Out with the Old, In with the New
A few months back I posted a blog on the decrease in the use of SSRIs. 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.
A significant number of people are prescribed Prozac and Seroquel, 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?
It - 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 and 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 bad side effects that reduced its use as an antidepressant. For example, sedation. Now it's used as a sleeper.
What's strange, however, is how many times Sinequan is used along with an antidepressant like Celexa. Celexa is the antidepressant, 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 (such as 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, ambient, but they wouldn't hesitate to mix it with Celexa.
Antipsychotics are now being relabeled as antidepressants. By this I mean that when an antipsychotic is used for depression (or anxiety) it is believed to be an antidepressant, not an antipsychotic. So, for example, considering the combination of Abilify and Seroquel: Abilify is the antipsychotic, and Seroquel is the antianxiety/antidepressant (or sleeper). In this example, you could simply have given the patient Abilify and an antidepressant, which would be safer and cheaper than two antipsychotics. If sedation is particularly important, simply prescribe enough Seroquel alone to function as an antipsychotic, along with an antidepressant/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 isn't so bad - it's relatively safe, and Sinequan and Celexa are both generic; but 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 is supposed to be doing. If two drugs are doing the same thing - especially if they are two new drugs - ask whether or not one can be stopped.