Dr. Singh is Assistant Professor, Department of Child and Adolescent Psychiatry, University of Toledo Medical Center, Toledo, Ohio; Dr. Prakash is from the Department of Child and Adolescent Psychiatry, University of Toledo Medical Center, Toledo, Ohio; Dr. Rais is Associate Professor, Department of Child and Adolescent Psychiatry, University of Toledo Medical Center, Toledo, Ohio; and Dr. Kumari is from the Department of Public Health, University Toledo Medical Center, Toledo, Ohio.

Psychiatry (Edgemont) 2009;6(10):30–34

Dr. R. Sansone is a professor in the Departments of Psychiatry and Internal Medicine at Wright State University School of Medicine in Dayton, Ohio, and Director of Psychiatry Education at Kettering Medical Center in Kettering, Ohio; Dr. L. Sansone is a family medicine physician (government service) and Medical Director of the Primary Care Clinic at Wright-Patterson Air Force Base. The views and opinions expressed in this column are those of the authors and do not reflect the official policy or the position of the United States Air Force, Department of Defense, or US government.

Dr. Sheehan is Distinguished University Health Professor, Professor of Psychiatry, Director, Depression and Anxiety Disorders Research Institute, University of South Florida College of Medicine, Tampa, Florida; Dr. Croft is Medical Director, San Antonio Psychiatric Research Center, San Antonio, Texas; Drs. Gossen, Levitt, Brullé, and Rozova are from Labopharm Inc., Laval, Québec, Canada; and Dr. Bouchard is from Lakeshore General Hospital, Montréal, Québec, Canada.

Dr. R. Sansone is a professor in the Departments of Psychiatry and Internal Medicine at Wright State University School of Medicine in Dayton, Ohio, and Director of Psychiatry Education at Kettering Medical Center in Kettering, Ohio; Dr. L. Sansone is a family medicine physician (government service) and Medical Director of the Primary Care Clinic at Wright-Patterson Air Force Base. The views and opinions expressed in this column are those of the authors and do not reflect the official policy or the position of the United States Air Force, Department of Defense, or US government.

Psychiatry (Edgemont) 2009;6(2):16–18

Abstract
In this article, we provide information on patient-reported side effects from a cross-section of real-world patients. Specifically, data on side effects was tabulated for patients taking one of the following selective serotonin reuptake inhibitor antidepressants: citalopram, escitalopram, fluoxetine, paroxetine, and sertraline. Thirty-eight percent of the approximately 700 patients surveyed reported having experienced a side effect as a result of taking a selective serotonin reuptake inhibitor antidepressant; the most common side effects mentioned were sexual functioning, sleepiness, and weight gain. Only 25 percent of the side effects were considered “very bothersome” or “extremely bothersome.” Regardless of how bothersome the side effects were, however, only 40 percent of patients mentioned the side effects to their prescribing physicians.

Key Words
SSRI, antidepressant, patient-reported side effect, real-world data

Introduction

Recognizing that time for patient care by the physician is limited, it is important for practicing physicians to understand which issues to prioritize in their patient interactions. In this article, we provide information on patient-reported side effects from a cross-section of real-world patients using selective serotonin reuptake inhibitors (SSRIs).

Methods

iGuard.org, a patient drug safety monitoring service, randomly surveys enrolled patients on a continuous basis to obtain data on treatment satisfaction, efficacy, and side effects using a validated, patient-reported, outcomes instrument called the Treatment Satisfaction Questionnaire for Medications (TSQM). Data on side effects were tabulated for patients taking one of the following SSRI antidepressants: citalopram, escitalopram, fluoxetine, paroxetine, and sertraline. Please note that surveyed patients may have been taking other central nervous system (CNS) and non-CNS products concurrently with SSRI antidepressants.

Results
Thirty-eight percent of the approximately 700 patients surveyed reported experiencing one or more side effects as a result of taking an SSRI antidepressant. Figure 1 displays the side effects most commonly mentioned by patients. Of the 229 patients who listed at least one side effect, sexual functioning, sleepiness, and weight gain were the most commonly mentioned items. Only about one-quarter of these patients (26%), however, indicated that these side effects were “very bothersome” or “extremely bothersome” (Figure 2).

Figure 3 shows the proportion of patients who discuss side effects with their prescribing physicians. As seen in Figure 3, only 39 percent of patients reported side effects to their physicians. Interestingly, the proportion of patients reporting side effects to their physicians was the same for all patients, including those who considered the side effects “very bothersome” or “extremely bothersome” (39% vs. 37%).

Discussion

The antidepressant side-effect debate has existed for many years. It was the beneficial side-effect profile of fluoxetine that differentiated it from tricyclic antidepressants after the drug was launched in 1988. There was no doubt that the reduction in cardiac arrhythmias and other potential lethalities played a major role in opening the door to the exponential growth of antidepressant prescribing. With growing recognition of the need for long-term antidepressant use and attention to quality of life, attempts to minimize antidepressant side effects and drug discontinuation have gained a prominent focus.

The side effects reported in this article emerged from a survey of 700 enrolled participants in a drug safety monitoring service who were identified as SSRI recipients. The nine most frequently endorsed side effects were identified together with a ranking of burden. Sexual dysfunction, sleepiness, and weight gain were the most encountered side effects, and, in total, 38 percent of the patients surveyed experienced at least one side effect, while 26 percent reported a high level of burden. This likely provides a fair cross-section of side effects biased toward continuation or maintenance phases of treatment and supports other clinical trial data showing that sexual dysfunction and weight gain are the most frequent reasons cited by patients for SSRI discontinuation. The most interesting aspect of this report is the disclosure that only 39 percent of patients reported side effects to their physicians, and there was no difference in those with “very bothersome” or “extremely bothersome” side effects compared to the total sample. An analysis of data that compares various factors, such as age, gender, or drug, goes beyond the scope of this report and therefore is not included.

In general, variations in side-effect profiles are attributed to mechanistic differences within or between drug classes. Of equal importance, however, is the difference in patient profiles, ranging from genetic polymorphisms to personality dimensions. SSRIs are predominantly metabolized by cytochrome 2D6. While microarrays are commercially available to detect extensive or poor metabolizer status, this strategy has not yet become a standard component of clinical care. There is also debate in the literature about polymorphism status for the serotonin transporter influencing SSRI side-effect reporting. Neuroticism as a personality dimension has also been shown to influence side-effect reporting, even with placebo, with high levels of neuroticism increasing side effects. Other variables that contribute to drug tolerability include time of dosing, intake with or without food, and smoking status. All of these factors should be considered during antidepressant therapy to promote optimal response.

Ms. Cascade is Vice President, Quintiles Inc./iGuard, Falls Church, Virginia; Dr. Kalali is Vice President, Global Therapeutic Group Leader CNS, Quintiles Inc., San Diego, California, and Professor of Psychiatry, University of California, San Diego; and Dr. Halbreich is Director, Biobehavior Research, Professor of Psychiatry and OB/GYN, SUNY, WPA Section on Interdisciplinary Collaboration, Buffalo, New York.

Psychiatry (Edgemont) 2008;5(12):14–15

ABSTRACT

Because of limitations in diagnosis coding, it is difficult to determine which products are used to treat premenstrual dysphoric disorder. To better understand treatment of premenstrual dysphoric disorder, we examined the antidepressant prescribing behavior of obstetrician/gynecologists as a marker for premenstrual dysphoric disorder treatment and compare these use patterns to psychiatrists and primary care physicians. Over the past quarter, only three percent of antidepressants were prescribed by obstetrician/ gynecologists as compared to 51 percent by primary care physicians and 20 percent by psychiatrists. Obstetrician/ gynecologists more frequently use selective serotonin reuptake inhibitors (69% compared to 58% in primary care and 48% in psychiatry) and are more likely to choose an selective serotonin reuptake inhibitors agent indicated for the treatment of premenstrual dysphoric disorder (e.g., fluoxetine, paroxetine, sertraline): 66 percent versus 59 percent for both primary care physicians and psychiatrists. Use of desvenlafaxine was slightly elevated in obstetrician/ gynecologists as compared to primary care physicians (0.3% vs. 0.1% of total antidepressants, respectively); however, psychiatrists prescribed more desvenlafaxine than either group: 0.4 percent of total antidepressant prescriptions. Discussion of this data is provided.

Key words
premenstrual dysphoric disorder, PMDD, SSRI, SNRI, antidepressant, psychiatry, OB/GYN, PCP

INTRODUCTION

Because of limitations in diagnosis coding, it is difficult to determine which products are currently used to treat premenstrual dysphoric disorder (PMDD). To date, the selective serotonin reuptake inhibitor (SSRI) antidepressants (e.g., fluoxetine, paroxetine, sertraline) are the only products indicated for PMDD treatment. However, the serotonin-norepinephrine reuptake inhibitor (SNRI) desvenlafaxine is currently being studied in the treatment of hot flashes. To better understand treatment of PMDD, we examined the antidepressant prescribing behavior of obstetrician/ gynecologists (OB/GYNs) as a marker for PMDD treatment and compare these use patterns to psychiatrists and primary care physicians (PCPs).

METHODS
We obtained data on total retail prescriptions for antidepressant medications in June, July, and August of 2008 from SDI/Verispan’s Vector One National (VONA), which captures nearly half of all prescription activity in the US.

RESULTS

Over the past quarter, only three percent of antidepressants were prescribed by OB/GYNs FIGURE 1. PCPs account for 51 percent of antidepressants prescribed and psychiatrists for an additional 20 percent.

FIGURE 2 displays the mix of therapeutic classes prescribed by physician specialty. As seen in FIGURE 2, OB/GYNs more frequently prescribe SSRIs (69%) relative to PCPs (58%) and psychiatrists (48%). With respect to individual SSRI selection, OB/GYNs are more likely to prescribe an agent indicated for the treatment of PMDD (e.g., fluoxetine, paroxetine, sertraline): 66 percent versus 59 percent for both PCPs and psychiatrists. Use of desvenlafaxine was slightly elevated in OB/GYNs as compared to PCPs (0.3% vs. 0.1% of total antidepressants, respectively); however, psychiatrists prescribed more desvenlafaxine than either group: 0.4 percent of total antidepressant prescriptions.

DISCUSSION

Premenstrual syndromes (PMS) and PMDD are interdisciplinary disorders that present with diversified clusters of symptoms. Women sufferers may seek treatment with their PCP, OB/GYN, or psychiatrist. Not surprisingly, the data from SDI/Verispan’s VONA confirm that the woman-patient’s entry point to the medical healthcare system substantially influenced the treatment prescribed to her. While a psychiatrist and a PCP would probably prescribe an antidepressant as the first line of treatment for PMDD, an OB/GYN would very rarely prescribe antidepressants.

Though the VONA data presented here do not specify it, it is plausible that OB/GYNs would prescribe more hormonal interventions, mostly oral contraceptives (OC), which are widely used, with at least one OC having an indication for PMDD.

So far, none of the medications indicated for PMDD have been shown to be effective for more than 60 percent of women sufferers. The reasons for this efficacy ceiling are intriguing and should be addressed. The main reason for the relatively weak response rate is probably the lack of precise, widely accepted, multidisciplinary, diagnostic criteria. This leaves much flexibility to the practitioner to prescribe according to his or her clinical orientation, beliefs, and traditions, as opposed to prescribing based on evidence. The lack of accepted knowledge on syndromal subgroups of PMS further contributes to imprecise treatments. Hopefully these issues will be rectified in the near future.

FIGURE 1

Ms. Cascade is Vice President, Quintiles Inc./iGuard, Falls Church, Virginia; and Dr. Kalali is Vice President, Global Therapeutic Group Leader CNS, Quintiles Inc., San Diego, California, and Professor of Psychiatry, University of California, San Diego.

Psychiatry (Edgemont) 2008;5(9):21–22

Abstract

We examined the role of benzodiazepines in the treatment of anxiety by both psychiatrists and primary care physicians. Over the past year, 112.8 million prescriptions were filled for a benzodiazepine: 55 percent were prescribed by a primary care physician, 16 percent by a psychiatrist, and the remaining 29 percent of prescriptions by another type of specialty physician. Benzodiazepine monotherapy is much more common in the treatment of anxiety by primary care physicians (42%) than psychiatrists (22%). Even when both benzodiazepine monotherapy and combination regimens are considered, total benzodiazepine use remains slightly greater in primary care than psychiatry (51% vs. 42%).

Key words

anxiety, benzodiazepine, antidepressant, monotherapy, combination therapy, psychiatrist, primary care physician

Introduction

Benzodiazepines remain an important option for treatment of anxiety. In this article, we examine the role of benzodiazepines in the treatment of anxiety by both psychiatrists and primary care physicians.

Methods

We obtained data from the following sources: 1) total benzodiazepine prescriptions from SDI Health’s (formerly Verispan) VONA, July 2007 to June 2008 and 2) July 2007 to June 2008 data from SDI Health’s Prescription Drug and Diagnosis Audit (PDDA) regarding products used to treat anxiety (ICD-9 diagnosis code 300). PDDA captures data on disease state and associated therapy from 3,100 office-based physicians representing 29 specialties across the United States.

Results

Over the past year, 112.8 million prescriptions were filled for a benzodiazepine. Slightly more than half of all benzodiazepine prescriptions (55%) were written by primary care physicians. Psychiatrists accounted for an additional 16 percent of prescriptions, and the remaining 29 percent of prescriptions were written by another type of specialty physician (Figure 1).

Figure 2 displays use of antidepressants and benzodiazepines in the treatment of anxiety by primary care physicians and psychiatrists. As seen in Figure 2, benzodiazepine monotherapy is much more common in the treatment of anxiety by primary care physicians (42%) than psychiatrists (22%). Even when both benzodiazepine monotherapy and combination regimens are considered, total benzodiazepine use remains slightly greater in primary care than psychiatry (51% vs. 42%).