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Old 02-27-2010, 04:50 PM   #1 (permalink)
 
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Default Primary care doctors prescribing antidepressants and antianxiety medication

My experience with primary care doctors prescribing antianxiety and antidepressant medications is that it causes trouble. My friend went to a primary care doctor who started her on Lexapro, but a full dose without slowly working up to a higher dose.
My mom is a psychiatrist, so I'm sure I'm biased in a way.
But it seems that a psychiatrist should be the one to consult for certain types of medications, and it causes a lot of problems when medications can be handed out like candy by a primary care doctor.
But I do see the other side also...I guess in the end I believe psychiatrists should be consulted when prescribing antidepressants, stimulants and antianxiety medications. Hmm...
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Old 02-27-2010, 04:58 PM   #2 (permalink)
 
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Primary care doctors just treat the symptoms. I don't think they're qualified to diagnose mental health issues. My doctor prescribed me an anti-depressant, and then an anti-psychotic when that didn't work right. He said I had a mood disorder based on a questionnaire. But I went to a counselor and he said nothing is wrong with me.
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Old 02-27-2010, 07:08 PM   #3 (permalink)
 
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Originally Posted by laura024 View Post
Primary care doctors just treat the symptoms.I don't think they're qualified to diagnose mental health issues. My doctor prescribed me an anti-depressant, and then an anti-psychotic when that didn't work right. He said I had a mood disorder based on a questionnaire. But I went to a counselor and he said nothing is wrong with me.
It is not difficult to diagnose anxiety or depression. For example, the official Major Depressive Disorder (MDD) criteria are 2 weeks or more of depressed mood and atleast 5 of the following (with no history of mania or hypomania),

Sleep changes
Interest (loss of)
Guilt
Energy changes
Concentration changes
Appetite changes
Psychomotor retardation/agitation
Suicidal ideation

mnemonic: SIGECAPS

Not really challenging. Primary care docs use these criteria as do psychiatrists.

I think primary care docs should be able to provide first line treatment for anxiety and depression. Refractory anxiety/depression, schizophrenia, psychotic disorders etc. should be managed by psychiatrists only.
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Old 02-27-2010, 07:24 PM   #4 (permalink)
 
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I have had experiences with primary care doctors prescribing me zoloft before I decided to go to a psychiatrist. They gave me like 75 mg to start off with and i felt like complete ****. i went to a psychiatrist after that and they were really thorough. then they started me on a bit of zoloft but also a small amount of xanax to control some immediate symptoms. it was not the primary care doctor that helped at all.
i don't think they should be handing out medication...ive heard of this happening with several other friends of mine
one friend got addicted to sleeping meds cuz the doctor didn't ask enough about past history but concentrated on jus the current physical symptoms...bad bad idea
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Old 02-27-2010, 08:24 PM   #5 (permalink)
 
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My GP put up a huge fuss when I wanted to be referred to a psychiatrist and would only refer me to the local mental health office, which meant like a TWO MONTH wait and a billion different appointments with a billion different people. Eventually I got kind of tired of being shuffled about.

Later, I saw a psychiatrist at school. But she wanted me to take stupid bloody effexor or paxil again, after I'd told her that they'd both done ****-all for me and that yes, I'd given them both an awfully fair shot.

I don't really know whether a GP or a psychiatrist would be better for me. So far I've been unable to get a drug that actually works from anyone other than a drug dealer.
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Old 02-28-2010, 01:05 AM   #6 (permalink)
 
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It seems like the psychiatrist would be best for this situation. They seem to be more aware of the side effects that may accompany mixing medications. Also a psychiatrist will probably work up your dose from a very small amount and keep track of that. They are specialized for this reason, so primary care doctors should not be handing out medication such as lexapro and zoloft, and stimulant medications. They should focus on health issues, and if they identify physical problems that are related to psychological problems, they should refer to a psychiatrist (or psychologist) instead of just guessing at what the best medication will be from the free samples that are in their office.
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Old 02-28-2010, 09:23 AM   #7 (permalink)
 
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I see no problem with a PCP prescribing SSRIs or very small amounts of benzos. BUT, I think this should only be done in the context of waiting for a referral to a psychiatrist. Perhaps I'm biased though as a live in Canada where seeing a psychiatrist costs me nothing, whereas I know in places like the US this can get quite expensive.

I was put on the supposed highest dose of Lexapro too by my PCP immediately (20mg). Maybe I was just lucky but I didn't have any side effects. He was wary about prescribing benzos, giving me maybe 5 at a time if I really needed it, and also added Wellbutrin to my regimen when I talked to him about it, but all this was while waiting to get my intake appointment at the local hospital's outpatient mental health clinic. Psychiatric services are VERY in demand here, the number of new patients is exploding really as society becomes more comfortable with the whole idea of mental illness, and so the referral took 6 months, so I think my GP was justified in giving me supportive treatment in the meantime, but for the last year and a half now, all my psychiatric care has gone to my psychiatrist (as well as seeing a social worker at the clinic for a kind of informal therapy that has helped me break out of my shell quite a bit.) Both of them I usually see every 2 weeks, although circumstances sometimes extend it to a month and at other times, like when starting an MAOI, it was every single week.

But... I totally disagree with the idea of a PCP taking on the responsibility of psychiatric care on their own. They are supposed to be involved in PRIMARY CARE, as the name suggest, and refer to an expert when warranted. Just like you'd want an oncologist treating your cancer rather than your PCP doing it on his own, you want a psychiatrist dealing with psychiatric issues. For the people who can't afford a psychiatrist... I really don't know what to say though, except that mental illness should be taken seriously (it IS often life-threatening), and even if you couldn't technically afford to see an oncologist, it would be absurd not to figure out a way how.
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Old 02-28-2010, 09:53 AM   #8 (permalink)
 
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Originally Posted by Mia23 View Post
My friend went to a primary care doctor who started her on Lexapro, but a full dose without slowly working up to a higher dose.
My own view is that one doesn't need a psychiatrist to hand out SSRIs. SSRIs are the first line treatment for most mental disorders, being used for depression, GAD, SA, OCD, PTSD, PMDD and I'm sure I missed some indications. Basically, SSRIs are used to treat damn near everything other than ADD, mania, or psychosis.

Automatically sending every case of depression or anxiety to a psychiatrist strikes me as overkill. Does one really need to bring in a specialist to hand out Lexapro at $250+ an hour? This would be like bringing in an electrician to change a light bulb.

Yes, that GP should know to start low and raise the dose along the way. That's very basic information that most of the people reading this forum would know even without any medical training.

Personally, I think pdocs should be saved for where their training is actually needed. And handing out SSRIs isn't an example of where they're needed in my view.
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Old 02-28-2010, 09:55 AM   #9 (permalink)
 
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My own view is that one doesn't need a psychiatrist to hand out SSRIs. SSRIs are the first line treatment for most mental disorders, being used for depression, GAD, SA, OCD, PTSD, PMDD and I'm sure I missed some indications. Basically, SSRIs are used to treat damn near everything other than ADD, mania, or psychosis.

Automatically sending every case of depression or anxiety to a psychiatrist strikes me as overkill. Does one really need to bring in a specialist to hand out Lexapro at $250+ an hour? This would be like bringing in an electrician to change a light bulb.

Yes, that GP should know to start low and raise the dose along the way. That's very basic information that most of the people reading this forum would know even without any medical training.

Personally, I think pdocs should be saved for where their training is actually needed. And handing out SSRIs isn't an example of where they're needed in my view.
Exactly my toughts.
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Old 02-28-2010, 10:02 AM   #10 (permalink)
 
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Originally Posted by meyaj View Post
But... I totally disagree with the idea of a PCP taking on the responsibility of psychiatric care on their own.
In cases like your own where you're on Parnate & an amphetamine -- two things that officially should NOT be mixed -- that would seem to be a clear case of where a pdoc is needed. Most GPs have never prescibed an MAOI in their entire career, much less tried mixing an MAOI with an amphetamine that in combination could send your blood pressure through the roof.

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Originally Posted by meyaj View Post
Just like you'd want an oncologist treating your cancer rather than your PCP doing it on his own, you want a psychiatrist dealing with psychiatric issues.
Given that cancer has a high mortality rate (even when treated by an oncologist), it's really not fair to compare it to handing out SSRIs that have very minimal risk.

The risk of SSRIs: they tend to have annoying side effects, specifically sexual ones like anorgasmia, and they often don't work. Anorgasmia isn't quite on par with death by cancer.
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Old 02-28-2010, 10:39 AM   #11 (permalink)
 
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The risk of SSRIs: they tend to have annoying side effects, specifically sexual ones like anorgasmia, and they often don't work. Anorgasmia isn't quite on par with death by cancer.
SSRIs, as we all know, are rarely adequate on their own and pretty much anybody with a mental illness is at an increased risk of self-injury and suicide. I'm not talking about the risk of the medication so much as the risks inherent in the mental illness, which GPs are not really trained to look for. I have no problem with GPs prescribing SSRIs but like I said, I really think a referral to somebody more equipped to deal with the illness (a psychiatrist), should be made immediately, but that it's okay for a GP to handle it with rather benign drugs like SSRIs in the meantime. It's much more preferable to just leaving a suffering patient completely stranded.

But again, this is based on my Canadian perspective. My mom has been stay-at-home, and my father self-employed, so in the US, psychiatric care could have very well been out of the question for me. I might not even be alive right now. Because, while you're totally right that only a psychiatrist should be dealing with medication combos such as Parnate and amphetamine, nobody ever really STARTS there, and it takes many different trials of different drugs to get to this point, many of which a GP doesn't really have any business facilitating. I probably would have never even gotten close to the care I'm receiving now without the benefits of UHC, which, like I mentioned, might very well be the reason I'm even alive right now.

So perhaps my comments don't apply so well to Americans, but for pretty much the rest of the developed world, I think it's prudent to let the experts handle it as soon as possible. Who knows, there may be other diagnoses that a GP is absolutely incapable of making - there's a lot more to it than just the prescription of a fairly harmless drug.
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Old 02-28-2010, 10:58 AM   #12 (permalink)
 
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...pretty much anybody with a mental illness is at an increased risk of self-injury and suicide. I'm not talking about the risk of the medication so much as the risks inherent in the mental illness, which GPs are not really trained to look for.
Pdocs don't have psychic powers either though. Unless a patient tells them of suicide plans they're not going to know what the patient is thinking but not saying. The mere fact that they actually came to any doctor rather than killing themself would already suggest they have at least some vague plan to remain alive a bit longer.

My pdoc has NEVER asked me if I engage in self-injury (something I've never done and don't expect I ever will). My pdoc has also NEVER asked if I've ever thought about suicide.

A GP can ask about self-injury or suicidal ideation just as a pdoc can and patients can effectively lie to either if they want. Even I can identify self-injury when I see this one cashier at a local store who has many dozens of white lines each about an inch long up and down both arms. It sure looks like long-healed cuts from something like a razor blade. And I'd sure suspect that a GP who was told by a patient about their chronic thoughts of suicide would refer them to a pdoc immediately as they're not going to want to deal with an issue of life & death.

I think the vast majority of GPs fully recognize that depressed people are more likely to kill themselves. After all, both of us know it and it's obvious that people don't off themselves because they're happy. If it's obvious to both of us, should it not also be obvious to those who graduated from medical school?
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