{"id":67950,"date":"2016-09-14T17:04:12","date_gmt":"2016-09-14T21:04:12","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=67950"},"modified":"2016-09-14T17:07:29","modified_gmt":"2016-09-14T21:07:29","slug":"re-view","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2016\/09\/14\/re-view\/","title":{"rendered":"re-view…"},"content":{"rendered":"\n

I was once a Primary Care Physician of sorts, an internist seeing referrals from general medical officers in a military hospital so I saw a lot of people whose physical complaints reduced down to matters psychological. I think it’s very different now, but thise the latter days of the Viet Nam War, and there was a reduction in force going on. It was hard to get active duty soldiers or even their dependenys to accept a mental health referral. They were afraid if would affect their promotions and retirement. I have no clue if that was true, but what I thought didn’t much matter. It’s what they thought. Detecting mental health problems and treating them became part of my job, so I had a some experience with the older generation antidepressants in non-melancholic "everyday" depression. <\/p>\n

I found them to be a sometimes effective treatment, but there was the a effect burden. Most of the soldiers were on the flight line and the side effects interfered with work, so they stopped them. And even among dependents, long term use wasn’t much of a question because even responders wanted to stop them as soon as they could. The party line in those days was "if you respond to an antidepressant, you should continue it for six months to prevent relapse.<\/font><\/em>" I said it, but that didn’t mean they did it. Constipation, blurry vision, and dry mouth are pretty annoying. Later, as a psychiatry resident, I was much more impressed with the drugs in hospitalized cases, but not so much in the outpatient clinic.<\/p>\n

Even later, in practice, almost all my referrals were people who came for what I did – psychotherapy. As the new antidepressants appeared, I used them some but mostly adjunctively. So the majority of my experience with the newer drugs comes from my post-retirement years in a general outpatient clinic. In "virgins" [kind of rare], when I prescribe Antidepressants, I always present them as a "therapeutic trial." I warn about side effects, particularly libido and akathisia. I talk about the withdrawal syndromes. And I do my "finger thing."<\/div>\n
\n
"As much as we’d like our antidepressants to help this<\/font><\/em><\/strong> much or this<\/font><\/em><\/strong> often, they’re more in this<\/font><\/strong><\/em> range, and it may take several weeks before you notice any change."<\/div>\n<\/blockquote>\n
Now to the point. In responders, I say:<\/div>\n
\n
"I’m glad it’s helping. Depression in most cases is time limited, so after a while, if everything’s going well, we’ll taper the drug and get you off of it. Some people have withdrawal symptoms and worry "the depression is coming back!", and get stuck on the meds. That’s why we taper off the drug."<\/div>\n<\/blockquote>\n
That prep works fine. Unfortunately, a majority of people I see aren’t "virgins." They’ve been on SSRIs for a long time and see them as either ongoing treatment or a preventive. Getting them to stop isn’t easy. So I’ve learned to wait until I know them better [and vice versa] and suggest a trial taper. That works for the  willing. But I have to admit, there are plenty who just don’t want to stop, so I go for a lower dose and don’t push it [guiltily]. I was glad to see this article that brings some science to bear [from a reputable source]:<\/div>\n
\n
The Safety, Tolerability and Risks Associated with the Use of Newer Generation Antidepressant Drugs: A Critical Review of the Literature<\/a><\/div>\n
by Carvalho A.F , Sharma M.S., Brunoni A.R, Vieta E., and Fava G.A.<\/div>\n
Psychotherapy and Psychosomatics<\/strong>.<\/font> 2016 85:270-288.<\/div>\n
[FullText PDF<\/a>] <\/div>\n

<\/p>\n

Newer generation antidepressant drugs [ADs] are widely used as the first line of treatment for major depressive disorders and are considered to be safer than tricyclic agents. In this critical review, we evaluated the literature on adverse events, tolerability and safety of selective serotonin reuptake inhibitors, serotonin noradrenaline reuptake inhibitors, bupropion, mirtazapine, trazodone, agomelatine, vilazodone, levomilnacipran and vortioxetine. Several side effects are transient and may disappear after a few weeks following treatment initiation, but potentially serious adverse events may persist or ensue later. They encompass gastrointestinal symptoms [nausea, diarrhea, gastric bleeding, dyspepsia], hepatotoxicity, weight gain and metabolic abnormalities, cardiovascular disturbances [heart rate, QT interval prolongation, hypertension, orthostatic hypotension], genitourinary symptoms [urinary retention, incontinence], sexual dysfunction, hyponatremia, osteoporosis and risk of fractures, bleeding, central nervous system disturbances [lowering of seizure threshold, extrapyramidal side effects, cognitive disturbances], sweating, sleep disturbances, affective disturbances [apathy, switches, paradoxical effects], ophthalmic manifestations[ glaucoma, cataract] and hyperprolactinemia. At times, such adverse events may persist after drug discontinuation, yielding iatrogenic comorbidity. Other areas of concern involve suicidality, safety in overdose, discontinuation syndromes, risks during pregnancy and breast feeding, as well as risk of malignancies. Thus, the rational selection of ADs should consider the potential benefits and risks, likelihood of responsiveness to the treatment option and vulnerability to adverse events. The findings of this review should alert the physician to carefully review the appropriateness of AD prescription on an individual basis and to consider alternative treatments if available.<\/div>\n<\/blockquote>\n
There was a time when I read most review articles that were ever put in front of me – just a way of keeping up. But the KOL\/PHARMA era ended all of that a long time ago. This one is like they used to be, information that I might trust enough to use.<\/div>\n","protected":false},"excerpt":{"rendered":"

I was once a Primary Care Physician of sorts, an internist seeing referrals from general medical officers in a military hospital so I saw a lot of people whose physical complaints reduced down to matters psychological. I think it’s very different now, but thise the latter days of the Viet Nam War, and there was […]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[5],"tags":[],"class_list":["post-67950","post","type-post","status-publish","format-standard","hentry","category-opinion"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/67950","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/comments?post=67950"}],"version-history":[{"count":14,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/67950\/revisions"}],"predecessor-version":[{"id":67964,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/67950\/revisions\/67964"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=67950"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=67950"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=67950"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}