Sunday, November 22, 2009

SSRI's psych meds

Quite often AD patients are placed on a psychiatric medication by their doctor. One such class of meds is the SSRI’s, or selective serotonin reuptake inhibitors. This is a certain class or type of antidepressants that are commonly prescribed to treat depression and or anxiety. These meds have been around for a long time now, the prototype or first one was Prozac or fluoxetine. It was approved back in 1987 by the government. I remember the first time I ever heard of this medication, it was back in February or 1988 and I was in my last year of medical school, and on a clinical rotation at Robert Packer Hospital in Sayre Pennsylvania. I was on a pulmonary “lung specialty” rotation. I had no idea how common this class of meds would become and how many would follow. We had Zoloft and Paxil, Luvox, Celexa, Lexapro that were developed over the years. We had other related meds in a similar but different class that were called SNRI’s -serotonergic noradrenergic reuptake inhibitors. Such meds as Effexor, Cymbalta, and more recently Pristiq. Other antidepressants were also developed in other classes over the 1990’s.
Sometimes these meds can be helpful with AD patients, sometimes they can help significantly and sometimes a little bit. Sometimes the effects can be subtle and sometimes they can make a person worse. They have potential beneficial effects and potential side effects.
As loved ones on some level we often expect these meds not to help or wait for the med to make someone worse. There are many reasons why these meds sometimes don’t seem to make much difference. We are often quick to blame the doctor and assume he or she does not know what they are doing, or is “experimenting”. Here is a piece of information that is important. When a med is prescribed, that is a pharmacological intervention; there are only three basic outcomes. The person gets better or worse or there is no major change. I have to say the honest to God truth is that sometimes a person gets worse, not always, sometimes they get dramatically better. But truthfully when a person gets side effects or gets worse, we tend to vilify the doctor sometimes. I have never known a physician out there who is interested in hurting their patient or making them worse. Those kinds of people just don’t generally make it through the years and years of process and weeding out of would-be doctors. In addition to intelligence, ones sense of commitment and ones integrity is tested and those without much are generally weeded out. They don’t make it as doctors.
Another myth is that a physician practicing clinical medicine is “experimenting” patients are “guinea pigs” again contrary to popular belief. It is not “fun” for the doctor to wait and see what happens. Sure there are clinical research studies, but there are ethical protocols and lots of waivers, and in our society it is impossible to be entered into a clinical study without knowing about it. So when a doctor is just trying to treat and clinically help somebody, they might not know the exact clinical outcome, but it is not experimental, they have specific reasons and target symptoms of what they want to improve.
Part of the problem on why we don’t get better outcomes often is because of the communication. We often have no idea exactly what the med is supposed to do. What are the expectations of the med? What are the limitations? What should we look for? How will we know? When we just expect a med to make someone better or make them happy, we are often set-up for a bad outcome. And so it goes form there. The doctor is bad the med is dangerous, “Natural” treatments are better the doctor does not care and so on and so forth. Explaining target symptoms, what the med can potentially help with, identifying markers of success, and understanding these, often leads to better outcomes. You tend to get past the “Nocebo” effect. This is a little known or written about phenomenon that I will blog about in weeks to come. As the health care delivery by physicians continues to deteriorate, bemuse of economics and politics at least in terms of the value and honor and time spent between a physician and patient, this nocebo effect probably will become more prominent. Unless society can let doctors practice medicine, doctors that are allowed to spend time with their patients, and develop a trusting physician-patient alliance with the patient (and family), there will continue to be poor outcomes with med interventions. The doctor may often feel as caught in the middle as the patient and family…

No comments:

Talking about the book with the Lake Superior wind....... a calm day