The idea of an antidepressant making it "easier for you to change" is an amazing way to convey how they work to patients. By including how it works on making you more resilient and inclined to do life in a way you may have not thought of previously is great and needs to be atleast I think the definition of antidepressant; not "this will make you feel less depressed". Loved the video
Thank you for reviewing this in such great detail! I am a new NP, haven’t started practicing as yet, and I am reading Stahl’s Essential, but this is way more applicable day to day! I just got your book on Depression! This is much more applicable day to day for actually managing a patient!! Could you also do the same for BP, schizophrenia, schizoaffective, GAD, OCD, etc? Your videos have been a necessary supplement. Thanks for all you do! Excellent teaching! I look forward to your course on this as well.
Hello from Denmark. I've just started as an outpatient nurse afters years of closed facility intensive psych. There's a helluva lot more SSRIs going around outside the hospital than inside so this is a super helpful primer. I've used your videos for years for myself and to teach nursing students some good rules of thumbs and I appreciate you still putting out content. It really has made a difference.
I'd like to hear you guys cover the lifestyle changes in another podcast episode if you two are up to it. This was really informative and I'd like to know more.
Awesome podcast for outpatient clinic! Appreciate the discussion, importantly emphasizing the non-pharmacologic/behavioral variables to treat depression.
Another great episode. Learned a lot. Unfortunately a lot of patients are worried about being forced into medication because they may have been done so in the past, as the use of anti-depressants and anti-psychotics often go hand in hand. Under Mental Health Act certain meds and treatments can be ‘forced’ on patients which can be traumatising, although often very necessary. Love that your outpatient practice acknowledges this and works with patients.
The word "antipsychotic" underratedly creates so much stigma and compliance issues. It is unfortunate that they are called this when they can be multimodal and treat different things. Ex: Low dose aripiprazole FDA approved for so many other things than psychosis. These class names need to be updated as they are being used much more. That name "antipsychotic" is a huge reason people dont take their medications and it is never talked about.
@@benzapp1 I think its important to note that we can still classify or call them something different as not everyone who takes them is psychotic..In other words, we can call them something different while still explaining the exact same possible side effects.
Great discussion, thanks so much for sharing. Wealth of great information here. One area that you didn’t go into much is eskatsmine (Spravato) therapy. Would love to hear your thoughts and clinical experience with that. Otherwise a really comprehensive covering of the best approaches to MDD. Thank you
What are your opinions on Pramipexole for TRD as an adjunct? Could you explain the mechanism of action on how it exerts its effect, particularly in patients suffering with symptoms like avolition or anhedonia? Why is the inhibition of value decay not instant, but rather after titration and maintenance at a tolerable dose, and often higher than that used in Parkinson's or RLS?
I've tried many, still severely depressed. What would you say (just first impressions) to someone like me who tried Pristiq at the highest dosage and felt wired to the point where it felt like amphetamines? (Had to stop urgently because I also have GAD and Panic Disorder). Tried Cipralex(multiple dosages, up to max), Effexor(same), Pristiq(same), Viibryd 20mg and currently on Trintellix 20mg. Starting to think I'm not a patient but more a case study.
Most appreciated is relatively consistent use of "SRI." Worst mistake in pharmacology to come up w/ the names "SSRI" and "SNRI" where the first "S" is (usually) a different word. What arrogance it is, anyway, to call something "selective" when we've literally discovered new receptors since then (and there's every incentive to try to get away w/ not testing @ putative antitargets). W/ exercise/being outside: it's therapeutic for me, too, in the moment. I know the research says there's an AUC effect from regular exercise, but I'm not convinced beyond, whenever dissatisfied, I can same "but I'm in SHAPE tho, so."
Worthless anecdote but I was prescribed quetiapine (at same type as amph; fun person?) and had Sfx I will not speak or write in public. I think it is to be disfavored in some circumstances.
3/3 thanks for Ken's blog. Great name, will look into it. And yeah. Amph helps w/ my depression because I don't have depression, rather just disillusionment w/ not managing my affairs well. The biggest stimulant redpill is the euphoria is not the point at all and arguably undesirable. I "can't tell" I'm taking my dose, but I sure can tell when I don't (which some would say is bad, but it's not, b/c I manage my affairs well. It's not cheating. GLPRAs aren't cheating. etc.).
There should be enough data available at this point (Fluoxetine 1988) for which researchers can look at those patients who have been on say an SRI or SSRI x 1 decade cont. usage outcomes/side effects etc SRI/SSRI X 2 decades cont. usage Many patients do not want to discontinue their anti-depressant for fear of relapse etc. but are unsure of long term effects. Are you aware of any such studies??
@@PsychoFarm I have a lot of bipolar patients who are on lithium/lamictal for mood stability but prefer Seroquel as a SGA because they explain to me that sleep is the most important for their stability in the out patient setting. I believe that sleep itself is a great natural 'mood stabilizer' for most people. If psychosis is involved, I don't reach for Quetiapine first because despite its sedating effects, its d2 occupancy is pretty clinically weak. Olanzapine is too much for them sometimes and most of this population is vaping or smoking so I do not want to induce that metabolite. I want treatment with low risk of akathaisia as well most of the time. I find the Dones, and Pips/rips to trigger akathaisia at pretty low doses. I see it all the time. Why set them up for polypharmacy because with this I 100% know at some point in their treatment they WILL need either propranolol or cogentin. Quetiapine has a quick on/off effect as a pearl, lower risk for eps, and worth using as it can help rule some things out for me. If they get better on 25mg seroquel i know that sleep is what did a lot of the heavy lifting and that tells me a lot on what they may or may not need. I never use 800mg - if someone needs 800mg quetiapine, they actually need a different medication in my opinion. I dont like XR, I think IR is most effective and I have no problem giving low dose quetiapine to help sleep and give informed consent on the side effects.
Too dang hot here in AU Pain clinic I went to offered me cymbalta for my particular problem -side effects way out the benefits (after 16>years still no diagnosis) No thnx
Why is cost such a major issue for you? It seems like psychofarma’s fatal flaw: a good medication is released yet you ignore it due to “cost”. Vortioxetine & Viibryd have amazing side effect profiles and efficacy reletive to older generic SSRIs. The same thing happened on the Insomnia video, DORAs were completely ignored. Such a yank, Australians and UK NHS provide it at a low cost
Hesitant to promote new things that have data similar to previous medications and haven’t had the time to actually see how effective they are or if the marketing claims hold up. Have seen too much excitement around meds that end up being no different than previous gen meds. I agree, DORAs should’ve been touched on more.
Also it’s good to see psychiatrists refer to cost as they understand patient compliance can be down to cost - although this may be different country to country. Med non-compliance due to cost is a big issue.
I was told that duloxetine was the most weight neutral, compared to SRI's, which is why my family doctor prescribed it to me for GAD and depression symptoms. Is this true?
Below is the result of one study on it. I’ve seen other ones contradict this. Idk how to make sense of it. I think of Fluoxetine as the best regarding SSRIs/SNRIs High-Risk Agents for Weight Gain 📍 Mirtazapine: Associated with significant weight gain of ~16.2 lbs over 24 months. 📍 Paroxetine: Average gain of ~6 lbs in two years; 50% of patients may experience a weight increase of 7% or more. 📍 Citalopram: Long-term use (≥24 months) results in weight gains of ~5.9 lbs. 🟠 Moderate-Risk Agents 📍 Sertraline: Short-term use may cause small weight loss (~1.9 lbs), but long-term treatment leads to weight gain (~10.5 lbs after 24 months). 📍 Duloxetine: Short-term effects include slight weight loss (~1.2 lbs), while long-term use may lead to weight gain (~3.6 lbs). 📍 Escitalopram: Typically weight-neutral during short-term use but linked to small long-term gains (~2.4 lbs). 📍 Venlafaxine: Generally weight-neutral, but some studies suggest moderate gains (~7 lbs over long-term use). 🟢 Low-Risk or Weight-Neutral Agents 📍 Fluoxetine: Generally weight-neutral, with slight short-term weight loss (~2 lbs) and modest long-term gains (~1.8 lbs). 📍 Desvenlafaxine: Minimal weight effects, with short-term decreases (~2 lbs). 📍 Vortioxetine: Long-term treatment shows minor weight gain (~1.5 lbs). 📍 Vilazodone: Minimal weight gain (~3.7 lbs over one year). 📍 Trazodone: Generally weight-neutral, with slight weight loss in some studies. 📍 Bupropion: Consistently promotes weight loss, particularly in individuals with higher BMI (~5-12 lbs over long-term use).
@PsychoFarm Your taking the time to comment means so much to me -- THANK YOU! I've taken a screenshot as part of the info I'm gathering to make better health decisions 🙏 As someone who has health anxiety, advice from a source I trust is really helpful. Your videos are helping people and making a difference!
The idea of an antidepressant making it "easier for you to change" is an amazing way to convey how they work to patients. By including how it works on making you more resilient and inclined to do life in a way you may have not thought of previously is great and needs to be atleast I think the definition of antidepressant; not "this will make you feel less depressed". Loved the video
Thanks for listening Joe
Thank you for reviewing this in such great detail! I am a new NP, haven’t started practicing as yet, and I am reading Stahl’s Essential, but this is way more applicable day to day! I just got your book on Depression! This is much more applicable day to day for actually managing a patient!! Could you also do the same for BP, schizophrenia, schizoaffective, GAD, OCD, etc? Your videos have been a necessary supplement. Thanks for all you do! Excellent teaching! I look forward to your course on this as well.
Thank you for the kind words and the support! Much appreciated.
Hello from Denmark. I've just started as an outpatient nurse afters years of closed facility intensive psych. There's a helluva lot more SSRIs going around outside the hospital than inside so this is a super helpful primer. I've used your videos for years for myself and to teach nursing students some good rules of thumbs and I appreciate you still putting out content. It really has made a difference.
Really appreicate it
I'd like to hear you guys cover the lifestyle changes in another podcast episode if you two are up to it. This was really informative and I'd like to know more.
Agreed. Thought about doing a solo one but hopefully will be able to get Fu on board
Awesome podcast for outpatient clinic! Appreciate the discussion, importantly emphasizing the non-pharmacologic/behavioral variables to treat depression.
Appreciate the perspective! Some really good pearls in this one
Good information. Thank you.
great episode !! ❤
Thank you!
Another great episode. Learned a lot. Unfortunately a lot of patients are worried about being forced into medication because they may have been done so in the past, as the use of anti-depressants and anti-psychotics often go hand in hand. Under Mental Health Act certain meds and treatments can be ‘forced’ on patients which can be traumatising, although often very necessary. Love that your outpatient practice acknowledges this and works with patients.
You fixed the audio ! Thank you !
Please remember to normalise to sound of every of your episodes.
Is the normalization good on this one?
@ Yes , thank you
The word "antipsychotic" underratedly creates so much stigma and compliance issues. It is unfortunate that they are called this when they can be multimodal and treat different things. Ex: Low dose aripiprazole FDA approved for so many other things than psychosis. These class names need to be updated as they are being used much more. That name "antipsychotic" is a huge reason people dont take their medications and it is never talked about.
Totally agree. It’s a major problem to be have to explain to every patient “I don’t think you’re psychotic”.
People will always be scared of TD. Whatever they are called, that risk is what they share in common.
@@benzapp1 I think its important to note that we can still classify or call them something different as not everyone who takes them is psychotic..In other words, we can call them something different while still explaining the exact same possible side effects.
Great discussion, thanks so much for sharing. Wealth of great information here. One area that you didn’t go into much is eskatsmine (Spravato) therapy. Would love to hear your thoughts and clinical experience with that. Otherwise a really comprehensive covering of the best approaches to MDD. Thank you
What are your opinions on Pramipexole for TRD as an adjunct?
Could you explain the mechanism of action on how it exerts its effect, particularly in patients suffering with symptoms like avolition or anhedonia?
Why is the inhibition of value decay not instant, but rather after titration and maintenance at a tolerable dose, and often higher than that used in Parkinson's or RLS?
I've tried many, still severely depressed. What would you say (just first impressions) to someone like me who tried Pristiq at the highest dosage and felt wired to the point where it felt like amphetamines? (Had to stop urgently because I also have GAD and Panic Disorder).
Tried Cipralex(multiple dosages, up to max), Effexor(same), Pristiq(same), Viibryd 20mg and currently on Trintellix 20mg. Starting to think I'm not a patient but more a case study.
Most appreciated is relatively consistent use of "SRI." Worst mistake in pharmacology to come up w/ the names "SSRI" and "SNRI" where the first "S" is (usually) a different word. What arrogance it is, anyway, to call something "selective" when we've literally discovered new receptors since then (and there's every incentive to try to get away w/ not testing @ putative antitargets).
W/ exercise/being outside: it's therapeutic for me, too, in the moment. I know the research says there's an AUC effect from regular exercise, but I'm not convinced beyond, whenever dissatisfied, I can same "but I'm in SHAPE tho, so."
Worthless anecdote but I was prescribed quetiapine (at same type as amph; fun person?) and had Sfx I will not speak or write in public. I think it is to be disfavored in some circumstances.
3/3 thanks for Ken's blog. Great name, will look into it. And yeah. Amph helps w/ my depression because I don't have depression, rather just disillusionment w/ not managing my affairs well. The biggest stimulant redpill is the euphoria is not the point at all and arguably undesirable. I "can't tell" I'm taking my dose, but I sure can tell when I don't (which some would say is bad, but it's not, b/c I manage my affairs well. It's not cheating. GLPRAs aren't cheating. etc.).
There should be enough data available at this point (Fluoxetine 1988) for which researchers can look at those patients who have been on say an
SRI or SSRI x 1 decade cont. usage outcomes/side effects etc
SRI/SSRI X 2 decades cont. usage
Many patients do not want to discontinue their anti-depressant for fear of relapse etc. but are unsure of long term effects.
Are you aware of any such studies??
I have found Quetiapine to be extremely helpful in augmentation
Love hearing people’s experiences. What patients and dose do you see differences?
@@PsychoFarm I have a lot of bipolar patients who are on lithium/lamictal for mood stability but prefer Seroquel as a SGA because they explain to me that sleep is the most important for their stability in the out patient setting. I believe that sleep itself is a great natural 'mood stabilizer' for most people. If psychosis is involved, I don't reach for Quetiapine first because despite its sedating effects, its d2 occupancy is pretty clinically weak. Olanzapine is too much for them sometimes and most of this population is vaping or smoking so I do not want to induce that metabolite. I want treatment with low risk of akathaisia as well most of the time. I find the Dones, and Pips/rips to trigger akathaisia at pretty low doses. I see it all the time. Why set them up for polypharmacy because with this I 100% know at some point in their treatment they WILL need either propranolol or cogentin. Quetiapine has a quick on/off effect as a pearl, lower risk for eps, and worth using as it can help rule some things out for me. If they get better on 25mg seroquel i know that sleep is what did a lot of the heavy lifting and that tells me a lot on what they may or may not need. I never use 800mg - if someone needs 800mg quetiapine, they actually need a different medication in my opinion. I dont like XR, I think IR is most effective and I have no problem giving low dose quetiapine to help sleep and give informed consent on the side effects.
Any thoughts on Moclobemide which is a reversable MAOI? Although it isnt available in the U.S it is available here in Australia and the U.K.
Ghaemi preaches fluoxetin why don't we use that as a first line?
MAOIs methylene Blue?
Too dang hot here in AU
Pain clinic I went to offered me cymbalta for my particular problem -side effects way out the benefits (after 16>years still no diagnosis)
No thnx
Why is cost such a major issue for you? It seems like psychofarma’s fatal flaw: a good medication is released yet you ignore it due to “cost”. Vortioxetine & Viibryd have amazing side effect profiles and efficacy reletive to older generic SSRIs. The same thing happened on the Insomnia video, DORAs were completely ignored. Such a yank, Australians and UK NHS provide it at a low cost
Hesitant to promote new things that have data similar to previous medications and haven’t had the time to actually see how effective they are or if the marketing claims hold up. Have seen too much excitement around meds that end up being no different than previous gen meds. I agree, DORAs should’ve been touched on more.
Also it’s good to see psychiatrists refer to cost as they understand patient compliance can be down to cost - although this may be different country to country. Med non-compliance due to cost is a big issue.
I was told that duloxetine was the most weight neutral, compared to SRI's, which is why my family doctor prescribed it to me for GAD and depression symptoms. Is this true?
Below is the result of one study on it. I’ve seen other ones contradict this. Idk how to make sense of it. I think of Fluoxetine as the best regarding SSRIs/SNRIs
High-Risk Agents for Weight Gain
📍 Mirtazapine: Associated with significant weight gain of ~16.2 lbs over 24 months.
📍 Paroxetine: Average gain of ~6 lbs in two years; 50% of patients may experience a weight increase of 7% or more.
📍 Citalopram: Long-term use (≥24 months) results in weight gains of ~5.9 lbs.
🟠 Moderate-Risk Agents
📍 Sertraline: Short-term use may cause small weight loss (~1.9 lbs), but long-term treatment leads to weight gain (~10.5 lbs after 24 months).
📍 Duloxetine: Short-term effects include slight weight loss (~1.2 lbs), while long-term use may lead to weight gain (~3.6 lbs).
📍 Escitalopram: Typically weight-neutral during short-term use but linked to small long-term gains (~2.4 lbs).
📍 Venlafaxine: Generally weight-neutral, but some studies suggest moderate gains (~7 lbs over long-term use).
🟢 Low-Risk or Weight-Neutral Agents
📍 Fluoxetine: Generally weight-neutral, with slight short-term weight loss (~2 lbs) and modest long-term gains (~1.8 lbs).
📍 Desvenlafaxine: Minimal weight effects, with short-term decreases (~2 lbs).
📍 Vortioxetine: Long-term treatment shows minor weight gain (~1.5 lbs).
📍 Vilazodone: Minimal weight gain (~3.7 lbs over one year).
📍 Trazodone: Generally weight-neutral, with slight weight loss in some studies.
📍 Bupropion: Consistently promotes weight loss, particularly in individuals with higher BMI (~5-12 lbs over long-term use).
@PsychoFarm Your taking the time to comment means so much to me -- THANK YOU! I've taken a screenshot as part of the info I'm gathering to make better health decisions 🙏 As someone who has health anxiety, advice from a source I trust is really helpful. Your videos are helping people and making a difference!