Like most physicians, I subscribe to several medical education and CME sites. One of my favorites is Primary Care Medical Abstracts. PCMA chooses 30 papers a month of interest to primary care physicians and then these papers are reviewed by two physicians (usually Rick Bukata and Jerry Hoffman). The reviews are insightful and funny and pretty fun to listen to. These guys have no problem calling B.S. when they review certain papers. I like that! (By the way, I have no affiliation with PCMA).
Each month, I find that of the 30 articles reviewed, maybe half have applicability to correctional medicine. That is enough to keep me listening! This month’s issue reviewed three psychiatry papers in a row that I thought were quite interesting and which I want to summarize here. You can click on the titles below to go to the article abstracts in Pubmed.
The Efficacy and Safety of Alprazolam versus other Benzodiazepines in the Treatment of Panic Disorder, Moylan, S., et al, J Clin Psychopharm 31(5):647, October 2011
Despite the fact that published guidelines and psychiatric textbooks call for SSRIs and TCAs to be used as the primary agents for the treatment of anxiety and panic disorder, and for benzodiazepines to be used second line and rarely chronically, in actual clinical practice, benzodiazepines are really the most prescribed first line agents, and Xanax is prescribed most of all. In fact, I was surprised to learn that Xanax is the number one prescribed psychotropic agent in the US! This paper reviewed eight trials that compared alprazolam with other benzodiazepines in the treatment of panic disorder and anxiety. Their conclusion is that alprazolam offers no benefits over other benzodiazepines but that it does cause more problems. Patients using alprazolam compared to other benzodiazepines have an increased risk of abuse, are more prone to withdrawal and dependence, and are particularly prone to rebound anxiety. The authors also note that alprazolam is more toxic in overdose than other benzos.
Hopefully, none of use uses alprazolam in our correctional facilities, but we certainly see plenty of patients come into our care taking this agent.
Efficacy and Comparative Effectiveness of Atypical Antipsychotic Medications for Off-label Uses in Adults: A Systematic Review and Meta-analysis, A.R., et al, JAMA 306(12):1359, September 28, 2011
This is a big study published in JAMA that reviewed 162 studies of off-label use of antipsychotics. The original authors of this study found 14 out of 162 studies that showed some benefit of atypical antipsychotics in certain situations although they admit that this benefit is inconsistent across all of the studies. The PCMA reviewers argue that the reported benefit was “tiny” and likely a statistical phenomenon rather than real clinical benefit; i.e., if you do 162 studies, a few are going to show benefit just by chance alone. On the other hand, the paper documents ample evidence of real harm caused by the atypicals, especially in the elderly. As one example, elderly patients taking atypical antipsychotics have an increased risk of death and stroke; the Number Needed to Harm was 87 for death and 54 for stroke. If you take all patients (young and old) and all harms, including weight gain, extrapyramidal symptoms, etc. the Number Needed to Harm is one in ten. The PCMA authors conclude that the reported risks far outweigh the reported benefits.
Antidepressant Use and Risk of Adverse Outcomes in Older People: Population Based Cohort Study, Coupland, C., et al, Br Med J 343:d4551, August 23, 2011
In Britain, 10-15% of people older than 65 are prescribed antidepressants for depression. This study followed more than sixty thousand of these patients over 10+ years and compared them with a group not taking antidepressants. This was a big study. The group taking antidepressants had a much increased risk of several serious adverse events including suicide, death (from all causes), falls, fractures and, weirdly, GI bleeds (I didn’t see that one coming). But the risk for each of these bad events varied widely depending on what antidepressants were being used. patients taking SSRIs and mirtazepine/venlafaxine were much more likely to die than those taking TCAs. (Here are the absolute numbers. Remember that these were elderly patients. If you were taking no antidepressant, your chance of dying within any given year was 7.04%. If you were taking a TCA, this risk went up to 8.12%. For SSRIs, it rose to 10.61% and for mirtazepine/venlafaxine, the chance of dying within one year was 11.43%. I find this astounding. I would have thought that the SSRIs would be the “safest” antidepressants. Of note also is that the TCAs themselves are not equal. Trazodone has a mortality risk at least as bad as the SSRIs and the “others.” (Note the comparison chart at the beginning of the article).
Here is where it gets even more interesting. Patients taking SSRIs were at increased risk for having heart attacks compared to those taking no anti-depressant–but patients taking Tricyclics or “Other” antidepressants (mirtazepine and venlafaxine) had no increased risk of heart attacks. Patients taking SSRIs and “other” antidepressants had increased risk of stokes, but not those taking TCAs.
Anyway, quite an interesting article. It would appear that, in the elderly at least, SSRIs have more adverse effects than do TCAs.
Any comments? I would love to hear your opinion.