Antidepressant rankings: Zoloft and Lexapro considered best overall

A number of antidepressants were recently ranked in different surveys:

Zoloft and Lexapro came in first for a combination of effectiveness and fewer side effects, followed by Prozac (fluoxetine), Paxil (paroxetine), Cymbalta, and Luvox among others.

The first was efficacy — or how likely patients were to experience the desired effects of the drug.

Efficacy:

1. Remeron (Mirtazapine)
2. Lexapro (Escitalopram)
3. Effexor (Venlafaxine)
4. Zoloft (Sertraline)
5. Celexa (Citalopram)
6. Wellbutrin (Buproprion)
7. Paxil (Paroxetine)
8. Savella (Milnacipran)
9. Prozac (Fluoxetine)
10. Cymbalta (Duloxetine)
11. Luvox (Fluvoxamine)
12. Vestra (Reboxetine)

The second was acceptability — the likelihood that a patient would continue using a drug for the duration of the study (it is generally assumed that a high ratio of patients dropping out indicates the presence of undesirable side effects for a drug).

Acceptability:

1. Zoloft (Sertraline)
2. Lexapro (Escitalopram)
3. Wellbutrin (Buproprion)
4. Celexa (Citalopram)
5. Prozac (Fluoxetine)
6. Savella (Milnacipran)
7. Remeron (Mirtazapine)
8. Effexor (Venlafaxine)
9. Paxil (Paroxetine)
10. Cymbalta (Duloxetine)
11. Luvox (Fluvoxamine)
12. Vestra (Reboxetine)

My experience with Lexapro was a disaster and I’ve written about Zoloft’s connection with irritability and rage. Paxil’s side effects are especially rough (see Bob Fiddaman’s Seroxat page) while Effexor’s withdrawal effects proved to be significantly challgenging. Although Prozac offset Effexor’s withdrawal symptoms, it causes severe somnolence that can impair cognitive functioning. And last but not least, Cymbalta contributed to the unfortunate death of Traci Johnson who had no history of depression.

These drugs may be effective for many people but it’s still a guessing game. Dr. Mark I. Levy, quoted in ABC News’s article on the rankings, mentioned that while psychiatrists may not have much use for the rankings, he sees them as beneficial for primary care physicians. And Dr. Harold G. Koenig, a professor at Duke University Medical Center, adds:

“I would be likely to start patients on either Zoloft [because it’s cheaper] or Lexapro … Unfortunately, that is almost none of my patients. By the time they get to me [a psychiatrist], the primary-care doctors have tried Zoloft and other antidepressants, so my patient are not the “new to medication” kind of patients,” he said.

I won’t rehash my thoughts on PCPs prescribing antidepressants and other psych meds. You can read about them here.

Christian counseling: Nouthetic vs. Biblical

Last night, I spent some time on the phone with my husband’s friend’s sister (aka my former pastor’s sister). We’ll call her Natalie.

Natalie was very sweet and kind, really encouraging and strengthening me by sharing her testimony of faith in God. She suffers from anxiety and panic attacks, which has led her to take Paxil (on and off) for the past 7 years. She says the drug has helped her tremendously and who am I to knock the drug (knowing what I know about Paxil/Seroxat) when she has seen the wonders that it has worked in her life?

I briefly explained my story of depression, history of suicide, and diagnosis of bipolar disorder. Although she couldn’t fully relate, she was very sympathetic and understanding. In fact, our conversation was so fruitful, I ended up taking notes!

We briefly touched on the issue of Nouthetic counseling (NC). She has undergone the course and simply needs to be certified. The counselor I currently see is associated with the Christian Counseling Education Foundation (CCEF), which has roots in NC and was founded by the man—Jay Adams—who developed the method. However, CCEF is now known for what is called biblical counseling. The organization has since moved away from pure Nouthetic methods and become more a bit more varied, taking bits and pieces of psychology (and perhaps psychiatry) that line up with the Bible. Adams, disagreeing with the organization’s approach, founded the Institute for Nouthetic Studies and uses the Bible as the sole counseling textbook. According to the wiki entry on Nouthetic counseling, Adams developed the word Nouthetic based on the “New Testament Greek word noutheteō (νουθετέω), which can be variously translated as ‘admonish,’ ‘warn,’ ‘correct,’ ‘exhort,’ or ‘instruct.'”

NC was developed back in the ’70s as a response to the popularity of psychology/psychiatry. Many Christians reject some of the teachings of such popular psychologists as Freud, Jung, Adler, Maslow, etc. Adams’ highly successful book, Competent to Counsel, criticizes the psychology industry and counters its teaching with a Nouthetic approach.

But NC has its Christian critics.

Pittman, Zoloft, and akathisia revisited

I’ve written about Christopher Pittman, now 19, who confessed to shooting and killing his grandparents when he was on psych meds at the age of 12. He appealed for a Supreme Court hearing but was denied, CNN reported today. He — and his defenders — appealed on the grounds that his 30-year sentence was “excessive for someone that age” and that the dosage of his antidepressants at the time (200 mg) “sent his mind spinning out of control.” Pittman was tried as an adult and, his lawyers argue, “no other inmate in the United States is serving so severe a sentence for a crime committed at such an early age.”

In previous posts here and here, I’ve questioned the link between Zoloft and violence/rage. Pittman, in 2001, had been switched to Zoloft a few days before the murder of his grandparents. However, it sounds like there had been some emotional problems in Pittman’s life that may have given prosecutors a solid case:

At the time of the crime, the boy had bounced around homes for years, experiencing a half dozen family splits and divorces after his mother had twice abandoned him as a child. She has not been in Pittman’s life for years.

Joe Pittman, the boy’s father, raised Christopher Pittman and his sister for much of their lives, but the relationship between father and son deteriorated. A state psychologist later testified this was a “young man who’d had difficulty with the adults in his life.”

On November 28, 2001, Pittman was sent home early for fighting in school and sent to bed by the grandparents. The boy claimed his “Pop-Pop” also beat him with a belt as punishment.

South Carolina prosecutors may easily have set Pittman up as a disturbed young man, which he very well may have been. But there are indications that this disturbance transcended his emotional state into his mental health:

After threatening to harm himself and suffering other emotional incidents, the boy was diagnosed as clinically depressed. His lawyers said Pittman was then given Paxil, a mild antidepressant no longer recommended for those under 18.

Just days before [shooting his grandparents], a doctor had begun prescribing Zoloft, another antidepressant. The family contends the abrupt substitution of drugs caused a bad chemical reaction, triggering violent outbursts.

At trial, a parade of psychiatrists offered conflicting testimony on whether the boy’s emotional problems excused his criminal behavior. Prosecutors called the Zoloft defense a “smokescreen.”

Juror Steven Platt later told CNN the crime appeared deliberate. “It always seemed like the defense was grasping at straws,” he said. “Just because you take prescription medicine doesn’t mean you can’t be held accountable for your actions.”

Loose Screws Mental Health News

I recently wrote about the MOTHERS Act and the unnecessary scare tactics surrounding it. A Dallas-Fort Worth TV station picked up on the story and provided a short one-sided view of the issue, continuing to purport that the bill is solely about drugging new moms. I don’t discount Ms. Philo’s terrible experience with her medication. In fact, I’d be against the act if its sole purpose was to force treatment on pregnant women – medicated or not. Again, I’d like to reiterate that the bill’s purpose is to educate moms about postpartum depression and postpartum psychosis – not to shove unnecessary pills down women’s throats.

If you have sleep apnea, your CPAP (Continuous Positive Airway Pressure) machine may alleviate depression symptoms. My husband has sleep apnea and hasn’t been able to use the CPAP machine because of sinus problems. When he doesn’t use it (he hasn’t for a while), he’s noticeably moodier and prone to depressive symptoms. But then again, anyone who doesn’t get good sleep for several days is pretty moody.

AstraZeneca (AZ) is going after Teva Pharmaceutical Industries and Novartis AG’s Sandoz unit after the two companies applied to make cheaper version of Seroquel available. AZ’s patent on Seroquel expires in 2011. The trial date for patent litigation is August 11. In the meantime, according to the Bloomberg report, the FDA is considering approval of Seroquel XR for bipolar depression and bipolar mania.

What is it about the U.K. that they seem to take pharma’s power more seriously than the U.S.? The UK Medicines and Healthcare products Regulatory Agency (MHRA) charged GlaxoSmithKline (GSK), the maker of Seroxat (Paxil in the U.S.), with not fully disclosing their clinical trial data that downplayed serious side effects such as increasing suicidal tendencies among those 18 years and younger. The MHRA also asserts that Seroxat didn’t alleviate depression as much as GSK’s initial data showed. GSK, of course, denied manipulating the data to show favorable results:

GSK denies withholding data, claiming the risks did not come to light until the results of nine studies were pooled.

The UK minister of public health, Dawn Primarilo, promised to address the issue of Big Pharma hiding negative clinical trial data.

“Notwithstanding the limitations that may exist in the law, pharmaceutical companies should disclose any information they have that would have a bearing on the protection of health,” she says.

In other news, I shouldn’t be a successful writer or novelist. The correlation between creative writers and suicide is ridiculously high. More than 70 well-known writers and poets have successfully committed suicide. How much more “unknown” writers and poets have as well?

(Image from Monthly Prescribing Reference)

Today's lesson: Paxil and Lexapro are not great antidepressants

Dawdy at Furious Seasons wrote a post on an editorial in the LA Times by Summer Beretsky’s experience with Paxil. After reading her editorial, I’m reminded that my own experience with one antidepressant wasn’t all that unique. Her drug was Paxil for panic attacks; mine was Lexapro for depression following a 3-month (on-and-off) stint with Paxil. I’m struck by the similarity of our experiences; not only did the same thing happened to me but I was also a communications major in college as well.

Paxil had one pretty undesirable effect on me: I started to lose interest in just about everything. I stopped initiating social activities (who needs that sort of thing?) and was no longer motivated to perform well academically.

My emotions had flat-lined: I hadn’t cried in months, nor had I proverbially jumped for joy. I felt — nothing.

I can still remember sleeping in bed at home on a weekday when I should have been at class. It was 2 in the afternoon, around the time my copy editing class was to begin. My boyfriend at the time (now my husband) lived in Kentucky while I attended college in New York. He planned to visit me that weekend but was getting fed up with my depression and listlessness. He called from work to tell me to get up and go to class. I mumbled on the phone, half-confused, and said no. He demanded, “Why not?” I said quite plainly, “Because I don’t care.” He said, “If you don’t get up and go to class, I won’t visit you this weekend.”

I replied, “I don’t care.”

Hirschfeld developed MDQ for GSK

“GlaxoSmithKline, one of the world’s leading research-based pharmaceutical healthcare companies, is committed to improving the quality of human life by enabling people to do more, feel better, and live longer.”

OK, I’ll be honest. I can’t keep up with my own posts and have no idea whether or not I’ve posted on this yet. Judging from the fact that I still have this bp booklet, I’m going to guess not. If I have, then there’s more.

When my psychiatrist diagnosed me with bipolar disorder in November, he handed me a bunch of material: a mood tracker (PDF), an article touting the benefits of Seroquel, and a booklet titled, “Bipolar Disorder,” which refers the reader to www.1on1.health.com.

The booklet seems pretty harmless to a patient newly diagnosed with bipolar disorder:

“Highs and lows can be part of life. But, with bipolar disorder, they can be severe. You may feel too depressed to get out of bed one day. Soon after, you may feel full of energy. You may have normal times between the highs and lows. When people have mood symptoms, it’s more likely to be depression.

Mood swings can be hard to predict. But you may have warning signs. You may even learn what can trigger your symptoms. You’ll read about this and more in this booklet.

Bipolar disorder is complex. Doctors docn’t know what causes it. They know that genes play a role. The illness may be linked to brain chemicals. These chemicals can get out of balance.

There are treatments to help control the symptoms. Learn about your condition. Get help for it. This booklet is a good first step.”

Thank you, GlaxoSmithKline.

GSK, the provider of such psych drugs as Lamictal, Paxil, and Wellbutrin, issues a series of booklets for patients referring them to 1on1health.com. The topics include depression, anxiety disorders, epilepsy, type 2 diabetes mellitus, high cholesterol, among others. The tips seems pretty simple and straightforward:

“Health and lifestyle chances may trigger your symptoms. Some common changes are:

Not having a sleep schedule
Misusing alcohol or drugs
Stopping your medicine, or starting medicine for depression or another illness
Having thyroid or other health problems”

Then it gets into the general stuff about the difference between mania, depression and further clarifies what hypomania and mixed moods are. Then, the kicker follows:

“If you think you may have bipolar disorder, fill out the checklist on the next two pages. Share it with your doctor. He or she can use it to help diagnose you.”

Furious Seasons posted a link about a fake drug named Havidol (which I totally got suckered into because I skimmed the post and missed the “OK, it’s a gag” part), but the hilarity stems from similarly stupid (and vague) questions. I’ve put a screenshot of the PDF GSK provides on their Web site to the right. My issue is not so much with the questions necessarily, but with the lead-in to them:

“Has there been a time when...” [emphasis mine]

It doesn’t matter whether you were 3 years old or 46 years old, if you answered “yes” to more than one “there’s ever been a time when” question, guess what? You MAY qualify for bipolar disorder! A sampling:

Has there ever been a time when…

• You were easily angered that you shouted at people or started fights?
• You felt much more sure of yourself than usual?
• You talked or spoke much faster than usual?
• You were so easily distracted that you couldn’t focus?
• You had much more energy than usual?
• You were much more active or did many more things than usual?
• You were much more social than usual?
• You were much more interested in sex than usual?

Guaranteed everyone reading this said “yes” to at least TWO questions. If not, I question whether you’re breathing. (Sadly enough, this makes me realize how easy it was for me to get fooled by the phony Havidol quiz.)

The follow-up to the questions above asks, “If you checked YES to more than one of the questions above, have several of these things happened during the same period of time?” Then, “How much of a problem did any of these things cause you (like not being able to work, or having money or legal troubles)? Choose one[:]

1. No problem
2. Minor problem
3. Moderate problem
4. Serious problem”

The multiple choice question above may not matter. Answering some of the lead-in questions in the affirmative may qualify you for the disorder.

Here’s a nice little tidbit. The questionnaire was “adapted with permission from Robert M.A. Hirschfeld, M.D.” So as an uninformed patient reading this (which I was at the time), I’m thinking, “Oh, this must be legit since they got permission from a doctor to use this checklist.” There’s more than meets the eye here.

On the surface, Dr. Hirschfeld seems like an awesome doctor – and he very well may be. Dr Hirschfeld’s bio from the University of Texas Medical Branch at Galveston (UTMB) extols the “Professor and Chair” of its psychiatry deparment. He has history of working with various national organizations such as the National Depressive and Manic-Depressive Association,  National Institute of Mental Health (NIMH), and National Alliance for Research on Schizophrenia and Depression (NARSAD). He’s written all kinds of articles and blah blah blah. He’s considered a leader in his research of bipolar disorder.

In fact, because Dr. Hirschfeld is so great, he’s a member of pharmaceutical boards and has acted as a consultant for pharmaceutical companies, according to ISI Highly Cited.com. Some of our favorite guys appear here: Pfizer, Wyeth, Abbott Labs., Bristol-Myers Squibb, Eli Lilly, Forest Labs, Janssen, and – lookee here! – GSK.

The duration of Dr. Hirschfeld’s affiliations with these pharmaceutical companies are unspecified. All other “appointments/affiliations” have assigned years, i.e. 1972-1977, 2001-Present. His consulting affiliations follow his internship in 1968-1969. It looks a bit misleading to follow the consulting jobs after, oh say, 1969, and not provide dates of when he became a consultant for all of these pharma companies. Toward the end of the document that I found, his affiliations from 1986-Present are listed with various boards, associations, journals, and a slew of pharmaceutical companies.

Hello, hello, hello. He is a MEMBER of the Zyprexa U.S. Bipolar Academic Advisory Board, the Celexa/Excitalopram [sic] Executive Advisory Board, the Lamictal National Advisory Board, and the Zoloft Advisory Board.

Humor me here. His clinical trials include:

• 1994 Paroxetine for Dysthymia (SmithKline Beecham)
• 1995-97 Several (I found five) double-blind studies on sertraline and imipramine in patients qualifying for the DSM-III definition of major depressive disorder
• 1996-98 Gabapentin therapy for bipolar patients

And the list, including mirtazapine, fluoxetine, venlafaxine, lamotrigine, goes on. You can also find the “grants” pharma companies gave to fund these clinical trials.

From 1997-2000, Hirschfeld received a $100K grant from Abbott Labs to develop “a new checklist for bipolar symptoms.” (I’m not sure what the old one was.) In 2001, he received a $142K grant for the “Bipolar Prevalence and Impact MDQ Project.”

I don’t even need to look MDQ up. It’s Mood Disorder Questionnaire. The grant came from GSK, who “adapted” the questionnaire with Hirschfeld’s “permission.” That sounds simply gravy.

To understand more about bipolar disorder, you can listen to the stories of Greg, Stuart and Leslie – all your classic bipolar cases and how medication and/or therapy has helped them so much. You can also watch the bipolar
disorder animation that regurgitates all the things that we’ve become skeptical about.

In the meantime, remember the instructions included in Seroquel’s safety information that no one reads (excuse the crappy “Paint” job):

The "Black Dog," Part II

In February 2004, I tried to kill myself. I don’t remember how now. But he pleaded with me to go see a doctor and get some help. Since I was 21, I no longer qualified under my mother’s health insurance so I tried to avoid docs as much as I could. My pediatric (PCP) doctor continued to treat me despite my age. Dr. X diagnosed me with depression and said, "Since you don’t have medical insurance, I’ll give you some samples of Paxil that a drug rep gave me."

Welcome to the beginning of my first experience with psych drugs.

(Just an aside: Before this, I had never taken medication for depression. My parents wouldn’t let me growing up. In the psych hospital, I said no even though the psychiatrist there gave me a tough time about it.)

I remained on Paxil through July. I wasn’t accustomed to taking medication each day so I’d take it for a day or two on and off. But no more than that. If I didn’t take it for three days, I knew it was time to get back on it. I’d suffer from dizziness and "brain shivers." It was also the first time that I developed eyelid twitching.

I went back to Dr. X and told her that Paxil wasn’t working. She told me that she knew I wasn’t consistent in taking my meds. But she still switched me to another med.

Enter Lexapro in September.

A crucial year in college. I was attempting to graduate that semester, juggle responsibilities as a reporter and copy editor for the college paper, manage a long-distance relationship, and complete a 50+ page honors paper. After accidentally reporting incorrect data on an investigative piece that I thought I’d thoroughly researched, university directors came down HARD on me. The managing editor made it a bigger deal that it really was (according to my teacher and newspaper advisor), freaking me out and sending me into a tailspin. I adhered to my Lexapro regimen much more carefully, but my depression worsened. By the end of October, I’d quit my job at the paper and found myself unable to get out of bed except for late afternoon and night classes. In November, I had to cut back from 16-18 credits down to 12 – just enough to keep me a full-time student. Of course, I didn’t graduate that semester.

I’d went to a psychologist (recommended by my PCP) who gave me "tough love" advice for $75 per half-hour. The "tough love" approach wasn’t for me and actually made me feel worse about myself. I continued to worsen under his care. In February, I switched to a Christian-based counselor and dramatically improved. She listened to me for $75 an hour and at the end of the session, gave me helpful advice. The support of my counselor and boyfriend helped me to get through the trying time. Bob helped pull me through graduation the next semester despite occasional moments of relapsing (into bed).

Bob, not accustomed to the severe depression at first, immediately became frustrated and used the "pull yourself up by your bootstraps" mentality. After all, despite his depression, he was still going to work, still living. When he noticed that strategy wasn’t working, he did some research on depression and became a little more sympathetic.

However, our relationship began taking a turn for the worse: we began arguing about pretty important things – where we’d live and whether we’d have biological children. We took "breaks" on and off and after several attempts at discussing breaking up, we tried to do so. Of course, it didn’t last. His depression kept him from feeling confident in our relationship and his ability to handle my depression. He conveniently left out how he was worried that his depression would conflict with mine.

Tyra Banks Fights Back

I liked Tyra Banks before because she seemed really down-to-earth, but I absolutely love her now.

People magazine has run a cover of Banks at an awful weight of 162 lb at 5’10”. (sarcasm) She received tabloid names like “America’s Next Top Waddle” and “Tyra Porkchop.” I’m not even Tyra and that hurt me. I’m barely 5’4″ and used to weigh 162. I was on the verge of being “obese” (as opposed to “morbidly obese.”) Yeah. Even my family told me I was fat and needed to lose weight. There was only one issue that drove me nuts:

“It’s when I put on the jeans that used to fit a year ago and don’t fit now and give me the muffin top, that’s when I say, ‘Damn!’ “

The bar is raised because she’s Tyra and a former model. But she’s absolutely cool about it and not in the business of running to change her new weight:

“Still, she isn’t freaking out about wearing size 32-waist jeans or about “the fat roll” she claims to have on her back. (Her biggest source of figure angst is her size-DD breasts, which she says make it hard to find clothes that fit: “I would love for them to be a size and a half smaller.”)

But, she adds, “I’ve made millions of dollars with the body I have, so where’s the pain in that? If I was in pain, I would have dieted. The pain is not there – the pain is someone printing a picture of me and saying those (horrible) things.”

She’s also aware that the tabloids not only hurt her, but also paint a false reality for young girls and teens:

“I get so much mail from young girls who say, ‘I look up to you, you’re not as skinny as everyone else, I think you’re beautiful,’ ” she says. “So when they say that my body is ‘ugly’ and ‘disgusting,’ what does that make those girls feel like?”

My brief struggle with weight — it was only from the beginning of 2004 to the end of 2006 — has taught me a lot about myself and others. I attribute much of my weight gain to Paxil and Lexapro.

Loose Screws Mental Health News

Since I was born on Groundhog Day (Google it if you don’t know when it is), I found this story about a groundhog so endearing. (And I make sure to turn around on my birthday to see my shadow.)

If you’re over 50 and on antidepressants, look out – you might be doubling your risk for osteoporosis. Fracture risks seem to be unrelated to falls caused by dizziness and low blood pressure. CLPsych’s analysis is also worth a read. (Many thanks to Bob Thompson for the link.)

People has an article on Cate Blanchett talking about marriage:

“Getting married is insanity; I mean, it’s a risk – who knows if you’re going to be together forever? But you both say, ‘’We’re going to take this chance, in the same spirit.’”

Seroquel abuse and medication weight gain

Furious Seasons has blogged about Seroquel (quetiapine) in the past and he recently posted on Seroquel abuse in an Ohio prison. Apparently, inmates have been snorting the atypical antipsychotic, also known in slang terms as “quell” or “Susie-Q.” Excerpt from Furious Seasons:

“Second, we all know that Seroquel is regularly handed out to bipolars and depressives and people with anxiety in order to address insomnia, as opposed to the kind of underlying psychosis/mania issues you’d expect it to be used for. PCPs hand it out this way and so do psychiatrists. What I have noticed among friends who’ve been given Seroquel for sleep issues is that they end up, over a few months time, needing more and more of the drug in order to get an effect. Or, put another way, people keep complaining of problems with sleep despite taking, say, 300 mgs. of Seroquel and their doctor will keep upping the dose to get the desired effect. As a result, I have seen people with very mild bipolar disorder wind up taking 800 mgs. of Seroquel a day–that’s roughly the same that a schizophrenic in a state hospital would get–and still they get no results, aside from putting on tons of weight. I have heard this from other readers of this blog as well.”

My aunt, who works in the psych wing of a hospital, warned me that she’s seen patients on Seroquel gain weight. A man I met at my Bipolar and Depression Alliance Group last night gained 60 lbs since taking Seroquel. I can’t image that everyone who takes Seroquel overeats to a point of obesity and leads a sedentary lifestyle. I have a random theory that Seroquel signficantly slows a person’s metabolism down to the point where it is difficult for a person to lose weight.