Editor Shares Practical Road Map Through Maze of Therapy Options

When are antidepressants appropriate for patients with bipolar disorder? Which antidepressant is safest during pregnancy? If my psychiatric patient is prescribed an antibiotic that cannot be taken with his regular medication, what can I prescribe instead?

Attendees at the 167th Annual Meeting of the American Psychiatric Association (APA), convening at the Jacob K. Javits Center in New York City, appreciated Sunday’s opportunity to hash out practical day-to-day issues at “Meet the Author: Evidence-Based Guide to Antidepressant Medications and Antipsychotic Medications,” with editor Anthony J. Rothschild, MD, director of the Center for Psychopharmacologic Research and Treatment, at University of Massachusetts Medical School.

Dr Rothschild explained that there are actually 2 guides; the first on antipsychotic medications was published in 2010,¹ and the volume on antidepressants followed in 2012.² Both books, published by the American Psychiatric Press, have received strong reviews for condensing hundreds of studies on medications into well-written chapters by experts,³ complete with helpful “Clinical Highlights.”

Although he is an academic physician, Dr Rothschild said he treats most of his patients in outpatient settings, apart from research protocols. His own expertise is in psychotic depression, a complex and hard-to-treat disorder in part because it has been the subject of few studies and because there is no specific therapy approved by the FDA. “It’s all off-label,” Dr Rothschild explained.

“I’ve been struck over the years how this illness is often missed,” he said. “Of samples of people with major depression in the community, somewhere between 15% and 18% will have major depression with psychotic features.”

With his own clinical experience, and the work in assembling the chapter authors for the guides, Dr Rothschild took on questions from his fellow psychiatrists, and he seemed as anxious to learn from them as they were to hear from him.

“So, do you use antidepressants in treating bipolar disorder?” Dr Rothschild asked. “I get lots of different answers when I travel.”

His own specialty, psychotic depression, offers insight into the gap between results of clinical trials and the practical realities of treating patients in the field. “If you look at the development of medications, from Prozac onward, if you had psychotic depression, you were excluded from the study.”

Consequently, he said, when new antidepressants came on the market, the trial data did not address effects in patients like his. That’s why Dr Rothschild encouraged this chapter authors to dig into controversies and address both on-label and off-label uses.

Examples of the practical advice included his discussion of the role of lithium as an augmentation to other therapy. “If I have someone on an antidepressant and an antipsychotic and they are a partial responder, I might add lithium,” he said.

The guides include chapters on the use of medications during pregnancy and lactation because there’s such a need, he said. “The postpartum period is an increased time of risk … It seems every year there is a tragic case in the news in which the woman killed or tried to kill children,” he said. Dr Rothschild researched the case of Andrea Yates, the Texas mother who drowned 5 small children in a bathtub in 2001, after learning her diagnosis. (Yates remains in a psychiatric hospital.)⁴

“Part of her legal defense was that she suffered from psychotic depression,” he said. “She probably did not get the best treatment; certainly not treatment following APA guidelines.”

Dr Rothschild fielded questions about individual cases and what augmentations might be tried, with some discussion of how insurance coverage drives choices for physicians. Coverage in Medicare and Medicaid can be especially challenging, as reported recently in The American Journal of Managed Care.⁵

“Weighing risks and benefits of atypicals versus older strategies—there’s not a simple answer to that,” he said. “The addition of Wellbutrin to an SSRI (selective serotonin reuptake inhibitor), which is a popular strategy, has not had very good evidence for it.”

As with all such cases, psychiatrists must look at the individual patient’s needs, evaluating specific symptoms and that particular patient’s ability to tolerate side effects.

References

1. Rothschild AJ. The Evidence-Based Guide to Antipsychotic Medications. Washington, DC: American Psychiatric Press; 2010.
2. Rothschild AJ. The Evidence-Based Guide to Antidepressant Medications. Washington, DC: American Psychiatric Press; 2012.
3. Ostergaard, SD. Review, The Evidence-Based Guide to Antidepressant Medications. Psychiatric Services. 2013;64(10): http://ps.psychiatryonline.org/article.aspx?articleid=1745254 October 1, 2013.
4. Quigley R. Andrea Yates wants more freedom … 10 years after drowing her 5 kids she seeks a weekly pass to attend church. The Daily Mail Online. http://www.dailymail.co.uk/news/article-2121592/Andrea-Yates-wants-freedom-Ten-years-drowning-five-kids-seeks-weekly-pass-mental-hospital-church.html. Published March 28, 2012, updated February 16, 2014. Accessed May 7, 2014.
5. Seabury SA, Goldman DP, Kalsekar I, Sheehan JJ, Laubmeier K, Lakdawalla DN. Formulary restrictions on atypical antipsychotics: impact on costs for patients with schizophrenia and bipolar disorder. Am J Manag Care. 2014;20(2):e35-e42. http://www.ajmc.com/publications/issue/2014/2014-vol20-n2/Formulary-Restrictions-on-Atypical-Antipsychotics-Impact-on-Costs-for-Patients-With-Schizophrenia-and-Bipolar-Disorder-in-Medicaid.