July 1, 2025 • 38 mins
Listen in as our expert panel discusses practical considerations for starting and optimizing antidepressants for treating depression and anxiety. You’ll listen to panelists cover various aspects of antidepressant use, such as serotonin syndrome, QT prolongation, and weight gain concerns.
Special guest(s):
- Tammie Lee Demler, BS, PharmD, MBA, BCGP, BCPP
- Director of Pharmacy and Residency Programs, New York State Office of Mental Health
- State University of New York at Buffalo School of Pharmacy and Pharmaceutical Sciences
- Sarah E. Grady, PharmD, BCPS, BCPP
- Professor, Drake University College of Pharmacy and Health Sciences
- Clinical Pharmacist, Inpatient Behavioral Health Unit, Broadlawns Medical Center
You’ll also hear practical advice from TRC’s Editorial Advisory Board member:
- Craig D. Williams, PharmD, FNLA, BCPS
- Clinical Professor of Pharmacy Practice
- Oregon Health and Science University
None of the speakers have anything to disclose.
This podcast is an excerpt from one of TRC’s monthly live CE webinars, the full webinar originally aired in May 2025.
TRC Healthcare offers CE credit for this podcast. Log in to your Pharmacist’s Letter, Pharmacy Technician’s Letter,or Prescriber Insights account and look for the title of this podcast in the list of available CE courses.
The clinical resources related to this podcast are part of a subscription to Pharmacist’s Letter, Pharmacy Technician’s Letter, and Prescriber Insights.
- Clinical Resources:
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
This transcript is automatically generated.
Tammie Lee Demler (00:00):
The discontinuation process is
different for everybody.
I think that thoseparesthesias, that electric
shock sensation that youdescribed, Sarah, has gotten
kind of a bad rap in that peoplehave been describing that to
(00:20):
each other as being addicted toyour antidepressant.
And that provides adisincentive for many people to
start it because they don't wantto be addicted to a medication.
So to be able to describe thatas being just a physiologic
response to discontinuingsomething that affects your
neurochemistry.
So I think in terms ofeducating our patients, we need
(00:41):
to also provide that informationthat you're not addicted to
your antidepressant, butdiscontinuation too quickly can
cause these physiologic sideeffects that would
Narrator (00:57):
Welcome to Medication Talk, an official podcast of TRC
Healthcare, home of pharmacistletter, prescriber insights, and
the most trusted clinicalresources.
Proud to be celebrating 40years of unbiased evidence and
recommendations.
On today's episode, listen inas our expert panel discusses
practical considerations forstarting and optimizing
antidepressants for treatingdepression and anxiety.
(01:18):
You'll listen to panelistscover various aspects of
antidepressant use, such asserotonin syndrome, QT
prolongation, and weight gainconcerns.
Our guests today are Dr.
Tammy Lee Demler from the NewYork State Office of Mental
Health and SUNY at BuffaloSchool of Pharmacy and
Pharmaceutical Sciences.
and Dr.
(01:38):
Sarah E.
Grady from the Drake UniversityCollege of Pharmacy and Health
Sciences.
You'll also hear practicaladvice from TRC's editorial
advisory board member, Dr.
Craig Williams from the OregonHealth and Science University.
This podcast is an excerpt fromone of TRC's monthly live CE
webinars.
Each month, experts andfrontline providers discuss and
(01:59):
debate challenges in practice,evidence-based practice
recommendations, and othertopics relevant to our
subscribers.
And now, the CE information.
This podcast offers continuingeducation credit for
pharmacists, pharmacytechnicians, physicians, and
nurses.
Please log into yourpharmacist's letter, pharmacy
(02:19):
technician's letter, orprescriber insights account and
look for the title of thispodcast in the list of available
CE courses.
None of the speakers haveanything to disclose.
Now, let's join TRC editor, Dr.
Sarah Clockers, and start ourdiscussion.
Sara Klockars (02:38):
For today's discussion, we'll spend most of
our focus on the use ofantidepressants for the
treatment of depression oranxiety, where they're one of
the initial treatment options,along with talk therapy or
cognitive behavioral therapy.
And the antidepressant choicewill be tailored to the
individual patient.
And so, Tammy, I was hopingyou'd get us started and share
(02:59):
some factors you consider inyour approach when evaluating
antidepressant options.
Tammie Lee Demler (03:06):
Sure.
I would like to say it's allabout shared decision-making
first.
But I have to go right to FDAapprovals because that's where
my pharmacist cap comes on.
And I look at what medicationshave FDA approval and rigor in
evidence for their use.
So it's surprising that not allantidepressants have every
(03:27):
indication as every other onefor either anxiety or different
types of depression.
So I go with FDA approvalsfirst and then work with our
patients to sort of look atpharmacodynamic characteristics,
what the side effects oradverse effects could
potentially be And I'll just addquickly that not all adverse
effects are bad.
Whereas, you know, some of themmay cause sedation or
(03:50):
sleepiness.
Some people may want that for asleep time improvement for
their particular condition.
Others may need a more energyboosting medication.
So I think tailoring the sideeffects, and I say that as a
term I don't like to use veryloosely.
I prefer adverse reaction oradverse experience.
We look at those as trying tooptimize what the
(04:10):
person-centered approach thenwould later be after we kind of
cover all those checkboxes.
Excellent.
Sarah,
Sarah E. Grady (04:18):
did you have anything to add?
I agree with everything thatTammy said.
I just want to make emphasis onthe shared decision-making.
If a patient really wants totake a certain medication and it
has FDA approval and they'recomfortable with the side effect
profile, then we definitelytake a look at that.
(04:39):
We also take a look at if theyhave a family history of a
certain antidepressant thatworked for their depression or
anxiety condition of that familymember, then we also consider
it in the differential.
Craig Williams (04:53):
I'll just add too, sir, a brief in
expectations that if, you know,we're talking second generation
antidepressants, we do kind ofmoderate expectations a bit.
So if patients don't know whatto expect, we tell them don't
necessarily expect to feel a lotdifferent tomorrow.
So stay with us for a bit onthis and we'll talk at your
follow-up appointment how you'refeeling.
So especially if you triedother agents that might have
more acute effects.
Sara Klockars (05:15):
Which leads me to just sharing a conversation you
have with a patient whenthey're starting on an
antidepressant.
How do you expand on some ofthose expectations.
Like you mentioned, Craig,you're not going to see benefit
overnight.
How do you have thatdiscussion, Sarah?
Sarah E. Grady (05:33):
Yeah, so really no different from anybody that
is starting on a medicine fordiabetes or hypertension or
COPD.
Just having a conversation.
Do let people know, as Craigmentioned already, that these
medications do not workinstantly.
They take weeks.
Sometimes months.
(05:54):
So that's one thing.
The other thing is, is that ifsomebody is using it for
depression, a lot of times thephysical symptoms of someone's
depression will start to improvebefore the emotional symptoms
of depression.
The physical symptoms ofdepression being poor sleep,
poor appetite, low energy, thosethings may start to improve
(06:14):
before mood improves, anhedoniadecreases, suicidal thoughts
reduce.
So I think making thatdifferentiation is very
important.
The other thing I make mentionof is depending on which
antidepressant it is, I may talkabout common side effects and
how to work with those.
(06:35):
And as far as duration, a lotof times people will ask me, how
long do I need to take this?
That is really anindividualized decision between
the patient and their provider.
However, if it's the firstepisode and they're getting
relief from the medication, wetreat for a minimum of six
months to a year.
And we may need to treat Iwould
Tammie Lee Demler (07:04):
add that also I like to share with the
patients that you're going tomaybe feel a little nauseous or
you might have some GI symptomsthat will go away with continued
use.
I've had so many patientswho've not been told that and
they just stop it because theyfeel so yucky for the first few
days.
Sara Klockars (07:19):
Excellent points.
So I wanted to dig into some ofthe side effects, interactions,
risks with these meds.
How would you recommendstarting a conversation with a
patient at the counter to justhelp evaluate how they're doing
on their antidepressant?
Or perhaps a pharmacist doingan MTM review and a patient, you
(07:40):
know, says they're on these.
How would you advise apharmacist to talk to the
patient about this?
Sarah E. Grady (07:48):
Yeah, absolutely.
Human to human, heart to heart.
I tend not to push people.
People aren't ready to talk.
They're not ready to talk, butI always let them know that I'm
here to assist, to help them.
Okay, so just kind of watchingif they're in the pharmacy,
watching the nonverbals.
And if they're not in thepharmacy and you're on the phone
(08:08):
with them, sometimes you cankind of tell by the tone of
their voice.
So again, just slowly,carefully, again, human to
human, heart to heart.
And let's say someone iswilling to talk.
You know, you just explain yourpurpose.
You know, my role here is tohelp answer your questions, help
(08:28):
you get the most effectivenessand safety from your medication.
And then I usually start byreally going over those
education points that wediscussed.
Because like Tammy hadmentioned, a lot of times people
aren't either informed or we dotell them, But because they
(08:49):
have depression or anxiety orboth, they are not able to
process what we actually toldthem about the medication.
So we may need some repetition.
I don't know how many timespeople have said, okay, I
started this Sertraline a weekago and I feel no different.
And I said, that's what I wouldexpect.
And I'm like, oh, here's somegood news because some of the
(09:09):
side effects we would have seenby now.
So again, repetition about keyeducation points with regards to
time course, maybe assessingabout side effects that Tammy
had mentioned correctly.
So that a lot of times peoplefeel worse before they feel
better.
Because the therapeuticbenefits of the medications have
(09:30):
not started to kick in yet andthe side effects show up.
So maybe starting there.
How have you been feeling?
Usually that's where I start.
What have you noticed sinceyou've been taking this
medication?
A lot of times they'll saynothing if it's been a couple
days.
Or they'll say, my stomachhurts.
And I say, oh, okay, you're onan SSRI.
That's to be expected.
Are you taking it with food?
Are you taking it with milk?
(09:50):
So really just startingsomewhere.
Get them talking.
Get them reporting.
You can also ask aboutsymptoms.
If they have depression, haveyou seen any changes in your
sleep?
Have you seen changes in yourappetite?
in your energy, in yourconcentration, in your mood, in
your focus, in your anxietylevels.
And then just reminders andreminders that these meds don't
(10:14):
work overnight, but they canwork and they improve symptoms.
And the other thing, the lastthing I'll add, have somebody
that's talking and particularlysomeone that says, I don't think
this is working.
I've been taking it for threeweeks.
I haven't noticed anything.
You know, depending on how wellI know someone, I'll ask them,
has anyone close to you commentit to you on how you look or
(10:36):
things along those natures.
Or sometimes patients will justoffer it.
They're like, yeah, I've beentold that I look better or I
seem brighter or something.
And so I just remind peoplethat with antidepressants, most
of them, the changes that peoplefeel are so slow and subtle
that oftentimes people don'teven notice it, but other people
close to them might.
So those are just some things,some places to start.
(11:00):
Let's be honest.
It's not an easy conversationto have.
Sure, it's easy for me becauseI work on an inpatient
behavioral health unit andpeople are pretty open about
starting conversations.
And because I've been in thisfield so long, depression and
hypertension look the same tome.
No big deal.
Both are treatable.
But I've been in this businessfor a long time and not
(11:21):
everybody else has.
And so there may be somediscomfort.
And I think that's why we justneed to recognize that.
Watch the nonverbals.
Watch the tone of voice.
And let's not push people.
Just say, hey, you know, Ifyou'd like to talk at another
time when you're feeling alittle bit better, here's my
name, here's my number.
I would like to chat with you.
Sara Klockars (11:42):
Very helpful tips.
I'd like to move along toanother question that we often
get and see in practice, andthat is, Serotonin syndrome.
Can you just briefly describewhat it is and your thoughts
about when we should worry aboutthis with some of our SSRIs and
(12:03):
SNRIs?
Sarah E. Grady (12:06):
Yeah, this is a great question.
The whole topic of serotoninsyndrome has honestly been
confusing me for decades.
You can look in the literature,and all of us have, as to how
common or uncommon it is.
It appears to be uncommon, butwhy is it uncommon?
Is it because it's really thesymptoms are very nonspecific
(12:29):
and they can look like manyother things?
Times when it's been diagnosedby one physician, the next
physician will come in the nextday and say it's not serotonin
syndrome, it's neurolepticmalignant syndrome.
So I'm not really sure howoften I have seen it over the
course of my career.
I have had a few patients tellme that they have been diagnosed
(12:51):
with serotonin syndrome.
And I asked them whatmedications they were were
prescribed at that time.
And it's always multipleserotonergic medications,
particularly those that haveserotonin reuptake inhibition
seem to be some of the moreproblematic ones.
But yes, I couldn't tell youhow common it is just because
the symptoms, signs and symptomstend to be very nonspecific.
(13:15):
And what do those look like?
Again, nonspecific symptoms, GIupset, muscle rigidity, fever,
seizures, agitation,restlessness, insomnia,
confusion, hypertension,sweating.
So really the best way we canmap this is to look at when did
they start certain medications?
(13:35):
When did these symptomsdevelop?
The few cases where we werepretty sure it was serotonin
syndrome, All these cases,people were on multiple
serotonergic medications, again,including a couple that had
serotonin reuptake inhibitionspecifically.
Okay, so multiple serotonergicmedications, no surprise there
(13:56):
because serotonin syndrome istoo much serotonin in the brain,
the periphery.
Our body doesn't like that.
Our body reacts in various waysas, you know, the not fun
symptoms that I mentioned.
But yes, serotonin syndrome, Iwon't lie, has been confusing me
my whole career.
So maybe someday I'll have aclear-cut answer for everybody.
Craig Williams (14:18):
It is a confusing topic.
For a while, it seemed to be invogue to be combining
second-generationantidepressants and SSRIs with
SNRIs and multiple SSRIs.
Fortunately, it's kind offallen out of favor.
The efficacy literature didn'tsupport that too well, but...
The case reports to severeserotonin syndrome almost always
(14:38):
involve multiple agents.
So I rarely think about thisfor starting a patient on a SSRI
or an SNRI.
But I will add that, you know,spending a lot of time in the
hospital setting last 15 years,we get an awful lot of patients
in the ED who on multiple agentswho just are confused and
they're just off enough and wehold everything for three days
(15:00):
and suddenly they're magicallybetter.
And so curious myself, there'smilder serotonin that maybe has
been unrecognized for a while,but yes, do be careful combining
multiple serotonin actingmedications in practice.
Tammie Lee Demler (15:15):
To your point, as far as combinations,
we have never seen, I don'tthink, any case of one single
agent contributing to anyadverse drug reaction that we've
seen relative to serotoninsyndrome.
What we have started to see,though, is with the popularity
of augmentation withantipsychotics that have
serotonin influence and perhapsa splash of something that they
(15:37):
get at the ED, a tramadolprescription, for example, that
nobody really thinks about.
You know, we've seen subtlemalaise, GI upset, that a
strategic deprescribing hassettled.
We just sort of assumed thatthat might have been a beginning
of a precursor to serotoninsyndrome, and we just do some
strategic deprescribing thatwould avoid that combination.
(15:58):
But it's the stuff that kind ofsneaks up on you.
And
Craig Williams (16:03):
Sarah made a nice point, too, about there
often is a temporal association.
So the lurch doesn't happenanytime, but it does seem to be
more likely closer to a secondagent being started.
So yeah, I do always look forsomething new, acipation, but I
mean, dexamethorphan is aclassic over-the-counter agent,
but lithium valproate are on thelist, certainly trazodone.
(16:25):
So, but yeah, I'm often lookingfor a temporal association
medication number two, ifsomeone's been stable on an SSRI
or an SNRI for years in myrefill pharmacy system, so.
Sara Klockars (16:38):
Thank you.
I want to transition over nowto cardiovascular risks with
antidepressants.
Here we get into our EKGchanges and a recent abstract
about increasing sudden cardiacdeath and QT prolongation.
So how do we balance this,especially for our cardiac
(16:59):
patients who need anantidepressant?
So are there certainantidepressants that are riskier
and ones that are safer that weshould be considering in this
population.
Can you comment on some ofthese risks, Tammy?
I
Tammie Lee Demler (17:17):
would love to comment on QTC because we've
really struggled with this overthe course of the last 10 years.
When your question is, arethere any riskier medications, I
would say that Of course, we'relooking at tricyclics off the
table because they have theirown cardiac issues.
The SSRI, citalopram is theonly current medication that the
(17:38):
FDA has put a cap onspecifically for QTC risk in
older adults, I believe aspeople over 60 on a limited
lower dose.
As a talopram, they are lookingat possibly a dose reduction,
but the FDA hasn't specificallymade a dose suggestion for that
that I know of.
But as far as QTC risks, thereare a lot of medications that
(18:01):
are on the list.
If people listening arewondering where our list could
be We look to Credible Meds.
I don't know if you all go intoCredibleMeds.org.
That's a free platform thatis...
robustly kept up to date.
And there's a tool inside ofthat that does a score for you.
So if you wanted to do, forexample, a burden of all the
(18:23):
meds a person's on, you can putthem into this platform and
it'll give you a score.
And I'll just quickly say thatwe had this hypothetical paper
score of risk strategy that wedidn't know if it was really
philosophical or really a legitscore.
You could do some clinicalrecommendations using.
And we did actually a studylooking at QTC and EKG.
(18:47):
And the QTC score we calculatedwas very statistically
significantly correlated to thisEKG score that was done.
So the QT prolongation factorwas very much in line with the
score you were able tocalculate.
So I would encourage people toconsider that.
I
Craig Williams (19:06):
agree, Tammy.
Credible Meds is the place togo.
It is a great And you can sortdrugs by class and by risk.
So citalopram and escitalopramare the I think the two to be
kind of aware of among thesedrugs.
But otherwise, the FDA is notsaying don't use any if the FDA
didn't like the drug enough,they take it off the market.
And it's just kind of a timefor us to pause and say, okay.
(19:28):
Do I really feel the benefitsof this drug outweigh the risk?
And this is one of the smallrisks.
But for an otherwise healthy,let's say 25, 30-year-old, the
risk is under 1 in 100,000 if wetry to put a number to the risk
of an actual cardiac event.
So we have it in the back ofour mind.
On the inpatient side, we thinkabout it a bit more because
electroid abnormalities can beplaying to the risk in severe
(19:49):
dehydration and illness.
But on the outpatient side, itis a difficult thing, I think,
to operationalize.
But I often find myselfreassuring providers that if you
feel like And SSRI and SRI isthe right drug to use here.
I would not be dissuaded by theEMR telling you there's this
tiny risk because when youquantify it, it really is quite
small.
Sara Klockars (20:06):
Thank you.
Question about hyponatremia orthe low sodium levels with
antidepressants.
When should we check a sodiumfor patients on SSRIs?
Sarah E. Grady (20:22):
Yes, so I think we should be checking sodium
regularly.
in our patients that are olderadults.
Older adults, I think, is thebest time to check that.
And this can be an issue withnot just SSRIs, but numerous
other antidepressants as well.
I feel like psychiatrists askme which antidepressant is least
(20:45):
likely to lower the sodiumlevel.
And again, think about thequestion I'm being asked, least
likely.
And usually I recommendbupropion, but not everybody is
a candidate for bupropion for anumber of different reasons.
But yes, mainly older adults isprobably when we want to check
sodium levels.
Sara Klockars (21:06):
Thank you.
Tammy, I have a question foryou.
Are eating disorders really acontraindication due to
bupropion use or can theysometimes be used?
Tammie Lee Demler (21:18):
So the real concern about eating disorders
and bupropion would be theseizure lowering threshold, that
issue of just thatpharmacodynamic phenomenon that
can happen.
And I always go withcontraindication.
There's very few reasons topush through a contraindication
when there are other medicationslike fluoxetine, which is
really ideal for people who haveeating disorders for a number
(21:39):
of reasons.
But I'll just add, since we'retalking about it, it doesn't
have as much of an appetitestimulant to it.
So people who have anorexia,for example, are more willing to
take it because it's lesslikely to cause them to gain
weight.
So I would really adhere tothat.
We don't want somebody being ina situation where they would
have a risk of seizure.
Can you do bupropion with amood-stabilizing anti-epileptic
(22:02):
drug?
Yes, I've seen it, but I preferjust to stay away from it.
I don't push throughchondroindication.
We explore other options.
Sara Klockars (22:10):
Great point and a good transition.
We had some questions aboutsome side effects.
And how do you help patientsreporting weight gain on
antidepressants?
Tammie Lee Demler (22:22):
I think when it comes to weight gain, I like
to ask people questions.
What was their baseline weightbefore they had the episode of
whatever it is that they'reexperiencing?
Did they gain weight becausethey were depressed?
Some people lose weight.
So it's not always a weightgain phenomenon.
Some people do lose weight whenthey have depression.
So depending on thatcircumstance is where I kind of
(22:43):
go with my recommendations aswell.
I'll just say a pitch formirtazapine for older adults who
are losing weight.
They're finding that they can'tkeep weight on.
They either have a chronicillness like cancer that It's
just preventing them fromgaining weight.
Mirtazapine has been really agodsend for us in that regard.
So I look at this in a littledifferent way in some cases.
(23:04):
It's not looking at preventingweight gain.
I'm sometimes looking forsomething that can cause
sedation and weight gain.
But for other people who areafraid of weight gain, they
should really be looking atperhaps what they're eating,
what their intake is.
Are they able to exercise?
Because exercise makes us allfeel better, even in the
smallest little bit.
Nobody likes the E word, butreally when we think about it,
(23:26):
it does make us feel better.
So I don't know if mycolleagues have anything else.
I'll just add two confoundingeffects of pain, for example.
Some people have pain anddepression and they're unable to
move as they would like to.
So knowing what thecontributing confounders are is
also important.
Sarah E. Grady (23:44):
Yeah, I want to echo Tammy's sentiments about
mirtazapine.
Individuals that can't sleep,can't eat, has been really
helpful.
And then also on my unit, wedon't use the E word, exercise.
We just call it moving.
Are you able to move?
Can we move?
Moving seems to go over betterthan exercise.
Craig Williams (24:07):
I'll just add, I mean, like the bookends here, I
think for everyone to recognizemirtazapine and proxine at one
end and bupropion at the otherend, I think is a very useful,
practical take home forlisteners.
Sara Klockars (24:20):
Excellent.
Let's move along and discussoptimizing treatment and answer
a few more subscriber questions.
Sarah, so how long do you treatwith a specific agent before
you consider a treatment failureand change agents?
And then when do you considerswitching a med versus combining
meds?
Sarah E. Grady (24:41):
Yeah, excellent question from the subscriber.
So a couple of things that weas pharmacists want to
investigate before there's anytalk of transitioning
medications or addingmedications on, a couple of very
important questions.
Number one, is the patient ableto take the medication every
day as prescribed?
That's question number one.
(25:01):
Are we taking it?
Number two, is our dose highenough?
So say, for instance, ifsomebody is prescribed
venlafaxine and they're threeweeks into it and they're still
on 37.5 or 75 milligrams, that'snot a target dose for most
people.
So are they taking it?
Is the dose high enough?
Is the duration long enough?
Looking at duration, if youlook at the trials, most of
(25:23):
those were six to eight weekslong.
And that was someone taking themedication every day.
The dose is high enough.
Okay, the duration needs to belong enough.
And the other thing that weneed to think about and we can
use this as a counseling point,but we have to do it so that
we're not coming off judgmental,is that gentle reminder that
alcohol is a depressant.
(25:45):
Okay, so if people are drinkinga lot of alcohol, of using
street drugs, these thingsinterfere with the effectiveness
of the antidepressants.
So looking at all thosescenarios is really important.
But let's say your patient,they're taking the med, they're
on a decent dose of the med,they've been on it six to eight
weeks.
Then we look at if it's notworking at all, if they're not
(26:09):
even getting a partial response,then we probably look at
switching meds.
If they are getting a partialresponse, then we can look at
maybe augmentation.
The guidelines aren't reallyclear as to what to do.
The guidelines tell you you cando one of three things.
You can increase the dose, makesure they're maxed out on the
dose.
You can switch or you cancombine.
(26:32):
It's not really clear which wayto go.
So involving the patient, dothey feel comfortable adding
another medication on board?
Some people do, some peopledon't.
Every time we add anothermedication on board we run the
risk of drug interactions andadditional side effects etc so
every outcome every possibilityhas risks and benefits
Craig Williams (26:56):
I'll just add, sir, briefly that it's the FDA's
classic news, eight to 12 weekstudies to make determinants of
this drug is effective or notcompared to a placebo.
So I think as a single number,eight weeks is what I tend to
use and teach our learners.
If the patient's reallyconvinced nothing has changed
and we're convinced they'retaking it, that eight weeks is a
sufficient duration.
And then, yeah, I'll share thatwe're really not big fans of
(27:18):
combining antidepressants.
So especially if it's of afirst failure, it's virtually
always going to be a switch ofan agent after a first try for
us.
Tammie Lee Demler (27:28):
I would just add, too, that patients are
very...
I would say susceptible,sensitive, and rightly so,
direct-to-consumer advertisingis very effective.
And so if they're seeingsomething like an augmentation
antipsychotic of whatever thegenre it is, I don't want to
bring one out for specificpurposes, but adding an
antipsychotic augmentation,perhaps after trying something
(27:51):
else like a switch instead, canput a person at metabolic risk,
adds the complications of druginteractions that may be
unnecessary.
So I think encouraging apatient to try Exclusive
monotherapy first that's reallyeffective might just be a better
way to go than adding stuff onand increasing the burden of
medications.
Even though that's an option, Ihesitate to add something if I
(28:14):
can do good monotherapy, ifthat's an option.
That's a
Sara Klockars (28:18):
great point.
Sarah E. Grady (28:20):
One thing I just want to add before I forget
about it is some of theguidelines talk about augmenting
with psychotherapy.
So if the patient, say, isgetting a partial response with
their antidepressant and theywant to go up on the dose for
whatever reason, they don't wantto switch, they don't want to
add anything, if they are notalready in psychotherapy, if
(28:42):
they are able to add inpsychotherapy as an augmentation
strategy.
Craig Williams (28:48):
Yeah, I'll say I don't have a particular app to
recommend, but we're gettingmore and more patients saying
they're using various onlinethings that the friends have
used, some referred.
And yeah, it seems to Sarah'spoint, talk therapy can be very
effective.
There's lots of ways to get itthese days.
So again, I don't have one Ican recommend and not want to
refer patients to, but that'shistorically, we should not be
(29:11):
just relying on pharmacotherapyhere, obviously, especially if
someone's saying I've given thisdrug an eight week try, I
really don't feel any different.
This is not working for me.
So.
Sara Klockars (29:19):
Good point.
Other non-drug measures.
We mentioned moving.
We have talk therapy, differentapps.
Are there any other things thatyou guys encourage or recommend
for your patients onantidepressants?
Craig Williams (29:33):
I'll just say outside of a closed psychiatric
ward, I do still call itexercise and recommend exercise
for ambulatory patients.
I know it does mean differentthings to different folks.
And we often do have to kind ofback up and say, this does not
mean you're going out for a 5Krun tomorrow.
It means you're walking aroundthe block or just getting
outside even.
Coming up with exercise andother euphemistic ways to refer
(29:55):
to as exercise, moving is agreat way to start.
But yeah, little bits go a longways there.
Tammie Lee Demler (30:02):
I would also advocate, you know, somebody
looking at their diet, ifthey're not specifically diet
centered or able to really lookat the nutrition they're
consuming, having an essentialprotein intake to help with
those amino acids and theneurochemicals.
A high carb diet that reallybrings you no value calorically
and just adds on the pounds canbe counterintuitive.
(30:23):
So we like to have nutritionconsults just to take a look at
what they're eating, because itmay just be empty calories that
aren't being considered and notreally helping drive the
production of thoseneurochemicals.
Sara Klockars (30:36):
Thank you.
And then just wanted to speakbriefly about the recommended
length of treatment.
How long are patients onantidepressants for anxiety and
depression?
If someone does want to stop,what's the best way to stop?
Sarah, would you mind tacklingsome of that?
(30:57):
Sure.
Sarah E. Grady (30:58):
Sure.
Absolutely.
Yes.
This is a common question thatI get from my patients and I'm
sure many people in thecommunity, a common question
that they have as well.
And I think it's justified.
I think it's important toinform people, just remind them
that this is a veryindividualized decision that
typically after the firstepisode of depression or anxiety
(31:21):
occurs, If people have a goodresponse with a particular
antidepressant, it isrecommended that they stay on
the medication for a minimum ofsix to 12 months.
Once you get out to about ayear, then you can have a
conversation with your provider.
I encourage people not to comeoff of antidepressants without
(31:42):
provider instruction anddirection.
If people just stopantidepressants, they can have
antidepressant discontinuationsyndrome.
Anti-discontinuation syndromecan be very bothersome.
People can have a very bad moodor irritability, anxiety,
insomnia, GI upset, shakes,tremors.
(32:02):
They can have what people havedescribed to me as electrical
shocks, brain zaps.
So once somebody has beentaking an antidepressant for a
while, one of the reasons why wewant them to be under the
provider's care is that we needto taper them off of the
antidepressants.
We don't just want a coldturkey off of six months or a
(32:23):
year.
It's a very strategic step-downprocess while symptoms are
being monitored.
Full disclaimer, I've notreally read this in the
literature.
It's just something I've heardmany of the psychiatrists I work
with tell patients is that whensomeone is in the middle of a
stressful life event, whetherit's good stress or bad stress,
(32:44):
that's not a good time to startcalming down off of
antidepressants.
I had a research student workwith me, had been feeling okay
with her antidepressant.
She was at about the year markand she's like, yeah, I think I
want to start coming off myantidepressant.
And I said, you know, it'smiddle of the semester of a very
stressful graduate schoolprogram.
Now that there's ever a time inlife where we are a hundred
(33:07):
percent stress-free, but there'sdefinitely times in our life
where there might be You know,we're not in graduate school.
We're not getting married.
We're not getting divorced.
We're not having kids.
You know, just looking at thosemajor life events that can be
stressful, both in a good way,potentially in a bad way too.
Maybe that's not the best timeto start implementing a tapering
(33:29):
process.
So lots of factors go into ittoo.
Strong family history.
We might want to stay onantidepressants longer than the
six months to a year mark too.
So everyone's going to have adifferent prescriptive treatment
plan, which makes sense.
Tammie Lee Demler (33:46):
I agree with Sarah.
And the one thing I would addto that is, you know, the
discontinuation process isdifferent for everybody.
You know, some people need aslower, more gradual
discontinuation.
Other people are a little bitmore apt to accept a maybe more
traditional taper, but it reallyis dependent on the person.
There's not anything that saysit has to be done a certain way.
(34:09):
I think that thoseparesthesias, that electric
shock sensation that youdescribed, Sarah, has gotten
kind of a bad rap in that peoplehave been describing that to
each other as being addicted toyour antidepressant.
and that provides adisincentive for many people to
start it because they don't wantto be addicted to a medication.
So to be able to describe thatas being just a physiologic
(34:32):
response to discontinuingsomething that affects your
neurochemistry, very similar toabruptly stopping perhaps a
blood pressure medicine whenyour body will rebound and have
that be kind of an oppositereaction.
So I think in terms ofeducating our patients, we need
to also provide that informationthat you're not addicted to
your antidepressant, butdiscontinuation too quickly can
(34:54):
cause these physiologic sideeffects that would be absolutely
expected.
Sara Klockars (34:59):
Thank you for addressing that.
And I have one other subscriberquestion that came in a couple
of times.
One comment was, I often seeSSRIs and SNRIs prescribed to
PRN for anxiety.
Does this provide any benefitor is it risky?
And then another question was,can you use antidepressants,
(35:19):
PRN, for any indication?
So curious if, Tammy, if youwant to comment on that.
Tammie Lee Demler (35:27):
My initial thought when you asked the
question was that PRNantidepressants are not the
traditionally prescribedantidepressant for depression or
anxiety.
Those need to be scheduled andtaken on a regular basis.
Optimal dose, optimal duration,traditional way.
But with the use of some of themedications for premenstrual
dysphoric disorder, PMDD, theintermittent dosing is
(35:51):
recommended for those particularconditions.
Now you can take themcontinuously for people who have
that indication, or you canchoose to do it during these
luteal phases or a specificallyprescribed intermittency.
So even that is anindividualized approach to
treatment.
So with the agreement of theprescriber and the
patient-centered treatment, aregimen is discovered and
(36:12):
derived and then prescribed.
Sarah E. Grady (36:15):
Yes, Tammy, I agree with everything that you
said.
To my knowledge, There's notgood evidence-based literature
on using antidepressants asneeded.
Again, there's decent evidencewith the luteal phase dosing
with PMDD, which we do a littlebit here.
I would say more of what we seehere is that we usually have
(36:39):
the women on the SSRI the wholemonth, say if it's sertraline,
They may be at 100 milligrams or150 milligrams.
And then the week before theirmenstrual cycle, we may increase
the dose.
We have done that.
But yes, antidepressants asneeded.
Based on what I know and whatI've seen, I don't recommend
(37:02):
that at this time until we'vegot better literature supporting
that practice.
Narrator (37:10):
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(37:32):
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Thanks for listening toMedication Talk.
This transcript is automatically generated.
Tammie Lee Demler (00:00):
The discontinuation process is
different for everybody.
I think that thoseparesthesias, that electric
shock sensation that youdescribed, Sarah, has gotten
kind of a bad rap in that peoplehave been describing that to
(00:20):
each other as being addicted toyour antidepressant.
And that provides adisincentive for many people to
start it because they don't wantto be addicted to a medication.
So to be able to describe thatas being just a physiologic
response to discontinuingsomething that affects your
neurochemistry.
So I think in terms ofeducating our patients, we need
(00:41):
to also provide that informationthat you're not addicted to
your antidepressant, butdiscontinuation too quickly can
cause these physiologic sideeffects that would
Narrator (00:57):
Welcome to Medication Talk, an official podcast of TRC
Healthcare, home of pharmacistletter, prescriber insights, and
the most trusted clinicalresources.
Proud to be celebrating 40years of unbiased evidence and
recommendations.
On today's episode, listen inas our expert panel discusses
practical considerations forstarting and optimizing
antidepressants for treatingdepression and anxiety.
(01:18):
You'll listen to panelistscover various aspects of
antidepressant use, such asserotonin syndrome, QT
prolongation, and weight gainconcerns.
Our guests today are Dr.
Tammy Lee Demler from the NewYork State Office of Mental
Health and SUNY at BuffaloSchool of Pharmacy and
Pharmaceutical Sciences.
and Dr.
(01:38):
Sarah E.
Grady from the Drake UniversityCollege of Pharmacy and Health
Sciences.
You'll also hear practicaladvice from TRC's editorial
advisory board member, Dr.
Craig Williams from the OregonHealth and Science University.
This podcast is an excerpt fromone of TRC's monthly live CE
webinars.
Each month, experts andfrontline providers discuss and
(01:59):
debate challenges in practice,evidence-based practice
recommendations, and othertopics relevant to our
subscribers.
And now, the CE information.
This podcast offers continuingeducation credit for
pharmacists, pharmacytechnicians, physicians, and
nurses.
Please log into yourpharmacist's letter, pharmacy
(02:19):
technician's letter, orprescriber insights account and
look for the title of thispodcast in the list of available
CE courses.
None of the speakers haveanything to disclose.
Now, let's join TRC editor, Dr.
Sarah Clockers, and start ourdiscussion.
Sara Klockars (02:38):
For today's discussion, we'll spend most of
our focus on the use ofantidepressants for the
treatment of depression oranxiety, where they're one of
the initial treatment options,along with talk therapy or
cognitive behavioral therapy.
And the antidepressant choicewill be tailored to the
individual patient.
And so, Tammy, I was hopingyou'd get us started and share
(02:59):
some factors you consider inyour approach when evaluating
antidepressant options.
Tammie Lee Demler (03:06):
Sure.
I would like to say it's allabout shared decision-making
first.
But I have to go right to FDAapprovals because that's where
my pharmacist cap comes on.
And I look at what medicationshave FDA approval and rigor in
evidence for their use.
So it's surprising that not allantidepressants have every
(03:27):
indication as every other onefor either anxiety or different
types of depression.
So I go with FDA approvalsfirst and then work with our
patients to sort of look atpharmacodynamic characteristics,
what the side effects oradverse effects could
potentially be And I'll just addquickly that not all adverse
effects are bad.
Whereas, you know, some of themmay cause sedation or
(03:50):
sleepiness.
Some people may want that for asleep time improvement for
their particular condition.
Others may need a more energyboosting medication.
So I think tailoring the sideeffects, and I say that as a
term I don't like to use veryloosely.
I prefer adverse reaction oradverse experience.
We look at those as trying tooptimize what the
(04:10):
person-centered approach thenwould later be after we kind of
cover all those checkboxes.
Excellent.
Sarah,
Sarah E. Grady (04:18):
did you have anything to add?
I agree with everything thatTammy said.
I just want to make emphasis onthe shared decision-making.
If a patient really wants totake a certain medication and it
has FDA approval and they'recomfortable with the side effect
profile, then we definitelytake a look at that.
(04:39):
We also take a look at if theyhave a family history of a
certain antidepressant thatworked for their depression or
anxiety condition of that familymember, then we also consider
it in the differential.
Craig Williams (04:53):
I'll just add too, sir, a brief in
expectations that if, you know,we're talking second generation
antidepressants, we do kind ofmoderate expectations a bit.
So if patients don't know whatto expect, we tell them don't
necessarily expect to feel a lotdifferent tomorrow.
So stay with us for a bit onthis and we'll talk at your
follow-up appointment how you'refeeling.
So especially if you triedother agents that might have
more acute effects.
Sara Klockars (05:15):
Which leads me to just sharing a conversation you
have with a patient whenthey're starting on an
antidepressant.
How do you expand on some ofthose expectations.
Like you mentioned, Craig,you're not going to see benefit
overnight.
How do you have thatdiscussion, Sarah?
Sarah E. Grady (05:33):
Yeah, so really no different from anybody that
is starting on a medicine fordiabetes or hypertension or
COPD.
Just having a conversation.
Do let people know, as Craigmentioned already, that these
medications do not workinstantly.
They take weeks.
Sometimes months.
(05:54):
So that's one thing.
The other thing is, is that ifsomebody is using it for
depression, a lot of times thephysical symptoms of someone's
depression will start to improvebefore the emotional symptoms
of depression.
The physical symptoms ofdepression being poor sleep,
poor appetite, low energy, thosethings may start to improve
(06:14):
before mood improves, anhedoniadecreases, suicidal thoughts
reduce.
So I think making thatdifferentiation is very
important.
The other thing I make mentionof is depending on which
antidepressant it is, I may talkabout common side effects and
how to work with those.
(06:35):
And as far as duration, a lotof times people will ask me, how
long do I need to take this?
That is really anindividualized decision between
the patient and their provider.
However, if it's the firstepisode and they're getting
relief from the medication, wetreat for a minimum of six
months to a year.
And we may need to treat Iwould
Tammie Lee Demler (07:04):
add that also I like to share with the
patients that you're going tomaybe feel a little nauseous or
you might have some GI symptomsthat will go away with continued
use.
I've had so many patientswho've not been told that and
they just stop it because theyfeel so yucky for the first few
days.
Sara Klockars (07:19):
Excellent points.
So I wanted to dig into some ofthe side effects, interactions,
risks with these meds.
How would you recommendstarting a conversation with a
patient at the counter to justhelp evaluate how they're doing
on their antidepressant?
Or perhaps a pharmacist doingan MTM review and a patient, you
(07:40):
know, says they're on these.
How would you advise apharmacist to talk to the
patient about this?
Sarah E. Grady (07:48):
Yeah, absolutely.
Human to human, heart to heart.
I tend not to push people.
People aren't ready to talk.
They're not ready to talk, butI always let them know that I'm
here to assist, to help them.
Okay, so just kind of watchingif they're in the pharmacy,
watching the nonverbals.
And if they're not in thepharmacy and you're on the phone
(08:08):
with them, sometimes you cankind of tell by the tone of
their voice.
So again, just slowly,carefully, again, human to
human, heart to heart.
And let's say someone iswilling to talk.
You know, you just explain yourpurpose.
You know, my role here is tohelp answer your questions, help
(08:28):
you get the most effectivenessand safety from your medication.
And then I usually start byreally going over those
education points that wediscussed.
Because like Tammy hadmentioned, a lot of times people
aren't either informed or we dotell them, But because they
(08:49):
have depression or anxiety orboth, they are not able to
process what we actually toldthem about the medication.
So we may need some repetition.
I don't know how many timespeople have said, okay, I
started this Sertraline a weekago and I feel no different.
And I said, that's what I wouldexpect.
And I'm like, oh, here's somegood news because some of the
(09:09):
side effects we would have seenby now.
So again, repetition about keyeducation points with regards to
time course, maybe assessingabout side effects that Tammy
had mentioned correctly.
So that a lot of times peoplefeel worse before they feel
better.
Because the therapeuticbenefits of the medications have
(09:30):
not started to kick in yet andthe side effects show up.
So maybe starting there.
How have you been feeling?
Usually that's where I start.
What have you noticed sinceyou've been taking this
medication?
A lot of times they'll saynothing if it's been a couple
days.
Or they'll say, my stomachhurts.
And I say, oh, okay, you're onan SSRI.
That's to be expected.
Are you taking it with food?
Are you taking it with milk?
(09:50):
So really just startingsomewhere.
Get them talking.
Get them reporting.
You can also ask aboutsymptoms.
If they have depression, haveyou seen any changes in your
sleep?
Have you seen changes in yourappetite?
in your energy, in yourconcentration, in your mood, in
your focus, in your anxietylevels.
And then just reminders andreminders that these meds don't
(10:14):
work overnight, but they canwork and they improve symptoms.
And the other thing, the lastthing I'll add, have somebody
that's talking and particularlysomeone that says, I don't think
this is working.
I've been taking it for threeweeks.
I haven't noticed anything.
You know, depending on how wellI know someone, I'll ask them,
has anyone close to you commentit to you on how you look or
(10:36):
things along those natures.
Or sometimes patients will justoffer it.
They're like, yeah, I've beentold that I look better or I
seem brighter or something.
And so I just remind peoplethat with antidepressants, most
of them, the changes that peoplefeel are so slow and subtle
that oftentimes people don'teven notice it, but other people
close to them might.
So those are just some things,some places to start.
(11:00):
Let's be honest.
It's not an easy conversationto have.
Sure, it's easy for me becauseI work on an inpatient
behavioral health unit andpeople are pretty open about
starting conversations.
And because I've been in thisfield so long, depression and
hypertension look the same tome.
No big deal.
Both are treatable.
But I've been in this businessfor a long time and not
(11:21):
everybody else has.
And so there may be somediscomfort.
And I think that's why we justneed to recognize that.
Watch the nonverbals.
Watch the tone of voice.
And let's not push people.
Just say, hey, you know, Ifyou'd like to talk at another
time when you're feeling alittle bit better, here's my
name, here's my number.
I would like to chat with you.
Sara Klockars (11:42):
Very helpful tips.
I'd like to move along toanother question that we often
get and see in practice, andthat is, Serotonin syndrome.
Can you just briefly describewhat it is and your thoughts
about when we should worry aboutthis with some of our SSRIs and
(12:03):
SNRIs?
Sarah E. Grady (12:06):
Yeah, this is a great question.
The whole topic of serotoninsyndrome has honestly been
confusing me for decades.
You can look in the literature,and all of us have, as to how
common or uncommon it is.
It appears to be uncommon, butwhy is it uncommon?
Is it because it's really thesymptoms are very nonspecific
(12:29):
and they can look like manyother things?
Times when it's been diagnosedby one physician, the next
physician will come in the nextday and say it's not serotonin
syndrome, it's neurolepticmalignant syndrome.
So I'm not really sure howoften I have seen it over the
course of my career.
I have had a few patients tellme that they have been diagnosed
(12:51):
with serotonin syndrome.
And I asked them whatmedications they were were
prescribed at that time.
And it's always multipleserotonergic medications,
particularly those that haveserotonin reuptake inhibition
seem to be some of the moreproblematic ones.
But yes, I couldn't tell youhow common it is just because
the symptoms, signs and symptomstend to be very nonspecific.
(13:15):
And what do those look like?
Again, nonspecific symptoms, GIupset, muscle rigidity, fever,
seizures, agitation,restlessness, insomnia,
confusion, hypertension,sweating.
So really the best way we canmap this is to look at when did
they start certain medications?
(13:35):
When did these symptomsdevelop?
The few cases where we werepretty sure it was serotonin
syndrome, All these cases,people were on multiple
serotonergic medications, again,including a couple that had
serotonin reuptake inhibitionspecifically.
Okay, so multiple serotonergicmedications, no surprise there
(13:56):
because serotonin syndrome istoo much serotonin in the brain,
the periphery.
Our body doesn't like that.
Our body reacts in various waysas, you know, the not fun
symptoms that I mentioned.
But yes, serotonin syndrome, Iwon't lie, has been confusing me
my whole career.
So maybe someday I'll have aclear-cut answer for everybody.
Craig Williams (14:18):
It is a confusing topic.
For a while, it seemed to be invogue to be combining
second-generationantidepressants and SSRIs with
SNRIs and multiple SSRIs.
Fortunately, it's kind offallen out of favor.
The efficacy literature didn'tsupport that too well, but...
The case reports to severeserotonin syndrome almost always
(14:38):
involve multiple agents.
So I rarely think about thisfor starting a patient on a SSRI
or an SNRI.
But I will add that, you know,spending a lot of time in the
hospital setting last 15 years,we get an awful lot of patients
in the ED who on multiple agentswho just are confused and
they're just off enough and wehold everything for three days
(15:00):
and suddenly they're magicallybetter.
And so curious myself, there'smilder serotonin that maybe has
been unrecognized for a while,but yes, do be careful combining
multiple serotonin actingmedications in practice.
Tammie Lee Demler (15:15):
To your point, as far as combinations,
we have never seen, I don'tthink, any case of one single
agent contributing to anyadverse drug reaction that we've
seen relative to serotoninsyndrome.
What we have started to see,though, is with the popularity
of augmentation withantipsychotics that have
serotonin influence and perhapsa splash of something that they
(15:37):
get at the ED, a tramadolprescription, for example, that
nobody really thinks about.
You know, we've seen subtlemalaise, GI upset, that a
strategic deprescribing hassettled.
We just sort of assumed thatthat might have been a beginning
of a precursor to serotoninsyndrome, and we just do some
strategic deprescribing thatwould avoid that combination.
(15:58):
But it's the stuff that kind ofsneaks up on you.
And
Craig Williams (16:03):
Sarah made a nice point, too, about there
often is a temporal association.
So the lurch doesn't happenanytime, but it does seem to be
more likely closer to a secondagent being started.
So yeah, I do always look forsomething new, acipation, but I
mean, dexamethorphan is aclassic over-the-counter agent,
but lithium valproate are on thelist, certainly trazodone.
(16:25):
So, but yeah, I'm often lookingfor a temporal association
medication number two, ifsomeone's been stable on an SSRI
or an SNRI for years in myrefill pharmacy system, so.
Sara Klockars (16:38):
Thank you.
I want to transition over nowto cardiovascular risks with
antidepressants.
Here we get into our EKGchanges and a recent abstract
about increasing sudden cardiacdeath and QT prolongation.
So how do we balance this,especially for our cardiac
(16:59):
patients who need anantidepressant?
So are there certainantidepressants that are riskier
and ones that are safer that weshould be considering in this
population.
Can you comment on some ofthese risks, Tammy?
I
Tammie Lee Demler (17:17):
would love to comment on QTC because we've
really struggled with this overthe course of the last 10 years.
When your question is, arethere any riskier medications, I
would say that Of course, we'relooking at tricyclics off the
table because they have theirown cardiac issues.
The SSRI, citalopram is theonly current medication that the
(17:38):
FDA has put a cap onspecifically for QTC risk in
older adults, I believe aspeople over 60 on a limited
lower dose.
As a talopram, they are lookingat possibly a dose reduction,
but the FDA hasn't specificallymade a dose suggestion for that
that I know of.
But as far as QTC risks, thereare a lot of medications that
(18:01):
are on the list.
If people listening arewondering where our list could
be We look to Credible Meds.
I don't know if you all go intoCredibleMeds.org.
That's a free platform thatis...
robustly kept up to date.
And there's a tool inside ofthat that does a score for you.
So if you wanted to do, forexample, a burden of all the
(18:23):
meds a person's on, you can putthem into this platform and
it'll give you a score.
And I'll just quickly say thatwe had this hypothetical paper
score of risk strategy that wedidn't know if it was really
philosophical or really a legitscore.
You could do some clinicalrecommendations using.
And we did actually a studylooking at QTC and EKG.
(18:47):
And the QTC score we calculatedwas very statistically
significantly correlated to thisEKG score that was done.
So the QT prolongation factorwas very much in line with the
score you were able tocalculate.
So I would encourage people toconsider that.
I
Craig Williams (19:06):
agree, Tammy.
Credible Meds is the place togo.
It is a great And you can sortdrugs by class and by risk.
So citalopram and escitalopramare the I think the two to be
kind of aware of among thesedrugs.
But otherwise, the FDA is notsaying don't use any if the FDA
didn't like the drug enough,they take it off the market.
And it's just kind of a timefor us to pause and say, okay.
(19:28):
Do I really feel the benefitsof this drug outweigh the risk?
And this is one of the smallrisks.
But for an otherwise healthy,let's say 25, 30-year-old, the
risk is under 1 in 100,000 if wetry to put a number to the risk
of an actual cardiac event.
So we have it in the back ofour mind.
On the inpatient side, we thinkabout it a bit more because
electroid abnormalities can beplaying to the risk in severe
(19:49):
dehydration and illness.
But on the outpatient side, itis a difficult thing, I think,
to operationalize.
But I often find myselfreassuring providers that if you
feel like And SSRI and SRI isthe right drug to use here.
I would not be dissuaded by theEMR telling you there's this
tiny risk because when youquantify it, it really is quite
small.
Sara Klockars (20:06):
Thank you.
Question about hyponatremia orthe low sodium levels with
antidepressants.
When should we check a sodiumfor patients on SSRIs?
Sarah E. Grady (20:22):
Yes, so I think we should be checking sodium
regularly.
in our patients that are olderadults.
Older adults, I think, is thebest time to check that.
And this can be an issue withnot just SSRIs, but numerous
other antidepressants as well.
I feel like psychiatrists askme which antidepressant is least
(20:45):
likely to lower the sodiumlevel.
And again, think about thequestion I'm being asked, least
likely.
And usually I recommendbupropion, but not everybody is
a candidate for bupropion for anumber of different reasons.
But yes, mainly older adults isprobably when we want to check
sodium levels.
Sara Klockars (21:06):
Thank you.
Tammy, I have a question foryou.
Are eating disorders really acontraindication due to
bupropion use or can theysometimes be used?
Tammie Lee Demler (21:18):
So the real concern about eating disorders
and bupropion would be theseizure lowering threshold, that
issue of just thatpharmacodynamic phenomenon that
can happen.
And I always go withcontraindication.
There's very few reasons topush through a contraindication
when there are other medicationslike fluoxetine, which is
really ideal for people who haveeating disorders for a number
(21:39):
of reasons.
But I'll just add, since we'retalking about it, it doesn't
have as much of an appetitestimulant to it.
So people who have anorexia,for example, are more willing to
take it because it's lesslikely to cause them to gain
weight.
So I would really adhere tothat.
We don't want somebody being ina situation where they would
have a risk of seizure.
Can you do bupropion with amood-stabilizing anti-epileptic
(22:02):
drug?
Yes, I've seen it, but I preferjust to stay away from it.
I don't push throughchondroindication.
We explore other options.
Sara Klockars (22:10):
Great point and a good transition.
We had some questions aboutsome side effects.
And how do you help patientsreporting weight gain on
antidepressants?
Tammie Lee Demler (22:22):
I think when it comes to weight gain, I like
to ask people questions.
What was their baseline weightbefore they had the episode of
whatever it is that they'reexperiencing?
Did they gain weight becausethey were depressed?
Some people lose weight.
So it's not always a weightgain phenomenon.
Some people do lose weight whenthey have depression.
So depending on thatcircumstance is where I kind of
(22:43):
go with my recommendations aswell.
I'll just say a pitch formirtazapine for older adults who
are losing weight.
They're finding that they can'tkeep weight on.
They either have a chronicillness like cancer that It's
just preventing them fromgaining weight.
Mirtazapine has been really agodsend for us in that regard.
So I look at this in a littledifferent way in some cases.
(23:04):
It's not looking at preventingweight gain.
I'm sometimes looking forsomething that can cause
sedation and weight gain.
But for other people who areafraid of weight gain, they
should really be looking atperhaps what they're eating,
what their intake is.
Are they able to exercise?
Because exercise makes us allfeel better, even in the
smallest little bit.
Nobody likes the E word, butreally when we think about it,
(23:26):
it does make us feel better.
So I don't know if mycolleagues have anything else.
I'll just add two confoundingeffects of pain, for example.
Some people have pain anddepression and they're unable to
move as they would like to.
So knowing what thecontributing confounders are is
also important.
Sarah E. Grady (23:44):
Yeah, I want to echo Tammy's sentiments about
mirtazapine.
Individuals that can't sleep,can't eat, has been really
helpful.
And then also on my unit, wedon't use the E word, exercise.
We just call it moving.
Are you able to move?
Can we move?
Moving seems to go over betterthan exercise.
Craig Williams (24:07):
I'll just add, I mean, like the bookends here, I
think for everyone to recognizemirtazapine and proxine at one
end and bupropion at the otherend, I think is a very useful,
practical take home forlisteners.
Sara Klockars (24:20):
Excellent.
Let's move along and discussoptimizing treatment and answer
a few more subscriber questions.
Sarah, so how long do you treatwith a specific agent before
you consider a treatment failureand change agents?
And then when do you considerswitching a med versus combining
meds?
Sarah E. Grady (24:41):
Yeah, excellent question from the subscriber.
So a couple of things that weas pharmacists want to
investigate before there's anytalk of transitioning
medications or addingmedications on, a couple of very
important questions.
Number one, is the patient ableto take the medication every
day as prescribed?
That's question number one.
(25:01):
Are we taking it?
Number two, is our dose highenough?
So say, for instance, ifsomebody is prescribed
venlafaxine and they're threeweeks into it and they're still
on 37.5 or 75 milligrams, that'snot a target dose for most
people.
So are they taking it?
Is the dose high enough?
Is the duration long enough?
Looking at duration, if youlook at the trials, most of
(25:23):
those were six to eight weekslong.
And that was someone taking themedication every day.
The dose is high enough.
Okay, the duration needs to belong enough.
And the other thing that weneed to think about and we can
use this as a counseling point,but we have to do it so that
we're not coming off judgmental,is that gentle reminder that
alcohol is a depressant.
(25:45):
Okay, so if people are drinkinga lot of alcohol, of using
street drugs, these thingsinterfere with the effectiveness
of the antidepressants.
So looking at all thosescenarios is really important.
But let's say your patient,they're taking the med, they're
on a decent dose of the med,they've been on it six to eight
weeks.
Then we look at if it's notworking at all, if they're not
(26:09):
even getting a partial response,then we probably look at
switching meds.
If they are getting a partialresponse, then we can look at
maybe augmentation.
The guidelines aren't reallyclear as to what to do.
The guidelines tell you you cando one of three things.
You can increase the dose, makesure they're maxed out on the
dose.
You can switch or you cancombine.
(26:32):
It's not really clear which wayto go.
So involving the patient, dothey feel comfortable adding
another medication on board?
Some people do, some peopledon't.
Every time we add anothermedication on board we run the
risk of drug interactions andadditional side effects etc so
every outcome every possibilityhas risks and benefits
Craig Williams (26:56):
I'll just add, sir, briefly that it's the FDA's
classic news, eight to 12 weekstudies to make determinants of
this drug is effective or notcompared to a placebo.
So I think as a single number,eight weeks is what I tend to
use and teach our learners.
If the patient's reallyconvinced nothing has changed
and we're convinced they'retaking it, that eight weeks is a
sufficient duration.
And then, yeah, I'll share thatwe're really not big fans of
(27:18):
combining antidepressants.
So especially if it's of afirst failure, it's virtually
always going to be a switch ofan agent after a first try for
us.
Tammie Lee Demler (27:28):
I would just add, too, that patients are
very...
I would say susceptible,sensitive, and rightly so,
direct-to-consumer advertisingis very effective.
And so if they're seeingsomething like an augmentation
antipsychotic of whatever thegenre it is, I don't want to
bring one out for specificpurposes, but adding an
antipsychotic augmentation,perhaps after trying something
(27:51):
else like a switch instead, canput a person at metabolic risk,
adds the complications of druginteractions that may be
unnecessary.
So I think encouraging apatient to try Exclusive
monotherapy first that's reallyeffective might just be a better
way to go than adding stuff onand increasing the burden of
medications.
Even though that's an option, Ihesitate to add something if I
(28:14):
can do good monotherapy, ifthat's an option.
That's a
Sara Klockars (28:18):
great point.
Sarah E. Grady (28:20):
One thing I just want to add before I forget
about it is some of theguidelines talk about augmenting
with psychotherapy.
So if the patient, say, isgetting a partial response with
their antidepressant and theywant to go up on the dose for
whatever reason, they don't wantto switch, they don't want to
add anything, if they are notalready in psychotherapy, if
(28:42):
they are able to add inpsychotherapy as an augmentation
strategy.
Craig Williams (28:48):
Yeah, I'll say I don't have a particular app to
recommend, but we're gettingmore and more patients saying
they're using various onlinethings that the friends have
used, some referred.
And yeah, it seems to Sarah'spoint, talk therapy can be very
effective.
There's lots of ways to get itthese days.
So again, I don't have one Ican recommend and not want to
refer patients to, but that'shistorically, we should not be
(29:11):
just relying on pharmacotherapyhere, obviously, especially if
someone's saying I've given thisdrug an eight week try, I
really don't feel any different.
This is not working for me.
So.
Sara Klockars (29:19):
Good point.
Other non-drug measures.
We mentioned moving.
We have talk therapy, differentapps.
Are there any other things thatyou guys encourage or recommend
for your patients onantidepressants?
Craig Williams (29:33):
I'll just say outside of a closed psychiatric
ward, I do still call itexercise and recommend exercise
for ambulatory patients.
I know it does mean differentthings to different folks.
And we often do have to kind ofback up and say, this does not
mean you're going out for a 5Krun tomorrow.
It means you're walking aroundthe block or just getting
outside even.
Coming up with exercise andother euphemistic ways to refer
(29:55):
to as exercise, moving is agreat way to start.
But yeah, little bits go a longways there.
Tammie Lee Demler (30:02):
I would also advocate, you know, somebody
looking at their diet, ifthey're not specifically diet
centered or able to really lookat the nutrition they're
consuming, having an essentialprotein intake to help with
those amino acids and theneurochemicals.
A high carb diet that reallybrings you no value calorically
and just adds on the pounds canbe counterintuitive.
(30:23):
So we like to have nutritionconsults just to take a look at
what they're eating, because itmay just be empty calories that
aren't being considered and notreally helping drive the
production of thoseneurochemicals.
Sara Klockars (30:36):
Thank you.
And then just wanted to speakbriefly about the recommended
length of treatment.
How long are patients onantidepressants for anxiety and
depression?
If someone does want to stop,what's the best way to stop?
Sarah, would you mind tacklingsome of that?
(30:57):
Sure.
Sarah E. Grady (30:58):
Sure.
Absolutely.
Yes.
This is a common question thatI get from my patients and I'm
sure many people in thecommunity, a common question
that they have as well.
And I think it's justified.
I think it's important toinform people, just remind them
that this is a veryindividualized decision that
typically after the firstepisode of depression or anxiety
(31:21):
occurs, If people have a goodresponse with a particular
antidepressant, it isrecommended that they stay on
the medication for a minimum ofsix to 12 months.
Once you get out to about ayear, then you can have a
conversation with your provider.
I encourage people not to comeoff of antidepressants without
(31:42):
provider instruction anddirection.
If people just stopantidepressants, they can have
antidepressant discontinuationsyndrome.
Anti-discontinuation syndromecan be very bothersome.
People can have a very bad moodor irritability, anxiety,
insomnia, GI upset, shakes,tremors.
(32:02):
They can have what people havedescribed to me as electrical
shocks, brain zaps.
So once somebody has beentaking an antidepressant for a
while, one of the reasons why wewant them to be under the
provider's care is that we needto taper them off of the
antidepressants.
We don't just want a coldturkey off of six months or a
(32:23):
year.
It's a very strategic step-downprocess while symptoms are
being monitored.
Full disclaimer, I've notreally read this in the
literature.
It's just something I've heardmany of the psychiatrists I work
with tell patients is that whensomeone is in the middle of a
stressful life event, whetherit's good stress or bad stress,
(32:44):
that's not a good time to startcalming down off of
antidepressants.
I had a research student workwith me, had been feeling okay
with her antidepressant.
She was at about the year markand she's like, yeah, I think I
want to start coming off myantidepressant.
And I said, you know, it'smiddle of the semester of a very
stressful graduate schoolprogram.
Now that there's ever a time inlife where we are a hundred
(33:07):
percent stress-free, but there'sdefinitely times in our life
where there might be You know,we're not in graduate school.
We're not getting married.
We're not getting divorced.
We're not having kids.
You know, just looking at thosemajor life events that can be
stressful, both in a good way,potentially in a bad way too.
Maybe that's not the best timeto start implementing a tapering
(33:29):
process.
So lots of factors go into ittoo.
Strong family history.
We might want to stay onantidepressants longer than the
six months to a year mark too.
So everyone's going to have adifferent prescriptive treatment
plan, which makes sense.
Tammie Lee Demler (33:46):
I agree with Sarah.
And the one thing I would addto that is, you know, the
discontinuation process isdifferent for everybody.
You know, some people need aslower, more gradual
discontinuation.
Other people are a little bitmore apt to accept a maybe more
traditional taper, but it reallyis dependent on the person.
There's not anything that saysit has to be done a certain way.
(34:09):
I think that thoseparesthesias, that electric
shock sensation that youdescribed, Sarah, has gotten
kind of a bad rap in that peoplehave been describing that to
each other as being addicted toyour antidepressant.
and that provides adisincentive for many people to
start it because they don't wantto be addicted to a medication.
So to be able to describe thatas being just a physiologic
(34:32):
response to discontinuingsomething that affects your
neurochemistry, very similar toabruptly stopping perhaps a
blood pressure medicine whenyour body will rebound and have
that be kind of an oppositereaction.
So I think in terms ofeducating our patients, we need
to also provide that informationthat you're not addicted to
your antidepressant, butdiscontinuation too quickly can
(34:54):
cause these physiologic sideeffects that would be absolutely
expected.
Sara Klockars (34:59):
Thank you for addressing that.
And I have one other subscriberquestion that came in a couple
of times.
One comment was, I often seeSSRIs and SNRIs prescribed to
PRN for anxiety.
Does this provide any benefitor is it risky?
And then another question was,can you use antidepressants,
(35:19):
PRN, for any indication?
So curious if, Tammy, if youwant to comment on that.
Tammie Lee Demler (35:27):
My initial thought when you asked the
question was that PRNantidepressants are not the
traditionally prescribedantidepressant for depression or
anxiety.
Those need to be scheduled andtaken on a regular basis.
Optimal dose, optimal duration,traditional way.
But with the use of some of themedications for premenstrual
dysphoric disorder, PMDD, theintermittent dosing is
(35:51):
recommended for those particularconditions.
Now you can take themcontinuously for people who have
that indication, or you canchoose to do it during these
luteal phases or a specificallyprescribed intermittency.
So even that is anindividualized approach to
treatment.
So with the agreement of theprescriber and the
patient-centered treatment, aregimen is discovered and
(36:12):
derived and then prescribed.
Sarah E. Grady (36:15):
Yes, Tammy, I agree with everything that you
said.
To my knowledge, There's notgood evidence-based literature
on using antidepressants asneeded.
Again, there's decent evidencewith the luteal phase dosing
with PMDD, which we do a littlebit here.
I would say more of what we seehere is that we usually have
(36:39):
the women on the SSRI the wholemonth, say if it's sertraline,
They may be at 100 milligrams or150 milligrams.
And then the week before theirmenstrual cycle, we may increase
the dose.
We have done that.
But yes, antidepressants asneeded.
Based on what I know and whatI've seen, I don't recommend
(37:02):
that at this time until we'vegot better literature supporting
that practice.
Narrator (37:10):
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