How an antidepressant can hurt your patient

Patients want a quick fix. Society wants patients to have a quick fix, so that they can quickly return to their usual performance at work and home.

Patients still have shame about seeking help from a psychiatrist or other mental health professional. So they ask help for their depression from their primary care physician. The PCP feels an emotional pressure to provide the quick fix in that 15-minute appointment – the same pressure that he responds to when prescribing antibiotics to a adequately squeaky wheel of a patient with a common cold. If he does talk to the patient about therapy, the patient balks at the cost (in time and effort, if not in price). Even if the patient doesn’t balk, there may be a wait to get the patient in. In the meantime, to help the patient feel some relief, an antidepressant is prescribed. It helps the PCP and the patient that as a group, SSRIs and the antidepressants that followed them are a lot safer than tricyclics.

This is how PCPs as a group came to write the vast majority of prescriptions for antidepressants, and this class of medications ended up in top 4 by U.S. sales.  Revelations that negative studies about these medications in the past were not reported or that  they may not work a lot better than placebo for those with mild-to-moderate depression, don’t seem to have much impact on sales.

I wish this were not so, that there was less stigma about mental illness, that our society did not demand quick fixes, that PCPs did not find themselves in the position of writing so many scripts for antidepressants, that when they did write such scripts they always did so after ruling out adjustment disorder, bipolar disorder, and mood disorders secondary to medical conditions, medications or substances of abuse, and other differential diagnoses.

Until this comes to pass, PCPs must watch for at least the following clues to determine, post hoc, which patients might be hurt by antidepressants:

  • Patient has a dramatic response (my rule of thumb: be very concerned if the patient is 50% better in less than 4 weeks or almost 100% in less than 2 months).
  • Patient has either new-onset anxiety, irritability or anger or worsening of existing anxiety, irritability or anger at any time after starting the antidepressant.
  • Patient starts to sleep a lot less than what would be expected and does not mind it because he’s not feeling too much tired.

All of the above could be clues of the worst harm (short of the rare actual suicide solely due to an antidepressant) that can come to patients prescribed antidepressants – a hypomanic or manic episode triggered by an antidepressant.  Every antidepressant script should be written initially for month at a time and only after the patient has understood the importance of promptly reporting any of the above signs and symptoms.

Patients do this if they are calmly counseled that while some jitteriness is expected early on with antidepressants and we want them to get better quickly, the above picture could be an early sign of worse side-effects to come. A patient with such a response may potentially be prescribed antidepressants again, but only after he has been evaluated thoroughly for bipolar disorder, and only with a lot closer monitoring than the usual patient with depression.

Admittedly, these clues don’t help determine which patients don’t need antidepressants in the first place. That determination requires spending time with the patient and collateral sources to adequately consider a broad enough differential diagnosis. Unfortunately, no short cuts there.

Dheeraj Raina is a psychiatrist who practices at the Depression Clinic of Chicago.

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  • http://ShrinkRap Dinah

    I linked to this on Shrink Rap

  • Justin

    psychiatry sounds like hard work. Can’t we just thread a stent into their limbic system?

  • Michael F. Mirochna, MD

    I’d wonder what the actual occurence of that harm is… How many depressed patients do we hand an SSRI to and then we open up a manic phase? 1 of 100, 1 of 10…

  • stargirl65

    I would love to refer to more mental health providers but:

    1. The wait time is about 2 months.
    2. They seem to have these hard to navigate systems with many therapists working under a psychiatrist who only does med reviews.
    3. They keep them coming back weekly for months to years.
    4. Many do not take insurance so cost can be prohibitive.
    5. Even with insurance cost can be prohibitive given high deductible plans.

    One of the harder things to manage is the patient that does not have TIME to see someone. Often this is their underlying problem. They are overworked and stressed and don’t take free time.

    Also my other concern is those that stay on antidepressants for years on end. They say they are fine on medicine and never want to come off medicine but are doing great on the medicine. They don’t want to come in for appointments since they are stable for years on this dose.

  • Solomd

    Is it me, or is there a condescending tone towards PCP in this article?

    • http://thedocsquawk.com thedocsquawk

      I feel similarly but outside of a consult, it must be hard to tell another doctor what they’re doing wrong without sounding slightly condescending. I’m sure the piece was not intended to slight PCPs.

  • Justin

    looking at some rough numbers (ie not digging too deeply into the literature), about Bipolar I/II effects 2.6% of the US pop. A 2006 study assessing switching from bipolar depression to hyopmania/mania found rates of 11-26% depending on the specific drug.

  • http://www.depressiondocs.com/blog Dheeraj Raina, MD

    Justin…thank you for responding to Michael F. Mirochna, MD’s question.

    Dr. Mirochna…I view antidepressant-induced mania as just as serious a complication as thrombolysis-induced brain hemorrhage would be. Even if it were rare, it would still be serious, and require vigilance.

    Solomd…I apologize if there was even a hint of condescension. My first 8 years in practice were spent in what was mainly a primary care clinic in a rural area. I know how hard PCPs work, how much is expected from them by society, and how little they are appreciated for it. In writing tips for the PCPs, I try to stick to simple, straightforward, specific and concrete tips that my former PCP colleagues would have found most helpful. I fear that simple & concrete may have come across as condescending.

    Stargirl65…;-(…I could explain a lot of the hurdles you face, but I don’t want to make excuses. You’ve probably heard them all. I hope there is someone in my specialty who is at least available to you for curbsides while your patient waits to get in for their first appointment.

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