Psychiatrists Favoring specific Drugs

[Poety]

Hi OPD and Sazi, and all other residents and or attendings:

I have a question, when I've rotated through a lot of different psych hospitals or when I was a nursing on the floors, I would notice that certain physicians tend to use the same meds over and over - ie some will prefer geodon to zyprexa, while others will use a lot of lexapro as opposed to zoloft - and I don't mean this in the "throw everyone on the same med deal" I mean in the initial treatment of d/o.

Is this the standard type of practice? ie do we tend to get comfortable with certain meds and then choose to keep using them - and is this a good or bad thing.

When I was seriously considerng CARDS as a specialty - I noticed the same thing during my electives there as well - so this is not specialty specific. But I am curious as to know what you all think about whether its good to mix em up a bit, or better to stay with what we know.

Thanks!

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[Anasazi23]

That's actually a really good question. In residency, you'll be told to become familiar with a few drugs, and get to know them VERY well. Because there are general classes of medications, and subclasses within the classes, usually with similar mechanisms of action, this is a good way to learn the most used meds, as well as the prototype drugs for each class.

As you become more sophisticated, your knowledge of other medications, their effects, quirky reactions, etc will become familiar to you, and it will be added to your repertoire. As you gain more and more experience with certain medications, you'll find that often these meds have worked for you, and allegiances develop for them. Since you therefore get to know this particular medication very well, you'll become more agressive with alternate dosing methods, enhancers, etc. The natural part of using these meds all day every day is that you do develop allegiances to meds that you've consistently seen work. Further and more importantly, you'll develop allegiances to medications for specific conditions, and subsets of symptoms within those conditions. This becomes the art of psychopharmacology.

 

[OldPsychDoc]

That's actually a really good question. In residency, you'll be told to become familiar with a few drugs, and get to know them VERY well. Because there are general classes of medications, and subclasses within the classes, usually with similar mechanisms of action, this is a good way to learn the most used meds, as well as the prototype drugs for each class.

As you become more sophisticated, your knowledge of other medications, their effects, quirky reactions, etc will become familiar to you, and it will be added to your repertoire. As you gain more and more experience with certain medications, you'll find that often these meds have worked for you, and allegiances develop for them. Since you therefore get to know this particular medication very well, you'll become more agressive with alternate dosing methods, enhancers, etc. The natural part of using these meds all day every day is that you do develop allegiances to meds that you've consistently seen work. Further and more importantly, you'll develop allegiances to medications for specific conditions, and subsets of symptoms within those conditions. This becomes the art of psychopharmacology.

Gee, and here all this time i thought it was just a matter of asking, "Let's see, which rep is going to buy me dinner tonight?"

 

[Poety]

Gee, and here all this time i thought it was just a matter of asking, "Let's see, which rep is going to buy me dinner tonight?"

Thanks so much Sazi !!! Anyone else?

 

[Anasazi23]

Gee, and here all this time i thought it was just a matter of asking, "Let's see, which rep is going to buy me dinner tonight?"

Of course dinners are a factor. Last week I wrote for nothing but Abilify because of the great dinner I had at Tavern on the Green. Yummy. The steak was cooked just right, and they had Pilsner Urquell in bottles. A good time was had by all.

I'm especially looking forward to the continuing education Ireland update.
Which one would you pick?

 

[OldPsychDoc]

Of course dinners are a factor. Last week I wrote for nothing but Abilify because of the great dinner I had at Tavern on the Green. Yummy.

Conversely, I once "boycotted" a med for a week because the pen the rep gave me didn't work...

 

[Anasazi23]

That'll learn 'em!!!

It's funny...as I'm writing this, I'm getting ready to go to a Christmas party sponsored by Lilly.

 

[Hurricane]

Geodon has the nicest pens. Therefore I shall hand it out like candy until I get a better pen from a competitor. That or a squishy brain. I'm a sucker for the squishy brains. I collect them.

 

[Anasazi23]

I have an Effexor green squish brain right here on my desk. I have a few extras. Want 'em?

 

[Hurricane]

I have an Effexor green squish brain right here on my desk. I have a few extras. Want 'em?

I've got an effexor one already. Thanks though!

 

[OldPsychDoc]

I have an Effexor green squish brain right here on my desk. I have a few extras. Want 'em?

I got a new squishy happy ovoid entity from Zoloft today!
I needed it, too!!!!

 

[Hurricane]

I got a new squishy happy ovoid entity from Zoloft today!
I needed it, too!!!!

Color me green with envy!

 

[Anasazi23]

Ooh, yeah. The ovoid entities make great indoor household footballs. The cats enjoy them too. Who would have known?

I'm on call tomorrow. I'll try to get some complaining in on the 'On-call diari,' which I still encourage other people to use as well.

 

[deuist]

It's funny...as I'm writing this, I'm getting ready to go to a Christmas party sponsored by Lilly.

Yay! I actually just got back from dinner and a movie hosted by Astra Zeneca.

 

[OldPsychDoc]

Hi OPD and Sazi, and all other residents and or attendings:

I have a question, when I've rotated through a lot of different psych hospitals or when I was a nursing on the floors, I would notice that certain physicians tend to use the same meds over and over - ie some will prefer geodon to zyprexa, while others will use a lot of lexapro as opposed to zoloft - and I don't mean this in the "throw everyone on the same med deal" I mean in the initial treatment of d/o.

Is this the standard type of practice? ie do we tend to get comfortable with certain meds and then choose to keep using them - and is this a good or bad thing.

When I was seriously considerng CARDS as a specialty - I noticed the same thing during my electives there as well - so this is not specialty specific. But I am curious as to know what you all think about whether its good to mix em up a bit, or better to stay with what we know.

Thanks!

Sorry Poety, I haven't had time to answer with anything but glib and cynical comments so far today. Could have used a few more no-shows...

I think that we all develop biases based on our own clinical experience, and hopefully somewhat backed up by empirical evidence. For example, Lexapro costs my patients (or their insurers) 4x as much as citalopram, the parent drug--so I've been prescribing a lot of citalopram lately--because I don't believe that the evidence necessarily supports a greater efficacy over the long run, and my experience hasn't really held fast that Lexapro has 4 times fewer side effects. OTOH, a patient comes in with definite depression sx after a decent period on any SSRI, and I'm probably putting them on Effexor XR, even though it costs 10 x what fluoxetine or citalopram does.

Sometimes I think my practice looks like "celexa, seroquel, DBT" all the time, but it is what stabilizes my borderlines on inpatient, or is a good mix for my recovering meth heads who can't sleep at night, and who have messed up their lives... I do use lots of other stuff too, and I usually don't change what's working for a patient. I'm still pretty new at this, but I know that the best med is the one the patient will take, and part of that is the doc's confidence in what the med will do.

Anyhow, there's a few thoughts for you. I think that having preferences is a good thing, as long as you can back them up with something more than marketing claims and drug rep swag.

And did I ever mention that I once had a Viagra pen that (I'm not joking here!) wouldn't stay up?

 

[Milo]

I love the orange lamictal gel pen. Will trade two for one on geodon pens or seroquel pens

 

[Anasazi23]

Usually I like the nice metal pens they give out.

But, I'll run someone over for those stupid green/clear Consta pens. The gel thingy keeps my finger from getting sore, and the ink is smooth.

lol...we're pathetic

 

[Poety]

OPD thanks so much for your thoughtful response - I'm sure I'm going to find myself picking up certain tendancies from whoever I'm working closely with during residency. At least I hope to have a mentor I trust that much.

With all the new challenges in prescribing with regard to patient monitoring and side effect management - I think its going to be important as Sazi said to obtain a personal "safe" repertoire that I feel "really" comfortable with.

I can't believe we're going to be out in the real world (well half real world) soon! Mosche you ready? Hurricane?

 

[Anasazi23]

The good thing about having a strong repertoire is that when things DO go wrong (and they will), you'll feel just as comfortable reacting to and treating the problem instead of panicing. You'll get to know every side effect and adverse reaction inside and out, and have no trouble or feeling of shock when you get that phone call.