We had an outstanding Clinical Problems in Consultation Psychiatry (CPCP) on heart failure and antidepressants today by Christie Hart, 2nd year psychiatric pharmacy resident. In fact, it’s one of the absolute best in recent memory because it exemplifies the importance of all of the core competencies, not just Practice-Based Learning and Self improvement.
The Consultation-Liaison Psychiatrist typically encounters the Core Competency Pizza while running all over the hospital trying to put out all kinds of fires.
The CPCP is a case conference and for obvious reasons I could not show all of Christie’s slides because of the obligation to protect the patient’s privacy. However, I can tell you that the question of the safety and efficacy of antidepressants in patients with medical illness crops up all the time. All of the competencies are in play in this arena and Communication and Interpersonal Skills are critically important. Without it we wouldn’t get much done in the hospital or in any other area of clinical medicine or research.
I was a little surprised to learn that the literature is mixed on both the safety and efficacy of antidepressants in the depressed patient with heart failure. Access to mental health care is difficult and sometimes it seems that all psychiatrists have to offer are pills. Psychotherapy can be very effective but it’s even harder to access psychotherapists who offer evidence-based therapies. More often than not, both medication and psychotherapy may be necessary.
On the other hand, in the case of antidepressants and heart failure, it might be wise to exercise more caution in prescribing medication. That does not mean they are never indicated.
In fact, many psychiatrists may harbor beliefs about antidepressants that might be wrong. This was highlighted in an article published in the Psych Congress Network article “Diagnosing and Treating Depression: What You Think You Know Might Not Be True” by Eileen Koutnik-Fotopoulos who interviewed Dr. Mark Zimmerman, MD, who is the Director of Outpatient Psychiatry and Partial Hospital Program at Rhode Island Hospital in Providence. Dr. Zimmerman is also Professor of Psychiatry and Human Behavior at The Warren Alpert Medical School of Brown University, Providence, Rhode Island. I’ll paraphrase a few excerpts and hope to goodness what I share constitutes fair use:
Q-What are some of the beliefs that clinicians may have regarding the treatment and management of depression?
A-The literature is limited regarding the generalizability of research to clinical practice on the efficacy of antidepressants. Study methodologies have inclusion restrictions and other limitations that lead clinicians to think the results may apply to their patients but we really don’t know if that is the case.
Q-What does the literature say about the beliefs clinicians may have about the diagnosis and treatment of depression?
A-It’s hard to show that medication is effective. “Only half the studies comparing medication to placebo find that medication is significantly better than placebo.” Patients who have comorbid conditions with Major Depression and whose severity of depression doesn’t meet the inclusion criterion are often excluded from studies. This can have a big impact on whether patients in real world clinical practice may respond to medication treatment.
Q-How much do clinicians really know about the efficacy of antidepressant medication in treating patients routinely seen in clinical practice?
A-It’s hard to tell if medication is the effective agent or nonspecific elements like the doctor’s bedside manner. And some clinicians may misinterpret the results of a well-known study like the STAR*D, which was thought to be more generalizable to the typical clinic patient. However, it didn’t include a placebo control group. That doesn’t mean people didn’t get better. But when we talk about whether or not antidepressants work, we usually mean whether they work better than placebo.
Dr. Zimmerman’s remarks clearly apply to diagnosing and treating depression in the medically ill. Christie pointed out these issues in the studies in today’s CPCP.
It’s important to have an informed consent discussion with patients and families about the risks and benefits of all psychiatric treatments. And we all need to remember that careful diagnosis before treatment is the correct order of business. Just like everything else in life…we can’t always get we want.
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