![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 114 to 138 of 8406. Go back in thread:
Posted by pharmrep on August 21, 2002, at 12:10:06
In reply to Where've I been? learning from Dr. Dave., posted by katekite on August 21, 2002, at 11:01:54
> Dr. Dave seems to have all his ducks in a row. I appreciate that he's taking the time to put forth some straight info that counter-acts what is in my opinion (just my opinion, no personal disrespect intended) misleading information about Lexapro.
>
> Thanks for missing me and enquiring after my whereabouts, Pharmrep. -- kate
>
** what ducks? He is in Europe...and has had the opportunity to see for himself what Lexapro/cipralex can do, and hasnt. Has a rep even given him sample in his remote location...I hope they find him. Either way...his opinions are as good as yours or mine...they are not based on real life experiences yet, but only studies. Dont get me wrong..I appreciate his input too, I just wish he would try it, then make a judgement.
Posted by IsoM on August 21, 2002, at 13:28:26
In reply to Re: Knowledge, posted by dr. dave on August 21, 2002, at 8:58:35
Dr. Dave, you've made two good points (the following quotes) but I'd like to show another slightly different argument for the possible use of Lexapro, if you'd like to consider my opinion.
You said:
"Having said that for a particular patient with a particular problem, where all other logical options have been tried, I would give the rather far-fetched claims for Lexapro a go, but I would prefer to make decisions based on strong evidence before satisfying curiosity about a new drug for which convincing support cannot be found."and
"I don't think it is unreasonable to look to scientific evidence to inform my prescribing habits rather than just 'having a go' with something new in case it works. If we all did that prescribing would be even more chaotic than it already is. I think large-scale well designed studies actually do carry more weight than one doctor's anecdotal evidence."
--------------------------------
I agree with you completely. BUT... There are always those few where available drugs haven't helped them. We still don't really understand how ADs work, but terms such as "...is thought responsible for its action..." or "...is believed to be related to its selective inhibition..." are used to describe how ADs are thought to work. Until researchers are truly able to understand all that's involved & tailor meds specifically, much of our prescribing treatments are still going to be based on conjecture. As much an art as a science in prescribing.
Even after large scale studies are done, it will be the individual doctors themselves who will be gathering the real data, long-term, on the efficiency of these new drugs in the general population. As you know, the initial studies are done in select groups & don't necessarily represent the ordinary population that will be using these medications long-term.
I know, personally, from my experience & that of my family, that I've appreciated a doctor's willingness to try a different, perhaps not thoroughly tested in the general population, drug. Surprisingly, against all obvious logic, such a drug will be the one that works for such a person where others have failed.
I know you may say that this is not a new drug but only the isomer of one already available, but it may be just the ticket for someone in whom Celexa has previously worked but has caused troublesome side effects - to the point that it was stopped. It may not be the choice for most, but in those few patients, it may be just what is needed.
It's up to doctors like you to be willing to give it a try for a select few, despite costs.
My doctor has never used Provigil (modafinil or Alertec in Canada) before & never heard of it either. But despite that, he was willing to prescribe it for me when asked & it's been a godsend for me. It's prohibitory expensive - costs me about $180/mo, but thankfully the union from my part-time job covers the total expense. Something similar may be true with others too, allowing them to use such expensive meds.
Posted by Anyuser on August 21, 2002, at 14:25:00
In reply to Re: Complete Knowledge Not Always Available » dr. dave, posted by IsoM on August 21, 2002, at 13:28:26
Click here: http://www.lexapro.com/mediacenter/background/default.asp
See "Isomer animation" link
Posted by Dr. Bob on August 21, 2002, at 15:15:09
In reply to Hey Pharm-rep, posted by Mr.Scott on August 20, 2002, at 13:00:21
> I am reposting this because even though I haven't picked out anything in your posts that cross any lines you are by definition biased. If your not here for help with a mental disorder it's kind of silly that your here at all.
Potential bias is important to take into account when deciding what to trust:
http://www.dr-bob.org/babble/faq.html#trust
But I'd also like people to feel welcome here, so please be sensitive to their feelings:
http://www.dr-bob.org/babble/faq.html#civil
Keep in mind that if you're blocked again, it would probably be for 4 weeks...
Bob
PS: Follow-ups regarding posting policies, and complaints about posts, should be redirected to Psycho-Babble Administration, thanks.
Posted by pharmrep on August 21, 2002, at 15:24:36
In reply to Re: Complete Knowledge Not Always Available » dr. dave, posted by IsoM on August 21, 2002, at 13:28:26
> Dr. Dave, you've made two good points (the following quotes) but I'd like to show another slightly different argument for the possible use of Lexapro, if you'd like to consider my opinion.
>
> You said:
> "Having said that for a particular patient with a particular problem, where all other logical options have been tried, I would give the rather far-fetched claims for Lexapro a go, but I would prefer to make decisions based on strong evidence before satisfying curiosity about a new drug for which convincing support cannot be found."
>
> and
>
> "I don't think it is unreasonable to look to scientific evidence to inform my prescribing habits rather than just 'having a go' with something new in case it works. If we all did that prescribing would be even more chaotic than it already is. I think large-scale well designed studies actually do carry more weight than one doctor's anecdotal evidence."
>
> --------------------------------
>
> I agree with you completely. BUT... There are always those few where available drugs haven't helped them. We still don't really understand how ADs work, but terms such as "...is thought responsible for its action..." or "...is believed to be related to its selective inhibition..." are used to describe how ADs are thought to work. Until researchers are truly able to understand all that's involved & tailor meds specifically, much of our prescribing treatments are still going to be based on conjecture. As much an art as a science in prescribing.
>
> Even after large scale studies are done, it will be the individual doctors themselves who will be gathering the real data, long-term, on the efficiency of these new drugs in the general population. As you know, the initial studies are done in select groups & don't necessarily represent the ordinary population that will be using these medications long-term.
>
> I know, personally, from my experience & that of my family, that I've appreciated a doctor's willingness to try a different, perhaps not thoroughly tested in the general population, drug. Surprisingly, against all obvious logic, such a drug will be the one that works for such a person where others have failed.
>
> I know you may say that this is not a new drug but only the isomer of one already available, but it may be just the ticket for someone in whom Celexa has previously worked but has caused troublesome side effects - to the point that it was stopped. It may not be the choice for most, but in those few patients, it may be just what is needed.
>
> It's up to doctors like you to be willing to give it a try for a select few, despite costs.
> My doctor has never used Provigil (modafinil or Alertec in Canada) before & never heard of it either. But despite that, he was willing to prescribe it for me when asked & it's been a godsend for me. It's prohibitory expensive - costs me about $180/mo, but thankfully the union from my part-time job covers the total expense. Something similar may be true with others too, allowing them to use such expensive meds.
*** bravo...nice thoughts...and as for cost for Lexapro...it will be less than Celexa. I would say (according to Dr's I've seen) that they need to switch from one AD to another about 25% of the time (usually based on adverse events, drug-to-drug interactions and side-effects) That is was Lexapro is for...those who want/need to switch and maybe those new patients since the "profile" appears good.
Posted by Bill L on August 21, 2002, at 15:53:13
In reply to Re: Complete Knowledge Not Always Available/bottom » IsoM, posted by pharmrep on August 21, 2002, at 15:24:36
Dr Dave - I have read about the studies on Lexapro but did not see what you claimed to be true. You said that out of a 40mg pill of Celexa, that 20mg is inert. Where did you read that?
I have read that the other isomer is not effective against depression, but I have not read that it is inert.
On the contrary, I have read about 2 different possible actions of the R isomer:
1) it may cause side effects
2) it may interfere with the S isomer (possibly by competing for binding sites or some other mechanism)You claimed that the R isomer is inert and that 20 mg of Lexapro is therefore equivalent to 40mg of Celexa. Since your facts go against other stuff that I have read (ie. items 1 and 2 above), can you tell me your sources? Thanks.
Posted by IsoM on August 21, 2002, at 16:04:27
In reply to Re: Complete Knowledge Not Always Available/bottom » IsoM, posted by pharmrep on August 21, 2002, at 15:24:36
Could you please give a link that I can read over that gives information of the cost of Lexapro vs Celexa, please? You mention that it will be cheaper but I'd like to see it in writing from a reputable source before I completely trust it. I do find it surprising that a new introduction would be cheaper than one already on the market. You must understand that I neither side with you nor Dr. Dave but am still gathering information for myself. I feel there's no 'your' side or 'his' side but just not all the facts yet. I currently take Celexa (along with some other meds) & am following this topic with interest but doing so completely objectively.
Posted by pharmrep on August 21, 2002, at 16:15:33
In reply to Re: Cost of Celexa vs Lexapro » pharmrep, posted by IsoM on August 21, 2002, at 16:04:27
> Could you please give a link that I can read over that gives information of the cost of Lexapro vs Celexa, please? You mention that it will be cheaper but I'd like to see it in writing from a reputable source before I completely trust it. I do find it surprising that a new introduction would be cheaper than one already on the market. You must understand that I neither side with you nor Dr. Dave but am still gathering information for myself. I feel there's no 'your' side or 'his' side but just not all the facts yet. I currently take Celexa (along with some other meds) & am following this topic with interest but doing so completely objectively.
***Good for you...be your own research guide. I'm sorry there's no "price-list" I'm referring to...only the company meeting where we learned about Lexapro/studies/isomer science/etc. It was told to us the despite the costs for making Lexapro...no increase in price...if fact about 10% less. At a place like Costco here in California...20mg Celexa is about $60/mo, so Lexapro should be about $54. As for the rest of the country, the same 10% should apply.
Posted by IsoM on August 21, 2002, at 16:17:25
In reply to Dr. Dave - where did you get your info?, posted by Bill L on August 21, 2002, at 15:53:13
I'd also like to know more about the differences between the two enantiomers of citaprolam.
Enantiomers can be strange objects. Case in point is thalidomide, the anti-nausea medication that was widely prescribed for pregnant women world-wide a few decades ago. It was found that it was the effects of the inert isomer of thalidomide that caused the horrific birth defects in children born to these women. Thalidomide still has potential as a drug in the treatment of rheumatoid arthritis & leprosy, among others. When it was found possible to separate the two isomers in a racemic mix of thalidomide, great hopes were raised for its general use again. But sadly, the pH of the body reverted the single effective isomer back to a racemic mixture in the body with its resultant side effects.
Isomeric chemistry is not always so clear cut & I'd like to pursue more on these two isomers of citaprolam & research being done on the ineffective one.
Posted by IsoM on August 21, 2002, at 16:23:02
In reply to Cost of Celexa vs Lexapro » IsoM, posted by pharmrep on August 21, 2002, at 16:15:33
I live in Canada. I'll wait when it comes out to find what the final price will end up. Sorry, but the best of plans or promises don't always turn out the way they were said to be - even with honest intentions. I'm in no big hurry.
Posted by LLL on August 21, 2002, at 16:38:32
In reply to where you been? » LLL, posted by pharmrep on August 20, 2002, at 23:03:56
Where have I been? Why? Unlike those who have resonded to me on this board with their kindness and concern regarding my issues and to whom I feel totally indebted and grateful, you are just a salesperson. I see you no differently than the person who recently sold me a car. When pharmaceutical companies begin to take an interest in people like me who's lives have been devastated by panic disorder and agoraphobia as opposed to depression - then I'll listen. I'm still getting the message that I need to do more CBT, that maybe if I listen to Claire Weeks tapes a few more times I'll finally get it, that if I try harder and work harder that I'll free myself from this "self-imposed" misery. When the pharm. co's and medical profession begin to put this disorder on the same level of urgency as it does those who suffer from depression - then you'll have my attention. The ONLY drugs that have ever helped me were the good old fashioned MAOI's and xanax. When you come up with a drug that reduces my symptoms to a manageable level (without worsening them as do ALL the SSRI's)with tolerable side effects and no drug dependence let me know. Not only do I have a "mental illness", I seem to have one that's "second class" and still terribly misunderstood and mistreated.
So please don't ask where I am or say you miss me. You're attempt to garner new consumers for your product is very thinly veiled.
Posted by pharmrep on August 21, 2002, at 16:48:03
In reply to Dr. Dave - where did you get your info?, posted by Bill L on August 21, 2002, at 15:53:13
> Dr Dave - I have read about the studies on Lexapro but did not see what you claimed to be true. You said that out of a 40mg pill of Celexa, that 20mg is inert. Where did you read that?
>
> I have read that the other isomer is not effective against depression, but I have not read that it is inert.
>
> On the contrary, I have read about 2 different possible actions of the R isomer:
> 1) it may cause side effects
> 2) it may interfere with the S isomer (possibly by competing for binding sites or some other mechanism)
>
> You claimed that the R isomer is inert and that 20 mg of Lexapro is therefore equivalent to 40mg of Celexa. Since your facts go against other stuff that I have read (ie. items 1 and 2 above), can you tell me your sources? Thanks.** I see a lot more objectivity these days. Did you see the C. Sanchez study done (microdialysis study comparing citalopram (celexa), s-citalopram (lexapro), r-citalopram and placebo?) In this study it was expected that equivalent increases in serotonin levels within the brain would be seen since 4mg of citalopram contains 2mg of s-cit, and 2mg of r-cit; however, s-cit (at 2mg) increased serotonin levels by about 300% as opposed to only about 200% increase in the celexa at 4mg. This finding indicates that the r-cit actually interferes with the ablility of the s-cit to increase serotonin levels in the brain. It is not known why yet, and additional studies are being done.
Posted by pharmrep on August 21, 2002, at 17:01:37
In reply to PHARM REP! Why do you care?! » pharmrep, posted by LLL on August 21, 2002, at 16:38:32
> Where have I been? Why? Unlike those who have resonded to me on this board with their kindness and concern regarding my issues and to whom I feel totally indebted and grateful, you are just a salesperson. I see you no differently than the person who recently sold me a car. When pharmaceutical companies begin to take an interest in people like me who's lives have been devastated by panic disorder and agoraphobia as opposed to depression - then I'll listen. I'm still getting the message that I need to do more CBT, that maybe if I listen to Claire Weeks tapes a few more times I'll finally get it, that if I try harder and work harder that I'll free myself from this "self-imposed" misery. When the pharm. co's and medical profession begin to put this disorder on the same level of urgency as it does those who suffer from depression - then you'll have my attention. The ONLY drugs that have ever helped me were the good old fashioned MAOI's and xanax. When you come up with a drug that reduces my symptoms to a manageable level (without worsening them as do ALL the SSRI's)with tolerable side effects and no drug dependence let me know. Not only do I have a "mental illness", I seem to have one that's "second class" and still terribly misunderstood and mistreated.
> So please don't ask where I am or say you miss me. You're attempt to garner new consumers for your product is very thinly veiled.** you know....you asked me about Lexapro and agoraphobia and panic disorder about 2 weeks ago...I was just getting back to you. But nevermind, if all you want to do is throw a tirade at a simple "where you been," since I did see you posting before...sorry for disturbing your peace. (And I do care...so I wont be posting you anymore)
Posted by IsoM on August 21, 2002, at 17:14:18
In reply to nice one » Bill L, posted by pharmrep on August 21, 2002, at 16:48:03
Do you have a link to this study you mention (the Sanchez study - microdialysis study comparing citalopram (celexa), s-citalopram (lexapro), r-citalopram and placebo)? I can find no info on it & would like to read it over.
And please don't start using expressions like "nice one" or "bravo" as if this is some debate as who's right & who's wrong. It's not. It certainly won't win you any support with such expressions.
I'd like to see this kept as objective as possible so discerning readers can cut through the crap & judge the facts for themselves. It's not a popularity contest, but should remain as dispassionate as possible. I don't wish to see challenges or arguments but simply good questions & answers for information, & sources to back it up so we can make an informed decision ourselves.
Posted by Dinah on August 21, 2002, at 17:14:21
In reply to PHARM REP! Why do you care?! » pharmrep, posted by LLL on August 21, 2002, at 16:38:32
> Where have I been? Why? Unlike those who have resonded to me on this board with their kindness and concern regarding my issues and to whom I feel totally indebted and grateful, you are just a salesperson. I see you no differently than the person who recently sold me a car. .
> So please don't ask where I am or say you miss me. You're attempt to garner new consumers for your product is very thinly veiled.Hi. Dinah here. I understand that you are frustrated, but please let's keep this discussion about ideas, and please don't jump to conclusions about the motives of others. Here is a link to Dr. Bob's civility guidelines.
http://www.dr-bob.org/babble/faq.html#civil
Thanks,
DinahP.S. Follow ups regarding posting policies, and complaints about posts, should be redirected to Psycho-Babble Administration. Thanks again.
Posted by LLL on August 21, 2002, at 18:00:34
In reply to relax » LLL, posted by pharmrep on August 21, 2002, at 17:01:37
Posted by Dr. Bob on August 21, 2002, at 18:55:54
In reply to relax » LLL, posted by pharmrep on August 21, 2002, at 17:01:37
> if all you want to do is throw a tirade
I know it's not exactly a warm reception you've received here, but please don't post anything that could lead others to feel accused or put down.
I also completely agree with what IsoM said earlier regarding staying focused on information:
http://www.dr-bob.org/babble/20020821/msgs/117290.html
Thanks,
Bob
Posted by Dr. Bob on August 21, 2002, at 19:09:09
In reply to Two weeks is a hell of a long time to take! (nm) » pharmrep, posted by LLL on August 21, 2002, at 18:00:34
> Two weeks is a hell of a long time to take!
Dinah already asked you to follow the civility guidelines here, which include not posting anything that could lead others to feel accused, so I'm going to block you from posting for a week.
Bob
PS: As Dinah also said, follow-ups regarding posting policies should be redirected to PBA. Here's a link:
Posted by Seamus2 on August 21, 2002, at 22:44:04
In reply to Re: R-isomers vs L-isomers » Bill L, posted by IsoM on August 21, 2002, at 16:17:25
>>But sadly, the pH of the body reverted the single effective isomer back to a racemic mixture in the body with its resultant side effects.<<
This doesn't sound possible from my rudimentary knowledge of chemistry.Seamus
PS -- send me an email and tell me what ticked you off about PB so much! Enquiring minds want to know...
Posted by pharmrep on August 21, 2002, at 22:57:22
In reply to Re: Sanchez study » pharmrep, posted by IsoM on August 21, 2002, at 17:14:18
> Do you have a link to this study you mention (the Sanchez study - microdialysis study comparing citalopram (celexa), s-citalopram (lexapro), r-citalopram and placebo)? I can find no info on it & would like to read it over.
>
> And please don't start using expressions like "nice one" or "bravo" as if this is some debate as who's right & who's wrong. It's not. It certainly won't win you any support with such expressions.
>
> I'd like to see this kept as objective as possible so discerning readers can cut through the crap & judge the facts for themselves. It's not a popularity contest, but should remain as dispassionate as possible. I don't wish to see challenges or arguments but simply good questions & answers for information, & sources to back it up so we can make an informed decision ourselves.**my bad..you're right..I want objectivity too, so no more "agreement" comments. As for Sanchez...I havent found it online yet, but will let you know when I do.
Posted by IsoM on August 22, 2002, at 1:47:46
In reply to Re:chirality » IsoM, posted by Seamus2 on August 21, 2002, at 22:44:04
My knowledge of chemistry isn't great either but I read lots & so come across interesting bits. I've read about the renewed interest & uses for thalidomide & have followed it with interest. Here's a link about its ability to change isomers:
http://www.chm.bris.ac.uk/motm/thalidomide/optical2iso.html
and more about thalidomide, if you're interested:
http://www.ama-assn.org/special/hiv/newsline/briefing/thalido.htmExpect an email from me tomorrow giving you my reasons for being 'ticked off' about PB & Bob's policies, & some news too.
Posted by dr. dave on August 22, 2002, at 4:58:29
In reply to Three points, and then I'll drop this » dr. dave, posted by Anyuser on August 21, 2002, at 11:02:21
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.
> 1. For all the reasons that are dwelled upon on
this board, FDA prescribing info should be viewed skeptically: the FDA is inept, the drug companies are corrupt, lawyers write the thing for lawyers, drug therapy in general is all placebo effect, the science is crap, the studies are too small and too short, etc, etc, etc. The fact remains that in the US there is officially sanctioned prescribing info that states "the overall incidence of adverse effects in 10mg Lexapro treated patients was similar to that of placebo treated patients." On that basis alone, I would not characterize a patient wanting to try that drug or a physician prescribing that drug as "just 'having a go' with something new in case it works."
>
> 2. It seems to me that skepticism about the science behind drug approvals can cut both ways. My pdoc, for what it's worth, says that in his clinical experience Serzone is far more effective than the published data indicates. My pdoc happens to be nuts ("barking mad" in the UK?). My point here is not that doctors and patients should hope for benefits not suggested by the scientific data. I do think, however, that clinical experience is a body of knowledge more important than the research data. For example, only 715 patients were tested in the Lexapro research. A busy pdoc would over the course of time have more experience, in absolute terms, with a greater number of patients than the researchers that got the drug approved. For another example, there are meta-surveys out there that "prove" scientfically that all ADs provide only placebo effect, yet you've got patients and practicing physicians that say they don't care what the meta-surveys say, ADs work, however imperfectly.
>
> 3. For me, and for most people I know, and for most doctors I know, doctor/patient relationships are evolving beyond what you imply about your practice.
Posted by dr. dave on August 22, 2002, at 5:23:48
In reply to Re: Three points, and then I'll drop this » Anyuser, posted by dr. dave on August 22, 2002, at 4:58:29
I've just seen my first patient who has been taking Lexapro 10mg for a month and says it has only very slghtly helped. He has asked for 'something stronger' although I offered the option of increasing the dose of Lexapro. This is just one patient, so pretty much meaningless in trying to establish Lexapro's overall characteristics, but I don't want it to be thought I wouldn't pursue Lexapro with someone who had started it if that's what they wanted, or that I wouldn't start it if someone particularly wanted to.
With regard to pharmrep's comments about my remote location - I'm not sure how it's relevant to a discussion about this antidepressant. The important thing is attempting to look at the facts objectively.
Why do I keep mentioning expense? I have explained this. With limited resources, it makes sense to spend them wisely, which I think means not paying for more expensive treatments unless it's clear they're more beneficial. In Europe, generic citalopram is at most 75% the cost of Lexapro.
I don't agree the side-effect profile is more favourable. Partly this is because Lundbeck are saying the side-effect profiles are the same. They are specifically not claiming any improved side-effect profile. Sometimes I do accept what the reps tell me.
There are new figures on side-effect rates in citalopram because they were measured at the same time as the Lexapro figures, in the studies analysed by Gorman. Strangely, they don't seem to have been publicised at all, nor are they included in the paper. This would seem very relevant information, wouldn't it?
Posted by Anyuser on August 22, 2002, at 10:01:06
In reply to Re: Three points, and then I'll drop this » Anyuser, posted by dr. dave on August 22, 2002, at 4:58:29
> 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!").
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!").
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Dr. Bob is Robert Hsiung, MD,
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