...in my patient who just came in earlier than her appt. next week b/c she was "freaking out and crying about everything". She sat there (as i filmed her interview with all the PBA episodes) telling me how she cries over everything, gets angry with her husband, cries during angry outbursts at her kid's soccer games, cried when i told her my father passed. Has been on 2 SSRI's, Lithium, Effexor (failed Risperdal) for her depression/anger/agitation. Or quit them b/c they made her gain weight. All of this from her TBI 7 YEARS ago! Why did it take ME so long?!!! She says because her husband was always at our appts. and the talk was always about her OTHER behaviors. She took the Nuedexta right there in my office 1 hour ago. I'll bring her back for filming in 2 weeks. Can't wait to share the results with the board here.
Thought you may want to revisit the thread I think you meant.
FWIW IMO Fellus and Drareh are not one. I'm not even sure you were thinking that they were the same.
Enjoy your weekend.
Dr. Aryeh said something like he had met Dr. Fellus at some meeting.
Dr. Fellus was quoted as disclosing he had been paid $20,000 by Avanir.
So I wondered if Dr. Aryeh had met Dr. Fellus in an Avanir-sponsored capacity.
I asked Dr. Aryeh if he had ever been paid by Avanir. I believe I asked three times and Dr. Aryeh never replied but he stopped posting.
I just wanted him to disclose if he had been paid by Avanir. He was apparently unwilling to do this.
The clinical situation is a physician has a patient sufferring from major clinical depression.
If it is mild depression a prescription of psychotherapy, exercise and good sleep habits without any medication is probably the best first approach.
But SSRIs are not dangerous and are well-tolerated. If the patient has moderate depression in a clinician's view it is reasonable to add an SSRI to the treatment recommendation above, to try to avoid progression to severe depression and also to hedge against the possibility that the clinician has underestimated the severity of the depression and has underestimated the risk of suicide or homicide.
Patients want to avoid recurrence of depression so it is sometimes hard to convince patients they should try to get off their SSRIs once the depression has improved.
So yes, SSRIs are used overmuch but part of the reason is that they are safer and pretty easily tolerated, (much more easily tolerated than the tricyclic antidepressants) and because major depression is a very disturbing and uncomfortable and debilitating and relationship-impairing and work-impairing and sometimes can progress to a lethal illness which can threaten the life of both the patient and even those he or she comes in contact with.
"benzo's impair memory (STM) which is already impaired in TBI. It's not a viable option."
If you manage spasticity in traumatic brain injury patients, I assume you use benzodiazepines at times, in which case you are using benzodiazepines in traumatic brain injury patients and you are admitting benzodiazepines are only relatively contraindicated.
In discussing approaches to treatment,
I think it's best to discuss things analytically including the amount of experience with a drug, including study data, the rationale for why it should or shouldn't work, relative contraindications and how relative they are to one another.
In treating psychiatric manifestations of traumatic brain injury, it is hard to evaluate anecdotal cases and even study data has more subjectivity than in other fields.
It is easy to get an exaggerated sense of the validity of one's own, "gut and experience."
Humility in approaching one's own thinking and discussion about the treatments in this inexact science is useful.
You are launching 45% of your patients on dex/quin.
Dex/quin is a drug with little study data behind it even for PBA and pain and even for MS and ALS patients.
Practically no data or clinical experience exists in the treatment of PBA or pain in traumatic brain injury patients.
Dex/quin has risks of lethal ventricular arrhythmia, lethal drug interactions, clinically important decreases in platelets with bleeding risks and hepatitis.
has its own CNS effects that could be problematic for traumatic brain injury patients.
You are treating these brain injury patients for a totally different indication (aggressiveness, agitation and irritability) than what dex/quin has been studied for.
And you are doing this BEFORE trying less dangerous drugs with more clinical experience behind them (and in combination with maximized alternative approaches for relaxation and anger management).
This is a dangerous clinical approach that is not maximized for effectiveness while minimizing potential harm to the patients, in my opinion.
And you do it and justify it with hubris, bullying and disdain for the opinions of others.
And you are way out on this investigational use limb, not in a study setting, with an undisclosed conflict of interest as a stockholder in the company.
You obviously think the world of yourself as a clinician and in your practice there probably isn't anyone around to tell you anything different which may be how you got to this point.
I suggest you look in the mirror I am holding up to you.
I understand these patients are difficult to treat and there is a lot at stake if they don't get better.
And trying dex/quin. IS reasonable in patients who fail multiple other approaches.
But I don't think it is wise to assume dex/quin is superior to other approaches for anger/aggression/irritability and I think dex/quin is not as safe as the other approaches we have been discussing.
I think it is misleading and unwise to call anger/aggression and irritability "PBA".
I think indirectly it does impact (if not address) the cost issue. People will pay for value as reflected in the efficacy of N vs. alternatives. As the perceived efficacy of alternatives drops the perceived value of N rises and people will pay more and physicians will be faster to prescribe.
Just a modest chunk out of the mammoth anchor that is N cost but every bit helps and hopefully the anchor is getting chunks removed on multiple fronts now.
The links I posted did not distinguish between grades of depression.
And even if we assume your statement is correct that “SSRIs are effective for severe depression”, there is little doubt in my mind that they are very much over prescribed for patients where they are ineffective as this excerpt from the Celexa study paper points out.
“However, the findings of this study show a remarkably low percentage of people actually had a remission (lessening) of symptoms…. Approximately 70% of the study’s participants did not have a remission of symptoms and over 50% did not even have a response to the drug.”
So if half the patient population is having no response and up to 70% aren’t seeing a significant benefit, doesn’t that call into question the history to which you point out is the major reason for using SSRI’s as a first line therapy?