Hey, Where'd all the SSRIs go?

Chris Ballas, M.D. Health Guide
  • Is anyone still on Prozac? Anyone?

    I don't know what to make of it: the number one drug in the universe (Prozac) has now been relegated to nearly last place, while a drug that ten years ago was at the bottom of the atypical antispychotic playlist is now number one with a bullet.

    Many people complain about pharmaceutical involvement in doctor prescribing practices, and while this certainly is an issue, what people don't seem to acknowledge is how doctors themselves, independent of Pharma, have prescribing drift. Doctors want to try the latest drugs and see if they're better; but even if they end up being the same and no better, they never drift back. That has nothing to do with Pharma. It's just a habit. Habits are comfortable.

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    I'd like to pretend that these habits result in a doctor's greater familiarity with the nuances of a drug. For example, if you're using Effexor as your first choice for the past three years, you would hope that at some point doctors bothered to look up the half life, or the effect on kidneys (is there one?) But generally the opposite happens - familiarity leads to a false sense of expertise.

    In one sense, the prescribing drift - trying out new meds and not really going back to the older ones - is the only defense that patients have from complete apathy. There is very little other impetus to learn new things if you are a doctor. At least doctors are forced to learn a little bit about something new every few years or so. Because the alternative, unfortunately, is that they learn very little, ever.

    But there's another aspect to the problem of "in with the new, out with the old" creep of medication usage in favor of the newer drugs.

    How many people are on Prozac or Seroquel? Chances are, it's a lot of people, especially considering the fact that it's only approved for bipolar disorder (4% of the population) and schizophrenia (1%). But here's the question: is the increased Seroquel use replacing older antipsychotics such as haldol, or is it replacing older antidepressants and sleeping pills?

    This and all antipsychotics are being used off label, which is completely fine. In fact, I'd argue that a psychiatrist who doesn't use medications off label is not aggressively trying to help the patient; he or she is being constricted by artificial delineations that might not adequately serve a patient's needs.

    I'm not talking about off label. I'm talking about re-label: when a class of medications becomes the default treatment for various conditions, not because they are better but simply because they are newer.

    Here's an example: Sinequan is an extremely popular sleep drug in community clinics and jails. Technically, it is an antidepressant, but it had side effects, such as sedation, that reduced its use as an antidepressant. Now Sinequan is used as a sleeper.

    What's strange, however, is how often Sinequan is used along with an antidepressant like Celexa. Celexa is the antidepressant, and Sinequan the sleeper. But why not simply use Sinequan as both the sleeper and the antidepressant? People might say it has other bad side effects (dry mouth) and this may be a partial explanation, but the main reason simply is that Celexa is newer.

  • So Sinequan has been "re-labeled" as a sleeping pill. No one would seriously consider mixing Sinequan with, say, Ambien, but they would mix it with Celexa in a minute.

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    Antipsychotics are now being relabeled as antidepressants. For example, when an antipsychotic is used for depression (or anxiety) it is thought of as an antidepressant, not an antipsychotic. So is Abilify and Seroquel are used together, Abilify is considered the antipsychotic, and Seroquel the anti-anxiety/antidepressant (or sleeper). In this example, it would have been better off to prescribe Ability and an antidepressant, which is both safer and cheaper than prescribing two antipsychotics. Or, if sedation is important, a doctor could simply prescribe enough Seroquel alone to function as both an antipsychotic and an antidepressant or anti-anxiety pill.

    I'm not against using medications for multiple effects, but it seems wasteful, if not a little unsafe, to duplicate therapy. Celexa and Sinequan aren't so bad together - they are a relatively safe combination, and Sinequan and Celexa are both generic drugs. The combination of Abilify and Seroquel is, frankly, silly.

    If you take more than three medications for depression, or any psychiatric condition, for that matter, ask your doctor specifically what each drug is supposed to be doing. If two drugs are doing the same thing, especially if they are two new drugs, ask whether or not they are both necessary.

Published On: August 23, 2007