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Depression Medications Tier List: Psychiatrists Rank Antidepressants for MDD — Transcript

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0:00Welcome to the Psychopharm podcast. This
0:01podcast is for education and
0:02entertainment. It certainly is not
0:03medical or psychiatric advice,
0:05diagnosis, or treatment. Listening does
0:06not create a doctor-patient relationship
0:07with me or Dr. Foo. If you're a patient,
0:09certainly don't change your treatment
0:09plan because of something you hear in
0:10the show. If you're a clinician, do not
0:11use this podcast as a clinical reference
0:13or substitute for your own training,
0:14judgment, thinking, and up-to-date
0:15sources. Opinions are our own and don't
0:16necessarily reflect any employer or
0:18affiliated organization and may even be
0:19detached from reality.
0:21Good morning, Dr. Malzburg.
0:23So, today we will
0:26we're making a tier list for
0:27medications. I think that you'll find
0:30it's going to be hard to see me
0:32violating my usual rules. And my usual
0:34rules are that
0:38I I'll never pick medications that will
0:40cause weight gain or appetite increase
0:43if I can help it. And I try to minimize
0:46uh side effects. That's kind of rule
0:48one. And then rule two is most
0:50efficacious. So, that tends to be how I
0:53go. Uh I feel like a lot of
0:55psychiatrists out there go in the
0:57opposite direction. I think a lot of
0:59people go for most efficacious first and
1:01then don't worry so much about the side
1:03effects. But, um you know, everyone's
1:04[clears throat] a little different.
1:06My only issue is like mirtazapine, I'm
1:08going to that's going to be a high tier
1:10on my list and that causes a lot of
1:11weight gain. So, it's like the patient
1:13population matters.
1:15It does, but that's what I mean, all
1:17arounders. I don't use much mirtazapine
1:19despite its great efficacy.
1:21All right. Well, I'm going to use your
1:24your list as what goes in the screen and
1:26then I'll just yell at you when I
1:28disagree.
1:29Okay, that sounds fine.
1:31All right. So, So, what diagnostic class
1:34are we starting with in terms of picking
1:36medications? We're doing depression. So,
1:39major depressive disorder.
1:41Okay. Do we mean true recurrent
1:44biological type major depressive
1:46disorder, the cousin to bipolar
1:47disorder, or do we mean um
1:50dime store depression from personality
1:53and stressors that happens to meet major
1:55depressive episode criteria? All the
1:57above. I want All of the above. Oh, boy.
2:01Okay.
2:03Yeah, understandably you want a very
2:05specific
2:06set of rules in what we're doing and I
2:08want
2:10nothing.
2:11>> [laughter]
2:11>> We just grade the medications.
2:13>> Okay.
2:14Well, obviously it's going to be
2:15Adderall because that's going to get you
2:16the most return visits. No, that that
2:18that's a joke. Do not put Adderall.
2:19Let's put Adderall into F or No, not
2:22even question mark. Adderall immediately
2:24goes into F tier.
2:25Uh why are we going to do that first?
2:26Because too many psychiatrists will
2:28essentially
2:30uh ignore anxiety and depressive
2:32disorders and call it
2:33neurodevelopmental. Uh
2:36maybe not too many psychiatrists though
2:38I definitely see psychiatrists doing it,
2:40but just a lot of clinicians out there.
2:42I think for run-of-the-mill
2:45meets criteria major depressive episode,
2:48you got to go with sertraline.
2:50Sertraline is
2:51your normal
2:52>> why Adderall's in the F class first? To
2:54me it's not obvious.
2:55>> just did. It's not obvious though.
2:57>> That's not enough? Okay okay, go ahead.
2:58There's I mean I think there's a lot of
3:00people will report that they feel better
3:03on Adderall and we also know that
3:06methylphenidate is commonly used for
3:09geriatric depression. So, we can't write
3:11off stimulants just with one sweeping
3:13blow.
3:14But maybe we can come back to it.
3:16>> but I will explain more. That's Those
3:17are some good points. Uh first of all,
3:20uh it's not a very good antidepressant.
3:22Uh what you feel on a stim uh on meth or
3:26cocaine or uh speed, which is what
3:29Adderall is, uh is a intoxicant effect.
3:33That is the euphoria and energy burst
3:35and you will build tolerance to that.
3:37Proper psychiatric treatment of a major
3:39depressive disorder is not something
3:42that you build tolerance to. Now, there
3:44is something called tachyphylaxis on the
3:46order of years of exposure to a
3:48medication where a medication becomes
3:50apparently less effective, but it's not
3:52a long-term solution. Freud tried to use
3:54it, cocaine, to treat a bunch of stuff.
3:57You can read his cocaine papers, and
3:59everyone concluded it didn't work. It's
4:00like every few years people try to treat
4:02everything under the sun in psychiatry
4:04with a stimulant because it feels great
4:06and people love it. It's not a solution.
4:08It's a drug. Uh now, for the geriatric
4:11class, um there is an exception that
4:13should be made for geriatric depression
4:15or geriatric uh neurocognitive disorders
4:19that come with apathy. Okay, apathy.
4:23This is sort of a unique thing, not
4:25exactly negative symptoms, but uh apathy
4:29can happen in older age uh people, and a
4:33little stimulant treatment can be
4:34helpful for that. But that that's very
4:36niche use and not
4:38run-of-the-mill major depressive
4:39disorder.
4:40Yeah, I'm I'm glad you brought this
4:41stuff up cuz
4:43what I do see is I see a lot of
4:45Now, you see all the time patients are
4:47treated for ADHD to the exclusion to all
4:50of all the other diagnoses. And the
4:52thing is, as you mentioned, people feel
4:54good on the medication. So often times
4:56they'll say like, "Oh, it actually
4:57really helps my depression." Because the
4:59first few times you take it, boom, you
5:01you feel great. It's it's a very
5:03rewarding drug. The important thing is
5:05it doesn't treat depression in the long
5:07term. And what I've seen with so many
5:09patients who have uh ADHD plus
5:12depression is you're
5:15you're not treating the depression, and
5:17you'll see irritability creep up, you'll
5:19see some added symptoms creep up, you'll
5:21see all these other things, and then the
5:23ADHD isn't getting treated because
5:26you're
5:27the person isn't addressing the
5:29underlying depression. So yes, it does
5:31work. In my opinion, it does {quote}
5:32{unquote} work the day the first day you
5:34take it.
5:35>> Symptomatically. But it does it is it is
5:37a very ineffective antidepressant.
5:40That's right. And uh if you've ever even
5:42just been treating what seems to be
5:45plain ADHD executive dysfunction, and
5:47there's a sense that the stimulant stops
5:50working in some sense or needs a higher
5:52dose after initially working for a few
5:55weeks. That's not the medication
5:56treatment effect. That's the drug
5:58effect. So, do not fall for that trap.
6:01Okay, folks. It's important one. So,
6:03does that mean can we should we put
6:05methylphenidate as D or F?
6:07F because we're talking about
6:09depression. Okay.
6:13Um
6:14Is it
6:15>> frozen? It looks Oh, there you go. We're
6:16going to snap it into place.
6:18I think we should stop you know, running
6:20our ideology and talk about actual
6:22depression of treatment of depression
6:24though and again, got to go with my boy
6:27sertraline. Oh.
6:29>> Zoloft.
6:30>> Boom. Boom. Sertraline. Sertraline as
6:31they like to call it due to the
6:32diarrhea.
6:34Um it is a great medication. First of
6:37all, you can titrate it on multiple
6:40steps. Okay, eight steps to the FDA
6:42maximum. Pretty useful. Uh secondly,
6:46just works. Works pretty great. Third,
6:49does not have much in the way of med-med
6:52interactions. Arguably at a higher dose
6:55may inhibit 2D6 according to some people
6:58or maybe in older adults, but basically
7:00clinically not a problem. No significant
7:03QTc prolongation. Uh yes, does have more
7:07GI side effects maybe, but those tend to
7:09dissipate at each dose after you know,
7:12up to a week or so. Um effective.
7:16Well tolerated. Great first line
7:18medication. Absolutely S tier. I 100%
7:21agree. It is almost always the
7:23medication I reach for first.
7:26Um I feel like I used to reach for
7:27Lexapro more. Like it was almost a 50/50
7:30split. And for some reason
7:33I I mean maybe there is a reason. I
7:34actually tended early on to reach for
7:36Lexapro for boys more and Zoloft for
7:38girls more. I wonder if that had had
7:40something to do with the fact that
7:42uh I we're supposed to use the name
7:44sertraline. I wonder if sertraline has
7:46the most I think the best safety in in
7:49pregnancy and breastfeeding. And I
7:51wonder if somehow that just seeped into
7:53my brain. That wasn't something I was
7:54doing intentionally. I think it was one
7:56of those like when I look back it's like
7:57oh I tend to to reach for escitalopram
8:00more often for men.
8:01Um now I tend to reach for sertraline
8:03first line uh
8:05pretty much for all patients. Now why do
8:07I reach for sertraline in front of
8:09escitalopram? So
8:12the main thing is you do see more
8:16um
8:16because of the the way these drugs are
8:19metabolized, sertraline has a bunch
8:22different sip sips that metabolize it.
8:25For patients that have uh
8:27ultra slow or ultra fast metabolization
8:30of whatever escitalopram's metabolized
8:32by, you will get patients who have
8:35really bad response to escitalopram more
8:37often than with sertraline.
8:41Yeah, I would say in my experience you
8:43do see a little bit more uh poor
8:45tolerance to Lexapro just a hair.
8:47Uh Lexapro used to be in my S tier. I
8:49used to reach for it first uh but that
8:52was earlier in the career and across
8:54increasing clinical experience. Again,
8:56still a great medication, probably my
8:57number two, but I wouldn't put it in the
8:59S tier. I would put it into A tier. And
9:02uh you know, it only has four titration
9:05uh steps unfortunately
9:07uh which I don't like. I like to have
9:09more steps. I think that works
9:11psychologically and physiologically for
9:13more people who are uh treatment naive.
9:16Um you've got to consider the
9:18possibility of QTc prolongation above 20
9:21mg because it hasn't been tested though
9:23it probably is unlikely.
9:25Um
9:26the FDA label kind of handcuffs you in
9:28the elderly population saying you can't
9:29go above 10 mg because you're being
9:31ultra careful about QTc prolongation,
9:34but uh similar to sertraline,
9:35efficacious uh relatively well tolerated
9:38compared to some of the other ones, and
9:40a few med-med interactions. So, uh
9:43pretty good med.
9:44Yeah, I used to in terms of I I guess
9:46we'll try to do a little bit of
9:47didactics in in in here. Escitalopram is
9:50the quote-unquote purest SSRI. I used to
9:53think that meant that it's going to have
9:54the least side effects or um just like
9:57the the the most direct effect. I I find
10:00that sertraline has less side effects
10:02overall, and sertraline's a little bit
10:03better tolerated. Even though it is the
10:06quote-unquote most pure
10:08uh SSRI, um you know, I've had patients
10:10who tolerate citalopram better than
10:12escitalopram, which goes against what
10:15we're taught. Um
10:17the
10:18You mentioned the doses on sertraline.
10:20My one complaint is There's no 150 mg
10:23pill.
10:24There's a capsule, actually.
10:27Really? I
10:28must not be able to get it covered.
10:30>> don't know if it's available everywhere,
10:31actually, cuz sometimes
10:32>> that I have to have on two pills,
10:34which is more inconvenient than
10:37um
10:38I I I feel like we got to
10:39>> got the option. You got the option. And
10:41then what I like about doing the step
10:43from 100 to 150 is that you can say,
10:45"Listen, uh if this doesn't work out for
10:47you, take the 100 and half of the 50."
10:50Giving the patients real control, and
10:53then also, of course, if you have real
10:54control, then you have the sense of
10:55control, uh I think can help uh a little
10:58bit of anxiety when it comes to med
10:59titration. Yeah.
11:02Um but yeah, we are in agreement. I have
11:03I have escitalopram at A tier. I would
11:06have been fine if you put it in S tier.
11:08I would not have have fought you.
11:11Now now now speaking of uh what you
11:13mentioned in terms of pure purity versus
11:16dirty,
11:18uh I think I agree, purity is very
11:20overrated
11:22um both in real life and in medications.
11:25And I would say that I love a dirty
11:27drug, okay? I love medications that can
11:30do multiple things at once. You get it
11:31all in one pill. Now, this is a problem
11:34when the dirtiness, uh, that means
11:36hitting multiple different types of
11:37receptors and having activity at
11:38multiple different types of receptors,
11:40it's a problem if that comes with weight
11:41gain and appetite increase because
11:43nobody likes that and it's bad for you
11:45physically. But, uh, for the rest of
11:47them who don't necessarily do that and
11:49have a little bit more, uh, multiple
11:50action, good meds. I like those.
11:53Yeah, and theoretically we should be
11:54using cuz I've seen people use the word
11:56dirty because it causes a lot of side
11:58effects. Dirty should mean if it's a
12:00bunch of different other receptors. I
12:01almost feel like is a better
12:02word, but, um,
12:05>> [laughter]
12:05>> Well, I mean, I I I I thought there was
12:07going to be a implication of that
12:09without staying stating it outright, Dr.
12:11Malzberg. We don't have to get all
12:13zoomer about that, speaking at YouTube.
12:15>> [laughter]
12:16>> All right, our next one is going to be
12:18fluoxetine, Prozac.
12:20What? I thought I was making this.
12:22You're You're playing it up there.
12:24>> No, I'm not putting it anywhere. I'm
12:25just holding it.
12:25>> No, that's okay. I I want to do a bit
12:27here. So, if you can put the Prozac down
12:29for a second. All right. I actually
12:30would have done that with you if I
12:31wasn't about to do a bit. All right,
12:33let's
12:33>> But, for major depressive disorder, I'm
12:35going to do a bit here and this is
12:36controversial, but I want to put lithium
12:38in S class.
12:40Okay, put it up there, but there's a
12:42caveat. Oh, great bit, Dr. Drew.
12:46>> It's because, uh, lithium is all the way
12:48at the bottom there under the Xanax.
12:51As it always is in real life.
12:52Wait. Oh.
12:54Yeah, there you go. Boom.
12:57Why? Well, if we narrowly define major
13:00depressive disorder as simply the state
13:03of depression that somebody is in and
13:05then we take the population of people
13:07who have recurrent major depressive
13:09episodes, uh, that require medication
13:12treatments and don't respond to, uh,
13:14psychotherapy treatments or lifestyle
13:16changes,
13:17um, as we go down and narrow the
13:20population of people that have
13:21experienced that, uh, over time, you are
13:24going to see more and more of those
13:25people who may have a bipolar depression
13:28that the underlying cause is a bipolar
13:30disorder, not a unipolar depression. And
13:33on top of that, we have to remember that
13:34there are varieties of major depression.
13:37Again, not from personality, not from
13:39trauma, not from stress, but any more
13:42biological major depressive episodes can
13:45be agitated depressions where you have
13:47severe
13:48insomnias,
13:50you have just psychomotor agitation. Are
13:53these bipolar disorders? Uh no, not by
13:56our modern definitions, but do they
13:58respond
13:59to mood stabilization? They may. And it
14:02can explain why the antipsychotic
14:04augmentation is so effective in the
14:07studies. In my opinion, that may be an
14:09artifact of our poor differentiation of
14:13people who have a physiology, let's call
14:15it a psychophysiology, closer to a
14:17bipolar disorder, yet never actually
14:19qualify for a bipolar disorder. And yes,
14:22there are a couple little studies
14:23showing efficacy of lithium as an
14:25augmentation agent in unipolar
14:27depression. So, I'm putting it up there
14:30more as a position statement than a true
14:33this is a first-line medication for
14:35depression.
14:36And that's I wanted to do position
14:38statements. That's why I wanted to make
14:40it feel space. Um I am supporting your S
14:44class of lithium. And again, not for
14:47first line. But uh we we talked about
14:50this. Nassir Ghaemi is a huge proponent.
14:52He he's
14:54He's a proponent of
14:56of the
14:58uh manic depressive illness being any
15:00sort of recurrent mood disorder
15:01independent of polarity and feels that
15:04lithium is first line for any patients
15:06who fit that. And he's a big proponent
15:08of arguing that lithium should be used
15:10significantly earlier. And he he puts it
15:13He thinks it should be used for any
15:14patients with temperament issues.
15:16Um
15:17one thing that's important that people
15:19need to I I people providers should get
15:21better at Is using low-dose lithium. So,
15:24Yes. there's a good um YouTube channel
15:26called Psych Education. It's Dr. Jim
15:28Phelps. He He has a few videos that kind
15:30of walk through thinking through using
15:32low-dose lithium. Now,
15:35the the thing is like it's just convent-
15:37it's not just convention, but with
15:39low-dose lithium we don't need to be
15:41monitoring all labs. Uh we don't need to
15:43have the same lab monitoring schedule
15:45that we have with with higher-dose
15:47lithium. We wouldn't expect the same
15:49level of kidney dysfunction, the same
15:51level of all the other problems with
15:53lithium. Um
15:54and
15:56I do agree that so many providers are
15:58scared of lithium. We should do it We
16:00need to do uh
16:01a lithium episode. I've had so many
16:03people that say like they're scared to
16:04use it. And I feel like if we just did
16:06one good episode on using it, I think we
16:09would change
16:10two people's practicing habits.
16:12>> [laughter]
16:13>> I hope so. Uh but as you know, I'm
16:15always like uh oh, you know, can we
16:17really make an episode out of that? Just
16:18like today when you mention this as a
16:20topic, I was like, this isn't going to
16:21make an episode. We have to cover every
16:23single diagnostic class ever. Uh but now
16:25it's obvious to me that you're right.
16:27So, uh we'll keep that in mind.
16:29All right. Let's Let's uh
16:31So, you did your bit. I I don't know if
16:33I would call it a bit. I didn't I didn't
16:36I don't know.
16:37I would call it a bit. But uh yeah,
16:39Prozac totally, man. I absolutely agree.
16:41That's the next one that we're going to
16:42put up.
16:44For me, that's A class.
16:47So,
16:49I'll let you go and then I'll explain
16:51why I have it in B class.
16:53Oh, B class for you, man. Okay, Prozac's
16:57awesome.
16:58Okay. Is it the best tolerated? No.
17:01But um it's kind of like Haldol.
17:04All right. It's so old that the FDA max
17:07is really high. So, you have a really
17:09high upper cap in terms of level of uh
17:11drug activity when you need it.
17:13Secondly, uh that also means that the
17:16starter dose, the low doses, even 10 mg
17:18can be completely efficacious
17:21for people who are medication naive or
17:23have relatively lower disease burden.
17:26Okay? Great med. Another good thing
17:28about Prozac, just like Abilify, if your
17:30patient tends to miss doses, skip doses,
17:33great medication. You can just give a
17:35higher dose and they skip a few doses a
17:37week.
17:38Long half-life, still gives you
17:39effective serum level. I believe they
17:42even had FDA approved a once-a-week
17:44version of Prozac at one point,
17:46fluoxetine that is. Called something
17:49else where you only have to take, I
17:50think it was like 80 mg once a week or
17:52something, which would be equivalent to
17:53a
17:54um
17:56you know,
17:5620 mg daily dose or something like that.
17:58I don't recommend you do this, by the
18:00way.
18:00These are strategies that you can use
18:03for patients with
18:04limited adherence despite counseling.
18:07Downsides, why it's not S-tier, well
18:12maybe a little bit more sexual side
18:14effects possibly.
18:16Maybe a little bit more activating or
18:18agitating in some.
18:20And
18:21plenty of medication medication side
18:24effects, med-med, not side effects,
18:26med-med interactions a little bit more
18:27common with Prozac.
18:30Yeah.
18:32Um
18:32I guess in terms of a few comments, the
18:35reason why I put it in B class is
18:37strictly has nothing to do with the
18:38medication itself.
18:40For some reason with with sertraline and
18:41escitalopram, like I know exactly how to
18:44think about the dosing
18:46in terms of like when I'm at halfway FDA
18:48max, when I'm thinking starting dose.
18:51For some reason fluoxetine always gets
18:53me a little bit nervous. And I don't
18:55know if it's cuz there's like capsules
18:56and tablets and
18:58uh I don't know, for some reason I get I
19:01get anxious about using fluoxetine
19:05just because I think I've used it
19:06slightly less than than sertraline and
19:09escitalopram. Now, [snorts] I guess if a
19:10few other comments I think you're right
19:12to feel that way. Go on. Yeah, and I
19:14don't know if it's just in my head. Um
19:18but the
19:19>> Um I would say that that's actually from
19:22the fact that it's the oldest one. And
19:24therefore like Haldol the FDA max is
19:27higher.
19:28Um
19:29fluoxetine I think it is easier to go
19:31too high to where you tip the scales for
19:35risk over benefit where there's more
19:37side effects than benefit. And people
19:39just think that FDA maximums are
19:42equivalent. They are not equivalent. Um
19:45do not assume that the max of FDA
19:47approval on one medication is equivalent
19:49to another.
19:50Uh fluoxetine is basically the Haldol of
19:53SSRIs.
19:55Now, the other comments with regards to
19:57what you're saying, I do think of it as
19:59being
20:00population-based slightly less efficacy
20:02compared to sertraline or escitalopram.
20:04I may maybe it's the Cipriani study. It
20:06just comes up a little bit less
20:08effective than escitalopram and
20:11sertraline.
20:13Um there are are there are more
20:15drug-drug interactions. So, any sort of
20:17patient uh that I'm I'm worried about
20:19drug-drug interactions, I'm going to be
20:20a little bit more wary about. Um
20:23I do really like the extended half-life.
20:26It is great for patients that you expect
20:28to miss a few doses.
20:30Um
20:32Now,
20:35people a lot of people categorize
20:37fluoxetine as the most weight neutral. I
20:40think there was some study that like in
20:41a short short very short term there
20:43might have been like some even weight
20:45loss.
20:46I don't see a significant difference. I
20:48don't think it's anything that um will
20:51make me actually think that there will
20:53be a big difference if I switch someone
20:54from
20:55one of the medications to fluoxetine. Um
20:58clinically I haven't seen a big
20:59difference.
21:01I'm trying to think if there's any other
21:02comments that I have
21:04with regards to fluoxetine. It is known
21:06to be a little bit more activating.
21:08Um
21:09I don't typically see it much worse
21:11though than than escitalopram.
21:15Yeah, that's that's my my reflections.
21:17>> Yeah, you know, when it comes to weight
21:18gain, I personally try to disregard
21:23the hard numbers found in population
21:25studies because the population studies
21:27can't differentiate uh between weight
21:30gain as a direct metabolic cause of a
21:32medication and weight gain as a
21:35consequence of treatment. What do I mean
21:37by this? Uh if you sedate a person or if
21:40you treat their anxious depression that
21:42lowers your appetite, then their
21:44appetite will come back. And if that
21:46person uh does not already have healthy
21:48eating habits and they happen to be in
21:50the United States like our patients,
21:53uh then they're probably going to gain
21:54weight. Right? That's different than a
21:56medication that we know to directly
21:59stimulate the appetite uh through some
22:02known mechanism or that even induces a
22:05uh drug-created metabolic syndrome like,
22:08for example, Seroquel. Right? So I I I
22:12don't consider any of the SSRIs except
22:17for Paxil a direct weight gain-causing
22:20medication. Can they apparently cause a
22:23more
22:24uh drug-driven weight gain in some
22:26patients? Yeah. Yeah, you see that
22:28occasionally. But you can kind of tell
22:31from actually checking in with the
22:32patient about their eating habits at
22:34baseline and their eating habits after
22:37the medication. Now, if we were being
22:40just straightforward about this, I think
22:43the next one um that we would rank would
22:47probably be Paxil. But before that, I
22:50want to add more into the F tier. Okay?
22:53Uh I want to add We have Dexedrine down
22:56there for some reason. Let's just put
22:57that right next to the Adderall. And I'm
23:00also going to go ahead and put in any
23:02benzos. So, Ativan, Xanax, uh both of
23:05those go into F tier as well.
23:08Uh where else do we What else is on this
23:10list here? Okay, that's all the ones
23:12that we have there. Uh we might as well
23:14put
23:14>> see dextroamphetamine. Oh, there we are.
23:16Right there, right there.
23:18Okay.
23:20Okay. We'll hold off on the rest for
23:22now, I think. We put all the benzos
23:24there, right?
23:25>> Why are you putting the benzos in F
23:26tier?
23:28Um again, similar to the stimulants,
23:30they are symptomatic treatments that
23:33create habits, uh build tolerance, and
23:36stop working. They're not fundamental
23:39uh treatments of the underlying
23:40condition, so much as they are that
23:42they're drugs that help people feel
23:44better temporarily, you know? Um really
23:46not too different than a prescribed
23:48version of a street drug in my mind.
23:50Okay, controversial, I know. I know back
23:52in the day, especially for the world
23:54well population, a lot of people would
23:56give a couple weeks of benzos uh with
23:58the first start of the SSRI. Okay, I
24:01think if you need to do that, you may be
24:04using SSRIs too early, okay? If a
24:07patient is going to react with that
24:09level of anxiety to an SSRI, and they
24:14are not so psychomotor
24:17uh
24:18you know, slowed and majorly depressed,
24:21why aren't we just giving them a talk
24:24therapy and behavioral activation
24:25instead? The effect size is the same.
24:28Why subject them to the SSRI? There's
24:30really no point to do that, right? No
24:32need for the medication um unless the
24:34patient is motivated, willing, feels
24:36good about it,
24:37uh or it's like a medical necessity. And
24:40anyway, I do prefer to stabilize the
24:42sleep using other agents anyway.
24:45I So, I agree with putting in the F
24:46class. I will again defend it a little
24:49bit. There are a lot of patients that
24:52I'm not acute stress reaction is not
24:54what I'm trying to say. When patients
24:55have very high stress, and I see an
24:57agitated type depression, um it it I've
25:01seen it be incredibly helpful,
25:02especially patients that have
25:04really really really bad insomnia. I'm
25:06not talking about chronic insomnia. I'm
25:08talking about patients who
25:10I I I'm thinking of a lot of patients
25:11who have like a ton of stress at work,
25:13um have some some major crisis or death
25:16in the family, and the
25:19benzodiazepines can help as a short-term
25:221-week prescription to get over that
25:26crisis, which is partially depression.
25:28Now, I agree I don't think of it as
25:31it is symptomatic treatment. You can use
25:33other sleepers.
25:35Um I do find the benzodiazepines are
25:39the most likely to have
25:42not a lot of problems when
25:44not in the long term. I'm talking about
25:45like
25:47trazodone, sometimes I'll have patients
25:48who have a paradoxical reaction with the
25:50metabolite.
25:51Um
25:52Other medications, sometimes they don't
25:54work as well or they work a little bit.
25:55The benzos will knock people out. So, I
25:58do keep it in my after year, but I don't
26:00think it's a completely useless
26:01medication even in
26:04short-term depression, although I'm not
26:05thinking of it as treating the
26:06depression so much as much as
26:08uh things going along with the
26:10depression. In essence, it's keeping
26:11them functional
26:13while
26:15under a lot of stress.
26:17Yeah, it's not ineffective. It's that
26:21it's not effective for what we're trying
26:23to do. That That's my philosophy. Yeah.
26:25Um I think that what you're referring to
26:28can just as easily be accomplished by
26:30high-dose hydroxyzine, low-dose
26:32trazodone,
26:34uh gabapentin at higher doses,
26:37uh
26:38you know,
26:40mirtazapine if you have to, Seroquel
26:42over benzodiazepine any day. There
26:44There's a lot of choices, I think. If
26:46we're going to do a short-term hypnotic,
26:49I would reach for Seroquel every time
26:50over a benzodiazepine. Don't get into it
26:52is what I say. We're doing We're doing a
26:54tier list for insomnia, so we'll we'll
26:55get there.
26:56>> of
26:58What's that? I said we're doing We're
26:59going to do a tier list for insomnia.
27:01So, we We'll We'll get into the more
27:03details in that one.
27:04>> Yeah.
27:05Yeah. Um yeah, it's not as if benzos are
27:08without adverse effects. It's just that
27:10so often people love the
27:13uh drug effects so much um
27:15understandably. They work great. You
27:17feel great. Um
27:19we ignore the adverse effects, but
27:20people are just as likely to have
27:22adverse effects on these medications. I
27:24just stay away from them.
27:25All right.
27:26Let's move on to our next one. I think
27:29we got the Paxil. Paxil.
27:33>> [gasps]
27:34>> Oh boy. You know, it's a very hard one
27:36for me to place. It's got to be either B
27:39or C and
27:42uh I have to fight against my bias. I
27:44think it is a B class medication
27:46ultimately with a big caveat. I would
27:48give it B- if
27:49I can.
27:51Because uh it's quite effective.
27:53Okay.
27:54Uh there's a reason why it's been FDA
27:57approved specifically for so many
27:59neurotic conditions.
28:01Uh
28:02it's great in terms of its efficacy. It
28:05works quickly, you know, and you it's a
28:08sleeper on top of being an
28:10antidepressant class medication. You get
28:12a lot of bang for your buck there on one
28:14tablet, easy to dose. Uh there's
28:16long-acting form and short-acting form.
28:19Uh a lot of good options. But, weight
28:21gain, weight gain, weight gain.
28:23Anticholinergic effects, dry mouth, dry
28:26eyes, constipation.
28:28Um what else with Paxil that's a
28:30problem? Well, it's a very short
28:32half-life. So, if somebody is not very
28:34med adherent, then it's likely to cause
28:37uh a little sense of withdrawal in some
28:40people. So, it's uncomfortable.
28:42Uh I've been I was taught that, "Hey,
28:45this is something you should consider
28:46for patients with poor med They'll
28:47notice the withdrawal and remember to
28:49take medication. I feel like that's very
28:51outdated. Set alarm on the phone, use a
28:52pill organizer. I think that's a
28:54ridiculous notion. So, um despite its
28:57efficacy, I cannot rank this one highly.
28:59I certainly never use it first line and
29:01I hardly ever prescribe it, uh as you
29:03know, because of the weight gain.
29:05Uh first off, that's hysterical. The
29:07idea of using it for patients who are
29:08non-adherent because it's so punishing
29:10when you miss it.
29:11>> [laughter]
29:12>> Yeah, it's ridiculous.
29:14Just a small plug to leave a review if
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29:36Foo reads absolutely every single one.
29:39Let's get back to the show.
29:41As I just got a dog, so there's you
29:43know, the the new movement is all
29:44positive reinforcement and that is not
29:47using positive reinforcement in in your
29:49line of reasoning for medications. So,
29:52paroxetine, cuz we got to make sure we
29:53use
29:54>> Don't tell me they're gentle parenting
29:55dogs now, too.
29:57There's a lot of people who refuse to
29:58use any sort of uh balanced training.
30:00But, paroxetine
30:02they're called SSRIs, selective
30:04serotonin reuptake inhibitors. They are
30:05not all selective. So, paroxetine hits
30:08is an is antimuscarinic and that helps
30:10me to organize all the information that
30:12you kind of just mentioned. So, it is
30:14sedating. Um it does have bad withdrawal
30:16because we know any antimuscarinic
30:18medication is going to have bad
30:19withdrawal. Short half-life. Um
30:22now, bad for pregnancy and
30:26uh what's the other bad one? Bad for
30:27weight gain. Most of that you can
30:29categorize as antimuscarinic. I'm not
30:31saying that that is the you know, reason
30:33why, but
30:34that does help me categorize a lot of
30:36the problems with Paxil.
30:37Now, as you mentioned, the
30:38antimuscarinic also probably has some
30:41effects with regards to helpfulness in
30:43some anxiety disorders. And that's why
30:45you said neurotic conditions, but
30:46anxiety
30:48Yeah, for for people who Mhm. Mhm. don't
30:50don't know what that means. The it has a
30:52lot of FDA indications for
30:53>> that's why it got an approval for PTSD,
30:55right? Cuz the PTSD treatment for
30:58diagnosable PTSD early on, majority of
31:00what you're really what you really
31:02should be doing is sleep stabilization.
31:05And Paxil will hit both your sleep
31:06stabilization and the treatment of the
31:09severity of core PTSD symptoms. So,
31:12great med for that, but I'd rather skip
31:14the weight gain and just give a sleeper
31:16with Zoloft, which is what I usually do.
31:18Yeah. I I would probably put it in C.
31:21Now, it's funny, I think we're balancing
31:22like right now a lot of people just
31:24simply don't use Paxil. So, I think it's
31:26higher ranked than that. But then anyone
31:28who's using Paxil first line, you got to
31:30knock it down. I probably would put it
31:31in C, but I'm fine with B.
31:32>> Yeah. You know what? Let's put it in C.
31:34You've convinced me. Okay, it was on the
31:36edge. Put it in C.
31:38You know, bad Paxil. Don't give it so
31:40much weight gain. We can use other
31:42things.
31:44All right. What's our I think
31:47round out the SSRIs, but I'll let you
31:49keep us going.
31:51Should we
31:53Well, let's briefly put Celexa in. It's
31:55basically Lexapro, but that makes you
31:58more sleepy and it causes you
32:00more QTc prolongation. I never use it
32:04because of that because there's just so
32:05many other choices, but I can see why an
32:07older psychiatrist might use it. It has
32:10to be in B class. It's again just
32:12Lexapro, but it makes you more sleepy
32:14and it prolongs your heart rhythm. So,
32:17it's not a bad medication by any means.
32:19It's just got some downsides and in my
32:21opinion, there's hardly a reason not to
32:23use a different medication.
32:25All right, I'll I'll I'll let me go off
32:26my soapbox on this one. So, little
32:28didactics.
32:29Citalopram is both an enantiomer of
32:32escitalopram. So, that's why it's named
32:34escitalopram cuz cuz the S enantiomer.
32:36So, theoretically, the R-enantiomer has
32:39a little bit of antihistaminergic
32:41activity, and that's why it's probably a
32:43little bit more sedating. Now, I have
32:45seen on the Reddits people being like,
32:47"Oh, uh a nurse practitioner." Now, I
32:49hate I I do I strongly dislike the NP
32:52hate on Reddit, and I try I try my best
32:54to defend the NPs. The
32:56they'll say like, "The nurse
32:57practitioner switched them from
32:58escitalopram to citalopram. What a
33:00moron." And
33:02what I'll say to that is
33:04often times these medication like
33:06reactions patients have to medications
33:08isn't what we would expect based on what
33:10we know pharmacologically. So, I don't
33:13see patients respond to citalopram as if
33:16it's escitalopram with a little bit of
33:17sedation. I've seen patients get
33:19opposite responses and opposite side
33:22effects. I've seen patients who have not
33:25been able to tolerate escitalopram and
33:27then tolerate citalopram perfectly fine.
33:29So,
33:31now
33:32I don't think it makes sense to go from
33:33escitalopram to citalopram
33:36for for most of the time. But, if
33:38someone does have a good response to
33:39citalopram, I don't say like that's not
33:41possible because they something, you
33:43know,
33:44we don't know how these medications work
33:45exactly and how patients respond to them
33:48is cannot be deduced from what we
33:50understand pharmacologically.
33:52So, that's that's my soapbox.
33:54Yeah, it can be defended exactly as you
33:57have. I simply never do it because
33:59there's just too many options out there,
34:01you know,
34:02uh if you take every permutation
34:05of hypnotic anxiolytic sleep support
34:08medication plus primary serotonin-based
34:11anxiety-depression medication,
34:14never have to reach for the same
34:15medication twice, you know,
34:18uh if it's been a few years
34:20and I want to do a trial again and
34:22they're super against escitalopram and
34:25there's some reason why I want to use
34:26it. I really can't imagine the
34:27situation. I might do it. But, um
34:30basically, if I'm on my third or fourth
34:34medication and this isn't some kind of a
34:36super zebra patient, like someone with
34:39autism spectrum disorder, borderline
34:41personality disorder, uh psychotic
34:43features, and like three
34:45hospitalizations where it's like clearly
34:48both a social, psychological, and a
34:52biological thing and I'm doing all kinds
34:54of weird stuff. Uh, if you're treating
34:57major depression and you're on your
34:58third medication in a row with no
35:00remission, reconsider your diagnosis.
35:02Yeah, absolutely.
35:04Um, one last comment about citalopram, I
35:06feel like uh
35:0840 mg is the max dose except it's 20 mg
35:13is the max dose for I think elderly
35:15patients. I think patients over 60,
35:17uh patients who are poor to C19
35:21metabolizers.
35:22Um
35:25Yeah, max dose is 20 mg.
35:27There might be another other population,
35:29but I can't think of it off
35:30top of my head.
35:33We have
35:35not yet exhausted the rest of the SSRIs,
35:38so let's do Luvox, the sigma
35:42the sigma of the SSRIs. Technically, it
35:46has sigma receptor activity. Um, where
35:49do we
35:50put Luvox?
35:52>> Yeah, sigma grindset antidepressant. I
35:54don't know.
35:55I don't know.
35:57I think we should keep it in a question
35:58mark. It's just simply such a backline
36:01choice uh that you pretty much only use
36:04in patients to have OCD
36:06uh that I don't think we can fairly
36:08grade it. The sigma they use it
36:12>> uh SSRI that goes its own way, isn't it?
36:14I've had some patients get a little
36:15sedated on it.
36:17It's not too hard to titrate. The main
36:19reason why I don't use it more
36:21is because I think there's random
36:23insurance denials and it's just um
36:26again, too many men-men drug
36:27interactions. There's no particularly
36:29good reason to use it over the other
36:31ones. I haven't seen that sigma thing
36:33actually play out in better clinical
36:35response for a major depression. So, uh,
36:38very niche pick, you know? But, maybe
36:40it's a sleeper hit that we're just not
36:41using enough. Hard for me to say.
36:43Yeah, the men-men interactions, it
36:45inhibits, um, especially sip 182, and
36:49then basically all of them, 2C9, 2C19,
36:51sip 3A4.
36:53Um,
36:54I think it was studied a little bit for
36:56like COVID because of the sigma enigma.
36:59Um,
37:01Yeah, apparently there was a signal that
37:04it reduced COVID mortality, I think.
37:08But, Who knows? Who knows?
37:10All right.
37:11What do we got next?
37:13Well, we surely are now in the realm of
37:15the SNRIs. Boom. And, uh, I think we
37:19should start with good old Effexor,
37:21venlafaxine.
37:23Okay, um,
37:25Jeez.
37:27Ah. Almost forgot to put it in B.
37:29>> B and A class for me.
37:31Between B and A class. Let's put it in
37:33B.
37:34Oh, definitely B class for me.
37:35Definitely B for me. Venlafaxine, mhm.
37:38And, why?
37:39Well, you know, um, it works.
37:43I have to admit it works, and you know,
37:44you're going to see all kinds of, uh,
37:46psychopharmacologists crying,
37:48uh, you guys are pretending this is a
37:51SNRI. There's no norepinephrine activity
37:54until at least 150. Some studies do not
37:57show a blood pressure response when used
37:59with so-and-so medication. In the
38:01studies, there's no norepinephrine
38:02activity. Well,
38:04there may not be,
38:06but belief is strong,
38:08and
38:09I just tend to see more response on this
38:13compared to some other medications for
38:15some reason. I can't explain it.
38:17Uh,
38:18seems to be pretty well tolerated,
38:19actually. The only downside is the awful
38:21withdrawal syndrome. I'd probably put it
38:23in A class and I'd probably use it a lot
38:25more often. I might even put it in S
38:27class if it weren't for that terrible
38:30withdrawal syndrome.
38:32Famously the worst withdrawal syndrome
38:34out of all the antidepressants. I've
38:35even seen an elderly person get
38:38medically hospitalized once because of
38:40the withdrawal from venlafaxine.
38:43So you know, it works well but just be
38:46careful. You you want to you know, taper
38:48it slowly.
38:50It's also a little annoying I feel like
38:53because I want I'm fine with it
38:56titrating up but I also feel like I wish
38:59it came in smaller increments for
39:01titrating down. But
39:03if you have to come off of it you're
39:04just going to accept some brain zaps and
39:06whatnot.
39:08Yeah, I I think I have less of less warm
39:11feelings for for venlafaxine.
39:13Um
39:15Yeah, the the withdrawal is famous.
39:17You'll hear lots of horror stories.
39:19That's it. I've actually had relative
39:21success. The the patients that I've
39:23tapered off I had no no major hiccups.
39:26Um but I'm not minimizing it. I've also
39:28seen horror cases. I've seen patients in
39:31the emergency room crying
39:33just feeling like absolutely horrendous
39:35as a result of of venlafaxine
39:37withdrawal. So I'm not It seems very hit
39:38and miss.
39:39>> saying I'm not minimizing and saying
39:41it's not real but for the average
39:43patient before they have a complicated
39:45withdrawal I don't kick and scream. I
39:47tell them to probably be careful about
39:50what they read online. Um
39:52Now I don't like venlafaxine because
39:55it's improvement over SSRIs is
39:57relatively small.
39:58So it's not like it's this big hit
40:00medication.
40:02There it can raise blood pressure.
40:05It Yep. can raise heart rate.
40:07So there are more side effects. There's
40:09more problems. Now
40:11in Europe there's a warning for overdose
40:15uh,
40:16because of its cardiac effects in
40:18overdose. I think
40:20um,
40:21I feel like that's something in the US
40:22that we don't pay as much attention to,
40:23that there are cardiac problems as a
40:25result in terms of arrhythmia risk with
40:27these medications.
40:28Um,
40:29Yeah. So, I tend to avoid it with anyone
40:31with any sort
40:32>> not as much as the TCAs. I mean, it's
40:33real, but it's just not as much as the
40:35TCAs. That's all. Yeah. Um, so, I think
40:38of it as like very marginal improvement
40:40over the SSRIs.
40:42Um,
40:42a lot of side effects, a lot of
40:43problems. Now, I don't think it's a
40:45useless medication. I will use it, but
40:48I I don't think you jump the gun. I
40:50don't think there's ever a patient that
40:52I'll use it first line unless I'm using
40:54the two birds one stone, like migraine
40:56or something very specific that makes me
40:58feel like it would work. But,
41:00in general, I'm doing first line
41:02sertraline, SSRIs. Um, I don't typically
41:05start with venlafaxine.
41:08Yeah, I don't go for the SNRIs unless,
41:11as you say, they have a migraine
41:12disorder, a diagnosed fibromyalgia.
41:16Um,
41:17I don't believe in it, by the way, for
41:19apparent ADHD. If you really think
41:21there's a diagnosable ADHD, you should
41:23probably be using at least atomoxetine,
41:25Strattera.
41:27Uh, but, you know,
41:29it's useful.
41:31I'm warm to it because I've been burned
41:34enough from receiving for some reason, I
41:37don't know why this is. Maybe you can
41:39shed some light on this. In the
41:40community here, for some reason, there's
41:43a lot of people doing venlafaxine
41:46And no, it's not a cross-taper. Okay,
41:48they love to do venlafaxine plus Zoloft,
41:51SNRI plus SSRI.
41:52>> Ooh. I totally disagree with it. Uh, but
41:55then I've been burned by trying to pull
41:57off the Effexor first and seeing
41:59worsening and then putting them onto
42:00Effexor monotherapy and maxing it out
42:02and seeing significant improvement. So,
42:05uh, you know, I've warmed to it a little
42:06bit. Um, the combo that is a little, you
42:10know, famous is the California rocket
42:12fuel as as coined by Stephen Stahl,
42:14which is mirtazapine and venlafaxine.
42:17Venlafaxine,
42:18anyone who's using an SSRI and SNRI,
42:20stop it.
42:21>> [laughter]
42:22>> Stop it. Yeah, pick one, please. Pick
42:25one. That's that's bad.
42:26>> Um you know, we might as well throw
42:28Cymbalta on here. I think it's C class.
42:31Uh you know, there's nothing terribly
42:32wrong with Cymbalta. It's on the first
42:34one. It's just the first one there.
42:37It's again C class. C class.
42:40I I
42:42I don't have I have venlafaxine Oh, you
42:43want to put it up in B class?
42:45>> I think of it as I think venlafaxine's
42:46probably a little bit more effective and
42:47then duloxetine has probably little
42:50special indications with regards to
42:51pain. Um
42:55Well, again, the duloxetine runs into
42:57the same problem as the venlafaxine.
42:58It's unclear how much of a
43:00norepinephrine reuptake inhibitor
43:01actually is.
43:02>> It's more balanced marketed that way.
43:04Yes, we believe it.
43:05What's that?
43:06>> It's more balanced than venlafaxine.
43:08Supposedly, but I believe when they
43:10actually go and then study the amount of
43:13norepinephrine reuptake inhibition using
43:16that method where they measure the blood
43:18pressure after giving I already forgot
43:20the name of the other chemical.
43:23Uh but it may not be very potent at all
43:25as far as that goes. The only true SNRI
43:29on the market
43:30may be
43:32um levomilnacipran
43:35Wow, it's I can't remember the brand
43:36name right now, but it's uh milnacipran.
43:39Savella
43:41Savella. Um I'm going to go off of my
43:43very limited experience with Savella,
43:45which I've been able to get approved for
43:47patients who have an existing diagnosis
43:48of fibromyalgia and who I'm treating for
43:50depression because I obviously can't use
43:52Fetzima. My patients are low income, so
43:54no one gets Fetzima. I would put this
43:57one
43:59maybe in A class.
44:00>> Whoa. Maybe. Maybe, maybe. Yeah.
44:04Um
44:05actually fulfilling the promise
44:08of the SNRI, you know,
44:11um
44:13and
44:14yeah, lots of good titration steps that
44:17you can use. Do we also have uh
44:19desvenlafaxine lying around here? Yes,
44:21we do. There's Pristiq.
44:23Um
44:24this is again theoretical and so I'm
44:26going to let you move these around if
44:28you've got more experience with them
44:29than me. I can't use it very much, again
44:31too expensive, uh but I'd put it up in A
44:33class. Better tolerated, less uh
44:36withdrawal I've heard than the
44:38venlafaxine for some reason, but who
44:40knows? I'm shooting in the dark here.
44:42Just that it's some some fact so it is
44:45not it isn't generic. Um whether it's on
44:48formulary is a different question.
44:50Desvenlafaxine
44:52um
44:53theoretically is
44:55uh
44:59has less drug-drug interactions than
45:01venlafaxine. Um I haven't noticed
45:03significant difference in terms of
45:04efficacy with the the two medications.
45:07I would put it at at probably probably a
45:09B class.
45:10>> hit and miss level for the SNRIs. I feel
45:13like it's uh some people it's like no
45:15better and then for some people suddenly
45:17it works. It's very hard to say. Could
45:19be completely random and based on the
45:23uh what's happening in their lives. I
45:24can't rule that out, but you know, when
45:26you're doing med management you just
45:27kind of have to work along a certain
45:30set of things.
45:32All right. Um
45:35What have we got next?
45:38You know, we probably should have done
45:39the atypicals. Oh, yeah, clonidine goes
45:42up there. We probably should have done
45:43the atypicals before we did the SNRIs
45:46because personally I would consider
45:48atypicals before the uh SNRIs. I don't
45:51mean atypical antipsychotics. I mean the
45:54uh you know, non-traditional
45:56antidepressants, Wellbutrin and Remeron.
45:58Okay, uh despite my hatred of weight
46:01gain, I must put Remeron in A class.
46:05Okay, if it was not for the weight gain
46:08and in many patients, especially Asian
46:10patients,
46:11who are more sensitive to antihistamine
46:13effects, significant sedation. Oh man,
46:16it works so good. Works so good. It's
46:18almost S class. Great med. Mirtazapine.
46:21I Let's put it at the front of the list.
46:23>> Yeah, I have it I have it on on Right
46:24after Lexapro.
46:25>> I have it in probably the S class. Now,
46:28in my opinion, oh
46:30Oh, for some reason. There we go. In my
46:31opinion, first-line medications for
46:33antidepressants, I'm thinking of
46:35escitalopram, sertraline, mirtazapine,
46:38bupropion. I I think those are all
46:40reasonable first choices depending on
46:42patient profile.
46:43Um I very very very rarely deviate from
46:46those four. Now, mirtazapine, weight
46:49gain. So, for patients that need to gain
46:52weight, great medication. It is
46:54incredibly sedating. Incredibly
46:56incredibly incredibly sedating. Warn
46:58your patients that they will feel like a
46:59zombie. Now, why do I think it's
47:01important to warn patients? Because I
47:03tell them the first three or four days
47:05you're going to feel like a zombie.
47:06Usually what I see with patients is it
47:07gets better. And as they adapt, the that
47:11zombie hollow like can't do anything
47:13feeling is better by day four. And
47:15usually it gets better every single day.
47:17And there's Think of the first period as
47:19kind of getting
47:20past the the hump. Another important
47:23thing, some people say at the higher
47:25doses it's not sedating or it's
47:27activating at the higher doses.
47:29The better way to put it in my opinion
47:31is it's not going from zero to seven and
47:35a half
47:36is not as sedating as going from 15 to
47:4030. So,
47:42to me the important thing to teach is
47:43it's Did you mean the opposite? It's
47:45more sedating to go from zero to seven
47:47and a half than it is to go from 15 to
47:4830.
47:49>> Correct. Correct. And that like it Going
47:51from 50 to 30 is more sedating, but it's
47:53significantly less of a jump
47:56than going from zero to 7.5. In fact,
47:59zero Yeah, the most sedating jump is
48:01zero to 2.5. So, so for patients who are
48:04on super low dose and they're on, you
48:06know, I'm on I'm on 7.5. What do you
48:08mean I need to get to 30 mg? They'd be
48:10like, are you nuts? I'm going to be a
48:11zombie.
48:12You have to teach that I don't say, oh,
48:14it's activating and you'll have more
48:16energy, but the jump isn't as big of a
48:19jump from the beginning stages.
48:22Yeah, uh
48:23that's the old tradition, right? I don't
48:25believe in it. I I don't think it stops
48:27being sedating or increasing sedation at
48:30any dose, as you say. Uh it is less of a
48:32serious issue for most patients once you
48:35get into the 30 range, uh but I've had
48:38patients that I just can't tolerate that
48:40change anyway. Yeah. So, it really
48:42depends. And again, Asians more
48:44sensitive to antihistamine effects, so
48:46just be aware of that sedation.
48:48Um
48:50great med, by the way, forgot to mention
48:52if you're afraid of GI side effects and
48:54sexual side effects, okay? Uh and
48:57actually gets you probably some
48:59norepinephrine action through a unique
49:00mechanism uh versus SNRIs, which on
49:04paper are named that but may not get you
49:06much norepinephrine action. Also, um
49:10has a pathetic but still statistically
49:12significant reduction in some
49:14populations for meth use disorder. You
49:17can get like three less meth days in the
49:19month. Pretty good, huh?
49:21Yeah, that that the the reason why I
49:22bring it up is there's like this paper
49:24of like, we don't have a drug to treat
49:26meth as if like this is going to uh
49:28to- totally change the landscape of meth
49:30use.
49:31Um yeah, it it helped a little bit. Uh
49:34well, it doesn't stop everyone here from
49:35throwing it on every single uh person
49:39who is incarcerated that has a meth use
49:41disorder and wants to sleep because the
49:42dorm is noisy.
49:43A lot of that going around around here.
49:45I imagine.
49:46Um so, yeah, great medication, very
49:48sedating, uh does increase weight,
49:51does help with GI side effects. So, it's
49:53a poor man's Zofran.
49:56Mhm.
49:57Okay.
49:58Uh Wellbutrin, great man.
50:00Uh hit and miss tolerability.
50:03Uh love to throw this on on almost
50:04everyone who doesn't respond to just one
50:07medication. Uh
50:09A class, certainly A class as well. Uh
50:12great medication, can give you a pep in
50:14your step. Uh beware of using it in
50:17patients who have a lot of baseline
50:18anxiety. Uh even if this is a medication
50:21that seems to treat anxiety in the long
50:23term, if the patient can tolerate it, uh
50:25the initial burst or worsening anxiety
50:27may be intolerable. Uh this is also a
50:30medication that you can use with or
50:32without depression if people are having
50:33problems reaching orgasm. There's been
50:35several studies showing that this helps
50:37you reach orgasm faster. So, you can use
50:39this for anyone with an orgasmic
50:41disorder. Um little weight uh loss and
50:46appetite decrease, which a lot of people
50:47like. Um people use it off-label for
50:50ADHD. Never seen it work for that, but
50:52why not? Go ahead and throw it on.
50:55Um
50:56watch out for the sleep problems. And
50:58lots of nice little formats, you can
51:00play around with it. You want to only
51:01have them exposed to it uh in the
51:03daytime for some reason, sure, use the
51:05SR uh once a day. But, do not play with
51:08the dosing if you're using it as
51:09monotherapy. If you're using it as
51:11monotherapy, you should probably just
51:12use the XL types. Absolutely. I think
51:15this is a spectacular medication. Um
51:17doesn't have very sought out by patients
51:20cuz it doesn't have the typical problems
51:22that we see with there's, you know, not
51:23weight gain, there's not sexual
51:24problems, uh there's not sedation. It's
51:26a you know, we think of it as a a mild
51:28stimulant. Now, my warning to providers
51:32is a lot of times people use bupropion
51:35for anyone who says they don't want
51:36weight gain for any sort of disorder.
51:39To me,
51:41as a clinician, you should be learning
51:43patients that respond well to SSRIs
51:46versus patients who will respond well to
51:47bupropion. There are patients with
51:49depression that I say like
51:51I'm telling you that Zoloft will be a
51:53much more effective medication for you.
51:55Um I I think
51:59as you mentioned with anxiety, yes, it
52:01does help anxiety for some patients, but
52:04it does worsen anxiety for a lot of
52:06other patients. And you see I feel like
52:10we see pendulum swing so far as if
52:12people are answering the question of
52:13like either yes, it's bad for anxiety or
52:15no, it's it's not bad for anxiety. And
52:17there's there's nuance here. So
52:20uh
52:21I I feel like in med school I learned
52:23like never use it for anyone with
52:24anxiety. And now I see all over LinkedIn
52:26of like why are you not using it in your
52:28anxiety patients? What's wrong with you?
52:30Um
52:31you know, the
52:33for for patients who have that very
52:35strong anxiety, I I do see it worsen
52:38long term. And oftentimes what I'll see
52:40is they'll get a little benefit in the
52:41beginning as their depression gets
52:43treated, but then 4 months, 6 months
52:45down the line, I do see a little bit
52:47increase in irritability, a little bit
52:48of less little more insomnia. There are
52:51problems. So there are patients that
52:53come wanting a medication that doesn't
52:55have problems and I provide the psychoed
52:57that like, yes, it would be ideal that
52:58we could have an SSRI that doesn't have
53:00problems, but that said, I don't think
53:01we use an incorrect medication for you
53:03be just because it doesn't have the
53:04problems you don't want to have.
53:06Um
53:07yeah. Yeah, you know, the anxiety
53:09increase can be substantial. Don't just
53:11throw it around because the database
53:14shows that the people who tolerate it
53:15improve their anxiety. I have had
53:17patients with severe anxiety uh
53:20actually end up having a major
53:21catastrophe at work because of how bad
53:24the anxiety was when they started it. Uh
53:26for a medication like Wellbutrin in the
53:28anxious patient, if we are going to
53:29trial it, I recommend they try it for
53:31the first time on a weekend or something
53:32or they when they have nothing to do.
53:33Yeah.
53:34Awesome.
53:36Um let's see. Also it is a 2D6
53:38inhibitor.
53:40Um
53:41make sure you get your your blood
53:42pressure and heart rate.
53:43>> 2D6 inhibitor and thus can be used to
53:45increase effective dose of your Abilify
53:48Maintena and Aristada,
53:50which maxes out at a 15 to 20 mg daily
53:53dose. This is not medical advice
53:55that may increase
53:57possible side effects
53:58and is technically off-label strategy.
54:01>> Yeah. And we also have a validity which
54:03I don't think I didn't I used a
54:07template that already existed. This one
54:08doesn't have a validity.
54:10Yeah, this is a weird template. Where
54:12are my TCAs? Where are my MAOIs? And
54:15yeah.
54:16I I had it on my template, but I like
54:19this one cuz it had colors.
54:21And it was already pre-made and I
54:22couldn't pick update it. Yeah. And why
54:24are there so many antipsychotics?
54:27To make it fun. It's weird. It's a it's
54:30a weird template.
54:31Let's do trazodone.
54:33I think I have to put poor old trazodone
54:37into
54:39C class
54:40C class because we're rating it for
54:42major depressive disorder. We're not
54:44rating it for trauma disorder or
54:47insomnia.
54:49It's just not tolerated enough by most
54:52people
54:54you know at a
54:56high dose, a dose that you would need
54:57for the antidepressant effect and I
55:00don't think when I have had it at that
55:03high for people that it's that
55:05efficacious for depression primarily.
55:07Quite efficacious for sleep, not
55:09necessarily all that efficacious for
55:11depression, but that again is probably a
55:13bias because I only get it up that high
55:15in very rare individuals who happen to
55:18need this severe polypharmacy type
55:21treatment and
55:23you know also somehow don't have a QTC
55:25problem at a higher dose of trazodone.
55:28Now
55:29I guess a little some teaching points.
55:31Low-dose trazodone is not a small
55:34antidepressant. So it is one of those
55:35medications that you need to get it to
55:36the higher doses. The mechanism is
55:39through
55:41serotonin reuptake the same as the SSRIs
55:43except it's not selective.
55:45Um
55:47I haven't seen it be a home run. I
55:50typically, as you say, will have low
55:52dose trazodone and then an SSRI. Um
55:55I I agree with the D class
55:57recommendation.
56:00Um one thing to add, um
56:02trazodone has an active metabolite
56:04called m-chlorophenylpiperazine and that
56:06can cause agitation in some people. So,
56:08don't be surprised if even that low dose
56:09trazodone or especially that low dose
56:11trazodone, some patients report a
56:13paradoxical effect on their sleep or
56:15their mood. Uh not everyone likes that.
56:18It's apparently a designer drug Now that
56:20people don't like and can can cause
56:22dysphoria.
56:22>> Important teaching point here. So, it's
56:25tough because
56:26what what I do with that information is
56:28be careful about how you talk to
56:30patients cuz you're using it for
56:31insomnia which has a lot to do with
56:33anxiety. And by telling them that they
56:35might have a paradoxical awful reaction
56:37and not sleep that night, you're going
56:38to worsen their anxiety using that
56:39medication. The flip side is if someone
56:42comes and says, "I slept terribly on my
56:44trazodone." you have to believe them.
56:45And it doesn't mean you don't provide
56:46psychoed, but just be wary about how you
56:48provide that psychoed.
56:51Yeah, I pretty much say, "Hey, this
56:52works great for a lot of people and for
56:54some people it doesn't work at all and
56:55might even make the sleep worse. Uh we
56:57don't know. Why don't you just try it
56:59out and see if you like it. If you like
57:00it, keep taking it. If you don't like
57:01it, don't keep taking it." Uh that can
57:03be helpful, but I think your population
57:05is more neurotic than mine. Believe all
57:07insomniacs.
57:09All right.
57:10Okay, um we're low on time. Let's go a
57:12bit quickly. I'm not going to put any of
57:14the antipsychotics on this list uh
57:17except for Abilify.
57:18No, no, no, don't even put them on the
57:19list. I don't even want them on the
57:20list. Get them off. Get them off.
57:22Terrible. Uh they shouldn't be on this
57:24list. Uh that's for a different day. But
57:26actually, I'm sorry, we're going to put
57:27Abilify, low dose Abilify in S tier. Oh,
57:31man, that's controversial. S tier, get
57:33it up there. But, it has to be
57:36under under 5 mg. Um
57:40the data and the clinical experience
57:42shows that this is a very good
57:44augmenting agent. Works great. Uh
57:47probably has a unique effect. Uh that's
57:49probably true also then the
57:50brexpiprazole and maybe of raylar, not
57:53clear, a little early to say.
57:55Uh but, you know, the dopamine partial
57:58agonists uh seem to be pretty good as an
58:00add-on. But, um
58:02while we're briefly putting it in S
58:04tier, let's put it down in A. Thank you
58:05very much. You read my mind.
58:07>> I refuse to let you get away with
58:08putting it in S tier. You are not going
58:10to be at You read my mind. I wanted to
58:11emphasize how efficacious it is, but
58:13even at low doses, the risk of tardive
58:15dyskinesia is there. And especially in
58:18patients without schizophrenias, okay?
58:20The risk of tardive dyskinesia is
58:21higher.
58:25Um
58:26Now, let's see if we can do. So, uh one
58:28helpful thing
58:30uh tdscreen.ai is a cool free AI to help
58:35um screen your patients for tardive
58:37dyskinesia.
58:38I didn't know this exists. I don't know.
58:41Until I can read the research on this,
58:43you should know how to do an AIMS.
58:44>> See the research.
58:45>> Okay. Read the AIMS. Read the AIMS. Read
58:48the uh you know, directions and actually
58:51do an AIMS and you can do a modified
58:53version of the AIMS over video if you
58:54have assistance from a family member or
58:56nurse. Um okay. Spravato as a nasal
59:00Yeah, man. I'm not letting you lead to
59:02an increase of antipsychotic use for for
59:05I don't think it can get any higher.
59:08Do not dose Abilify above 5 mg if what
59:11you are trying to do is trying to treat
59:13major depressive disorder without
59:14psychotic features. Do not do it. Just
59:16don't do it. It's not worth it.
59:19So, yes. Please please be wary be
59:22mindful when you use it. Don't throw it
59:23out. Uh
59:25I I think there's so many important
59:26caveats. Make sure you have the right
59:27diagnosis. Make sure you're not ignoring
59:29other things. Please don't use more
59:30antipsychotics unless you feel very
59:32confident with what you're dealing with.
59:34Okay.
59:35You know, there's going to be a lot of
59:36lay people who are going to skip to the
59:37end of this video, so let's put put it
59:39down in the question mark section.
59:40Abilify.
59:41>> go from S tier to A tier to question
59:42mark.
59:44Yeah, I think that's indicative of how
59:46we want to think about it.
59:47>> Okay.
59:48And in the same way, let's go ahead and
59:50put Seroquel in the question mark. Well,
59:53I agree with the skip, but I think you
59:55should put it in
59:57Oh, no. No. Come on. Good old Seroquel.
59:59I'm just thinking I'm just thinking I
1:00:00would I didn't I didn't have it in in
1:00:02particular. I think I should be going
1:00:03like this. I would not put it anywhere
1:00:07just because it's augmentation agent.
1:00:08So, it goes in the question mark, but as
1:00:10augmentation agent is pretty dang good.
1:00:12I would give it a B. It works great in
1:00:14anyone who doesn't care about weight
1:00:16gain appetite increase, but definitely
1:00:17causes a ton of weight gain appetite
1:00:19increase. It's got lower risk of tardive
1:00:21dyskinesia than other ones and it's
1:00:23pretty dang well tolerated. So well
1:00:25tolerated, it's hard to get patients off
1:00:26of it sometimes once they're stabilized
1:00:28because they're like, "Oh man, this
1:00:29helped me so much." And then they're
1:00:31asleep while destabilized when you pull
1:00:32it off at least temporarily. So, use
1:00:34with caution Seroquel.
1:00:36Um
1:00:38Yeah, and I hate I don't want to have
1:00:39the high-risk medications be up top
1:00:41where they have people be prescribing
1:00:43lithium and antipsychotics. Make sure
1:00:44you have the right diagnosis, people. Um
1:00:47Treatment-resistant depression is where
1:00:48personality disorders go to hide.
1:00:50Let's carry on.
1:00:51Yeah.
1:00:52Oh, lithium.
1:00:54Actually, I'm not as worried about if
1:00:56you're sticking to 300 to 450 as long as
1:00:58you're there.
1:00:59That does. Yeah. Okay. Vortioxetine.
1:01:02It's okay.
1:01:04It's all right. You know, you know that
1:01:06meme maybe on YouTube where if that guy
1:01:08eating that I think it's like a burger
1:01:09or something, he's like, "It's all
1:01:11right." That's Trintellix. So, I think
1:01:13it belongs in B tier.
1:01:14>> it's B. I've used more than a couple
1:01:16times.
1:01:17Where did you go?
1:01:18Okay. It didn't really pan out in terms
1:01:20of the promises, right? Like helping
1:01:21with cognition or is just the one where
1:01:23they claim there was um some improvement
1:01:25in sexual side effects. I think there
1:01:27might be a little bit of signal for
1:01:28that. Or is that another one?
1:01:30>> and vortioxetine have the signal for
1:01:32sexual side effects. Vortioxetine has
1:01:34the maybe cognitive effects question
1:01:36mark.
1:01:38Oh yeah, when they wanted to call it
1:01:39Brintellix but there was always like
1:01:41some kind of onset already called that.
1:01:42Anyway,
1:01:43I would put vortioxetine and vilazodone
1:01:47on the same tier B. This is expensive,
1:01:50it's not particularly more effective
1:01:51than others. If you're having someone
1:01:53who has a hard time tolerating
1:01:54medications, they might be able to
1:01:56tolerate it better than the other ones.
1:01:57It's worth a try.
1:01:59Is it something you reach for first?
1:02:01Absolutely not. Is it something that you
1:02:03avoid? No. It's called solid B tier.
1:02:05>> Yeah, I so I've used a little bit more
1:02:06of the vilazodone. Um, you know, I don't
1:02:09think I'm not going to be using it first
1:02:11line. I have It did help a little bit
1:02:12with the sexual side effects. So I had a
1:02:13bunch of guys that
1:02:15it helped a little bit. It wasn't
1:02:17foolproof. It wasn't like they had no
1:02:18sexual side effects.
1:02:20Um, but it did help a little bit. So I
1:02:22do like it as a medication. And I will
1:02:24it is I feel like some of these
1:02:25medications I'll just never get to.
1:02:27Vilazodone I do get to.
1:02:29Um.
1:02:30Yeah.
1:02:31How about esketamine? Whoa. Everyone
1:02:34loves their ketamine today.
1:02:37This is a C tier class medication for
1:02:38me. Yeah. This is a C or a D. Maybe D.
1:02:43We're going to upset the people.
1:02:45Putting in D.
1:02:46It's in D. Why is it in D? It's in D for
1:02:49me and I won't budge from that. Why? Uh,
1:02:52works great in a select amount of
1:02:53people. Can be life saving in a select
1:02:55amount of people but unfortunately
1:02:57probably has opened up the field to more
1:03:00peddling of drugs instead of treatment.
1:03:03And also only a 7-day treatment effect
1:03:06and I don't think that a lot of these
1:03:09clinics giving out Spravato are doing
1:03:11the work that they should be in actually
1:03:13getting patients into therapy and
1:03:15lifestyle changes which is how Spravato
1:03:17is going to work. It is a short-term
1:03:19treatment that helps you lift out of
1:03:21depression and then you have to do
1:03:22hardcore lifestyle changes and
1:03:25psychotherapy on top of that. It's not
1:03:27like one of the other medications in the
1:03:29S or the A tier where you can basically
1:03:31get someone mostly out of remission even
1:03:33if they do zero work and you know, have
1:03:36them live their life long term with
1:03:37minimal side effects. Spravato a bit of
1:03:40a problematic medication. I'm glad it
1:03:42was discovered. I'm glad it's being used
1:03:44sometimes responsibly but lot of
1:03:47caveats.
1:03:47>> lots of thoughts that I'm not going to
1:03:48go into here. I'm going to say something
1:03:50which I shouldn't say cuz it's not going
1:03:52to be heard correctly by the people who
1:03:53I want to hear it. But to me an
1:03:55archetypal risk is and I'm basing this
1:03:58off of the few things I've read. This is
1:04:00not a political but this is nothing.
1:04:02Elon Musk to me is an archetypal hit
1:04:04story of the risks that I see with Mhm.
1:04:07esketamine. And what I mean by that is
1:04:10that there's so many patients now who
1:04:12are seeking it out to use it in a sense
1:04:15to ignore other problems. And they're
1:04:17using it essentially as a drug as in
1:04:19they're they're making lifestyle choices
1:04:21that are
1:04:23leading to that almost bound to lead to
1:04:25stress levels that are not manageable.
1:04:27And then they're trying to compensate
1:04:29with a drug to keep them going. And
1:04:31that's what I see with a lot of patients
1:04:32who are seeking out a lot of the
1:04:33controlled substances is uh
1:04:36and that's not all patients. I've seen
1:04:38it spectacular treatment. I love that
1:04:39it's short-acting
1:04:41short
1:04:42I like I love that it works right away.
1:04:44There's a lot of patients that it helps
1:04:45a ton but
1:04:47so many patients are now seeking it out
1:04:49instead of looking at the other problems
1:04:50in their lives. And
1:04:53I have a lot more to say that I'm not
1:04:53going to right now but yeah, I agree
1:04:55with the CD.
1:04:59I wish there was buspirone here.
1:05:02And I know it's not an approved
1:05:03medication for depression.
1:05:05But I do think that the a zip arounds
1:05:08cuz there's a new one too which I don't
1:05:10see a point in using when we have brown.
1:05:12I hope you can edit this in, but I would
1:05:14put buspirone into the B class.
1:05:17Buspirone class.
1:05:18>> Because it's just so low risk
1:05:20and relatively well tolerated and it is
1:05:24pretty efficacious for anxiety, trauma,
1:05:26and irritability, which often can come
1:05:29hand in hand in your major depression
1:05:30patients.
1:05:31It works for augmentation.
1:05:34Just don't under dose it. Start at 15,
1:05:37but be ready to go down if the patient
1:05:40is more sensitive to it and don't be
1:05:42afraid to take it to the max. Buspirone,
1:05:43buspirone, buspirone, buspirone.
1:05:45>> Also
1:05:46Big fan of it these days.
1:05:47>> Um I've also seen Isn't there that small
1:05:48study that it helped with the sexual
1:05:50side effects of the SSRIs?
1:05:53Yes, I also use it along with bupropion
1:05:55to help with sexual side effects and
1:05:57yeah, it seems to have some efficacy for
1:05:59that. So if someone needs to stay on
1:06:01something and they're having too much
1:06:02anorgasmia,
1:06:03reach for the buspirone or the
1:06:05bupropion. Not a bad idea.
1:06:07>> lamictal.
1:06:10I'm not going to put it up there. It's
1:06:12too niche. I would use it for people
1:06:14with obviously mixed depression or
1:06:16bipolar features. I would consider it
1:06:18for OCD. Do not put it up there. Stop
1:06:20it. Stop it.
1:06:22>> [laughter]
1:06:23>> And then for some reason they put
1:06:24lamictal XR for some reason. Why do you
1:06:26do XR? I don't need it. Just use
1:06:28regular.
1:06:29>> It's got enough risk that I don't want
1:06:31it being given more often
1:06:34unless you're real pro and you know what
1:06:36you're doing. And stop it. Where do you
1:06:38want to put it? I will not sign off on
1:06:40this if you leave it up there. It should
1:06:42stay at the bottom. It is not mainstream
1:06:44treatment.
1:06:45Um Yeah.
1:06:48Now it's interesting. I think there's
1:06:49there's more to say about that. I think
1:06:52um
1:06:53it does have some evidence for
1:06:55depression. I think of it as Now some
1:06:57people like to use it
1:06:59I kind of I was rallying against the
1:07:02bupropion cuz it's like people are
1:07:03saying like oh it just If someone
1:07:05doesn't want side effects, then I use a
1:07:06medication that doesn't have side
1:07:07effects, but you don't use something
1:07:08that's not indicated just because the
1:07:10side effect profile matches the side
1:07:11effect profile that you want. Um, I do
1:07:14for patients with emotional
1:07:15dysregulation and
1:07:19uh, reporting depression, I do see it
1:07:21helpful. I don't see it helpful in MDD
1:07:22proper.
1:07:25Yeah, it's it's too hit and miss. The
1:07:28risk is too high. Uh, and it's too easy
1:07:32for it to be basically a placebo because
1:07:36it doesn't really have so many side
1:07:38effects. I think it's an S-tier med for
1:07:40bipolar, but we should not put it in the
1:07:43MDD columns. That's all I'm going to say
1:07:45about it.
1:07:46Um,
1:07:48where would you put your TCAs? I would
1:07:50put doxepin in C.
1:07:52Uh, I'll put amitriptyline in D.
1:07:54>> Doxepin is used as a sleep aid
1:07:56for sleep, not for depression.
1:07:58Oh, you can use it for both.
1:07:59>> Yeah.
1:07:59And then, um, probably clomipramine
1:08:03is like
1:08:05B
1:08:06and, uh, what's that other one? I don't
1:08:09use them enough.
1:08:10>> Clomipramine?
1:08:11No one uses them. No point in doing a
1:08:12tier list. Um,
1:08:14I wish we did I've I've had the MAOIs.
1:08:16>> But, consider them. Consider them if you
1:08:17have true, uh, treatment-resistant
1:08:19depression, not just we're calling
1:08:21something that's trauma and personality
1:08:23depression. Uh, please consider your
1:08:25TCAs and your MAOIs if you know what
1:08:29you're doing.
1:08:29>> the phenelzine and selegiline patch in A
1:08:32or B tier, probably.
1:08:35Yeah, they're pretty good.
1:08:35>> Yeah. Okay, that's all the time I got.
1:08:38Uh, I hope people like this one. Uh,
1:08:40it's very click-baity, very internet,
1:08:43um, but hopefully it also has some
1:08:44useful information for people to at
1:08:46least make your own tier list, you know,
1:08:48because the tier list I use for
1:08:50medication should really be tailored to
1:08:52your patient population. Patient
1:08:53populations are different and, uh, your
1:08:55diagnostic pool is going to be different
1:08:57and so your treatment response is going
1:08:59to be different, too.
1:08:59>> Awesome. Great ending point. I will see
1:09:01you next time, Dr. Phil.
1:09:04All right. See you.
1:09:05Thanks for listening. If you want to
1:09:07support the show, check out my very
1:09:09practical antidepressant course. If you
1:09:12want to check that out, go to
1:09:14psychopharm.farm.
1:09:17If you prefer to read, you can go to
1:09:19amazon.com.
1:09:21You can search my name, Gregory, g r e g
1:09:24o r y, Malzburg, m a l z b e r g.
1:09:28And the book is Psychopharm's Guide to
1:09:30Treating Depression.
1:09:31>> [music]
1:09:31>> It's a nice, easy, readable, practical
1:09:34guide to medications for depression.

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