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I am reasonably comfortable with pramipexole and sometimes have used it (way different dosing, obviously) for depression.

Mirapex for depression? I am learning things. What dose and when would you use?

Of course, I often end up going right to sleep restriction, which most people reluctantly agree to try. Most of the time when they actually do it it works and I look like a wizard. About ten percent of the time people say they do it 'and it didn't work', but funnily enough they can't supply any details of what they attempted to do or the way in which it didn't work. And I'd say twenty percent of the time people don't really implement it at all and still have the same complaint, so I go all excruciatingly detailed DBT BCA style in figuring out precisely what prevented them from doing it and eventually they do try it to make me shut up.

That's interesting! IME sleep restriction generates more resistance than any other intervention so I don't even suggest it without full CBTi framework with sleep journaling etc.

Basic sleep hygiene I do a lot as an add-on code, but if that's not working I switch to focused CBTi for a few sessions and that's the only context in which I recommend sleep restriction. I agree it works great but I feel like without the full background the acceptability and likelihood of compliance are just too low.

 

[liquidshadow22]

Mirapex for depression? I am learning things. What dose and when would you use?




That's interesting! IME sleep restriction generates more resistance than any other intervention so I don't even suggest it without full CBTi framework with sleep journaling etc.

Basic sleep hygiene I do a lot as an add-on code, but if that's not working I switch to focused CBTi for a few sessions and that's the only context in which I recommend sleep restriction. I agree it works great but I feel like without the full background the acceptability and likelihood of compliance are just too low.

Mirapex seems like an option for TRD and bipolar depression unresponsive to other fda approved tx. Very interesting, I will try this out in the future.
From random article I found :

PRACTICAL TIPS IN PRESCRIBING PRAMIPEXOLE

1. Slower titration rate in younger patients
2. Starting dose not more than 0.125–0.50 mg/day
3. Dose only once a day at bedtime, unless the patient has trouble with sleep (rare)
4. Therapeutic dose range, 1.0–5.0 mg/day
5. Common adverse events: nausea, sleepiness, dizziness, tremors, compulsive behaviours, sleep attacks
6. If nausea occurs, reduce the dosage, then increase after 1–2 weeks
7. Severe anhedonia, lack of motivation, inability to initiate behaviours, and unreactive mood are predictors of response
8. Expected benefit, occurs by 4 weeks at a maximally tolerated dose
9. Avoid abrupt discontinuation because of the risk of dopamine agonist withdrawal syndrome (1 in

 

[clausewitz2]

Mirapex for depression? I am learning things. What dose and when would you use?

Here's a relatively recent case series that I like because it is detailed in addressing clinical practicalities of how one might do this:

Psychiatry Online

ajp.psychiatryonline.org

This is not something with RCTs of course and I am thinking about it usually in folks like the median ones described in that case series, i.e. has not gotten any benefit from six-ish adequate trials of other ADs. I am also sort of listening for how anhedonic they seem to be, the more so the more I think about it. I put this in the same category as supraphysiologic thyroid hormone - something to offer with a frank discussion of risks and relative paucity of evidence for people running out of options.

That's interesting! IME sleep restriction generates more resistance than any other intervention so I don't even suggest it without full CBTi framework with sleep journaling etc.

Basic sleep hygiene I do a lot as an add-on code, but if that's not working I switch to focused CBTi for a few sessions and that's the only context in which I recommend sleep restriction. I agree it works great but I feel like without the full background the acceptability and likelihood of compliance are just too low.

There is definitely resistance that comes with it in my experience as well. I agree with you about sleep journalling, that is a high priority for me with anyone who is especially bothered by their sleep. I pitch it where appropriate after looking over the journal (or detailed reconstruction of the last week's sleep patterns) and discussing patterns, explaining sleep drive by analogy to need to urinate, and asking if they'd like to hear about a strategy that works for the overwhelming majority of people and involves zero medication side effects. I repeatedly say that it is very easy for me to sit in my chair and tell them about this and very hard to actually do it and it probably sounds like a cruel thing to tell someone who can't sleep to do, so I wouldn't dream of suggesting it if I didn't think it was a reliable and effective strategy.

I also validate all their difficulties falling asleep and how it is basically impossible to make yourself fall asleep but this is the closest we can get. I say I have many medications that can make you unconscious but in a way similar to how hitting you in the head with a bat might make you unconscious, your brain will not be doing exactly the same thing as when it's sleeping.


The whole conversation takes me about twenty minutes on average, with a good amount of time in subsequent sessions. I frame the goal as being not to make them sleep more, because we probably can't, but to make it so that their time awake is spent doing something more pleasant than tossing and turning and being pissed that you're not asleep, i.e. almost anything.


I do this mainly with people who are having very poor sleep efficiency but getting a reasonable number of hours of sleep and don't seem to be especially sleepy during the day (I get epworths on the reg in addition to asking directly about naps and unintentional dozing). People who seem to have something going on that is legitimately reducing their sleep drive to an unhealthy extent or don't fit that classic psychophysiologic insomnia pattern I am much less likely to harp on this and am more prepared to talk meds.

If someone can't reconstruct their recent sleep in detail they get a sleep diary and we talk about in a couple weeks after some psychoeducation.[/QUOTE]

 

[calvnandhobbs68]

I'm running close to zero no-shows with the transition to telepsych. So I don't doubt these big practices are rolling through 24 per day and from the incomes they've alluded to me.

Insurance never cared about therapy. They only care about the cheapest option that somewhat works. They've realized their push for 15 min med-only checks, combined with cheap social worker "therapy", isn't as cost-effective as a 20/25/30 min visit with a psychiatrist whom patients feel listen and spend time with them. You can view the 90833 add-on code as merely a calculated, pragmatic carrot used by insurance/Medicare to discourage 15 min med checks and lure psychiatrists back to taking insurance. The carrot does work... I plan to take insurance seeing two an hour, combined med + therapy. Without the add-on, a cash practice makes much more financial sense.

Yeah this is kinda sorta true. The therapy add on code was also advocated for by psychiatry as well though to bring billing into parity with other specialities. No offense to primary care here but PCPs can bill 5-10 minute 99213s and 15-20 minute 99214s no problem (HTN, HLD, nicotine use, increasing lisinopril-> bam instant 214 complexity). It’s pretty hard to get a quality 99214 visit in psych in less than 25-30 minute total time. Never mind the sub specialty billing for follow ups.

So the add on code basically recognizes we have to spend so much time compared to other specialties because half our time is really therapy (and people viewing psychiatry appts as therapy anyway so waiting until this visit to want to talk about all the stuff in life that’s bothering them...). The add on code lets you say yeah we spend more time talking in a structured way and here’s how I approached it now please let me get more money for this since I cant bill a 99214 in 10 minutes like derm.

Ive said this before here but if more patients would actually look at what their private insurance pays out for different specialty visits on their EOB they would get why we complain about rates per unit of time. Other psychiatrists or physicians who are shocked and appalled by the large amount of cash only psychiatry would also realize that the rates aren’t actually that crazy. 175 for 30 minute followup visits is actually very in line with a subspecist or PCP billing and collecting 2x 99213/99314 in 30 minutes (even just 1x 99214 depending on the insurance).

 

[WisNeuro]

And if you take a good sleep history every. single. time you encounter someone with any kind of sleep complaint, you'd be surprised how often you catch narcolepsy or serious RLS, which is great because as physicians we totally can treat those things. It's like with migraines, if you can actually do something that works and is effective, you instantly win a ginormous amount of trust.

Also, no patient ever needed to be persuaded that their problems sleeping were significant or of relevance to their life.

Heck. I'd love it if even a quarter of the undiagnosed sleep apnea cases were treated before they came to me for evaluation. As to the latter point of people knowing that sleep problems are relevant. Having them believe that it's relevant vs. them willing to make significant changes to sleep environment or routine are very different things 🙂

 

[PikminOC]

Mirapex seems like an option for TRD and bipolar depression unresponsive to other fda approved tx. Very interesting, I will try this out in the future.
From random article I found :

PRACTICAL TIPS IN PRESCRIBING PRAMIPEXOLE

1. Slower titration rate in younger patients
2. Starting dose not more than 0.125–0.50 mg/day
3. Dose only once a day at bedtime, unless the patient has trouble with sleep (rare)
4. Therapeutic dose range, 1.0–5.0 mg/day
5. Common adverse events: nausea, sleepiness, dizziness, tremors, compulsive behaviours, sleep attacks
6. If nausea occurs, reduce the dosage, then increase after 1–2 weeks
7. Severe anhedonia, lack of motivation, inability to initiate behaviours, and unreactive mood are predictors of response
8. Expected benefit, occurs by 4 weeks at a maximally tolerated dose
9. Avoid abrupt discontinuation because of the risk of dopamine agonist withdrawal syndrome (1 in

What's this mean? Give it if they have these things or if they get these things then stop it?

1. Severe anhedonia, lack of motivation, inability to initiate behaviours, and unreactive mood are predictors of response

 

[clausewitz2]

What's this mean? Give it if they have these things or if they get these things then stop it?

1. Severe anhedonia, lack of motivation, inability to initiate behaviours, and unreactive mood are predictors of response

The first one.

 

[liquidshadow22]

The first one.

More likely to respond to treatment with these symptoms. Essentially targeting anhedonia and apathy

 

[PikminOC]

More likely to respond to treatment with these symptoms. Essentially targeting anhedonia and apathy

This is rls treatment only right? I'm just making sure I'm not missing anything

 

[Stagg737]

I do this mainly with people who are having very poor sleep efficiency but getting a reasonable number of hours of sleep and don't seem to be especially sleepy during the day

How are you defining poor efficiency? Delayed Latency? Number of awakenings? Feeling fatigued in the morning?

I'd love it if even a quarter of the undiagnosed sleep apnea cases were treated before they came to me for evaluation.

I pound OSA into our med student's heads. If someone has a sleep problem and they don't ask about what SO's say or snoring, I tell them to go back and ask. I hate giving patients with OSA significantly sedating meds, especially since they often have a bunch of other medical co-morbidities that sedation won't do anything to help.

The first one.

More likely to respond to treatment with these symptoms. Essentially targeting anhedonia and apathy

I'm assuming this is being used after the patient fails a fair trial of Wellbutrin? If not, why not try that first?

 

[clausewitz2]

How are you defining poor efficiency? Delayed Latency? Number of awakenings? Feeling fatigued in the morning?

Sleep efficiency = time asleep/time in bed. Ideally you are shooting for around 80-85% as a realistic goal. Most people I have worked with complaining about not being able to sleep are at more like 50-60%.

I pound OSA into our med student's heads. If someone has a sleep problem and they don't ask about what SO's say or snoring, I tell them to go back and ask. I hate giving patients with OSA significantly sedating meds, especially since they often have a bunch of other medical co-morbidities that sedation won't do anything to help.

OSA definitely not something to miss for sure. It is unfortunate that CPAP is something so many people struggle with adhering to, and my impression from the more recent literature is that even with good adherence, the benefits for blood pressure are well-established but it's not clear that your (properly diagnosed) depression is going to get much better if you wear it perfectly. I generally agree with you about giving anyone who's excessively sleepy sedating meds.

I'm assuming this is being used after the patient fails a fair trial of Wellbutrin? If not, why not try that first?

I mean, I wouldn't use it unless wellbutrin was not effective/tolerable for sure. I have seriously considered Mirapex for this a handful of times, it is not at all my go-to. I definitely start people on MAOIs more often.

You would also sort of expect there to be people for whom wellbutrin was not super helpful who might benefit from DAs. Re-uptake inhibition is fine if you are robustly synthesizing/transporting dopamine in the first place but in a scenario in which it is not being synthesized as robustly at baseline and/or there is something deficient in VMAT2 in some respect that slows down release of it, something that actually directly engages post-synaptic dopaminergic receptors would have an effect that just trying to reduce the rate at which synaptic dopamine is retrieved would not. Pramipexole et al. also seem to be doing something to mitochondria separate from dopaminergic action but I haven't found any characterization or theories about this that make much sense to this non-molecular biologist.

 

[whopper]

I have almost zero no shows.
Here's things I've done that dramatically cut them down
1-All new patients must pay $100 that can be credited into their account before they see me. If they don't show up to their first meeting, that $100 pays for the no show fee.
2-Almost always charge the no show fee. I do let people go if they can prove they were in an emergency or we've had them for several visits, they are cooperative, polite, and never missed a previous meeting-but we only let them go once unless the next time they miss an appointment it was a long time later with several visits in between.
3-Terminate trouble makers. Patients frequently causing problems with my receptionist that are not illness based get the boot. E.g. someone calling someone else the N-word in the waiting room and it's clearly not due to an Axis I illness, etc.
4-Educate patients to the practice's dynamics that if they don't show up or are late it's throwing a wrench into the works.
and MOST IMPORTANT: 5 AN AWESOME RECEPTIONIST who can shuffle all the patients around like this is a game of Tetris going on all day long.

My income went up every year I've been in private practice in large part due to cutting down people who missed appointments. I also do keep some people who frequently miss appointments that also aren't troublemakers and pay no show fees without hesitation.

 

[WisNeuro]

Sleep efficiency = time asleep/time in bed. Ideally you are shooting for around 80-85% as a realistic goal. Most people I have worked with complaining about not being able to sleep are at more like 50-60%.

I will say, estimated sleep efficiency vs actual sleep efficiency when logged can range pretty dramatically, at least in my experience treating this specifically. Probably worse in the VA, mostly because vets always claim that they almost never sleep, but still pretty different. Heck, even tracking sleep patterns can be pretty eye opening and therapeutic for some people.

 

[clausewitz2]

I will say, estimated sleep efficiency vs actual sleep efficiency when logged can range pretty dramatically, at least in my experience treating this specifically. Probably worse in the VA, mostly because vets always claim that they almost never sleep, but still pretty different. Heck, even tracking sleep patterns can be pretty eye opening and therapeutic for some people.

For sure! I do insist on sleep logs; I love that the moment when the realization dawns that 'hey, maybe going to bed even earlier isn't the answer here.' I have actually mostly stopped asking people about total hours of sleep even in the absence of sleep logs, the answers are so rarely useful. Get much better information breaking down last week's time in bed, onset latency etc and calculating from that.

 

[WisNeuro]

For sure! I do insist on sleep logs; I love that the moment when the realization dawns that 'hey, maybe going to be even earlier isn't the answer here.' I have actually mostly stopped asking people about total hours of sleep even in the absence of sleep logs, the answers are so rarely useful. Get much better information breaking down last week's time in bed, onset latency etc and calculating from that.

Yeah, if I'm targeting sleep in therapy, sleep logs are a must. In my neuropsych evals, I'm more concerned about undiagnosed sleep apnea or REM sleep disorder, so it's usually more useful to talk to a spouse or sig other. Gets a little dicier if they are living alone, then you have to ask about things like being exhausted upon awakening, falling asleep multiple times a day in chair/couch, and waking up tangled in the sheets.

 

[watto]

Yeah, if I'm targeting sleep in therapy, sleep logs are a must. In my neuropsych evals, I'm more concerned about undiagnosed sleep apnea or REM sleep disorder, so it's usually more useful to talk to a spouse or sig other. Gets a little dicier if they are living alone, then you have to ask about things like being exhausted upon awakening, falling asleep multiple times a day in chair/couch, and waking up tangled in the sheets.

Hurrah! I love reading this. I do sleep primarily, and wish more psychiatrists would throw in a STOP-BANG, Epworth, or heck, even Swiss Narcolepsy Scale once in a blue moon, to help narrow things down a little on the old "insomnia" referral.

With sleep state misperception, having an actigraph for some slightly more objective data can be helpful. Those folks tend though to just be in NREM 1 for a large portion of the night, and actually have some awareness during sleep. Normalizing it can be helpful, comparing it to objective data can be helpful, increasing sleep drive by delaying lights out can be helpful. Interestingly, this is one group sedative hypnotics seem to treat fairly well, likely due to impairing their memory for having a rough night of sleep.