Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists, interested bystanders are also welcome. A place to talk; no one has to listen.
Wednesday, October 27, 2010
Antidepressants on Kevin.MD
Dheeraj Raina is a psychiatrist who has a blog post on KevinMD called "How an Antidepressant Can Hurt Your Patient."
The post is directed at primary care docs and talks about the danger and downside of prescribing anti-depressants. Too much use as 'feel good' drugs without careful consideration of the diagnosis, appropriate treatment with adjunctive psychotherapy, and the risk of manic induction and suicide.
It's probably not likely that every patient with anxiety and depression will end up seeing a psychiatrist. Obviously, we at Shrink Rap don't think antidepressants should be doled out mindlessly--- if primary care docs are going to prescribe them, they should--
Know how to diagnose depression.
Know how to use the medications. This is not as easy as it might sound: Antidepressants take time to work and the dosing requires titration. Sometimes they need to be changed, increased, augmented. If the first try at a standard dose works, you can call it a day---but this is why the meds have the rap for being only as good as placebo. They don't work if you don't know how to use them and one size doesn't fit all.
There are risks, side effects, adverse reactions, and contraindications.
With psychotherapy, time, and support, there are people who won't need treatment with medications and those options get bypassed when a script gets written in a quick visit.
PS. I agree with Dr. Raina that this can't be done in a 15 minute office visit.
Posted by Dinah on Wednesday, October 27, 2010
Labels: antidepressants, prescribing
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Thank you for picking up my post from KevinMD and advancing the discussion. We seem to be on the same page about antidepressants not being as easy to use as they are perceived to be, and that they are invaluable when properly used.
How is a 15 min med check any different than the 15 min with a primary care doc? Oh, wait, on my first visit with my shrink I got 30min so that must have been enough time for her to get to know me so much better than the primary care doc I've seen for the last 14 years and who will routinely spend as much time as needed to explain and take care of me. He also knows what he doesnt know which is why he he makes me go see a specialist for my 15min med checks.
Antidepressants, like other drugs (and other treatments like ECT and psychotherapy), either work or not. Using them requires swallowing them. If you know how to swallow, you know how to use them. It's much easier than psychotherapy and much cheaper. Dr. Raina seems to have forgotten that many of them work very well for anxiety disorders. Fluoxetine is even FDA approved for treating premenstrual dysphoric disorder (PMDD) and bulimia nervosa.
If they don't work, which they often don't, or if they make you feel worse, you should probably stop taking them. Most patients, yes, even psychiatric patients, have more than enough common sense to know this.
15 minutes is often more than enough time for a patient to tell you a) they like the way antidepressants work for them, b) they experience no side effects, c) they have no interest whatsoever in talking to someone about their childhood for 50 minutes once or more per week ad infinitum, and d) they would like to continue taking them, ad infinitum.
Sometimes 60 minutes does not suffice to elicit all the symptoms, all the patterns, review all the past and current drugs, all their adverse effects, review the potential choices for change, and the possible adverse effects, dosing strategies, etc, ad infinitum. But if you need 60 minutes, you should take 60 minutes.
I had to fire my second psychiatrist for, one of several reasons being, I'd been on Cymbalta for 7 months and it pretty much put in bed most days for the entire 7 months, and he wasn't taking me off it and trying something else. Yes, I told him how I was on it, and that I wasn't getting out of bed. Heck, initially I had a suicidal reaction on it, and he didn't pull me off; eventually when I pulled myself off it, I learned that that reaction hadn't gone away, it had just gone down to a "slow simmer" in the background. I was mighty pissed when I learned this; I thought it was just me feeling suicidal, and not the med. To learn it was the med, still, pissed me off. I did report to him occasionally this low-level suicidal ideation as well.
So after 7 months on it (I'd been seeing him longer than that) he was fired.
So not all psychiatrists know how to use anti-depressants well. Heck, when considering which one to switch me to before settling on Cymbalta (my Effexor had quit working) he tried to shove Pristiq down my throat, which is practically the same thing as Effexor (yeah, I even heard the drug rep for that company thanking him for showing up to a company shindig, before that appointment)
Which also contributed to me firing him; I'm not a bloody idiot. I want the doc working for ME, not the drug companies . . .
Here is a link to a primary care doctor blogging about how he has rethought the issue of prescribing psych meds in his practice.
I've found that even some psychiatrists don't do a thorough enough history before prescribing antidepressants. I had two psychiatrists question me about euphoria which I never had never experienced and I didn't realize that dysphoric mania was mania, and was not questioned about it. I went mildly manic on the first antidepressant. I didn't care for the psychiatrist so my therapist suggested another. I had another eval and was again prescribed antidepressants. I went completely psychotically manic on Lexapro. My husband called the therapist and psychiatrist and threw away the Lexapro. The psychiatrist then prescribed Effexor. The therapist said not to take the Effexor and to go to a different psychiatrist, a very good one but that took no insurance, for another eval. He took a 100 minute, very thorough history and instead prescribed mood stabilizers and eventually diagnosed bipolar. I stayed with that psychiatrist and pay out of pocket for the 30 minute med checks and high quality care.
Sarebear: Sometimes one must be creative to get a physician's attention. My grandmother, who lived a few hours drive from the Shrink Rappers, at the age of 70 or 80 could not get her doctor to take her seriously when she complained of vaginal bleeding, so she placed a pair of bloodstained panties in a "Baggie" (pre-ZipLock) and mailed them to him.
First time poster. Enjoy your blog very much.
I was impressed with my current psychiatrist taking three full 50 minute sessions before prescribing anything.
I wanted my meds, but was still impressed that he was being so careful.
As one of those who swallow the pills, I learned that it takes time to match the meds with 1) my own chemistry and 2) what side effects I can tolerate, or which my body adjusts to. And each time a change is made, there are at least several days, often 2 or 3 weeks before I can begin to fairly judge how it is working for me.
I always liked to believe I'm unique. I've found out that in many ways I'm not, but when it comes to combinations of psych meds, I'm closer to being unique than in other ways.
The passage of body- and mind-time are both different than clock time. And further, it takes more of all types of time to decide if a medication, especially if you're taking a combination, is working for you.
As fast as things move around us in society these days, anything that takes longer than a few seconds or a few minutes requires the practice of patience. That is something I've learned as a necessary by-product of finding the right meds: I can be patient, though I'm not really a patient person.
Perhaps, once the right combination is found a 30 min med check works, but until then--at least if you want to be a partner in your own care--take that 50 minute appt.
& btw: I too go to a shrink not on my insurance's 'provider' list, pay full price, and am happier with the working partnership in my health care than I've been with others.
And I'm currently considering having to find yet another psychiatrist, since my current one doesn't take Medicaid; my church MIGHT pay for me to access my current one but it's emotionally painful for me to go through the process of asking for that kind of help, then again, having to go through the rigmarole of starting over again with a whole new psychiatrist yet again and being switched around on new meds, let alone getting put on an antidepressent, which I really NEED to, since I became so suicidal the other night I spent some time on the phone with my psychologist, and today he actually got rather more confrontational with me than he usually does, with some issues regarding keeping me safe (ie, getting rid of the means to do it).
Anyway, it's become CLEAR to me I MUST have access to a psychiatrist, whether it's my current one who doesn't take medicaid or whether I need to find a new one who does. I just need to figure out which process of accessing a psychiatrist, I can stomach, emotionally, which is hard to figure out given my current fragile state. ugh.
Oh, and moviedoc, your grandma sounds like a spirited woman, lol. I'd never have the guts.
Dr. Raina focuses on the possibility of manic episodes on antidepressants. I do wonder about the PCP's ability to recognize a non-textbook case of mania or hypomania. Anonymous 10/28 describes psychiatrists having missed her(?) mania. I've had the opposite experience of having anxious agitation misdiagnosed as some kind of manic state. (Once i was even told that my premenstrual anxiety was evidence of a rapid cycling bipolar disorder.)
moviedoc: Though i agree with Dr. Raina that patients often have to accept a "quick fix" as she calls it, i also appreciate your point that we shouldn't assume that a meds-only treatment regimen is necessarily substandard. Sometimes meds are what a person needs. (Were you making that point? If not, then i'd be happy to make an attempt. =)
Sarebear: It always strikes me as massively unfair that the whole insurance/payment mess, which might floor even a healthy person, is foisted upon people who already feel bad to begin with. I feel for you and wish you lots of luck.
S: "Sometimes meds are what a person needs. (Were you making that point?..."
Several points: Sometimes a patient "needs" the right meds, sometimes it's just the patient's choice, sometimes meds don't work. Ditto psychotherapy. Some patients do better with both. Unfortunately, some patients don't get much help from both/either.
I believe some psychiatrists require patients to participate in the form of psychotherapy that psychiatrist happens to know, usually psychodynamic, whether the patient needs it or not, and when they do psychotherapy it really doesn't address the actual illness, even though the patient may like the psychotherapy and find it very helpful. Another problem with getting both psychotherapy and meds is that when you get better, it's hard to know which made the difference (or both). I tell my patients to give themselves all the credit, but keep taking the meds just in case.
Hey, moviedoc, thanks for your response! I was trying not to bombard everyone with too many words, but what the hell... =) Here's where i was coming from with that. When i was a young adult in my early 20s, i got to a point where the talk therapy had been too intense, too much upheaval, and i couldn't tolerate it anymore; quit therapy and meds. Much later, i did another stint in therapy; turns out the cognitive behavioral stuff made such complete and obvious sense after the meds kicked in and i had real emotions that i could actually feel! With that i eventually reached a point where any more would've just been rehashing, so i stopped talk therapy but stayed on the meds awhile longer so i could get comfortable in what i'd learned. (Not to imply i'm any kind of expert now!) What i mean to say is that there is a time and a role for both options.
Ah, there's my usual longwindedness; it maybe helps that i'm drunk. Sorry for getting a bit off the topic of PCP versus shrink a/d prescribing. I'm a former self-injurer, and even though that's years ago, i get the sense once the PCP sees my somewhat extensive scarring that they want me referred far, far the hell away (i mean they want to refer me to psych for everything; GI complaints, travel immunizations). Though i did have a great PCP back at home when i was in college; my student insurance was awful, so my shrink at school would fax the PCP at home, who'd call in the script, which my parents would pick up and mail to me the pills. He was also the only doc who ever did a thyroid panel on his own initiative; i've never had a shrink attempt to rule out other medical conditions before diagnosing me.
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