Sunday, September 23, 2007

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.

23 comments:

Rach said...

Dinah - thanks for the comments about Weight Gain as a SE of meds and therefore the hesitation to try the med. I certainly fall into that category. I know that as soon as the shrink suggests something new (or something I've had limited experience with) I'll come home and spend hours googling and reading before I'll agree to it. I just think I've spent too much time, money, energy and aggrevation to conceed to something without weighing (sorry for the pun) the pros and cons of the benefits of the drug vs. the demoralizing effects of weight gain.

Someone made a comment on another post regarding using meds as a trigger for eating disordered behavior/ meds triggering past eating disorders. I thought I was the only one who manipulated my prescriptions for those purposes, but clearly not. I wonder if female psychiatrists are more empathetic to the plight of overweight psychiatric patients... My (male) psychiatrist hasn't (as yet) seemed that concerned... or if he has, he certainly hasn't voiced these concerns too loudly.

michelle said...

Ah, the weight gain side effect. I drive my neurologist nuts with this right now. He wants to put me on Depakote for a bad bout of migraines and tension headaches. I won't let him do it until he's tried everything else.

I gained 60+lbs on antidepressants trying to get well. When my moods finally evened out on Lamictal, I worked really hard to lose weight. So far I've lost 30lbs. It's taken 2 years to do that. I would be absolutely devastated to gain that back in 3mos on Depakote. I know side effects don't happen to everyone, but with some meds you can be reasonably sure it's going to happen.

Luckikly, my neurologist respects this. He doesn't like it, but he's done everything he can to keep me off it. We're trying one more thing before we go to the Depakote. I'm sure he thinks I'm nuts, but the weight gain is not a trivial matter to me.

(I'm not unreasonable though. If I were stark raving mad, I'd take the meds. I won't argue over weight gain when I know I'm in trouble.)

Aqua said...

I was very worried about weight gain when I tried depakote/epival...my pdoc really understood how important it was for me to look good and he had great advice for monitoring my weight and ensuring I was ontop of it immediately. Because of his suggestions I haven't gained weight on any meds and I've tried most of them. His suggestion was close to Dinah's, but a bit more regemented:
1) weigh yourself everyday and write weight on a chart
2) average out your weight each week...(do not care about daily weight...only average weekly weight)
3) If you have gained a pound or more (the average that week), start exercising a bit more...short walks count, and start eating less of the bad foods...
4) do until pound is lost. The idea is that losing one pound is easier than losing 5, or 10 or 20 etc. so if you keep on top of your average weekly weight it doesn't take much to maintain.
Works for me...and I am not one to exercise, but I will add a few walks around the block, and watch closely what I eat if I gain a pound over the week.

ladyk73 said...

BLAHHHHHHHH!!!!!!!!!

Alrighty... a month on Seroquel and I can SEE my waist line bigger! This really really really sucks....

Supremacy Claus said...

As good a list of "guidelines" for anti-depressant choice, as exists anywhere. It stems from what patients have taught this clinician, and all others.

Yet, this list is not in any official guideline. That shows the difference between the thinking of experienced clinicians and paper shuffler academics. They write guidelines with half the experience.

c said...

On the weight gain - I mentioned this in my loooooong comment on your previous post, but pamelor (nortriptyline) was the med that got me out of my first stay for headaches inpatient - after 8 days of not getting better, 24 hours on that and my headache was a 2 out of 10. My mom and I didn't like the idea of my being on an AD and the weight gain side effect, so we brought it up to the neuro. Now, neuro probably should have said, "It's always a risk, but this is the first thing that has made a dent in 6 months of chronic migraine and 8 days of intensive IV therapy, so let's just try it for a little bit, and if the weight gain becomes a problem, we can consider coming off." That is not what neuro said. (This is a neuro who only ever managed me that inpatient stay - not a headache specialist...) He said, "Ok...we'll take you off that and try topamax." So when I was worse again 2 weeks later, other non-headache-specialist neuro said, "Hmm...pamelor was working, topamax isn't working and has side effects, let's go back to pamelor..." Hmpf... I know it had some effect, but after the first couple of months being on it, my headaches were just as bad as always. It helped most that very first day of the first time I ever tried it. Never had a prevent help me that much that quickly. Most have no effect at all - and we were begging to change it after a day due to fear of weight gain!! If I had no headache, I'd accept being twice my size... (Well, that's not entirely true....but I'd take a risk of weight gain or even SOME weight gain if my headaches went away!) And I speak from someone who does have a past history with mild eating disorder/obsession about weight. If I'm willing to take on weight gain for no headache, then I must be desperate!

Depakote didn't make me gain actual pounds. I had such bad reflux from it that I couldn't eat. But what it did was make me balloon up - I was so puffy, my hair was coming out in handfuls, my skin was pasty and my lips were even peeling. I slept through 4 alarm clocks and my mom calling me to get up in the morning. I fell asleep in classes. I looked sick. And I was definitely heavier looking, even though I was hardly eating a thing. It wasn't real weight gain - it was just this weird edema in my face and other places... I looked like I was receiving chemo...it was bad.

But the only things that ever made me actively gain weight - inpatient hospital stays with lots of IV meds/steroids, frequent steroid tapers, taking a lot of zyprexa for headache abortive, and I think there were maybe a couple other things - but most meds did not cause it. The TCAs caused me to gain maybe 5-10lbs that just sat with me, but nothing huge like some people report.

Truly, weight is still a very important thing for me. I don't want to gain weight as a side effect - and if I do gain weight, then that med better darn well be helping! And if the med does help, then I'll take the weight gain, TYVM. My philosophy on side effects is that yes, there are the possibilities of lots of them, and I've personally even experienced some that never went away, even after discontinuing the med, but for the most part I feel that if you start experiencing side effects on a med, you can always come off. That's been my philosophy and also the reason why I've said yes to trying some pretty insane things in terms of headache treatment and am even on MTX now for the autoimmune stuff. I know it's all a huge risk and a huge gamble, but if I'm willing to risk all that, then I must be feeling pretty horrendous on a daily basis. I still feel that if the SE's get bad, then I can always come off. My psychiatrist has said to me a number of times (before going on a new headache prevent or going to outpatient infusions), "Is the treatment worse than the disease?" I know he means well, but that often frustrates me - it makes me feel like he truly does not understand how debilitating my headaches are for me. I would eat dirt if someone told me my head would stop hurting.... I've always been willing to try *almost* anything, once. Yes, I go to work and appear to be a very functional human being, but that pain/fatigue/etc take so much away from my life, words cannot even describe. The only reason I've gone off meds is because they didn't help at all. If something actually helped significantly (daily pain dropping to <5 is my measure of significant), then I would be willing to tolerate many side effects. It's just that when I have no benefit and the only effects ARE negative side effects, well, it gets depressing!

Take care,
C :)

c said...

P.S. I voted for lamictal as fav mood stabilizer, even though when I took it, I didn't note an effect on mood - it helped tremendously with migraine auras of vertigo/ringing ears/confusion, though! I would also vote for depakote, but it only lets you vote for one!! Yes, depakote, even with what I said above about what I experienced on it - that stuff truly helped!!

Dr. Smak said...

Dinah,

Thanks for these posts. In primary care I sometimes feel like you shrinks have some secret way of knowing which SSRI will work the best. Looks like we follow pretty much the same method for choosing, minus the TCA option, which I virtually never use.

Dr. Smak

The Shrink said...

Patient preference is in there, I'm a little surprised that psychiatrist preference isn't.

Most psychiatrists become very familiar with a few drugs rather than dabbling with zillions. This way they can genuinely make more informed decisions (rather than heeding guidelines and statistics).

Too, personal experience should have impact, we should learn from adverse events, no? My first patient to become profoundly hyponatraemic made me look at that particular antidepressant in a whole new light.

Surely it's right to balance all the factors you listed and to give them weight but I'd additionally suggest it's the professional responsibility of the medic to determine what's brought to the table and offered as an option with their patient. As such bias and prejudice must be excluded but a clinician's expertise, experience and acumen must not . . .

Anonymous said...

ladyk73,

Seroquel= 40 pounds.I was always on the slim side and now I walk around in tents. I can't look in the mirror and it doesn't even totally to the trick on its own. It is evil stuff

michelle said...

The worst part that I've found is that weight gain with these meds seems nearly impossible to get off, especially if you're already prone to weight gain. Exercising and eating right often just seems like a losing battle. You can do it, but if the med is going to make you gain weight, you're going to gain weight, just at a slightly slower pace. I've wanted to deck a few shrinks who naively tell me to just "eat right and exercise more," and I'll be just fine. Look where that got me, not to mention that's nearly impossible advice for the seriously depressed...

If I go on Depakote for migraines, I will be obsessed with my scale, and the first five pounds I see will be the last because that med is history. I'd rather live with a certain amount of pain than be labeled in the "obese" category again. At least I don't have to worry as much about developing heart disease, high blood preassure, and diabetes. Obesity kills too.


Again, though, if I'm stark raving mad or in agonizing pain, I'll take the meds. Right now I can deal. My coping strategies are working well enough that I can afford to be a little picky while I find the right med for me.

michelle said...

I chose Lamictal as my favorite mood stabilizer because of its lower side effect profile and its antidepressant qualities. A big plus is that it appears to be weight neutral. My biggest complaint, however, is that Lamictal has a tendency to mess with my language, memory, and concentration. I have a hard time reading because sometimes the words just don't make sense, and I also forget very quickly what I have just read. I also find that when I am writing I will often randomly insert the wrong words. I will do it when I am speaking also. It's very frustrating. As far as mood stabilization goes, Lamictal does very well. As long as I'm not forgetting doses, I rarely have mood blips on this med. The antidepressant effect is especially nice since SSRI's, SNRI's, etc tend to cause switching for me.

Roy said...

Shrink, not so sure about that (or maybe I am atypical... ha). Uhh, I wrote so much, I turned it into a post. Please see Part 2.

Ian Hunter said...

OK Shrinks

I used to work for Pfizer and sell Zoloft. You really need to stop and think....hey...if I am going to prescribe a SSRI...my first choice should be the generics (Prozac generic, Zoloft generic, Paxil generic, Celexa generic)....I do not get Lexapro ....it is a patent extension scheme !! Samples....who cares in the long run....why don't you give a patient crack...all the samples do is keep you and the patient addicted and beholden to the drug companies

Rach said...

And once again, Dinah... I've carried on the conversation (although... switched it up a bit) on my blog... Boy you make me think!

isabella mori said...

hello, great blog, happy i found you (through confessions of a psychotherapist, i believe).

as a counsellor, i don't prescribe drugs but of course many of my clients talk about them.

i'd be interested what your take is on experimenting with medication when the first attempt isn't working, or when a drug has worked for a while and doesn't anymore. it appears to me that's where a lot of people need help.

racingmind said...

In my five years of visiting a psychiatrist and meeting with a therapist I have never come across a psychiatrist willing to against my wishes. I often find this frustrating merely in the sense that I figure this doc when to medical school for a reason and yet she/he is not giving me any feedback. Suffering from chronic major depression I've become frustrated with doctors being content with keeping me on the same drugs for long long periods of time and the fact that they really aren't monitoring anything but the amount of pills they give me. I perscripe my own medication, the doctors merely someone who signs the blank Rx pad. pathetic, who needs shrinks, they're all quaks.

Kellen said...

This article is so very useful for my clients. I can't thank you enough for writing it.

jen said...

Need a question answered: What kind of a shrink tells a mom she should leave her husband and kids [almost 2 and 3 yrs old] to find her own happiness. Mind you she had 2 babies in one yr both C-sections and difficult. Caught her H totally off guard as well as all her friends and family.
Shrink is telling her the kids will be OK. They are not. She has been on antidepressants since 2nd kid was born and is doing all sorts of nasty things she never did before. Crazy stuff. Drinking heavily....check out this blog ...
http://blog.myspace.com/index.cfm?fuseaction=blog.ListAll&friendID=400510998 /
She has most of the warning signs. We think this shrink, along with the drugs, has totally screwed up her thinking.
http://profile.myspace.com/index.cfm?fuseaction=user.viewprofile&friendid=400510998

Thanks.

Scream said...

What if your patient was a female bodied person? Would you still used masculine personal pronouns?

Anonymous said...

Is there an anti-depressant that causes weight loss? I'd like to be on that on please. :)

I've been on Lexapro for 4 years now and weigh 50 lbs more than when I started (size 8 then, size 16-18 now). In fact I seem to have all the major Lexapro side effects and they seem to get worse the longer I'm on the medicine.

I'm very much in need of a new drug.

Tara Larwick said...

I just want to say that anti-depressants and weight gain are a very real and serious problem. I have been overweight ever since I started having kids in my mid-twenties. There is no history of weight problems on either side of my family and my three siblings, all in their 50's, still weigh what they did in highschool. But after my third child I was put on Prozac. For the next thirteen years, I took Prozac, Pazil, and Zoloft. Each one added more weight until I weighed 240 lbs at 5'6". I tried everything to lose weight over the years and finally at 50, under doctor supervision (and no longer taking antidepressants for several years), I went on a very strict diet that limited my processed carbohydrate intake and calories. I lost 96 lbs. It was very, very difficult but I stuck with it. Food became the enemy as well as an obsession. Truly, I was worried that at the end of it all I might end up being anorexic because I was so afraid to eat anything. But I finally did it and kept it off for a year and learned to eat healthy and normally. Then, due to several life factors, periomenepause included, the doctor put me on an anti-depressant. I started to gain weight (about 15 lbs) so she switched me to another antidepressant; one that was the least likely to cause weight gain. I gained 30 lbs in 3 months!!!! By the time I was taken off the anti-depressant, it was too late. I was back up 190 lbs! My doctor, in the meantime, retired and I had to find a new doctor. When I went in to see her and told her I had gained 30 lbs in three months she said, "You'll just have to watch your calories and exercise more."!!!!! I was devastated. I have stopped taking antidepressants and stopped gaining weight but the amount of damage that has occurred - physically, mentally, and emotionally - is immense. The mind set that goes into losing the kind of weight I lost is very difficult to hold on to and to try to recapture it is impossible. Prior to my weight loss, I was eligible for bariatric surgery. Now, I'm not heavy enough to qualify for surgery but too heavy to be healthy or happy. I continue to try to lose weight but have had no success and my heart and my spirit are broken. It is very unlikely I will ever take another antidepressant again.

Tara Larwick said...

I just want to say that anti-depressants and weight gain are a very real and serious problem. I have been overweight ever since I started having kids in my mid-twenties. There is no history of weight problems on either side of my family and my three siblings, all in their 50's, still weigh what they did in highschool. But after my third child I was put on Prozac. For the next thirteen years, I took Prozac, Pazil, and Zoloft. Each one added more weight until I weighed 240 lbs at 5'6". I tried everything to lose weight over the years and finally at 50, under doctor supervision (and no longer taking antidepressants for several years), I went on a very strict diet that limited my processed carbohydrate intake and calories. I lost 96 lbs. It was very, very difficult but I stuck with it. Food became the enemy as well as an obsession. Truly, I was worried that at the end of it all I might end up being anorexic because I was so afraid to eat anything. But I finally did it and kept it off for a year and learned to eat healthy and normally. Then, due to several life factors, periomenepause included, the doctor put me on an anti-depressant. I started to gain weight (about 15 lbs) so she switched me to another antidepressant; one that was the least likely to cause weight gain. I gained 30 lbs in 3 months!!!! By the time I was taken off the anti-depressant, it was too late. I was back up 190 lbs! My doctor, in the meantime, retired and I had to find a new doctor. When I went in to see her and told her I had gained 30 lbs in three months she said, "You'll just have to watch your calories and exercise more."!!!!! I was devastated. I have stopped taking antidepressants and stopped gaining weight but the amount of damage that has occurred - physically, mentally, and emotionally - is immense. The mind set that goes into losing the kind of weight I lost is very difficult to hold on to and to try to recapture it is impossible. Prior to my weight loss, I was eligible for bariatric surgery. Now, I'm not heavy enough to qualify for surgery but too heavy to be healthy or happy. I continue to try to lose weight but have had no success and my heart and my spirit are broken. It is very unlikely I will ever take another antidepressant again.