Saturday, September 22, 2007

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%)