SSRI's

[radslooking]

What are your guys general feelings on SSRI's? overused? underused?

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[OldPsychDoc]

What are your guys general feelings on SSRI's? overused? underused?

Yes.

 

[radslooking]

Yes.

Interestingly enough, even though you didn't answer my question, I agree with you. Care to explain though?

 

[Therapist4Chnge]

Interestingly enough, even though you didn't answer my question, I agree with you. Care to explain though?

Much like other classes of meds (psychostimulants come to mind), they are over-utilized in some instances/populations and under-utilized in others. It comes down to what is best for the pt, which is easier said than done.

The med may provide the desired clinical response, but the side effects may not be acceptable to the pt, so that doesn't work. Other times a partial response is obtained with lower side effects....but is that good enough? Ultimately if the med provides the desired result and is tolerable to the pt (and they are compliant), then it is the right med for them.

 

[radslooking]

i see a lot of patients who are on these medications continuously and i serouisly doubt whether anyone has addressed that they be stopped- or could be stopped.

Moreover, I see demented patients on ssri's and question their benefit.

Lastly, I see plenty of patients who simply get stuck on ssri's without any counseling. Which i think is counter to how it should be done.

It just seems like a lot of inappropriate oversight/starting/continuation i see with a lot of these meds. I'm not implicating anyone, it just seems there is a lot of misuse.

 

[radslooking]

..

 

[OldPsychDoc]

i see a lot of patients who are on these medications continuously and i serouisly doubt whether anyone has addressed that they be stopped- or could be stopped.

Moreover, I see demented patients on ssri's and question their benefit.

Lastly, I see plenty of patients who simply get stuck on ssri's without any counseling. Which i think is counter to how it should be done.

It just seems like a lot of inappropriate oversight/starting/continuation i see with a lot of these meds. I'm not implicating anyone, it just seems there is a lot of misuse.

You answered your own question. I also see them not used in places where they would be appropriate, low-cost, non-addictive interventions for mood and anxiety problems--but where the patient has been given something more expensive and second-line from the sample cabinet, or based on advertising, or they've been given benzos inappropriately.

 

[whopper]

Problems I'm seeing with SSRIs is that some docs are giving them out for any psyche disorder. I think some of these docs only remembered that SSRIs are used in several psyche disorders. OK fine, but you don't use Zoloft on a patient with Schizophrenia.

Another problem is several docs seemingly are giving one & only 1 SSRI, and not picking the SSRI that best matches the patient's profile. Not something that I'd expect a non-psychiatrist to know.

 

[Therapist4Chnge]

Another problem is several docs seemingly are giving one & only 1 SSRI, and not picking the SSRI that best matches the patient's profile. Not something that I'd expect a non-psychiatrist to know.

In my anecdotal experience, I've seen a pretty consistent trend of, "learn two meds in each class really well" approach. There is something a bit problematic with staking your trust in something like Prozac and Paxil and passing on the rest.

 

[Doc Samson]

You answered your own question. I also see them not used in places where they would be appropriate, low-cost, non-addictive interventions for mood and anxiety problems--but where the patient has been given something more expensive and second-line from the sample cabinet, or based on advertising, or they've been given benzos inappropriately.

Or they're prescribed for patients with no psychiatric illness - just appropriately dysphoric or anxious reactions to difficult situations. I've seen someone started on an SSRI days after their parent died or their spouse left them because the PCP found them "situationally depressed."

 

[whopper]

Had the same thing happen several times, often times detected during consults.

When I'd report this to my attending, he'd often say something to the effect of--we can call up the GP that ordered this antidepressant, spin that wheel for an hour while we educate him on the proper use of antidepressants, all the while getting him upset at us, after which he'll probably not listen to us anyways, or we can just leave it alone--

The majority of antidepressants are prescribed by the primary care doctor, not a psychiatrist. This is based on several studies, and it is in part due to the shortage of psychiatrists. I've met very few GPs that could differentiate between the benefits & disadvantages of the antidepressants in a head to head comparison. Several of them did not want to but had to because they could not refer to a psychiatrist or the referral would take several months.

Of course, that's not to imply that psychiatrists know more, or are better. Just that this is our field of specialty.

Any good primary practice often times employs a psychiatrist or psychologist for backup purposes to assist them. I encountered a few practices that were large enough to employ one as an advisor or consultant in mental health areas.

In my anecdotal experience, I've seen a pretty consistent trend of, "learn two meds in each class really well" approach. There is something a bit problematic with staking your trust in something like Prozac and Paxil and passing on the rest.

What is really pathetic is when a psychiatrist does this approach, and unfortunately I've seen quite a bit of that too. The GPs I understand, and I'm sure those GPs could break me in 2 if comparing my knowledge of antiobiotics or other non-psychiatric areas vs theirs. However if a psychiatrist pulled this level of shameful performance--this is a lowdown insult to the profession.

 

[Therapist4Chnge]

What is really pathetic is when a psychiatrist does this approach, and unfortunately I've seen quite a bit of that too. The GPs I understand, and I'm sure those GPs could break me in 2 if comparing my knowledge of antiobiotics or other non-psychiatric areas vs theirs. However if a psychiatrist pulled this level of shameful performance--this is a lowdown insult to the profession.

Sadly I've heard this approach verbatim by multiple psychiatrists I've come across in my work. One explained to me that it is a common way to train...because "they can't be experts on everything." It isn't my place to question a med recommendation as it is outside of my scope, but that general mentality concerned me. I'm lucky that the two main psychiatrists I've worked with over the past two years have been very well versed in their pharma knowledge and have regularly caught all sorts of issues with the cocktails prescribed to pts coming in.

 

[TheWowEffect]

If we look at the structure of SSRIs, there are actually no similarities. I guess some older psychiatrists may have this attitude of "learning about two meds in the same class" but things have changed in a big way. I would take an issue with an attending who espouses such views.

 

[Therapist4Chnge]

If we look at the structure of SSRIs, there are actually no similarities.

Well, there is always citalopram and escitalopram.

 

[TheWowEffect]

Well

 

[billypilgrim37]

Well, there is always citalopram and escitalopram.

They do come in very different bottles...

 

[Therapist4Chnge]

They do come in very different bottles...

Though the punch/med cards look pretty similar.

I love that example because Lundbeck/Forest was able to use primarily "old" research to get Lexapro through, but was still able to convince the FDA to accept a second patent because it was an (S) enantiomer of Celexa. Considering the cost of trials and typical timeframes, it was like they did a Buy One, Get One Free deal.

 

[Anasazi23]

This is the norm in pharm research. Most extended release formulas don't require going back to phase I testing.

 

[whopper]

One explained to me that it is a common way to train...because "they can't be experts on everything."

One can't be an expert in everything--sure, but you can at least read up on your own field.

Reading the CATIE Trial, STAR*D, STEP-BD (one time tasks) & spending just 1about 1 hr a week would keep these docs up to par on their meds.

But for some doctors, once they're past residency, they don't feel they have to do this 1 hr a week of work.

 

[masterofmonkeys]

not necessarily overused or underused, but definitely overemphasized.

By which I mean we find it all too easy to prescribe SSRIs and not look at the exacerbating and/or causative factors behind a patient's MDD or GAD.

SSRIs are great at symptomatic relief. Not so good at actually healing the underlying lesion. Nothing wrong with prescribing a med to help a patient deal with debilitating symptoms, but the fight shouldn't end there.

 

[whopper]

not necessarily overused or underused, but definitely overemphasized.

I sometimes think we psychiatrists are trained to think inside the box too much--that box being the use of meds.

For example, another mental health professional I know of successfully treated someone someone's panic attack through psychotherapy. The therapist used CBT, got the person to be able to tell when a panic attack was going to come on, and that person would leave work for a 20 minutes, go right outside to an area that was alright- scream & punch a punching bag, and after that, they were fine & able to get back to work. The boss knew what was going on & was fine with it.

Meds are more effective, but several psychiatrists would not even consider the psychotherapy aspects in treatment, and meds + psychotherapy is the most effective treatment. To spread around the blame---its largely due to the way managed care has tied our hands. No meds prescribed--no pay from them. They don't reimburse for psychotherapy.

 

[Doc Samson]

I sometimes think we psychiatrists are trained to think inside the box too much--that box being the use of meds.

For example, another mental health professional I know of successfully treated someone someone's panic attack through psychotherapy. The therapist used CBT, got the person to be able to tell when a panic attack was going to come on, and that person would leave work for a 20 minutes, go right outside to an area that was alright- scream & punch a punching bag, and after that, they were fine & able to get back to work. The boss knew what was going on & was fine with it.

Meds are more effective, but several psychiatrists would not even consider the psychotherapy aspects in treatment, and meds + psychotherapy is the most effective treatment. To spread around the blame---its largely due to the way managed care has tied our hands. No meds prescribed--no pay from them. They don't reimburse for psychotherapy.

Yes they do.

 

[Therapist4Chnge]

I sometimes think we psychiatrists are trained to think inside the box too much--that box being the use of meds.

For example, another mental health professional I know of successfully treated someone someone's panic attack through psychotherapy. The therapist used CBT, got the person to be able to tell when a panic attack was going to come on, and that person would leave work for a 20 minutes...etc

IIRC, panic attacks are best treated with talk therapy, as meds aren't a great long term solution.....though a combination of both can also be effective.

 

[masterofmonkeys]

Meds are more effective, but several psychiatrists would not even consider the psychotherapy aspects in treatment, and meds + psychotherapy is the most effective treatment. To spread around the blame---its largely due to the way managed care has tied our hands. No meds prescribed--no pay from them. They don't reimburse for psychotherapy.

actually meds aren't more effective. Especially now that new data is coming out. The med trials are often heavily slanted. But even with the old stuff, it showed that psychotherapy had similar or higher initial efficacy and much better prevention of relapse rates.

 

[masterofmonkeys]

Yes they do.

darn tootin. My psych advisor told me that most plans approved 20 sessions per year without prior auth, and that if needed, it wasn't too hard to get that authorization for more. It's true that compensation is somewhat crappy (45 minute session is significantly less payout than 3 15 minute med checks).

And don't forget the new mental health parity laws that are cropping up. Significantly improves our chances of billing for psychotherapy rather than meds.

And as I already mentioned newer studies are showing that meds aren't THAT effective. Eventually, I'll hope at least, this will mean that insurance will look more favorably on talk therapy.

 

[whopper]

Especially now that new data is coming out.

Thanks for the update, and this is definitely a reason why CME's and reading at least 1 hr a week need to be done by attendings. Its also a reason why I love being active on this board even after graduating residency.

The staff at the place I'm at tell me they're very happy to have me because a lot of the docs that have been there for years are not up to date on their psychopharmacology.

If I don't keep up with reading and discussing with those willing to teach & learn, I'm going to end up being one of those psychiatrists I can't stand--the type that's practicing based on the data when they were residents--but that was several years ago.

And as I already mentioned newer studies are showing that meds aren't THAT effective. Eventually, I'll hope at least, this will mean that insurance will look more favorably on talk therapy.

My wife is currently getting a masters in counseling & the level of her psychotherapy training is at a level I've never seen at any residency program. She's teaching me a lot of stuff I've never learned. We're considering making a practice together. It also would make me comfortable to know that our patients could be getting the best of both worlds.

 

[masterofmonkeys]

http://medicine.plosjournals.org/perlserv/?request=get-document&doi=10.1371/journal.pmed.0050045

Full paper. I must say that the scientific rigor these guys displayed deserves a freaking nobel prize and I'm not joking. I have seen papers this thorough by the dozens in my original field, but never in psychiatry and rarely in medicine in general.

Just for some perspective, I recently performed a meta-analysis of the effect of exercise on depression, which netted an effect size three times that of SSRIs.

 

[whopper]

I am aware of the paper you mentioned but doesn't that paper focus on depression? Not Panic Disorder or other anxiety disorders?

There's another serious problem with that study that I think we need to address. Yes, its true that several meds have to have a few studies done before one of them shows enough significance for the FDA to give approval. That doesn't exactly make the meds sound efficacious when 10 studies might have had to be done, 9 of them not showing much efficacy, & the 10th is the only one doing so.

However that issue is true of pretty much all meds that get FDA approval--statins, pain meds, chemotherapy meds, what have you. These same meds also have the same problem of unaccepted data that if added to the meta-analysis, would greatly reduce their perceived efficacy.

I sat through a grand rounds where a psychiatrist (forgot his name but he's on the forefront of antidepressant research, if you'd like, I can call up the program to ask for his name) also used unpublished data on other nonpsychiatric meds such as statins to show the same problems with them as well.

Its the old Peter Breggin argument he uses to attack psyche meds. He brings up some great points, but the arguments he brings up call into the question the efficacy of any medication, but he selectively chooses to attack psychiatry & not the entire process. (e.g. he mentions that he believes medication will always beat placebo because medications cause side effects, & when side effects are experienced, the patient will then believe they have a medication that is at least doing something--> creating a cognitive distortion that it'll help their ailment. While this may in fact be true (and no one as far as I know has ever addressed that issue), he only uses it to attack psychiatric meds. Why not attack chemotherapy meds, statins, coagulation meds, the whole spectrum of all meds with this argument? Why does he only choose to attack psyche meds?)

I'm not saying that we should ignore this data. Heck if the truth is some of these meds don't work or as well as we thought, we need to know this & so do our patients. I'm saying that all fields of medicine, all the meds of those fields should also have this level of scrutiny.

By the way, and this is something I was not able to have answered by this paper or had anyone be able to answer. Several studies are not accepted or published, not only because no significance was found, but also because some studies are thrown out because of faulty data gathering or other poor practice during the study. They were in fact just bad studies which if graded would've gotten an F. I questioned if some of the studies that were not accepted that were used in this meta-analysis that got so much hype were due to being of poor quality. I never was able to get an answer on that. I'll double check that study because it might address that question.

(I double checked, it still didn't address it or I missed the part that did address it)
Personally for me, the best source on antidepressants we got so far is the STAR*D, which is considered to have been well done, involved thousands of patients at several centers & was conducted by a the NIMH. Even that study too points out antidepressants as far from being a miracle therapy, however it did not leave several questions in my mind open as the above study did.

 

[masterofmonkeys]

We still haven't proven that statins are effective in a primary prevention setting. And we tend to downplay their side effects. Effective and life-saving in the setting of established and evolving disease? Absolutely. Then again, I recently read a call for even stricter cholesterol guidelines that would set my target at an LDL of 100. Because I have a family history of diabetes. And Diabetes is a heart disease equivalent. Even though my family has NO history of heart disease going out 4 generations down and out through third cousins (plenty of diabetes though). Bit much don't you think?

Higher perceived over actual efficacy is a problem for all meds. The issue for me with psych drugs especially is that many patients who could benefit from psychotherapy and who might otherwise be interested in it, are discouraged due to the overemphasis of SSRIs and the whole 'depression is caused by a serotonin imbalance' thing. No fool, depression IS a serotonin imbalance. Not the same thing. Another worrisome thing is the sheer number and classes of drugs being approved for depression, from atypical antipsychotics to anti-epileptics. With the side effect profiles of those drugs, not to mention the neurocognitive effects, I can't say that seems entirely in the patient's best interest. Alleviate depression? POSSIBLY. But at what cost to their mental richness?

Seriously what better way to promote learned helplessness than to tell someone that they can't help feeling sad because their own brain is working against them?

An SSRI won't fix poor relationships or dangerously maladaptive thought patterns. It'll just make you care about them less.

 

[Anasazi23]

Just for some perspective, I recently performed a meta-analysis of the effect of exercise on depression, which netted an effect size three times that of SSRIs.

Wasn't the effect of exercise (not vs. SSRI therapy) just refuted in the archives? Too lazy/tired to look up ref now.

 

[whopper]

Agree with you MOM.. (no joke intended). Its been my clinical opinion that antidepressants work but don't work well. I'm just calling that 1 study in question. Nothing against you.

There are other STAR*D studies that back the same, though their numbers yield more efficacy for antidepressants vs the other study.

I don't know what institution/program you're at, but if you were taught that study, I hope that you were also given the contextual data that all meds have the same problems against them that were brought up in the study. The problem I got with the way it was presented in the media was it focused on antidepressants, but let all other meds off the hook when they too have these failings.

 

[billypilgrim37]

Wasn't the effect of exercise (not vs. SSRI therapy) just refuted in the archives? Too lazy/tired to look up ref now.

I believe that much of the literature confuses efficacy and effectiveness, since depressed people are much more likely to take a pill than they are to go exercise or show up for psychotherapy visits.

So, if you recommend exercise, you're going to have to start a course of Motivational Interviewing, since a physician recommending exercise without further followup is a waste of time and approximately as effective as me asking a supermodel out on a date (it ain't gonna happen). The patient probably isn't gonna show up for Motivational Interviewing sessions, so you'll have to prescribe a med with no refills to get them to come back for their MI booster sessions so they'll exercise!

Vicious cycles. I like them.

 

[masterofmonkeys]

Agree with you MOM.. (no joke intended). Its been my clinical opinion that antidepressants work but don't work well. I'm just calling that 1 study in question. Nothing against you.

There are other STAR*D studies that back the same, though their numbers yield more efficacy for antidepressants vs the other study.

I don't know what institution/program you're at, but if you were taught that study, I hope that you were also given the contextual data that all meds have the same problems against them that were brought up in the study. The problem I got with the way it was presented in the media was it focused on antidepressants, but let all other meds off the hook when they too have these failings.

I'm aware of the fact that this is an issue with all meds, and that if researchers were to take a look at ALL drugs this way, that ALL would appear less effective than originally thought. I have the same problem with the media portrayal that you do.

 

[whopper]

On a related note, I mentioned this before several months ago on the forum, a teacher I had in residency mentioned he believed the efficacy of antidepressants aren't much because often times there's legitimate reasons for a person to be depressed that cannot be addressed with medications.

Depression, given our current understanding much more than other disorders follows a bio-psycho-social model--with the psycho & social more so than other disorders such as OCD or Schizophrenia.

Depression, while it does show several biological components (increased correlation with families, geographic regions-sunlight, etc), there is often times the psycho-social aspects.

If someone is depressed as a result of several negative outcomes in their life such as learned helplessness, constant & chronic negative feedback etc--giving them an antidepressant will not change these psychosocial circumstances.

However correlate that with another disorder such as Schizophrenia--where the current data shows much more of a biological component than a psycho-social component (though there too is a psychosocial component to it). In this disorder-medication is much more effective than psychotherapy.

He of course added the caveat that this was his own anectdotal theory & didn't have much hard evidence to support it.

From what I've read of STAR*D, my own approach to depression includes ruling out Bipolar, initial aggressive antidepressant treatment, offering the patient several non-medication approaches in addition to the medication such as education on excercise, proper diet (make sure they get enough Vitamin B, folate & Omega 3 Fatty Acids with EPA), advising them to take Fish oil 1 g a day, make sure they get enough sunlight and that their circadian rhythms are stable & ruling out medical causes for depression, and also a psychotherapeutic approach that evaluates their psychosocial causes of depression. If there is success with the treatment plan, I will discuss with the patient eventual plans to taper down the antidepressant & discuss the risks & benefits of doing that with the patient.

If anything, STAR*D's data with the weak efficacy of antidepressants suggests that aggressive medication needs to be done if the depression is strong (e.g. vegetative sx, suicidality, unable to care for self). Higher doses were correlated with higher efficacy. If the depressioni is not strong, I leave it up to the patient. Of course if the depression is not strong, they'll most likely be in outpatient & everything that's done there is up to the patient's voluntary consent.

 

[luft]

Sadly I've heard this approach verbatim by multiple psychiatrists I've come across in my work. One explained to me that it is a common way to train...because "they can't be experts on everything."...

WHICH IS WHY ONE CHOOSES TO SPECIALIZE ONLY IN PSYCHIATRY!!!! Good grief, how did these people get through med school?