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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 6 of 6. This is the beginning of the thread.
Posted by Phillipa on November 21, 2008, at 19:45:44
Patients should have a choice in picking an ad and now it's considered okay to continue an ad for longer periods and maybe for life. Phillipa
Adverse Effects, Patient Preference, and Cost Should Dictate Antidepressant Choice
Pauline Anderson
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November 20, 2008 Physicians should consider adverse effects, cost, and a patient's personal preferences when prescribing second-generation antidepressants, since research shows all of these agents have equivalent efficacy, according to a new guideline issued by the American College of Physicians (ACP).This was 1 of 4 recommendations included in the new guideline published in the November 18 issue of the Annals of Internal Medicine.
The other recommendations highlight the importance of regularly assessing patients for response and adverse effects, changing drugs when necessary, and continuing therapy for an adequate period of time.
"With 16% of the American population diagnosed with depression at some point in their lives, and with the economic burden of depression approaching $85 billion, it's important to provide primary-care physicians with evidence-based information on what steps to take to treat patients with this disorder," the guideline's lead author, Amir Qaseem, MD, PhD, senior medical associate in ACP's clinical programs and quality-of-care department, told Medscape Psychiatry.
In developing the guideline, investigators conducted a systematic review of published research. Using various medical databases, they searched for studies that included at least 1 of 12 antidepressants (bupropion, citalopram, duloxetine, escitalopram, fluoxetine, fluvoxamine, mirtazapine, nefazodone, paroxetine, sertraline, trazadone, and venlafaxine) that were restricted for use in adults 19 years of age or older. Their review included 203 head-to-head or placebo-controlled trials.
Same Efficacy, Effectiveness and Qualify Of Life
Among various categories of antidepressant drugs, including selective serotonin-reuptake inhibitors (SSRIs), serotonin-norepinephrine-reuptake inhibitors (SNRIs), or selective serotonin-norepinephrine-reuptake inhibitors (SSNRIs), the researchers found no difference in efficacy, effectiveness, or quality of life in patients with major depressive disorder (MDD).
The review also did not reveal any difference in efficacy among these drugs in patients with accompanying symptoms or subgroups based on age, sex, race or ethnicity, or other comorbid conditions.
However, the researchers did find several differences among these drugs with respect to response rate and the incidence of certain adverse events. For example, some studies found that mirtazapine had a faster onset of action than citalopram, fluoxetine, paroxetine, or sertraline and that bupropion has fewer sexual adverse events than fluoxetine, paroxetine, or sertraline.
SSRIs in general were associated with an increased risk for suicide attempts compared with placebo. "The side effects of these medications vary from mild ones like constipation and diarrhea to some major ones like suicidality and sexual dysfunction," said Dr. Qaseem. Since each of these drugs has benefits and drawbacks, doctors should be sure to discuss these issues with patients, he added.
Patient Preferences Also Important
Patients themselves may have drug preferences, and physicians need to explore these. For example, they may have had a previous negative experience with a particular antidepressant and want to avoid further use of the drug. Discussions with patients should also include cost, as insurance companies may have varying coverage, said Dr. Qaseem.
The review also showed that 38% of patients did not achieve a treatment response during 6 to 12 weeks of therapy and more than 50% did not achieve remission.
The guideline also recommends that physicians assess patient status, therapeutic response, and adverse effects on a regular basis starting 1 to 2 weeks after initiating therapy. "The major reason for this is that the risk of suicide attempts is greater during the first 1 to 2 months of treatment," said Dr. Qaseem.
In addition, the guideline recommends treatment modification if the patient does not adequately respond within 6 to 8 weeks after starting therapy. "The response might not be sufficient, and you might need to add an additional drug, or multiple drugs may be required," he said.
Keep Relapse in Mind
Finally, the guideline suggests patients with a first episode of MDD continue treatment for 4 to 9 months after a satisfactory response and possibly longer in patients with a history of relapse.
"In depression, relapse and recurrence are important to keep in mind. Patients with 2 or more episodes may need to take [antidepressant] mediation for years or even for life," said Dr. Qaseem.
Prescribing maximum but tolerable doses for at least 8 weeks seems at least as important as the choice of specific drug, according to the authors of an accompanying background paper created for the ACP.
"Given the difficulty in predicting what medication will be both efficacious for and tolerated by an individual patient, familiarity with a broad spectrum of antidepressants is prudent," they write.
With first author Gerald Gartlehner, MD, from Danube University, in Krems, Austria, the investigators assert more research is needed on the most appropriate duration of drug treatment and the effects of different doses on maintaining response and remission
Future studies should evaluate whether different formulations affect adherence and relapse or recurrence.
Encouraging News
Psychiatrists have long known that second-generation antidepressants are about the same when it comes to efficacy, so it is encouraging to see that this information is being extended to the field of primary care, said Alan Gelenberg, MD, from the University of Wisconsin, in Madison, who is developing a new guideline on major depression for the American Psychiatric Association.
"What's newsworthy to me as a psychiatrist is that this organization of internal-medicine doctors has seen depression as important," he said. "Depression should be recognized. It's treatable, but no treatment works if the patient doesn't take it. Therefore, you should discuss the treatment with the patient, see them at regular intervals and monitor the patient for side effects."
Posted by desolationrower on November 21, 2008, at 23:58:28
In reply to Patients Should Have Choice In Picking An Ad, posted by Phillipa on November 21, 2008, at 19:45:44
I disagree with this. Their assumption seems to be that doctors decide how best to treat the illness, then give patient decision on what side effect profile they want from the various treatments. It isn't the doctors place to decide how to treat. The doctor is there to guide the patient through the process and give the patient control of their medical situation. If a patient wants a drug that is less effective but has certain other benefits, that should be offered as well (or more likely the case, a drug more effective but with higher side effects like a TCA should be offered along side the newer drugs). More rotteness at the core of the medical approach to mental illness.
-d/r
Posted by yxibow on November 22, 2008, at 4:37:01
In reply to Re: Patients Should Have Choice In Picking An Ad, posted by desolationrower on November 21, 2008, at 23:58:28
> I disagree with this. Their assumption seems to be that doctors decide how best to treat the illness, then give patient decision on what side effect profile they want from the various treatments. It isn't the doctors place to decide how to treat.
And what did they go to medical school for and sit through years of residency and maybe private practice and possibly care for their patients ??? Who has the medical license and pays 50 grand for malpractice?
The doctor is there to guide the patient through the process and give the patient control of their medical situation.
I saw that in the article....
If a patient wants a drug that is less effective but has certain other benefits, that should be offered as well (or more likely the case, a drug more effective but with higher side effects like a TCA should be offered along side the newer drugs).
I agree there should be a doctor-patient discussion about medication but ultimately the patient may be playing armchair psychiatrist to themselves.
It becomes that there are two doctors in the room. Knowledge by the patient is to be commended but a good psychiatrist has seen 10 years of patients or more.
If they're "green" to the practice, you're probably in a university setting, I hope, and they are shadowed by other psychiatrists.
Also psychiatrists have "journal clubs" sometimes, where they share patient X confidentially and get input.
That doesn't mean ultimately that the patient may get their choice, but it has to be weighed in the mind of the psychiatrist/psychopharmacologist, things like family history, race (yes, ethnicity has places in how drugs are metabolized), and suicidality
(certain agents may be better for that, but then again, certain agents in the hands of someone who has repeatedly mentioned the thought may not be the best because they have a low margin of safety before the patient can just 'check out' with the bottle, I hate to say...).
Psychiatrists, medical practitioners, are not script pad factories. There's a lot at stake, besides malpractice and DEA watching their backs -- they might actually care about their patients.
More rotteness at the core of the medical approach to mental illness.No comment.
>
> -d/r
Posted by seldomseen on November 22, 2008, at 6:58:58
In reply to Re: Patients Should Have Choice In Picking An Ad, posted by desolationrower on November 21, 2008, at 23:58:28
"It isn't the doctors place to decide how to treat."
Actually, I think that this is exactly what to the doctor is there to do. Obviously, a good doctor will listen to the patient and develop a treatment plan that suits the patient and one in which the patient is likely to be compliant.
"The doctor is there to guide the patient through the process and give the patient control of their medical situation."
This goes without saying I think, but I also think that it is incumbent on the patient to listen to the doctor's plan. IMO, we need to seek out doctors whose opinion and experience we trust. I think treatment should definately be a two way street.
Seldom.
Posted by ricker on November 22, 2008, at 15:53:40
In reply to Patients Should Have Choice In Picking An Ad, posted by Phillipa on November 21, 2008, at 19:45:44
This has become more of an issue with the advent of "internet" and the millions of self proclaimed "Instant Doc's"????
Regards, Rick
Posted by desolationrower on November 22, 2008, at 16:40:10
In reply to Re: Patients Should Have Choice In Picking An Ad » desolationrower, posted by seldomseen on November 22, 2008, at 6:58:58
> "It isn't the doctors place to decide how to treat."
>
> Actually, I think that this is exactly what to the doctor is there to do. Obviously, a good doctor will listen to the patient and develop a treatment plan that suits the patient and one in which the patient is likely to be compliant.
>
> "The doctor is there to guide the patient through the process and give the patient control of their medical situation."
>
> This goes without saying I think, but I also think that it is incumbent on the patient to listen to the doctor's plan. IMO, we need to seek out doctors whose opinion and experience we trust. I think treatment should definately be a two way street.
>
> Seldom.yes i agree with you.
-d/r
This is the end of the thread.
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