Posted by dr. dave on August 22, 2002, at 10:25:36
In reply to Allow me to rephrase . . . . » dr. dave, posted by Anyuser on August 22, 2002, at 10:01:06
To answer your first question, if there was no obvious reason not to prescribe an SSRI I would definitely prescribe Lexapro. It is, in my view, effectively identical to Celexa which is a very good antidepressant which I prescribe all the time. I would tell you my views on it though. I think I would do this even though it would not cost you anything but would cost the National Health Service extra money.
Second question - I am not forced to factor in social policies in my decision making, but there is encouragement to use common sense in terms of not changing prescribing habits unless there is reasonable justification. There is a general consensus I think that if two treatments are equivalent, in general the cheaper should be used - that just seems sensible for everybody. Our health service is free and universal, and paid for out of general taxation. It's not Utopia for sure, but everyone gets equal access to treatment.
In private practice of course the issue of expense has very different implications. If you were paying or an insurance company was paying, that's absolutely your own business, and as I have said Lexapro is undoubtedly a good antidepressant - because it is the same as Celexa.
The most important thing is the science and the evidence. I'm pretty happy to prescribe most things that have a reasonable evidence base behind them if a patient is particularly keen, even if I don't think it is necessarily the most appropriate.
I would however reserve the right to present my own and others' appraisal of the evidence, and point out when they seem consistently different depending on whether you are financially involved e.g Micromedex and Danish Medicines Authority vs. Forest and Lundbeck.
> > About point three - please expand on your concerns about my apparently poorly evolved practice and relationships with my patients. I just wonder what you are inferring from my comments in terms of how you think I relate to my patients.
>
> I see that the way I wrote my third point is insulting, but I meant no insult and I apologize. No excuse, but I was running out of time when I wrote it.
>
> Let me ask you a question. If I scheduled an appointment with you, and you diagnosed depression, and I told you I wanted a prescription for Lexapro, and I told you why (along the lines of what I've said in my previous posts), and money wasn't an issue for me, would you give me the prescription? Perhaps along with your caveat that you think I'm wasting my (or my insurer's) money?
>
> Another question. In your practice, when making a decision about treatment for an individual patient, are you required by professional ethics or governmental regulation to factor in social policies regarding public resources available for mental health, or are such concerns personal to you? Do such concerns arise from your employment situation? Perhaps you work in a public hospital with uninsured patients, I don't know. I don't know anything about, what do you call it, National Health in the UK.
>
> What I'm getting at is that I hear you saying that there is in your thinking a convergence of science and public policy. That is, the science behind Lexapro is deficient and it would be wrongful, in a social sense, to waste money, anbody's money, on such an enterprise.
>
> If I asked you for Lexapro on grounds that it might be somewhat better but in any event no worse than Celexa, and I said money is no issue, and you said to me, "The financial issue is relevant as there will always be some limit on the funds available for treating mental disorder. I think that as much benefit should be obtained from those resources as possible. I don't think we can afford to waste money." I would say, in the US, hey Dr. Dave, that's between me and United Health Care, and ultimately, I suppose, between United Health Care and Forest Labs. I wouldn't want my private physician factoring public policy issues into the decisions he makes about my treatment. I care about such public policy issues, but I would discuss them and act upon them outside my doctor's office ("President Hillary in '04!").
poster:dr. dave
thread:109458
URL: http://www.dr-bob.org/babble/20020821/msgs/117376.html