Older psychotherapeutics

[sdude]

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Hello,

I'm a grad student considering applying to medical school in a couple years. I've been fascinated by medicine for several years now, and I enjoy reading books on psychiatry, pharmacology, and internal medicine, etc.

One thing that has bothered me is that it appears to be common knowledge (though not openly discussed) that in general the tricyclic AD's are superior to the SSRI's and other modern AD's in treating severe depression. (In British texts, they are recommended as first line treatment) The MAOI's seem to be regarded by some very respectable sources as the most powerful AD's known to man, particularly for the most debilitating atypical cases.

One writer bluntly stated that essentially no progress has been made in treating the worst forms of unipolar depression; the modern drugs are generally inferior for these cases, and at best, they simply offer a different set of side-effects.

Naturally, everyone responds to these drugs slightly differently, and the SSRI's are a great option to have, particularly because they are so safe physiologically.

I'm concerned that psychiatrists have so little IM training, and so little time with their patients, that these older drugs have fallen into disuse even for very ill patients who really need the most effective medications available.

I'm curious to know if people think their psych residency trains them adequately to use the full range of AD's (and lithium), even the older drugs may require cardiovascular assessment and regular blood work.

Thanks for the info,

Dave

 

[mdblue]

SSRIs are the 1st line drugs in depression because they are safer in OD than TCAs. The same holds true for MAOIs. Most SSRIs are prescribed by the PCPs. TCAs and MAOIs are do prescribed by the psychiatrists and most of them know about these drugs in their residency but rarely used in clinical practice because of the risk issues and subsquent lawsuits. Having said that it has been repeatedly documented that antidep are effective in only 2/3 of the cases of depression-which is also debatable because people ha used different criterias of depression and different outcome measures.
Li is the firstline tx for Bipolar d/o and it is the only true MS(excellent articles comparing Li and AEDs can be found in Feb/Mar issue of AJP).
However the drug reps have got a different opinion. For them profit comes before good clinical practice. Unfortunately what's happening w/ the SSRI/suicide issue, it is indeed a backlash of their shameless campaigning for these drugs. To my experience a lot of PCPs and non-psych physicians are indeed handing over these drugs to their patients as an answer to all their life problems and my view is treating and prescribing for psych illness should be initiated by a trained psychiatrist.
U would recommend to take alook at the APA guideline for depression-it's free online http://www.psych.org/psych_pract/treatg/pg/Depression2e.book.cfm
Hope this helps. 🙂

 

[mdblue]

Also ECT is one of the most effective tx for depression.
And if one of my patients ODs on a TCA I will sent him/her to ER/GMF/MICU because of the supportive tx and monitoring which is not present in psych unit. It's not a question of "IM training", rather a good and safe clinical practice.

 

[sdude]

Also ECT is one of the most effective tx for depression.
And if one of my patients ODs on a TCA I will sent him/her to ER/GMF/MICU because of the supportive tx and monitoring which is not present in psych unit. It's not a question of "IM training", rather a good and safe clinical practice.

Hello,

When I talked about IM training, I didn't mean physiological crisis management--obviously you want the ER guys for that. I'm simply talking about having enough experience with patients who are hypertensive or have other CV problems, diabetic, on beta-blockers, etc. (hopefully not all at the same time!) that you would feel comfortable using TCA's, lithium (for BP, or as an augmenting agent), or MAOI's if necessary. For a patient with health probs, SSRI's would be my first line treatment too for unipolar dep., but all too often they don't work.

As you know, ECT costs a fortune, and so it isn't a great option for a lot of people. I have high hopes for TCS, though. I hope it turns out to be as good as the early studies suggest.

 

[PsychNOS]

SDude,

Psych residency requires anywhere from 4 months to one year of internal medicine. This is plenty of time to learn the basics of managing hypertension and diabetes. Some psychatrists I know have patients that see them for primary care needs, as well as psychiatry.

As mdblue wrote, safety and the fear of litigation have everything to do with not using older medications like TCAs. TCAs have a high potential for overdose and have higher side effect profiles (arrhythmias, anticholinergic toxicity, etc.) than do SSRIs. When you start seeing patients, you'll realize that medications are user-dependent. In other words, the doc prescribes medications and it is the responsibility of the patient to take the drugs correctly. Many patients either do not take the drugs, take them in the wrong doses, or even worse, hand them to their buddies. Giving drugs with better safety profiles is then obviously more appealing, especially when you have a patient that is suicidal. Sacrificing what little gain you recieve in efficacy for a great gain in safety is much more prudent.

In terms of transcranial magnetic stimulation, I would appreciate if someone can point me in the direction of some good data. I know that the University of Washington is involved in some clinical trials, but currently there is very little info out there.

 

[Anasazi23]

Hello,

I'm simply talking about having enough experience with patients who are hypertensive or have other CV problems, diabetic, on beta-blockers, etc. (hopefully not all at the same time!) that you would feel comfortable using TCA's, lithium (for BP, or as an augmenting agent), or MAOI's if necessary.

Psychiatrists are medical doctors. They have experience with all these and countless other comorbid conditions and take them into account when prescribing. This is what separates psychiatrists from psychologists who want prescription privilages which, unfortunately, will slowly or immediately kill people.

A competent psychiatrist will not be scared of prescribing TCA's. I see it all the time. They are highly effective medications, and have side effect profiles which can benefit certain patients a great deal. In fact, I would go as far to say that a psychiatrist who never considers a TCA is doing their patients a disservice. As PsychNOS mentions, however, they do come with their problems that tend to make some psychiatrists shy away from their routine use.

As for residency programs preparing you for use of older medications, I would say that it is not only expected, but the DUTY of psychiatry residency programs to enable their graduates to become competent prescribing all classes of psychotropic meds, and how to interpret the effects of their use via physical exam, lab results and all other means of physiological/biological testing.

You mentioned you were in graduate school. For psychology? I myself was in a PhD for clinical neuropsychology. There are some old threads that might still be around on the differences that I discussed with people. Feel free to PM me if you have any questions.