Thursday, February 26, 2009

Paxil, anyone?

I ran a poll, not long ago, after reading Peter Kramer's blog post on the relative efficacy of the different SSRI's. Here's what we found:

Which SSRI is the most Effective?

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Lexapro 19% (28 votes)
Cymbalta (SNRI) 13% (20 votes)

Total Votes: 150

Which Medicine Causes the Most Side Effects
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Total Votes: 134

Okay, so let's start by talking about how this 'poll' is meaningless. We don't know who took it-- patients, docs, random plumbers surfing through. We don't know what experience these people have had with antidepressants-- so the question has different meaning if it's asked to a doc who has only ever prescribed Prozac and Zoloft, then if it's asked to a patient who has been on a long trial of every medication. There's no real head-to-head here, no measures of efficacy, no controls. And I didn't even specify what the efficacy was for: Depression? Anxiety? OCD? Panic? Halitosis? Slipping behind your ear to hold your glasses in place?

Still, we had a clear loser, and I was surprised: Paxil. Few people voted for it's efficacy, many for it's side effects.

I don't start people on Paxil so much anymore: the lore is that it causes more weight gain then the others, and when I do prescribe it, I tell people to get weighed. It may cause weight gain, as an overall risk to populations, but all I care about is if it causes weight gain to my particular patient, and clearly, some people do not gain weight on it. The more concerning thing about Paxil has been the withdrawal syndrome that some people experience and so far I've found that it's manageable, especially if people come off very slowly. Still, all things being equal, these days I may start with something else.

So why was I surprised: I guess I haven't heard a lot of patients complain about side effects, and I have patients who've been on this medicine for some time. It seems to work particularly well, at least that's my impression, for Anxiety, and it seems to be well tolerated, the 'polls' would say otherwise. And for the uninsured, the generic is on Walmart's $4 list (as is Celexa).
Just my thoughts.

And to those who've read yesterday's post about does Facebook wreck your brain: If you read either the original article or the comments to our post, you'll note that the original piece is simply theories that all this computer time may re-wire people; there were no studies, no proof. And as some of our readers pointed out, On-line interactions may well be a segway into the world of Real Life encounters for people who might otherwise hesitate. I often wonder if my college experience would have been broadened by the world of the internet---