SSRIs and suicidality

[mdblue]

Hi all,
With the recent warning from FDA it seems that they are simply stressing the importance of good clinical practice of monitoring risk issues in every patient who is on an antidepressant. It appears to me this debate also focuses on the habit of antidep prescribing by the PCPs who(not all) lack the skills of a psychiatrist. Maybe now they will defer the prescribing of psych meds to properly trained psychiatrists. And maybe the psychologists lobbying for scripting power will learn a lesson or two

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[SDN]

Hi all,
With the recent warning from FDA it seems that they are simply stressing the importance of good clinical practice of monitoring risk issues in every patient who is on an antidepressant. It appears to me this debate also focuses on the habit of antidep prescribing by the PCPs who(not all) lack the skills of a psychiatrist. Maybe now they will defer the prescribing of psych meds to properly trained psychiatrists. And maybe the psychologists lobbying for scripting power will learn a lesson or two

The average depressed or anxious patient can be well cared for by board certified FM or IM physicians. I don't think the study implies anything along the lines of what you're suggesting.

I'd venture that most psychiatrists in my area would be pretty pissed if I was referring every depressed/anxious patient to them for basic SSRI therapy -- just as an orthopedic surgeon would get pissed if I referred every patient with a sprained ankle -- specialists need to spend their time caring for patients with more complicated conditions.

 

[Anasazi23]

That's funny Mdblue...when I heard of the warning going official, the first thoughts I had as well were something to the effect, "maybe family docs won't be giving out SSRI's like candy anymore."

As a practicing physician (which I'm not yet), I'd rather have too many referrals than not enough.

 

[Kalel]

That's funny Mdblue...when I heard of the warning going official, the first thoughts I had as well were something to the effect, "maybe family docs won't be giving out SSRI's like candy anymore."

That is the exact effect that the fda is having on some primary care practioners. I was talking with med/peds private physician recently and he was telling me how he is no longer comfortable starting any of his peds patients on anti-depressant therapy because he is worried about getting sued if one of his peds patients decides to commit suicide. I haven't read the actual studies (since I don't even think that they've been published), but the "increased risk" that the FDA claims that some of the studies of SSRI's have shown with respect to suicide in the pediatric population may not even be a true risk. One of my psych professors told us that some severely depressed patients who just begin anti-depressant therapy gain a little bit of motivation so that they are no longer "catonic", but they are still pretty depressed so they ironically use this "better mood with more energy" to go and commit suicide. I don't see this FDA move as being good for psychiatrist either, because if the FDA reaches a final position of being unsure about whether or not SSRI's cause suicidal behavior or if it suggests that SSRI's may cause suicidal behavior in some patients, then any patient that commits or attempts suicide while taking an SSRI (probably most patients) is a potential malpractice lawsuit against the psychiatrist who prescribed the medicine. We have pretty regular advertising in my area advising anyone who as been prescribed Vioxx or Baychol to call these malpractice lawyers, I wouldn't be surprised if we started seeing advertisements from malpractice lawyers telling anyone who has been prescribed an SSRI to call them if the FDA comes out against using them in kids.

 

[mdblue]

"maybe family docs won't be giving out SSRI's like candy anymore"
It's true- and probably that's what FDA means. SSRIs are not exactly a benign group of drugs. They do have side-effects, some nasty, some more of a nuisance, but definitely they are much safer than TCAs( a 7 day supply of TCA may kill you). That said in a depressed patient needing SSRI, you have to monitor for risk issues e.g. akathisia, "awakening effect" (as previously mentioned), previous suicidality, other psychosocial factors etc. It's just not possible for a PCP to appropriately assess and evaluate these risk issues given their extremely short duration of pt encounter, lack of training etc. Also the recent trend of using SW/psychologists and their checklists for evaluating pts and F/U care is a bad, bad clinical practice which definitely promotes standardization of care but in a negative way. The best person to prescribe a psych med is a properly trained psychiatrist and iat the minimum it needs a 45 min interview incl a properly done MSE. That's what they call as the standard of care.
I will encourage everyone to read the guidelines for treating a suicidal patient issued by the APA and understand predicting suicidality is a extremely complex task-the only way to prevent suicide is proper assessment and contnuious monitoring(which unfortunately may not be an economically viable option).
I presume the next in line are the SGA/atypical antipsychotics-it just needs a single lawsuit!

 

[Anasazi23]

I presume the next in line are the SGA/atypical antipsychotics-it just needs a single lawsuit!

Unfortunately, you're right. The other day, I saw a TV ad for some lawyers advertising for you to call them if you have ever taken Zyprexa....they went on to talk about the "horrible side effects that your doctor ignored" such as hyperglycemia, etc, etc.

These people make me sick