More often than not I think psych diagnoses give an indication as to what's wrong with the doctor who made the dx. Like I know this one attending, who diagnoses "anxiety" in every single patient, the reason being that they may drink coffee, and he doesn't. The patient could be complaining of chest pain radiating to the left arm and the jaw with diaphoresis, SOB, a solid smoking history, nitroglycerin in their chart, 3 stents and uncontrolled DM but if this attending hears "coffee" you're not going to get any farther. You've immediately bought a lecture about sleep hygiene and the evils of caffeine, a dx of GAD +/- panic d/o, and a script for Zoloft.
This is so true! Except at my program, we are almost not allowed to use benzos, and I can count on one hand how many patients I've seen (let alone continued) on stimulants. (Although if I was out in the community this would differ a bit). Our city is pretty much America's Xanax capital, and a lot of attendings and residents are really paranoid about prescribing even 1 mg of any benzo, once, ever, for any cause, in any patient, no exceptions. Instead they are enamored with atarax, which, I don't know what that medication does but I really don't feel like you need a medical degree and residency training to prescribe something which is basically just a cousin of benadryl which the patients can actually buy and dose for themselves OTC.
But anyway take the combo of Seroquel + Zoloft. Or Abilify + Prozac. Now what does that tell you? It should tell you schizoaffective d/o and only schizoaffective because you have an antipsychotic and an antidepressant, but actually it could be anything from GAD to some impulse control disorder to bipolar to schizophrenia to malingering to insomnia to OCD to an eating disorder to Axis II to some weird pain regimen to a sleep disorder to a paraphilia.
And of course the mood stabilizer for "irritability." And then there is Neurontin, which you can give to anyone, anywhere at anytime for any condition.
It's too bad you don't get much experience with benzodiazepines. If used appropriately, i.e. short term for most patients, they work quite well. You can use them to ease the suffering of your patients while the SRI kicks in or while they get engaged in a psychotherapeutic process that hopefully reduces their symptoms.
I feel the same way about psychostimulants. New York Times articles notwithstanding, there is clearly a place for psychostimulants in psychiatric practice, and if used judiciously, they can be a life-changer for patients.
Atarax is hydroxyzine. The other brand name is Vistaril.
With respect to the combination of SRI and antipsychotic, meaningful information can be gleaned about the diagnosis based on the dose of the medication.
Low dose antipsychotic (particularly Abilify) with normal-high dose SRI is likely major depression.
Normal dose antipsychotic with normal dose SRI is likely schizoaffective, depressive type.
Normal dose antipsychotic with very high dose SRI is likely OCD.
SRIs don't really have a place in schizophrenia.
Antipsychotic plus anticonvulsant plus SRI/SNRI is almost always bipolar or badly managed borderline personality disorder.
Try looking at the doses and see what they tell you. There's a lot of information out there.
Psychiatric diagnosis is terrible, I give you that. Psychopharm is pretty crappy too, and polypharmacy is pretty out of control in many cases.
Polypsychopharm can be done in a rational fashion, however. For instance, it's reasonable to consider whether an additional agent has a discrete mechanism of action and the potential to provide additional clinical benefit.
Example, 2 SSRIs is pretty stupid. 1 SSRI and 1 SNRI is a little less stupid. 1 SSRI and Wellbutrin makes sense. 1 SNRI and Wellbutrin makes even more sense because it approximates the effect of an MAOI but with fewer side effects and no dietary restrictions. SNRI plus Wellbutrin plus atypical antidepressant like mirtazapine or nefazodone is complicated, but is rational and has been demonstrated to have efficacy that is equivalent/superior to MAOI. MAOI plus lithium plus a dopamine agonist like pramipexole even is at least rational for some patients. Add good psychotherapy to any of the latter regimens and you may have a decent shot at helping a person with severe and treatment-resistant depression.
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