The Y in Psychiatry
"The Y in Psychiatry" – a pragmatically endearing podcast talking to the med students, residents, fellows, and attendings of the medicine world about the nuances of psychiatry.
Each episode features focused discussions that explore the intersection of the mental health, medicine, and the human experience.
Together, we'll uncover the hidden "Y" – the compelling reasons, profound insights, and groundbreaking discoveries shaping the psychiatric landscape.
So grab a seat, warm beverage, tune in, and let's embark on this journey to unlock the mysteries of the human psyche, only on "The Y in Psychiatry."
The Y in Psychiatry
E7 - Depression - Second Steps - Psychopharmacology Options with SSRIs
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Because it happen and whenever you are actually eating with friends and bro have a lot of opiates that is released in your body, does have antidepressant property,
Thanh:Welcome to the Y in Psychiatry!
Dr. Amayo:Hi, this is Dr. Amayo C/L fellow.
Thanh:Where we delve into the intricate nuances of psychiatric topics.
Dr. Handratta:My name is Dr. Handratta attending psychiatrist. I did my residency from University of Connecticut and then I did my fellowship from Georgetown University in consultation and liaison.
Thanh:Each episode features interview style discussions that explore the intersection of the mind medicine and the human experience. Together we'll uncover the hidden why and the groundbreaking discovery shaping the psychiatric landscape. So grab a seat, warm beverage, tune in, and let's embark on this journey to unlock the mysteries of the human psyche. Only on The Y in Psychiatry.
Dr. Amayo:Welcome back to The Y in psychiatry. This is your host, Dr. Amayo C/L fellow. I go by Miracle and here with me is Dr. Handratta. Say hi, bro.
Dr. Handratta:Hi bro. Hello guys. How are you doing?
Dr. Amayo:Today we're gonna be continuing on that algorithm of depression. Two episodes ago we talked about why to treat depression, how you diagnose depression, and the first step. Last episode we talked about other factors you need to optimize besides medication, including psychotherapy, sleep, making sure there's no other confounding diagnosis and comorbidities. And today we are gonna talk about what I know you guys came for the medication part, right? What medication to use why to use those medication, what steps to pick. So if I'm gonna pick an SSRI, which one should I pick?
Dr. Handratta:So let's jump into SSRIs, right? So how do we select our SSRIs? So the SSRIs, they basically work the same way, except there is small differences between them, right? So I don't want people to consider all SSRIs are the same, Let's go stepwise. So few things that I look for when I'm using an SSRI. Like I've ruled out bipolar disorder in a patient, I've ruled out underlying medical conditions that is causing depression. I've ruled a substance use uh, and all the other factors, which might precipitate depression, So this particular patient has a family history of depression and just had an acute episode of depression, which is causing functional impairment, first I look at the side effect profile as Miracle mentioned. what is the side effect of the medication? Some side effects. You can actually use it for your benefits for the patient's benefit and some side effects you know, that the patient will not be able to tolerate and you need to avoid it. Second thing is I need to know the steady state. How long does it take for the medication to reach a steady state? Because that will tell that is about approximately five half-lives. that basically will tell you when do you increase the dose of the medication. So I like medications, which has a steady state of one week because then I can increase the dose every week, Rather than a medication which has a steady state of one month, which you have to wait for four weeks before you increase the dosage. Because if a medication has a steady state of four weeks and you increase it every one week, then what is gonna happen is that the fourth week when it reaches steady state, you see the side effects because it has accumulated, right? So it's very important to know the steady state. And then what's it cardiac effect? How safe it is on the heart? Because now we are one of the medication that the F D A basically said, Hey, you need to watch for Q TC prolongation And then when do you dose them? Morning or evening? Because a lot of time, a medication that is dosed in the evening, you dose in the morning, it'll cause a lot of fatigue and sedation. And the patient basically comes and tells you, doc, I am tired the entire day. So you're not helping the patient at all, You're causing more functional impairment. So it's very important to know when you're going to dose it. And then the drug interaction, right? Young patient 20, 25 years old is not on too many medications, so you don't have to worry. But patients over the age of 40, You start accumulating different medical conditions, you start accumulating medications itself. So you're on a long list of medications. So you need to know the drug drug interaction. so these are some of the factors I take into consideration when I'm picking my antidepressant.
Dr. Amayo:So it sounds like you're keeping track of side effects and it sounds like sometimes side effects might be wanted depending on the patient. I would guess like Sleeping or eating more. You also want to keep track Of half life of the medication, other comorbidities and then effects like cardiovascular effects Let's get deep into, so what symptoms would make you pick something. So what's, what symptoms would make you pick Sertraline over Fluoxetine?
Dr. Handratta:So let's delve into it. So let's talk about citalopram. I'm not going to use any brand name because we are not funded by anybody, right? Sadly. Yeah. We are poor little bros. Three bro, four bros. Here, actually barely surviving and episodes just for the education purpose and we love doing this, right? So citalopram has an antihistamine property, So it's pretty good choice in patients who have insomnia,Patients who are not eating well, because antihistamine medications can increase your appetite too, So just make sure citalopram is dosed in the, at bedtime and not in the morning. Antidepressants always tell the patients to eat when they take antidepressants, right? Because the five HT3 receptors, which are present in your gut when you stimulated, can cause nausea and vomiting. So when you eat with food, it can decrease the nausea and vomiting. A patient taught me, he said doc, I took my medication, I ate a little bit, took my medication, and then finished the meal. That was the best advice a patient ever gave me. And I have been telling this to every patient. And the nausea is helped
Dr. Amayo:So you take it in between your meal?
Dr. Handratta:Yes. Like a sandwich. Eat a little bit of your breakfast, take the medication completely, eat a little bit of your dinner, take the medication and finish your dinner so I take that patient experience and let the other patients know, but I give the credit to that particular patient. Okay. This is not something that I came up with. We learn every day. And then so citalopram bedtime with dinner, Steady state of citalopram is just a week So it's great you can increase the dose every week, but just be careful. Don't go above 40 milligram because of the risk of QTC. But if you want to use a higher dose, suppose a patient has obsessive compulsive disorder, get an E K G, increase the dose and do a follow-up E K G, just to make sure that the QTC is not prolonged. This is not going happen in every patient, So you should not deprive a patient or the benefit of the medication just because you're worried that the, there's a Q T C risk, Take the precaution that you need to take, monitor the patient and use it. So the problem, is that when F D A came up with this patients who are on 60 milligrams citalopram or 80 milligrams citalopram, physicians are scared and they decrease the dose. And these patients decompensated though they didn't have any Q T C problem, So you have to be careful. You should take it actually, all these advice with a grain of salt, Every patient is different, right? For example, a cardiologist will tell you, don't treat the EKG. Treat the patient. Same thing here, Look at the clinical symptoms. Be cautious. Don't just blindly prescribe it.
Dr. Amayo:Sounds like citalopram is a good medication. Just have to, watch for that Q T C prolongation when you go above 40. Dose at night because of the antihistaminergic properties that can make people sleepy. Is there any reason why I should pick citalopram? If I have someone that might miss a medication, I'll pick Fluoxetine because that has a very long half-life. is there, one niche area that citalopram is like amazing for? Like a patient that citalopram would be wonderful for
Dr. Handratta:So citalopram can actually be used in patients with liver disease who have depression. That's one condition that you can use it, you can use citalopram in patients who have severe insomnia. It's also a pretty good medication to pick. So especially in these two conditions, You can pick citalopram. And one more addition is that in geriatric patients dosage, more than 20 milligram, just get a E K G before you actually go up on the dosage. So if the patient has liver disease, go with citalopram. Now, suppose that you are pretty busy in your practice, you don't have time to open up your iPhone and look for drug interaction, citalopram is a great medication because it doesn't have much of cytochrome P450 interaction. It's a very mild 2D6 inhibitor. So that also makes it a great medication actually, because you don't have to look for drug interactions.
Dr. Amayo:So great for liver disease Great for if there's multiple drugs the patient is on, is great because there is less drug interaction. Okay. I've never thought of citalopram like that. Good to know So that's it for citalopram. How about escitalopram? What's so special about escitalopram?
Dr. Handratta:So, escitalopram Is very similar to citalopram, but there is a changes in S-enantiomer. So it's, there's a structure change. The advantage of escitalopram is that it's antihistamine property is six times less than that of citalopram, right? But it's still slightly sedating. It does have an antihistaminic property. So again, dose it in the evening. I always tell the patient, take it in the evening. If it causes insomnia, switch it to the morning. Again, take it with food. Steady state one week you can increase the dose on a weekly basis. Cardiovascular effect, plus and minus. There is mixed data on it. But you want to be a little cautious, get an EKG done. Once you reach a dosage of like around 20 milligrams and then follow the E K G, the patient's, the next E K G is normal. You don't have to worry. Plus the patient doesn't have any cardiovascular risk factor. It should be good. There's no hypomagnesemia, there's no hypokalemia, there is no bradycardia. So escitalopram again, no drug interaction because it's a very mild cytochrome 2D6 inhibitor plus like citalopram. You can use it in liver disease. so citalopram and escitalopram, both can be used in liver disease. No drug interaction. Steady state one week, easy to titrate the dosage.
Dr. Amayo:So the problem I have with escitalopram, it has a very limited range, so it's five to 20 for escitalopram. why is that? Is it just more potent or why is it such a low range
Dr. Handratta:So we don't know whether it's actually more potent, but if you look at the enantiomer, the s enantiomer is more potent than the Rs. But we don't know that for sure. And most likely in the clinical trial, the doses that they used actually, the 5, 10, 15, 20 was the most effective. But there are people who use up to 30 milligrams So it totally depends upon what are you treating Be very careful actually, because it totally depends upon your pharmacogenomics. if you're a poor 2C19 metabolizer or you're an extensive or ultra rapid 2C19 metabolizer. So if you're extensive or ultra rapid, then you'll have to use a higher dose of escitalopram to see the benefit. If you're a poor metabolizer, then you have to actually use a lower dosage, right? For example, if you look at a small subset, African American and Asian population, they are poor 2C19 metabolizers. So in that population you have to be a little careful, start low and go slow. Okay?
Dr. Amayo:And so citalopram and escitalopram are metabolized by CYP 2C19?
Dr. Handratta:Yeah, both citalopram and citalopram.
Dr. Amayo:All right, so let's talk about sertraline.
Dr. Handratta:So sertraline, again, a medication metabolized by 2C19. I just actually threw it there so that you can actually, the three medications by 2C19. Sertraline is a great medication, This is one of the medication. I like the reason being is that it's safe in patients with cardiovascular problem, QTC interval. Plus the studies that they did post MI was with sertraline, It's safe in patients with the renal disease we can give to patients with dialysis. And we spoke about it in one of our podcasts which I don't think so, we have published yet. That it's also prevents the post dialysis hypotension. Don't ask me why I do not know, bro. And plus it can also be actually used in patients who are pregnant. It's very safe in pregnancy as well as breastfeeding. So a lot of advantage, but don't use it in liver disease because it undergoes first past metabolism. Right? So sertraline is a pretty good choice, right? Plus you don't have to worry about the drug interaction unless you go above 150, then it becomes a moderate 2D6 inhibitor, plus the little bit of disadvantage of sertraline is It cause more nausea, vomiting, and headache as compared to other medication because it does have affinity for 5HT3 receptors. It has a steady state of one month, so you have to actually do a very slow dose titration, And it is also the, one of the only SSRI that is preferred in patients with A D H D because serotonergic medication can decrease the dopamine and therefore can affect the processing speed. But sertraline also has a dopaminergic effect to it. So it's considered to be one of the SSRI that can prescribe to patients with A D H D without affecting the processing speed. And you can dose it in the evening, but you can also dose it in the morning if you want.
Dr. Amayo:If I didn't know better I would think sertraline was sponsoring you. So for sertraline steady state of one month metabolized by 2C19 at higher doses up to 150. It's a 2D6 inhibitor. Safe in cardiovascular, safe in renal patients and preferred in patients with A D H D because it also has some dopaminergic properties to it. Side effects. It's more likely to have the nausea, vomiting side effect cause it has a affinity for the 5HT3 and besides the inhibition of 2D6, that's pretty much sertraline and I'm guessing less sedating, right? Because of the dopaminergic dose in the morning
Dr. Handratta:You can dose, but some patients do feel a little tired on it. So majority of the time, like in my experience, I usually dose it in the evening and the patient basically says I cannot sleep. Then I say, Hey, take it in the morning.
Dr. Amayo:Okay. is that your normal go-to all the SSRIs in the evening.
Dr. Handratta:No. So the SSRIs like citalopram, escitalopram, sertraline, fluvoxamine and paroxetine. So all the SSRIs are dosed in the evening except fluoxetine.
Dr. Amayo:And we'll get to Fluoxetine in a while and then I think I forgot to talk about this sertraline is also good for the pregnant population, good for breastfeeding. Let's see what we have next: paroxetine!
Dr. Handratta:Paroxetine is a good SSRI r, right? But you have to be a little careful when you're using paroxetine, First of all, because it has an anticholinergic side effect. So you ought to be careful in patients with benign prostatic, hypoplasia with myasthenia gravis. Patients who are delirious or are cognitive impairment peptic ulcer disease, so all those things, you have to be a little bit careful, but you can prescribe it, It has a steady state of about a month. So you have to wait four weeks because you increase before you increase the dose, because if you do a quick increase, then you'll see the side effects when it reaches a steady state.
Dr. Amayo:Even though it has a short half-life it still has a long, steady state?
Dr. Handratta:That's a great question. So don't quote me on this, but paroxetine inhibits its own metabolism, right? It's metabolized by 3D6 and it's also an inhibitor of 2D6 so it can cause an auto inhibition increasing its own plasma level. That could be the reason why the study state is a month, right? So I basically, I'm little careful, especially with any medication that auto inhibits itself, like paroxetine is one and fluoxetine is another one. So you ought to be very careful increasing the dose wait watch, Because otherwise, like you will basically just build up the dose of medication and you'll have severe anticholinergic side effects, Plus it has a very safe Q T C profile. in patients with Q TC prolongation, the two SSRIs that you can safely use is paroxetine as well as sertraline, always dose in the evening you give paroxetine in the morning, the patient with it is sleepy. And this is very common. Patient will go to primary care providers for depression. Majority of our patient goes to a, go to a P C P to manage depression. And this prescribed paroxetine, they say once a day, whenever you say once a day, patient will take it in the morning and they're tired the entire day, So that's the easiest consult you're going to get, Miracle: patient tired and sleepy during the daytime on paroxetine"Doc, what should I do?" Switch it to the bedtime: done! So that is actually about paroxetine, but you also keep an eye on the weight according to research data. With paroxetine, when you gain weight, you keep on gaining weight in susceptible patients. So you have to be careful actually with the weight gain, And then withdrawal, if you skip a dose short half, like you actually see severe withdrawal, right? And plus it inhibits 2D6, so you have to be careful regarding the drug-drug interaction.
Dr. Amayo:Wow. And then also it's one of the least favorite SSRI for pregnancy, especially in the first trimester because of its risk of causing cardiac malformation. But apparently It's very good for breastfeeding because there's little percentage of it found in the breast milk, but not great during the first trimester. So in summary paroxetine has anticholinergic properties. Is sedating, can cause weight gain. Give it At night. It is a 2D6 inhibitor, so there's a possibility it auto induces itself. So starts low, go slow. And then there is the withdrawal. Down titrates easily, but it's great for patients with cardiac issues It has less Q T C prolongation.
Dr. Handratta:One correction actually, that it inhibits 2D6 so it calls auto inhibition of 2D6.
Dr. Amayo:Real quick, big highlight. Citalopran escitalopram used for liver disease, less c y p drug interactions. Citalopram has antihistaminic stomach properties so maybe more sedating dose at night. Paroxetine, anticholinergic do not use in the first trimester for pregnancy. safe for Q T C prolongation, however. And sertraline, our baby favorites out of the four Negative issues might be more nausea generating but safe with cardiac as well. Is a moderate inhibitor of 2D6, especially at higher doses. Preferred in ADHD'cause it has some dopaminergic properties and paroxetine and citalopram and they have a one month lag to get to steady state. So in both of them don't go up too fast. So we've talked about citalopram, escitalopram, sertraline, and paroxetine, and those are four out of the six SSRIs. We're gonna talk about the two other SSRIs with the SNRIs and that is it for today in the Y is psychiatry. Peace out guys.
Katrina:Thank you for joining us on today's episode. our tireless team is already hard at work, cobbling together another potpourri of fascinating discussion for next week, so be sure to tune in, visit our website and our podcast feed and let us know your thoughts on the episode. Subscribe so you don't miss our releases every Wednesday. Until next time, keep smiling, keep shining, and stay curious.
