn't cause much weight gain (though some people definitely do get fat with it). Also, the placebo effect is greater for new drugs and since by far the largest effects of antidepressants come from the placebo effect, you would be harnessing this in patients who have failed other treatments. Even personality disorder patients respond marvelously to placebos (albeit for a short while). It can also be safely added to bupropion or mirtazapine in patients who a single antidepressant is not sufficient and who wish to minimize risk of sexual dysfunction. Personally I like the oldies but goodies - TCAs and MAOIs +/- lithium or T3 but not all patients can tolerate or are appropriate for this. In my geriatric patients I also like using methylphenidate as an augmentation to an SSRI (typically escitalopram nowadays as there is some evidence it may be the most efficacious of the class).

Agreed. They either have an underlying personality disorder as the likely cause of their symptoms. Otherwise you go to ECT if it's truly treatment resistant depression.
I haven't met a patient with chronic depression who doesn't (look like they) have a personality disorder in some form or other, even if it's "unspecified". one upon a time, chronic depression was a personality disorder. That doesn't mean we shouldn't use pharmacotherapy to treat the depression, it just means you are not going to get as much bang for your buck, and need to use appropriate psychotherapy, ideally with an attachment-informed heavy interpersonal focus and shaping behaviors through the transference affect. Having always been a skeptic about ECT, I have now treated several hundred of patients with it and I am still not keen on going to ECT for treatment-resistant depression. ECT works best for acute severe, suicidal depression, particularly if there are melancholic, delusional, or catatonic features. Even then, many patients don't respond and in the real world few patients respond in the 6-8 sessions that are the typical course in the textbooks. ECT is a sacred cow of psychiatry but the evidence base doesn't really support this. Especially when it comes to maintenance ECT (which is what you would most likely have to do for the refractory cases). When it works results are rapid but have very poor durability. The problem with this is that. Also borderline patients LOVE ECT - they get miraculously better after one treatment but if you keep going they get worse and worse. I have seen several patients who have become addicted to ECT. There are also too many ECT docs who minimize the risks and don't tell patients that permanent autobiographical memory loss frequently occurs. Many patients are willing to take the risk for relief of their depression but we do a disservice if we don't provide proper informed consent. Many patients, quite understandably do not want ECT, and in some respects it is a bit of red flag if someone comes along requesting it.
 

PistolPete

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Good points, but I think ECT is vastly underutilized, and despite it not being an amazing treatment, it is still the best we got, so to speak. When patients have put forward a good, sustained effort with a quality therapist, and have tried every medication under the sun, it's time to consider ECT or TMS or vagal nerve stimulation.
 

cookymonster

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By my count, there are 29 FDA approved antidepressants (I trot that out a lot to patients who say they've tried "everything"). If you have to get through all 29 before discussing ECT with a patient you think is genuinely depressed, they should find a new doctor.

Also, if you're "frequently" inducing "permanent" autobiographical memory loss with ECT, you're probably doing it wrong.
 

Extralong

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Brintellix, had great success with TBI patients
 
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Blitz2006

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Trintillex as it's now called is not going to be your first line treatment, nor are you going to use it for better efficacy. The main benefits are 1) much lower rate of sexual dysfunction compared with SRIs. This is a big deal for a lot of patients; 2) it is well tolerated in elderly patients and might boost cognitive function (supposedly does so on a neuropsychological test, what this means it practice remains to be seen); and 3) doesn't cause much weight gain (though some people definitely do get fat with it). Also, the placebo effect is greater for new drugs and since by far the largest effects of antidepressants come from the placebo effect, you would be harnessing this in patients who have failed other treatments. Even personality disorder patients respond marvelously to placebos (albeit for a short while). It can also be safely added to bupropion or mirtazapine in patients who a single antidepressant is not sufficient and who wish to minimize risk of sexual dysfunction. Personally I like the oldies but goodies - TCAs and MAOIs +/- lithium or T3 but not all patients can tolerate or are appropriate for this. In my geriatric patients I also like using methylphenidate as an augmentation to an SSRI (typically escitalopram nowadays as there is some evidence it may be the most efficacious of the class).


I haven't met a patient with chronic depression who doesn't (look like they) have a personality disorder in some form or other, even if it's "unspecified". one upon a time, chronic depression was a personality disorder. That doesn't mean we shouldn't use pharmacotherapy to treat the depression, it just means you are not going to get as much bang for your buck, and need to use appropriate psychotherapy, ideally with an attachment-informed heavy interpersonal focus and shaping behaviors through the transference affect. Having always been a skeptic about ECT, I have now treated several hundred of patients with it and I am still not keen on going to ECT for treatment-resistant depression. ECT works best for acute severe, suicidal depression, particularly if there are melancholic, delusional, or catatonic features. Even then, many patients don't respond and in the real world few patients respond in the 6-8 sessions that are the typical course in the textbooks. ECT is a sacred cow of psychiatry but the evidence base doesn't really support this. Especially when it comes to maintenance ECT (which is what you would most likely have to do for the refractory cases). When it works results are rapid but have very poor durability. The problem with this is that. Also borderline patients LOVE ECT - they get miraculously better after one treatment but if you keep going they get worse and worse. I have seen several patients who have become addicted to ECT. There are also too many ECT docs who minimize the risks and don't tell patients that permanent autobiographical memory loss frequently occurs. Many patients are willing to take the risk for relief of their depression but we do a disservice if we don't provide proper informed consent. Many patients, quite understandably do not want ECT, and in some respects it is a bit of red flag if someone comes along requesting it.

You mind posting any sources/links that suggest lexapro is top dog SSRI?
 

JustAGuy

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I think I have 2 patients on it. 1 whom I inherited and 1 due to sexual side effects after failing some of the other options.
 

SeniorWrangler

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Is it less nauseating than regular milnacipran?
 

jettavr6

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Have any of you guys used Fetzima, and if so, what's your experience been like with it?
Use Cymbalta -- it's cheaper and quite possibly better.

Want to see what everyone things - the following "new" drugs don't impress me much" Vybrid, Fetzima

Brintellix-- In my mind, I compare it (and probably wrongly) to prozac. Nausea and other crappy side effects upon takeoff, but smooth sailing once you hit cruising altitude. However, I still think Prozac is better.
 

PistolPete

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Use Cymbalta -- it's cheaper and quite possibly better.

Want to see what everyone things - the following "new" drugs don't impress me much" Vybrid, Fetzima

Brintellix-- In my mind, I compare it (and probably wrongly) to prozac. Nausea and other crappy side effects upon takeoff, but smooth sailing once you hit cruising altitude. However, I still think Prozac is better.
I've used Cymbalta quite a bit, but interestingly a new studies comparing SSRI's and SNRI's shows that it's one of the least tolerated (can't find the link at the moment). I've never used Viibryd or Fetzima.

I've never really had any major issues with fluoxetine, but I start low and go slow with most things. Interesting, a recent study shows it's the only SSRI that separates from placebo in treating MDD in children and adolescents. http://onlinelibrary.wiley.com/doi/10.1002/cpu.30139/full
 

jettavr6

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I've used Cymbalta quite a bit, but interestingly a new studies comparing SSRI's and SNRI's shows that it's one of the least tolerated (can't find the link at the moment).
You are probably correct - Effexor may be better tolerated. However, the withdrawal from Effexor seems to be horrible. Given the nature of my practice (I'm also pain pain management), Cymbalta nails two birds with one stone. Less medication the better.
 
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Shikima

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You are probably correct - Effexor may be better tolerated. However, the withdrawal from Effexor seems to be horrible. Given the nature of my practice (I'm also pain pain management), Cymbalta nails two birds with one stone. Less medication the better.
Don't forget to buffer the withdrawal effects with some Prozac if possible.
 

Shikima

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What's the story on Viibryd? Is it the next model after Lexapro similarly to how Lexapro is the next model after Celexa?