Paxil, anyone?

I ran a poll, not long ago, after reading Peter Kramer's blog post on the relative efficacy of the different SSRI's. Here's what we found:

Which SSRI is the most Effective?

Prozac 15% (22 votes)
Zoloft 14% (21 votes)
Luvox 0% (0 votes)

Paxil 5% (8 votes)
Celexa 7% (10 votes)

Lexapro 19% (28 votes)

Cymbalta (SNRI) 13% (20 votes)

Effexor (SNRI) 18% (27 votes)
Wellbutrin (neither, but it's here anyway) 9% (14 votes)

Total Votes: 150

Which Medicine Causes the Most Side Effects

Prozac 13% (17 votes)
Zoloft 7% (10 votes)
Luvox 5% (7 votes)
Paxil 31% (41 votes)
Celexa 1% (1 votes)

Lexapro 4% (6 votes)
Cymbalta 7% (10 votes)
Effexor 25% (33 votes)

Wellbutrin 7% (9 votes)

Total Votes: 134

Okay, so let's start by talking about how this 'poll' is meaningless. We don't know who took it-- patients, docs, random plumbers surfing through. We don't know what experience these people have had with antidepressants-- so the question has different meaning if it's asked to a doc who has only ever prescribed Prozac and Zoloft, then if it's asked to a patient who has been on a long trial of every medication. There's no real head-to-head here, no measures of efficacy, no controls. And I didn't even specify what the efficacy was for: Depression? Anxiety? OCD? Panic? Halitosis? Slipping behind your ear to hold your glasses in place?

Still, we had a clear loser, and I was surprised: Paxil. Few people voted for it's efficacy, many for it's side effects.

I don't start people on Paxil so much anymore: the lore is that it causes more weight gain then the others, and when I do prescribe it, I tell people to get weighed. It may cause weight gain, as an overall risk to populations, but all I care about is if it causes weight gain to my particular patient, and clearly, some people do not gain weight on it. The more concerning thing about Paxil has been the withdrawal syndrome that some people experience and so far I've found that it's manageable, especially if people come off very slowly. Still, all things being equal, these days I may start with something else.

So why was I surprised: I guess I haven't heard a lot of patients complain about side effects, and I have patients who've been on this medicine for some time. It seems to work particularly well, at least that's my impression, for Anxiety, and it seems to be well tolerated, the 'polls' would say otherwise. And for the uninsured, the generic is on Walmart's $4 list (as is Celexa).
Just my thoughts.

And to those who've read yesterday's post about does Facebook wreck your brain: If you read either the original article or the comments to our post, you'll note that the original piece is simply theories that all this computer time may re-wire people; there were no studies, no proof. And as some of our readers pointed out, On-line interactions may well be a segway into the world of Real Life encounters for people who might otherwise hesitate. I often wonder if my college experience would have been broadened by the world of the internet---

The Co$t of Being Depressed

Okay, I've truly lost it. I've just spent the last half hour on the phone calling a couple of pharmacies to find out the cost of antidepressants, all for Shrink Rap. You see, as a doctor, I've never learned what this stuff costs. I know vaguely that the older stuff is cheap, and the latest greatest is expensive, sometimes really expensive. I actually started my research yesterday. I thought I'd compare the prices at a local independent boutique pharmacist in a ritzy neighborhood where home delivery is offered, to a chain, to Walmart or Sams Club with the assumption that Walmart would be the cheapest--though really, I'm not sure of this. My quest was limited, however. By the time I really sat down to do this, it was so late I was limited to 24-hour pharmacies, so no Walmart in the comparison.

With my gratitude to the pharmacists who humored me, here's what I found.

The local independent pharmacy informed me that "our system doesn't allow us to look it up without a prescription." Huh? I asked again several times, they couldn't tell me what a medication cost. Okay....

CVS-- a large chain store-- I got a pleasant sales person on the phone.
Similarly at Walgreens. Pharmacists are generally nice people, I've found.
So all prices are for 30 pills, I aimed at the usual antidepressant doses. A little bit of confusion around Elavil (amitryptiline), one of the older tricyclic antidepressants which I just about never use, but it's cheap. I asked about a 100mg dose and CVS told me it came as 75 mg while Walgreens said they had it as 100mg. I only asked for a few prices at Walgreens, mostly to see if there was variation (there was). Zoloft, Lexapro, and Trazodone are scored pills, so if you take half the listed dose, this will last you two months. Many people, however, are on 200 mg of zoloft, and since the largest pill is the 100mg tablet, double the price for high doses. These are the cash prices, in US dollars, and I called pharmacies in Maryland. I tried to set this up as a table spreadsheet, but blogger ate that format.

Paxil, 20 mg...................... 125.99
generic Paxil 20 mg............ 48.95
generic Prozac, 20 mg ........19.19 .............29.99 (Walgreens)
Zoloft, 100 mg ....................140.99
generic Zoloft, 100mg ......... 45.19
Celexa, 40mg .......................122.99
generic Celexa, 40mg............ 33.69
Cymbalta, 60mg .................. 149.99........... 142.99 (Walgreens)
Nortryptiltine, generic, 75mg.. 31.69
Lexapro, 20 mg ..................... 106.99......... 105.99( Walgreens)
Elavil, 75mg ............................53.59
generic Elavil, 75mg................ 10.99,,,,,,,,,,, 12.39 (walgreens)
Trazodone, 150mg ,,,,,,,,,,,,,,,,,,, 23.19
Wellbutrin XL, 300mg............ 215.99
generic Wellbutrin XL, 300mg... 149.99....... 139.99 (Walgreens)

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[from Roy]
Don't forget about Walmart's $4 list. You can buy 30 pills of any of these for $4, whether you have insurance or not. In the hospital, we frequently choose meds for uninsured pts based on this list (eg, Prozac 20 mg = $4/mo. Elavil, Paxil, Trazodone and Doxepin are other choices for antidepressants.)

How A Shrink Picks An Anti-Depressant

[Part Two of this post is here]

Midwife With A Knife wants to know how a psychiatrist chooses a medication for an SSRI-naive patient. Wow, I'd already started that post when she asked.

So a patient comes for treatment. His symptoms meet criteria for Major Depression, no question here, and he wants medication to help his condition. This is his first visit to see me.

Prozac Paxil Zoloft Lexapro Celexa Luvox Effexor Cymbalta Lamictal
Wellbutrin Remeron Serzone Pamelor Elavil Nardil Parnate Emsam Trazodone

I probably missed a few.

So how does a shrink decide what medicine to begin?

1) Past history of response. If the patient says, Oh, yeah, six years ago I felt this way, I took Paxil for six months and that helped a lot and I didn't have any side effects, then Paxil it is.
The path changes if the story is that the medication didn't work or had side effects.

2) Family history of response. This is the patient's first episode, but mom swears by Wellbutrin, it's helped her when nothing else would. This would be a good first choice.

3) Patient preference. He's here because his best friend took Celexa and became a new and wonderful person. I have no idea what friend's diagnosis is or why Celexa was chosen for friend, but if there isn't a contra-indication, then I might as well honor a patient's wishes and there's some power to believing something will help. Similarly, if patient reports that Celexa caused best friend to commit outrageous acts of horror and he wants anything but Celexa, I pick something else.

4) Other Medical Issues. I don't start with meds that interact with what the patient's already on. I don't pick meds that might exacerbate an existing medical condition. Wellbutrin is contra-indicated in patients with seizure disorders, eating disorders, or a history of CNS lesions, so I don't start with it in these patients. I save the risky stuff for after we've been at it a while, and then only with a fair amount of discussion about possible risks compared to possible benefits.

5) My Best Guess at What Will Help the Target Symptoms. Patient is tired and unmotivated...Wellbutrin is reportedly a bit energizing, so maybe that's what I use. Patient also has a lot of OCD symptoms, I might go with an SSRI. If someone has a concurrent pain syndrome, Cymbalta or a TCA might be my first choice.

6) My Best Guess at the Side Effect Profile, for better or for worse. Really, this is a guess. I actually hate this issue because patients often worry about side effects they never get, but okay, if someone is agitated, I might start something I think of as being more calming. If someone says they'll die if they gain a single pound, I pick something more weight neutral.

7) The Patient's Financial Concerns and What I have Samples of. This is only a consideration if the patient is uninsured and paying cash for the meds, but this is not a trivial thing. After that, I move to What's Cheapest that will work and won't cause intolerable side effects. If the patient has been on something and had good success, then loses their insurance, I might try something cheaper in the same class of meds, but I wouldn't recommend a switch from say a working SSRI to a cheap Tricylic-- it's not worth the risk.

Can I say a word about Weight Gain as a side effect? Some patients refuse any medication that's been associated with this. But clearly, and I'm probably repeating myself at this point, there are people who don't gain weight on medicines that are said to cause weight gain, just like there are people who don't get better with anti-anythings. People respond to meds differently. My suggestion to those who are concerned they'll gain weight-- if there's some reason to believe a medicine might help, it may be worth a try. Buy a scale. Get weighed before starting the medication. Get weighed every 2-3 days after starting it. If you gain 5 pounds (1 or 2 or 3 can be variations in fluid retention or scale flakiness), Then it's worth worrying about weight gain and addressing whether it makes sense to continue.

We've been at this blog so long, I've lost track of what I've said already, what I've thought about saying, what I want to say.

What's Your Favorite SSRI?

I like polls....something about asking questions and thinking about the answers. It started on our sidebar with Who Are You? Then, What Do You Want To Read About on Shrink Rap? Then, for lack of anything more creative to ask, What's Your Favorite Color? One day it seemed like the question should be more psychiatric to fit the Shrink Rap theme, so with little thought, I changed it to What's Your Favorite SSRI? Only I suddenly found myself tracking the answers. I didn't ask, purposely, things that might give the question some perspective: like what are you basing your answer on-- the comparison of results of your 732 patients, all of whom have been on every SSRI, or your own experience taking them--which may or may not include a comparative factor. I see lots of people who better on the first SSRI they take, swear by that med, and there's no reason to go further. Some patients are clear that one works for them while another doesn't. Tried my wife's Zoloft and it just isn't Prozac (the names have been changed to protect the innocent).

SSRI's wandered into the psychiatric scene at the start of my training, so I've watched the evolution. First let me tell you my totally random, not-particularly scientific but observational thoughts on each of the SSRI's on the poll. Then you can tell me what you think in the comment section (or Roy & Clink can hi-jack the post and add their profound thoughts if they so wish).
Prozac: It wasn't around when I was a med student, so I saw glimpses of the world before and after. This medicine clearly changed some people's lives in dramatic ways. It's easy to use-- at first the smallest pill was 20 mg and that was the therapeutic dose (though soon we were zooming it up for OCD patients). Fewer side effects than TCAs, not all that hassle with EKGs and blood levels and therapeutic windows and pretty dramatic toxicities. I worked on the inpatient units during it's earliest days where sexual side effects weren't such a big deal. Not that they weren't a big deal, but the patients would get better and go home and then they'd be a big deal, but the outpatient docs were the ones to hear about it. For the people they worked for, Prozac was a good medicine, and it opened up some people's lives.

Zoloft: It's selling point was a shorter half life, fewer side effects, less agitation, and if you don't tolerate it, it's out of your system sooner than Prozac. At first, I didn't think it worked as well-- it didn't seem to have the life-changing benefits of Zoloft. I started asking other people I worked with: Have you seen patients have great responses with Zoloft? This was an informal poll. A few said yes. A few said, "I've seen people have great responses with Prozac." It became a kind of self-fulfilling prophesy for a bit there-- I used Prozac more so of course I saw more responses to Prozac. Oh, it's been decades: I've seen a lot of patients have great responses to Zoloft, and because of the shorter half-life issue, I prescribe it a lot. Oh, the other good/bad thing about Zoloft-- the big dose range. The FDA max is 200 mg. I've seen it used up to 300mg and that patient had no side effects (at all) and the OCD experts apparently go even higher off label. While most people seem to need 100-200 mg for a good response, some people feel better on 25mg, and so for them it's nice to have the option of very low dosing. The bad is that for those who need the whole 200mg, well, it can take a while to get there.

Paxil: This was definitely good stuff, seemed to be well-tolerated, work well, my best guess was that it was more calming, or at least less agitation producing than Prozac, I've prescribed a fair amount of this stuff and still have patients on it who do very well. Time--- two bad things I've seen: a few patients complain of weight gain. I had one patient, certainly the outlier, who gained a huge amount of weight. I would have taken her off the medicine, but she didn't want to stop it. She'd been a skinny kid, she didn't like being the skinny kid, while she didn't like being so much heavier, I was shrink number 3, she'd been on lots of medicines, had lots of diagnoses, her life was a wreck. I'd stopped everything, started 10 mg of paxil, her life was better than ever, and she'd rather be heavy and happy. The years went by, it started to bother her that she was so heavy, eventually changed to Serzone, dropped a lot of the weight, and last I saw her, was still well. Oh, but then the really bad: some people had withdrawal syndrome. Most didn't. But of those who did, well there have been a few where it lingered, where the patient had this very disconcerting and distressing sense of being off balance. I still use Paxil, it still helps people, but before I start it, I tell people there is this risk, and I never just stop it, there's always a slow taper, pill breaking, and every other day dosing when it's time to come off. This helps, and I'd say it's been a while since I've heard about a withdrawal syndrome, but really, the numbers I'm dealing with are too low to be relevant.

Luvox: I've only used this a handful of times. Seems like an SSRI. It's hype is it's indication for OCD. It seems to be the least used SSRI and the poll thingy wouldn't let me have all of them as choices, so this one got dropped. By all means, write in with your Luvox experiences.

Celexa: I've worked in clinics where I get to see other people's prescribing habits, and I worked in a clinic with a doc who liked using Celexa in very high, over-the-FDA-recommended, doses. Seems like it works and is well tolerated. I have a few people on it, mostly they came to me on it. I tend to forget it exists.

Lexapro: Like the others, it seems like a good medicine. Well tolerated, and it works when it works and doesn't work when it doesn't. Same side effect profile as the others, people don't complain much about it. This was our voter's favorite and I wonder if it's because it's the newest that it's what lots of people get prescribed. I think there are now a few of people out there on Lexapro because I've thought "It's the favorite of our readers."

And the poll results, of 105 respondents:

Prozac	16 (15%)
Zoloft	25 (23%)
Celexa	16 (15%)
Paxil	14 (13%)
Lexapro	34 (32%)

Is THIS SSRI Withdrawal Syndrome???

Forgive the silly pic, I couldn't resist stealing it even if it doesn't quite fit.





This is a clinical case, but it's not my patient-- it's a little more personal than that, but still, no distinguishing characteristics, the names have been changed to protect my friends. You might ask why I'm rendering a clinical opinion on someone who is not my patient, who I haven't really examined but for pieces of a brief phone conversation, and that would be a good question. That can be it's own post, maybe one day when Roy is let out?

So I get a call from a dear friend from another state. Her father died last year shortly after being diagnosed with a terminal illness. Her mother happened to see her own GI doc and mentioned that her husband was dying. The story goes, "He told me it would be a rough time for me and prescribed paxil, it helped a lot." I personally don't prescribe medications simply for Hard Times or uncomplicated grief, and I didn't ask for a retroactive history, symptom list or mental status exam. She took paxil, it helped, time passed, she was doing better. So my friend's mother...let's call her Sally... spoke with her primary care doc who had her taper down off paxil cr 12.5 mg by taking one every other day then stopping.

The day after stopping she began to feel sick. Roughly 4-5 days later she was brought to the emergency room: she felt awful. Sally had a bad cold. She had a bad headache. She was confused, she began hallucinating. "Hallucinating? --She saw people moving, she woke someone in the middle of the night asking what a non-existent noise was, she insisted something wasn't written on a paper that was, repeatedly, until it was pointed at for her. Everyone was worried. I should mention that Sally is in her 80's, but she lives alone, drives, takes part in a number of organizations, and is the proud user of some of my favorite hair chemicals. She's not usually confused and she looks years younger than she is. She also suffers from a chronic GI problem, I don't know the rest of the medical history other than Hypertension and that med had been changed recently, too. And I don't know about past psychiatric history, but there's no psychiatrist in the story.

In the ER many tests were run, a brain CT was done. Nothing. The psychiatrist came and proclaimed "Paxil withdrawal." Relatives looked it up on the internet, all these symptoms have been described. She went home to wait it out, but she was feeling worse and worse and now developed a cough. Her primary care doctor said she could go back on Paxil but would then need to remain on it for life, and she didn't want to do this. Friend read on the internet that she could take a single dose of Prozac, which has a longer half-life than paxil, leaves the body more slowly, also increases serotonin levels, and this would help. Primary care doc agreed to call in a few prozac pills.

What did I think? Would this prozac thing work? He only called in 10 mg, was that enough?
Given that I didn't see the patient, I thought a lot, and I'll tell you my thoughts, as I told them.

1) This could be paxil withdrawal, though I personally have never seen anyone hallucinate and the hallucinations sounded a bit too close to delirium for me (Sally sounded fine on the phone). I was much more worried that something else was wrong, that an infectious process might be missed, that this could be related to her GI disease. This was my number one concern, though I was repeatedly told the ER did lots, all tests were fine, that 3 doctors had confirmed this was Paxil withdrawal.

2) Okay, so take a dose of paxil-- if it's withdrawal the symptoms should go away, soon and dramatically. Sally didn't want to do this because then she'd have to stay on paxil forever. No no no no no, I said, it would just be helpful to be sure that's what it was. She could take one dose, be sure she was okay, than happily withdraw. Or she could taper more slowly using 10mg and then 5 mg dosages.

3) Sally took the Paxil. She didn't know if she felt better-- not a good sign. The next day she took it again, she still had URI symptoms, now she had a low-grade temp. Confusion occasionally. The headache was better.

4) Friend wanted to give Sally the dose of Prozac. I said not to-- her symptoms had not resolved, I didn't think this was paxil withdrawal, adding Prozac would not help and she would be subjected to any side effects or adverse effects of the new medication.

The days went by, Sally did better, but hasn't returned to baseline. She's stayed on Paxil. She's staying alone most nights, still gets confused, and honestly, I haven't had an update in days.

The answer? I don't really know. I doubt that it was SSRI withdrawal given that some of the symptoms were not the usual and that she didn't get noticeably better after taking the Paxil. Though I do imagine this could explain part of the picture. Bronchitis (or pneumonia-- I don't know if a CXR was done)? Exacerbation of GI illness wouldn't explain headache, cold symptoms, but might explain some GI symptoms that developed after the Paxil challenge, the low grade fever, the likely delirium. Hopefully they're all doing better.
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And just in case you thought I forgot my Novel obsession, here what people are saying about Double Billing over on The Interactive Novel Project:
Parked : "Now, you have my attention! Kudos! The first chapter just didn't hit me like the second one did. "
ClinkShrink: Wow, is that an improvement over the first chapter! The first chapter was just too short and sketchy and I felt no pull for the character. This is totally different. Very cool.
emy I. nosti: Love it. I'm hooked.