Ssri

[firedoor]

How often have you had a patient fail an adequate trial of an initial SSRI, followed by a positive response to a subsequent SSRI?

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[whopper]

I can't give you hard numbers, but from anectdotal experience it's the point where I'm not surprised when it happens.

Based on studies, all antidepressants work about as well (55-70% show any benefit whatsoever even at the maximum dose) in regards to treating depression but the results are based on testing on several people. What works on one may not work in another.

There is some data suggesting that Escitalopram, Citalopram, and Sertraline may work somewhat faster vs. the other SSRIs but the data is not to the point where it's convincingly so.

I often have a patient where one SSRI didn't work, or it did work but the patient wanted to try another because of the side effects. It's not the majority, but it is a minority to the point where I'm never surprised when it does happen.

 

[billypilgrim37]

And depression is an episodic illness. At some level, you could feed them jolly ranchers and find that the watermelon ones worked while the cherry ones didn't.

 

[kugel]

Last I checked, there were studies showing the following:
After one failed SSRI trial, the chances that another SSRI will work is the same as the chances that an antidepressant from another family will work.

I went to MD Consult to try to check, but the search function is currently disabled.

 

[whopper]

STAR*D researched the issue and gave hard numbers.

But nuts, my saved copy of it is somewhere under a stack of several things.

I made my own algorithm largely based on the results of the STAR*D.

I tend to start on an SSRI, usually Citalopram or Sertraline first. The reason for that is both are cheap, equally effective (pretty much all antidepressants are), and tend to have less side effects and interactions with other meds and liver enzymes. This is not about having a "favorite." It's about picking based on evidenced-based medicine.

If an SSRI doesn't work (evidenced by no benefit even at the maximum dosage for at least a month or inability to tolerate the medication), what I do next depends.

I tend to switch out of the SSRI family more quickly if the person has no comorbid anxiety. E.g. Wellbutrin.

If the person has a more vegetative depression: Wellbutrin or Prozac. Both are stimulatory.

Chronic pain: Wellbutrin, Effexor XR, Cymbalta, or Elavil. I will also consider adding Lamictal. In case you didn't know there is data that Lamictal, aside from being an antidepressant augmentation agent, does also reduce chronic pain.http://www.aafp.org/afp/2005/0201/p483.html

Excessive weight but no anxiety: Wellbutrin.

Hypotension: Effexor XR

If the person was shifted into mania or other bipolar like symptoms, I double-check for bipolar disorder and try a mood stabilizer (usually Lamictal).

As one could pretty much tell, the choices become complicated and it gets to the point where one doctor, based on the data out there, may pick another medication. That is no problem so long as that doctor's choice is based on good evidenced-based medicine and the patient understands the reasons for the choice. I've encountered situations where one doctor picked a medication and it wasn't the one I would've picked but it was still a good choice based on the data out there.

It's also clear that learning about the complicated interactions of the medications is a life-long process. Every year of residency the meds I picked and chose differed because I learned more things. It was only until about one year as an attending that I noticed myself not changing them much but I still learn more and more in ways that challenge my previous opinion. I had not known about Lamictal's benefits with pain until a few months ago. I learned months after residency ended that Carbamazepine could possibly be dangerous to those of Eastern Asian ancestry. I never would've given Neurontin for anxiety during residency and I picked that idea up after seeing an attending successfully treat panic disorder in someone who had adverse reactions to every single SSRI and SNRI tried. I never encountered patients that were resistant or had an adverse reaction to every single SSRI and SNRI until the last 1.5 years and had an anxiety disorder. Now I've encountered a few. This can make things difficult because I do not prefer to give out benzos for the obvious reasons.

When doctors start picking meds because they like the color of the pill or "it's my favorite" that really rubs me the wrong way. I've seen plenty of doctors do that. E.g. the patient is obese, can't afford non-generics, and wants to lose weight and the doctor uses Seroquel as the antidepressant augmentation medication. Then the patient mentions their appetite has gone up, they are tired all the time, and they can't afford it, but the doctor continues them on it.

If I had a dime for every situation like the above, I'd have about $50 in my pocket.

 

[kugel]

I really like Whopper's approach of tailoring the next steps to the Patient's associated symptoms and other conditions, rather than just applying an algorithm designed for thousands. Statistics can help you make educated decisions, but you still have to treat THIS patient. We don't treat lists of symptoms and you cannot treat an algorithm.

I know I've harped on this before, but I still think we generally don't involve our patients in this decision-making as much as we should. Why not lay out the basic strategic options for the patient and get his opinion before proceeding?

For instance, when an SSRI antidepressant (AD) isn't working and we have looked again at possible mis-diagnosis, tell the patient, "Here are our basic options regarding your prescription (i.e., not including therapy, exercise, group therapy or support groups, etc):
1) incr the dose,
2) switch to another SSRI,
3) switch to another class of AD,
4) add an augmenting agent,
5) do nothing (give it more time),
6) stop AD prescribing altogether for now.
Here is a list of the basic advantages and disadvantages of each approach.
My preference in these situations is to change to a different class of AD, but it's not an absolute of any kind. Lots of people choose to do other things off this list and none of them is inherently "Wrong."
What do you think YOU would like to do?
The point here is that I want your help choosing what direction we go next."

If they choose to pursue a different AD, we then proceed to discuss the advantages and disadvantages of the other classes of AD's. As we do that, I very often learn things about the patient, his history, family history, his fears and expectations about treatment, etc. that I did not know before.

In addition to maintaining the pt's dignity and autonomy, (I think) this approach increases the likelihood of continued treatment because it is something the pt. chose rather than something I did "To him." Also, if problems occur (side-effects, etc), the pt. is more likely to blame the medicine than me, preserving our relationship and my opportunity to help them choose the next action.

There are certainly some patients who say, "I have no idea. I can't even make decisions any more. I need you to choose for me." When that happens, I record that response and my reasoning for the next change into the chart. It's perfectly okay for them to request a paternalistic approach from me, and I tell them my hope is that they can get better enough to decide on their own in the near future.

 

[OldPsychDoc]

What they said. This is a good time to ask the "Magic Pill" question: "If I had a magic pill that would solve one problem right now, what would you want it to be?" Helps the patient to guide this decision-making process and narrow our options.

 

[whopper]

Agree with all the above. You will get patients that mention that they don't know what to pick out of the several possible choices.

A good guide I've seen that is easy to understand and based on good evidenced-based medicine is the Consumer Reports Guide to Antidepressants. It very cleanly describes the modern antidepressants, what to expect, side effects, prices, and treatment strategies. It's available in PDF format. You can download it from their website if you have a subscription.

I have it in PDF format but I'm not allowed as far as I can tell to give it out to the people here without being accused of software piracy. I do, however, often times give my patients a hard copy of it, and many of them feel reassured because it's from Consumer Reports and not from the drug company. I'd bet you if a patient read a copy of the guide, they'd actually know more than most M.D.s about antidepressants.

It gives very useful data such as head-to-head comparisons on the type of side effects to expect on one antidepressant vs. another and the % of patients that had to stop the antidepressant due to side effects all in one chart. When my patients have that guide, they know I'm picking Citalopram or Sertraline first because those meds work just as well as the others (possibly faster too), are cheap, and have lesser side effects for most.

CR also has guides on other psychotropics, but I did not feel those guides were on the same level of quality as their antidepressant guide.

 

[shidox]

Also need hormonal analyses: a hypophysis, a thyroid gland, adrenal glands, sexual hormones, MRI, EEG are necessary. Check vascular deseases.
For therapy potentiation usually I use
Mood stabilyzers - usually lithium, lamotrigine.
Synergic antipedressants - + four-cyclic antidepressant, imao-B
Atypical neuroleptics aripiprazole, quetiapine.
If we have no effect can use Electroconvulsive therapy, or rare therapy Atroponcomatosis therapy that mostly using in europe.

 

[dl2dp2]

Also need hormonal analyses: a hypophysis, a thyroid gland, adrenal glands, sexual hormones, MRI, EEG are necessary. Check vascular deseases.
For therapy potentiation usually I use
Mood stabilyzers - usually lithium, lamotrigine.
Synergic antipedressants - + four-cyclic antidepressant, imao-B
Atypical neuroleptics aripiprazole, quetiapine.
If we have no effect can use Electroconvulsive therapy, or rare therapy Atroponcomatosis therapy that mostly using in europe.

FYI, this is not standard practice in the US. There is no utility for MRI/EEG/sex hormone/corticasteroid eval. in otherwise healthy patients, and they are expensive and have very little yield. Routine screening with TSH in depressed patients with no other symptoms is controversial. And I have no idea what you mean with your other stuff. Just want to make sure people don't get misled by a non-sense post.

 

[shidox]

It's not a problem to make screening in our hospital (THS cost 3$, MRI 100$, EEG 10$). I understand that countries have diffrent standarts, it's practice in europe, Ukraine.
Depression can be with hypothyreosis, even without a somatic component, diagnostics is necessary for an exception of an organic background of disease, it is very difficult without labs inspections find for example microtumours, chronic infections, changes on EEG etc.

 

[kugel]

From:
Am J Psychiatry 167:12, December 2010
"Personalized Medicine for Depression:
Can We Match Patients With Treatments?"
Gregory E. Simon, M.D., M.P.H.
Roy H. Perlis, M.D., M.Sc.

"Past treatment response is often suggested as a guide to medication selection (40). Surprisingly, almost no empirical data exist regarding consistency of response to specific medications over time. Remillard et al. (41) described 59 inpatients with a history of good antidepressant response in a prior inpatient episode. Of 35 patients prescribed the same medication, 57% responded. Of 24 patients prescribed a different antidepressant, 79% responded. We are aware of no other studies examining whether history of favorable response to a specifi c medication predicts another favorable response in a subsequent treatment episode. Prior treatment during the current depressive episode has also been proposed as a guide to medication selection. Several studies have evaluated this question with respect to SSRIs, but none found that poor response to one SSRI drug predicted response to a subsequent drug in the same class. For example, the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial (8) found that poor response to citalopram did not predict differential probability of subsequent response to sertraline, bupropion, or venlafaxine."

"Implications for Practice
Given our limited ability to predict differential response to specific depression treatments, clinical recommendations in this area derive more from what we do not know than from what we do. When selecting between psychotherapy and medication, modest evidence suggests that personality disorder predicts better initial response to medication and a history of stressful or traumatic life events predicts better response to psychotherapy. When selecting between medications, neither biomarkers nor specific symptom patterns (e.g., anxiety symptoms, insomnia) predict clinically important differences in response. While conventional wisdom would base treatment selection on past response of an individual patient or the patient’s family members, we lack evidence that response to a specific treatment is consistent within families or even within individuals over time. Treatment selection should also consider patients’ preferences and (in the case of psychotherapy) the availability of adequately trained providers. Our limited ability to predict response to specific treatments does have important implications for the organization of practice, especially in the selection and prescribing of antidepressant medications. Of patients starting antidepressant treatment, only one-half will experience a good outcome with the fi rst treatment selected. Unfortunately, we have scant evidence that attempts to match specific treatments to specifi c patients will improve the rate of success. We should contrast this disappointing conclusion with the very strong evidence that organized follow-up programs significantly increase the success of antidepressant treatment (84, 85). Monitoring outcomes and personalizing treatment over time will have a much greater effect on outcomes than will attempts to personalize initial treatment selection. But opportunities for monitoring and tailoring of treatment are frequently missed. Of patients initiating antidepressant treatment, as many as one-half will not return for follow-up visits (11, 12). Of those starting psychotherapy in community practice, one-half make fewer than four visits (86). Because low motivation, discouragement, and selfblame are core features of depression, aggressive outreach may be necessary to reach those who fail to return (87).
Our limited ability to match patients with specific treatments also raises questions about how we share uncertainty with our patients. Communicating hope is an essential element of any healing relationship. But it would be less than honest to imply that we can accurately select the best treatment for any individual. Prudence and respect for patients’ autonomy argue for following an honestly optimistic approach, such as: “We have several good treatment options to choose from. On the average, they have about the same chance of success. But you are not an average; you are an individual. At this time, there is no scientific way to predict which treatment will work best for you. Together we will look at your options and decide what treatment to start with. But it is important to remember that there are other options. If the first treatment we pick does not work out for you, some other treatment might work well. Regular follow-up over the next several weeks will tell us whether to stay with our first choice or try something else.”