What's with the resistance in primary care to prescribing basic stuff

[DD214_DOC]

---

Members don't see this ad.

What are your thoughts on this? Is this rampant? I am getting so much push back from primary care in accepting stable patients who are not high-risk with uncomplicated medication regimens. 9/10 the reason is, "I'm not comfortable prescribing that" and it's usually a stimulant.

How are people handling this? I inherited a panel of almost 400 and I cannot sustain this unless primary care starts taking stable patients back.

 

[mojetter]

Yes theyre not only uncomfortable with prescribing psychotropic medications but they are even more uncomfortable with handling psychiatric emergencies or a declining patient and a lot of that pushback comes from that more so.

Im curious, who is pressuring you to see more patients? Wherever you work sounds like they need an additional psychiatrist....dont take on that pressure.

 

[wolfvgang22]

My panel is around 1,5000 veterans.
I get the same push back because VA primary care is swamped.
Today I'm treating urinary incontinence in a veteran because primary care won't try anything other than a brief trial of antimuscarinic that the patient couldn't tolerateand then throw up their hands and says "its all in his head". So, yeah.

 

[DD214_DOC]

Yes theyre not only uncomfortable with prescribing psychotropic medications but they are even more uncomfortable with handling psychiatric emergencies or a declining patient and a lot of that pushback comes from that more so.

Im curious, who is pressuring you to see more patients? Wherever you work sounds like they need an additional psychiatrist....dont take on that pressure.

I understand if the patient has a history of hospitalizations, suicide attempts, or whatever; I never send those back to primary care even if they've been stable for a long time because I realize it's futile. I'm talking basic stuff that isn't high-risk.

Yes, where I am needs another psychiatrist. I won't say exactly where I am, but I'm the only full-time c/a person serving a patient population of, hmmm, around 10,000 - 15,000

 

[Shikima]

Just be patient and don't put the pressure on yourself that all of them need to be solved right at this time. Go with the path of least resistance in continuing their prescription for now and as you start working with them closely, you can change that with education and reviewing their history.

 

[F0nzie]

No time to talk, no time for crying, not sure what to say if crying, not sure how to adjust meds if needed, liability for practicing outside scope, more no shows, don't know how to set boundaries, don't like addiction, don't like personality disorders, can't deal with crisis, don't feel like it, don't think it's real...

 

[F0nzie]

I have a stable patient on 1mg of Guanfacine for ADHD but PCP refused to take over his care. PCP still wins big because he doesn't have to deal with senseless repetitive calls due to his forgetfulness and him never paying attention to anything in the session.

 

[shan564]

I think a big part of this is that we don't do a good job of teaching people about psychotropic drugs in med school. Board exams love to ask about serotonin syndrome, lithium toxicity, NMS, precipitation of mania, etc, instead of asking about how to evaluate and manage a psychiatric patient... so the average doctor thinks that these drugs are all really scary. Think of all the times you've seen an internist or neurologist try to diagnose serotonin syndrome when it's completely nonsensical?

On the other hand, I'll bet those same doctors aren't scared to put their patients on Dilaudid, Xanax, etc. People seem to think that Xanax is safer than SSRIs, probably just because doctors have omre experience with seeing it work immediately rather than doing thorough evaluations.

 

[keifernny2]

1500 pt panel in the VA? Geez. You know, for comparison, my VA usually panels the psychiatrists at around 500-600 (though some are only at 400!) , and from what I understand the average is usually around 800 from my job hunting experiences (first question I asked!). I would go nuts trying to manage 1500 unless they were just refills and entirely stable.

Secondly- I would be pretty grumpy if a psychiatrist was trying to dump their controlled RX patients on me just the same as when pain docs and neurologists try to get me to write for their provigil for OSA & klonopin for "muscle cramps." These are meds I use regularly, but they are indications that I don't generally treat (or examine the patient for) regularly, and in some ways I feel like they're just trying to lower their monthly Rx reports from the state database (especially when I know the other doc continues to prescribe their pain meds).

My thoughts are, the doc doing the controlled Rx recommending should be the one accepting liability for the prescribing, unless otherwise agreed to.

Also, the PCP doesn't want to have to go to court if a psych patient requires it, as they don't really practice CYA documentation as much as we do w/r/t psychiatric notes.

 

[wolfvgang22]

I think a big part of this is that we don't do a good job of teaching people about psychotropic drugs in med school. Board exams love to ask about serotonin syndrome, lithium toxicity, NMS, precipitation of mania, etc, instead of asking about how to evaluate and manage a psychiatric patient... so the average doctor thinks that these drugs are all really scary. Think of all the times you've seen an internist or neurologist try to diagnose serotonin syndrome when it's completely nonsensical?

On the other hand, I'll bet those same doctors aren't scared to put their patients on Dilaudid, Xanax, etc. People seem to think that Xanax is safer than SSRIs, probably just because doctors have omre experience with seeing it work immediately rather than doing thorough evaluations.

Funny you mention serotonin syndrome. The ER doc called me in the middle of the night. The question: "What are the symptoms of serotonin syndrome? And should I be worried about it in this patient with dementia who forgot he took his Paxil 30mg dose this morning and so he took it twice today?". I was just relieved I didn't have to go admit anybody.

 

[shan564]

Funny you mention serotonin syndrome. The ER doc called me in the middle of the night. The question: "What are the symptoms of serotonin syndrome? And should I be worried about it in this patient with dementia who forgot he took his Paxil 30mg dose this morning and so he took it twice today?". I was just relieved I didn't have to go admit anybody.

Ha, wouldn't it have been faster/easier to consult Dr. Google on that one?

 

[Crayola227]

I think a big part of this is that we don't do a good job of teaching people about psychotropic drugs in med school. Board exams love to ask about serotonin syndrome, lithium toxicity, NMS, precipitation of mania, etc, instead of asking about how to evaluate and manage a psychiatric patient... so the average doctor thinks that these drugs are all really scary. Think of all the times you've seen an internist or neurologist try to diagnose serotonin syndrome when it's completely nonsensical?

On the other hand, I'll bet those same doctors aren't scared to put their patients on Dilaudid, Xanax, etc. People seem to think that Xanax is safer than SSRIs, probably just because doctors have omre experience with seeing it work immediately rather than doing thorough evaluations.

The only issue with psych in med school wasn't coverage but none of my colleagues giving a ****. They go on and on about how "easy" the **** is then forget how to not precipitate mania in a bipolar patient, so I don't think there's an issue with those sorts of questions being on boards.

There was definitely issues at my school and I think others from what I hear in students getting to do enough evaluations, so I agree with you there.

And while non-psych people definitely have more experience with Xanax over SSRIs, no one thinks they're safer or prefers rxing it between the two. Xanax in the elderly, even just during an inpt stay, is a ****ing nightmare.

Which gets to me agreeing that the issue is both one of bad ****ing attitudes in non-psych docs and lack of time.

For sure shying away from rxing the "fun" stuff is a form of self preservation (narcs, benzos, uppers), and I definitely get that in the interest of time wanting a full psych eval for any psych disorder that's needing multi-drug regimens and disorders towards the psychotic needing antipsychotics (do you need a 4 yr residency to sort schizophrenic from schizoaffective from mania with psychotic features from some other baffling **** I saw stump psychs during my psych rotation? My hat will go off to psych for that and say yes) and just generally complicated like you said.

But yes I agree with you other docs like PCPs are not working to the top of their training, being sissies, passing the buck, not using common sense even when it comes to psych stuff, even when time's not the issue.

Sorry guys.

 

[AcronymAllergy]

From an outside perspective, I know our PCPs (VA clinic) tend are very hesitant to manage benzos (despite it likely having been primary care who'd started the med years ago) and their weening, to the point that they were wanting to refer all these folks up to behavioral health. They seem to be ok with managing SSRIs if the pt is stable, although they also have a psychiatrist and NP in PCMHI for the initial eval. All pts with suspected ADHD are referred for f/u testing, and it's then psychiatry who must prescribe psychostimulants, if approrpiate.

 

[Shikima]

One of my Pt's, struggling with depression had been on and off SSRI therapy over the years until I started seeing her. She talked about these seizure-like and shaking events while asleep and would wake-up experiencing them. One day she presented to my clinic after having such an event the previous night and was still recovering from it while she felt the after effects. I sent her immediately to the ER for hospitalization and recommended that she have a sleep study. The hospitalists discharged citing that it was serotonin syndrome as the likely cause and said to stop the [offending] agent.

A while later, she comes back citing that her PSG was significant, no seizure/spike-and-wave activity but did have an AHI of 148. She was having an apneic episode every 20-30 seconds while she was sleeping.

Is started her back on something at a low dosage to help with anxiety and the sadness she felt - PCP (NP) calls me asking if this is safe as she has a history of serotonin syndrome. Education brought her back on board with treatment and what was necessary to get the Pt to feel better, including a 2 night home pulse oximetry while using PAP therapy and managing her severe OSA much better than what her current pressures are allowing her. It's funny, the hospital and PHO aren't interested in me being able to bill for any other services in my clinic which aren't directly related to psych.

 

[Ceke2002]

We're kind of getting the opposite problem here now. GPs receive training to handle straightforward stuff like uncomplicated depression and anxiety disorders, with a set number of medicare rebated Psychologist visits they can refer patients to. In other cases they can request a Psychiatric assessment and then have a Psychiatrist draw up a treatment plan which is primarily managed by the GP with the Psychiatrist acting as consultant when needed. It's good from the point of view that it does free the mental health system up to actually deal with cases that should be dealt with by a Psychiatrist, and I know they're planning to increase training in mental health care for GPs, but unfortunately in some situations it's ended up with GPs thinking they know more than Psychiatrists and have the ability to treat complex cases of mental illness that they don't actually have anywhere near the level of training to do. So cue patients like me occasionally having to sit through borderline anti psychiatry lectures and being told all our conditions can just me managed by them, because clearly the fact that as a GP they've now received enough training to manage uncomplicated cases of mental illness now makes them the equivalent of an actual Psychiatrist.

 

[shan564]

The only issue with psych in med school wasn't coverage but none of my colleagues giving a ****. They go on and on about how "easy" the **** is then forget how to not precipitate mania in a bipolar patient, so I don't think there's an issue with those sorts of questions being on boards.

There was definitely issues at my school and I think others from what I hear in students getting to do enough evaluations, so I agree with you there.

Yeah, that's another one of my complaints about how we teach psych in med school. There's so much variability in how psychiatry is practiced that we don't have a well-established way of teaching the basics. I want to implement more of this paradigm: https://hms.harvard.edu/departments/medical-education/md-programs/pathways

And while non-psych people definitely have more experience with Xanax over SSRIs, no one thinks they're safer or prefers rxing it between the two. Xanax in the elderly, even just during an inpt stay, is a ****ing nightmare.

Maybe the word "safer" was a bit hyperbolic, but I do feel like many PCPs would feel more comfortable prescribing Xanax than SSRIs because they're worried about something silly like serotonin syndrome.

But yes I agree with you other docs like PCPs are not working to the top of their training, being sissies, passing the buck, not using common sense even when it comes to psych stuff, even when time's not the issue.

They don't have much standardized psych training either. I feel like every IM/FM residency program should have a brief lecture series called something like "basic principles of psychiatry for PCPs" or "common mistakes/misconceptions about psychiatric management in primary care." At my program, the psych chief resident gives a few lectures about this topic to the IM residents.

 

[Crayola227]

Yeah, that's another one of my complaints about how we teach psych in med school. There's so much variability in how psychiatry is practiced that we don't have a well-established way of teaching the basics. I want to implement more of this paradigm: https://hms.harvard.edu/departments/medical-education/md-programs/pathways

All I hope is that whatever that is is not like these stupid supercontrolling modules, like what I did in med school, were like. Or like EHR training that won't let you go at your own speed or do silly "write in the box" exercises and "click here" stuff.

But yes, I'm with you more standardization would be great. Unlike a lot of people, I did the required reading (you would think that would be enough) and the psych shelf still was really really hard. Of course the problem with the shelf was that was the end of the course and not a dealbreaker. The didactic part of psych the first two years was pretty lacking.

Maybe the word "safer" was a bit hyperbolic, but I do feel like many PCPs would feel more comfortable prescribing Xanax than SSRIs because they're worried about something silly like serotonin syndrome.

You're right, people seem way more scared of it than I think is warranted. Of course, I've only seen in it psych med ODs, and hilariously enough no one believed me that was what the patient had. I would probably respect it more if I had seen an iatrogenic cause or anything severe, so that's probably just lack of experience on my part.

They don't have much standardized psych training either. I feel like every IM/FM residency program should have a brief lecture series called something like "basic principles of psychiatry for PCPs" or "common mistakes/misconceptions about psychiatric management in primary care." At my program, the psych chief resident gives a few lectures about this topic to the IM residents.

It really really gets my goat that the primary care fields don't put psych/social issues, patient education, way higher. Like we should be doing an Axis 1,2,3,4,5 A/P on everything (only we'd address axis 3 first, then how axis 1/2 and 4 affect management of 3).

Yes, I know the DSM IV went out and a lot of people didn't like the Axis classification stuff but you get my drift.

Please guys, keep the anecdotes and bitch session going. I really enjoy reading other specialties' threads on here. Not the most EBM-y but SDN offers some insight you can't get from noon conference.

 

[Ceke2002]

Which gets to me agreeing that the issue is both one of bad ****ing attitudes in non-psych docs and lack of time.

Ugh, speaking of non-Psych Docs with bad effin' attitudes ...My regular GP is great and actually works with my Psychiatrist so that between the two of them they can try and give me the best level of care - unfortunately I can't say the same for the substitute Doctor I had to see recently when my GP was away sick. The entire appointment was more or less her raging against Psychiatry in general, calling my Psychiatrist a complete idiot, urging me to stop seeing him immediately, and offering to take my case on herself, which in this instance meant offering no other treatment options apart from 'I can taper you off of Valium in less than 6 months'. All that based on the fact that I was honest enough to say that I had a discussed doing a benzo taper with my Psychiatrist and that in his opinion whilst I was a) in the early stages of starting some pretty heavy psychodynamic/object relations type therapy work dealing with past childhood trauma/abuse issues, b) currently needing to be monitored, and re-stabilised, in regards to a recent relapse of my rather long term, persistent little bugger of an eating disorder, and c) under an increased amount of stress in general that placing me in a benzodiazepine tapering program post haste, when I'm on a stable and relatively low dosage of Valium as it is, was not in fact a good idea at this point in time and taking into account the factors listed above was also not exactly high on the list of current treatment priorities either. Of course I tried explaining all of this to her, but all I heard in return was a generalised repeating loop of "blah blah blah Psychiatry doesn't work, blah blah blah Psychiatrists get people hooked on medication so they can make more money, blah blah blah Psychiatry makes people worse, stop seeing your Psychiatrist, your Psychiatrist is bad, bad Psychiatrist very bad", and I was sitting there trying to adopt an affect of politeness, and thinking to myself, "Okay, he's a senior consultant in Psychiatry, who's been treating and managing my case for more than 5 years, and you're a General Practitioner who has only seen me one other time before today. I wonder who I'm actually going to bother listening to? Um, gee, let me think." 🙄

 

[shan564]

i

All I hope is that whatever that is is not like these stupid supercontrolling modules, like what I did in med school, were like. Or like EHR training that won't let you go at your own speed or do silly "write in the box" exercises and "click here" stuff.

Yeah, I'm not sure about how they're implementing it specifically, but I think that the overall paradigm is something that clould be very useful if it's implemented well.

But yes, I'm with you more standardization would be great. Unlike a lot of people, I did the required reading (you would think that would be enough) and the psych shelf still was really really hard. Of course the problem with the shelf was that was the end of the course and not a dealbreaker. The didactic part of psych the first two years was pretty lacking.

Med students need to have more standardized teaching in psych instead of just "here are four lectures, now read the following." Psychiatric assessment and management has a lot of intricacies that you can't just learn from reading. I do a shelf review session with our med students for that reason. At my med school, we had an 8-week psych rotation with 1 week that was 100% didactic, followed by a full didactic day once a week for the rest of the rotation. That really gave us an opportunity to learn about how the experts manage basic psychiatric issues. I was an average med student, but I came out of med school with a much better understanding of psychiatry than what I've seen among med students at the place where I am now (which is a much more competitive med school that is full of rock-star students).

You're right, people seem way more scared of it than I think is warranted. Of course, I've only seen in it psych med ODs, and hilariously enough no one believed me that was what the patient had. I would probably respect it more if I had seen an iatrogenic cause or anything severe, so that's probably just lack of experience on my part.

I've seen a ridiculous amount of misdiagnosis of serotonin syndrome when the actual problem was very obviously something else. It's because the diagnostic criteria are too lax, and people ignore the part at the end that says "rule out other causes of the presenting symptoms."

It really really gets my goat that the primary care fields don't put psych/social issues, patient education, way higher. Like we should be doing an Axis 1,2,3,4,5 A/P on everything (only we'd address axis 3 first, then how axis 1/2 and 4 affect management of 3).

That's a good idea. Maybe that should be included next time we have something along the lines of a Flexner report.

Please guys, keep the anecdotes and bitch session going. I really enjoy reading other specialties' threads on here. Not the most EBM-y but SDN offers some insight you can't get from noon conference.

Ha, yeah. What's your specialty?

 

[Ceke2002]

people seem way more scared of it than I think is warranted. Of course, I've only seen in it psych med ODs, and hilariously enough no one believed me that was what the patient had. I would probably respect it more if I had seen an iatrogenic cause or anything severe, so that's probably just lack of experience on my part.

By 'it' I'm assuming you're referring to Serotonin syndrome. In that case...Hello, iatrogenic caused Serotonin syndrome case sitting right here at your command. (although if it's caused by a combination of an SSRI/SNRI and another serotonergic agent, and not by the SSRI/SNRI alone does that still make it iatrogenic? Hmm ) Anyway, long story short, ended up in Emergency, was originally admitted as urgent priority from memory, that very quickly shifted to a 'priority one emergency' (highest level, immediately life threatening) right about the time they started taking my vitals. You know when you're in the ED, and everything's kinda chugging along all nice and smooth, and then you actually see the patient's vital signs on the monitor and all of a sudden there's this 'okay, **** just got real' change of atmosphere that happens in the room? Yeah, it was like that. Scary, very unpleasant experience to begin with, and I don't remember things all that clearly by the time I was actually being treated (I was kind of spacing in and out a lot), except I do remember lines going in, and something about Valium, and fluids, and some other stuff being pushed through as well but I have no idea what that was. They did get me stabilised pretty quickly, and then I spent several hours (pretty much the rest of the day) under observation, before being released with a nifty little diagnosis and explanation of something called Serotonin syndrome (which up until then I had never even heard of). This was all before I was seeing my current Psychiatrist, so it was one of my previous GPs who decided that combining 75 mgs of Effexor with 300 mg of Tramadol was perfectly safe, except for me it ended up being a case of 'not so much'.

Having said all that I don't think I've ever met anybody else, that I know of, or can remember at least, who has experienced a legitimate episode of Serotonin syndrome, but I have plenty of overly anxious, emotionally disregulated friends who will cart themselves off to hospital in a complete panic at a moment's notice, because they've read about this thing called Serotonin syndrome and suddenly every bodily twitch, cramp, ache, or minor fluctuation in temperature is a potentially life threatening emergency. Not that I don't ever tell them *not* to go, because hello I'm not a Doctor but I can understand why claims or fears of Serotonin syndrome are sometimes met with skepticism by those in the medical profession.

 

[shan564]

By 'it' I'm assuming you're referring to Serotonin syndrome. In that case...Hello, iatrogenic caused Serotonin syndrome case sitting right here at your command. (although if it's caused by a combination of an SSRI/SNRI and another serotonergic agent, and not by the SSRI/SNRI alone does that still make it iatrogenic? Hmm ) Anyway, long story short, ended up in Emergency, was originally admitted as urgent priority from memory, that very quickly shifted to a 'priority one emergency' (highest level, immediately life threatening) right about the time they started taking my vitals. You know when you're in the ED, and everything's kinda chugging along all nice and smooth, and then you actually see the patient's vital signs on the monitor and all of a sudden there's this 'okay, **** just got real' change of atmosphere that happens in the room? Yeah, it was like that. Scary, very unpleasant experience to begin with, and I don't remember things all that clearly by the time I was actually being treated (I was kind of spacing in and out a lot), except I do remember lines going in, and something about Valium, and fluids, and some other stuff being pushed through as well but I have no idea what that was. They did get me stabilised pretty quickly, and then I spent several hours (pretty much the rest of the day) under observation, before being released with a nifty little diagnosis and explanation of something called Serotonin syndrome (which up until then I had never even heard of). This was all before I was seeing my current Psychiatrist, so it was one of my previous GPs who decided that combining 75 mgs of Effexor with 300 mg of Tramadol was perfectly safe, except for me it ended up being a case of 'not so much'.

Having said all that I don't think I've ever met anybody else, that I know of, or can remember at least, who has experienced a legitimate episode of Serotonin syndrome, but I have plenty of overly anxious, emotionally disregulated friends who will cart themselves off to hospital in a complete panic at a moment's notice, because they've read about this thing called Serotonin syndrome and suddenly every bodily twitch, cramp, ache, or minor fluctuation in temperature is a potentially life threatening emergency. Not that I don't ever tell them *not* to go, because hello I'm not a Doctor but I can understand why claims or fears of Serotonin syndrome are sometimes met with skepticism by those in the medical profession.

I'm looking back to my own level of knowledge when I was a med student. When a family member was started on an SSRI, I said something like "well, that's probably the right medication for you, but just look out for (symptoms of serotonin syndrome)." I was genuinely nervous about that possibility, although I knew that it was unlikely. I just didn't realize at the time how rare it was. Most general doctors have the same amount of psychiatry training that I had at that stage in my career.

 

[Ceke2002]

I'm looking back to my own level of knowledge when I was a med student. When a family member was started on an SSRI, I said something like "well, that's probably the right medication for you, but just look out for (symptoms of serotonin syndrome)." I was genuinely nervous about that possibility, although I knew that it was unlikely. I just didn't realize at the time how rare it was. Most general doctors have the same amount of psychiatry training that I had at that stage in my career.

I certainly didn't harbour any sort of ill will toward my GP for what happened, she simply wasn't aware of the risks. Once she got the report on what had happened to me she made a note of it for future reference with other patients. At the time GPs weren't getting the sort of extra mental health training that they are now as well. These days I think most of them at least know the basics of drug X in combination with drug Y = chance of rare Serotonin syndrome side effect, and if they don't the computer systems they use for prescriptions will throw up a red letter warning telling them of any contraindications. Even my Psychiatrist was surprised early on when we were going through my medication history and I mentioned having had Serotonin syndrome, I remember him saying something to the effect of 'Wow, that is unusual'.

 

[DD214_DOC]

The problem with many scope-of-practice arguments is that basic psychiatry IS within the scope of practice of primary care. I find the problem children tend to more often be the FNP than the docs or PAs.

Maybe it's just the way that i practice, but even when working on an inpt psych unit I would at least try to do something for medical problems before consulting, unless I just had absolutely no clue what to do and looking it up didn't help.

 

[shan564]

I certainly didn't harbour any sort of ill will toward my GP for what happened, she simply wasn't aware of the risks. Once she got the report on what had happened to me she made a note of it for future reference with other patients. At the time GPs weren't getting the sort of extra mental health training that they are now as well. These days I think most of them at least know the basics of drug X in combination with drug Y = chance of rare Serotonin syndrome side effect, and if they don't the computer systems they use for prescriptions will throw up a red letter warning telling them of any contraindications. Even my Psychiatrist was surprised early on when we were going through my medication history and I mentioned having had Serotonin syndrome, I remember him saying something to the effect of 'Wow, that is unusual'.

Yeah, I agree that it's unusual, but 300mg of tramadol is a lot. I think that's above the max daily dose. People often forget that tramadol causes serotonergic effects, but I've seen it cause weird side effects that aren't consistent with its opiate activity.

Regardless, if a patient is taking tramadol, that probably wouldn't stop me from prescribing 75mg of Effexor... that's a pretty small dose, and I'm surprised that it would cause serotonin syndrome even when combined with a lot of tramadol.

As for your point about GPs getting extra mental health training - they get more in Australia than they do in the US.

The problem with many scope-of-practice arguments is that basic psychiatry IS within the scope of practice of primary care. I find the problem children tend to more often be the FNP than the docs or PAs.

Yes, that's true, but a lot of primary docs don't consider psychiatry to be within their scope of practice. Which is silly - if you can treat COPD or diabetes without referring to a specialist, why can't you do the same for depression? A PCP should be familiar with intricacies of management of all common illnesses.

Maybe it's just the way that i practice, but even when working on an inpt psych unit I would at least try to do something for medical problems before consulting, unless I just had absolutely no clue what to do and looking it up didn't help.

I agree, but you're probably in the minority there.

 

[Ceke2002]

Yeah, I agree that it's unusual, but 300mg of tramadol is a lot. I think that's above the max daily dose. People often forget that tramadol causes serotonergic effects, but I've seen it cause weird side effects that aren't consistent with its opiate activity.

Regardless, if a patient is taking tramadol, that probably wouldn't stop me from prescribing 75mg of Effexor... that's a pretty small dose, and I'm surprised that it would cause serotonin syndrome even when combined with a lot of tramadol.

As for your point about GPs getting extra mental health training - they get more in Australia than they do in the US.

I think under Australian prescriber guidelines the maximum dosage is 400 mg, which is what I'm on now (1 200mg sr tablet in the morning, 1 at night). I've been on Tramadol for over 10 years now though so I don't really get any sort of opiate effects of it, or even side effects really. The only thing I really need to be mindful of is just making sure I keep my fluid levels up in warm weather, or when I'm sick, or else I have a tendency to have presyncope episodes (which is kind of mortifyingly embarrassing when they happen in your Psychiatrist's office...stand up, fall over...and he has to waste almost $60 of the clinics money arranging a taxi ride home). Anyway, dosage of Tramadol at the time I had serotonin syndrome was within normal prescribing ranges, although I think there might have been a spate of admissions in one period of time for people experiencing serotonin syndrome, who were on Tramadol, so I do remember my GP receiving a notification from the Medical Board with a warning about being careful with patients on this particular medication, and she was just like 'Oh great, now they tell me'. Okay, sorry, rambling - point in all that, I think what happened to me was just one of those 'what the hell, wasn't expecting that' kind of events. Guess I was just one of the unlucky ones that drew the short straw when 99.9% of other people on the same combo of meds and dosages would have been fine. It's certainly not an experience I care to repeat in a hurry though, so now I am admittedly probably a tad over cautious with what I will and won't take in terms of antidepressants.