Posted by Ame Sans Vie on August 14, 2003, at 12:34:33
In reply to Re: Lost in SAD, which med really is BEST?, posted by becksA on August 14, 2003, at 11:04:56
All the SSRIs are more or less equally effective for a very wide range of disorders -- depression, social anxiety, obsessive-compulsive disorder, panic disorder, and generalized anxiety are the ones they're most commonly prescribed for. But they are all also sometimes useful for bipolar II, kleptomania, borderline personality disorder, alcoholism, migraine, post-traumatic stress disorder, cataplexy, Tourette's syndrome, diabetic neuropathy, schizophrenia, premature ejaculation, trichotillomania, and levodopa-induce dyskinesia. Prozac is additionally sometimes effective for bulimia, anorexia, ADHD, obesity, and narcolepsy.
So what I'm essentially trying to say is that, for the most part, the SSRIs are interchangeable and can all be used to treat the same disorders. It's more a matter of subjective side effects and personal preference that plays a role in deciding which drug you end up taking. Here are some links to information pertaining to Lexapro in treating SP:
http://www.docguide.com/news/content.nsf/news/8525697700573E1885256D59005A30A8 -- "Citalopram Therapy Effective in Treating Social Anxiety Disorder and Comorbid Major Depressive Disorder"; technically, this link is about Celexa (citalopram), but as I mentioned in my last post, Lexapro (escitalopram) is really just a more effective version of Celexa with fewer side effects.
http://www.docguide.com/news/content.nsf/news/8525697700573E1885256CFA005DD559 -- This study is entitled "Escitalopram Effective in Social Anxiety Disorder for Up to 36 Weeks", but remember that time limit is put on there only because that's all the longer the study lasted. In practice, SSRIs, when they work, normally work at least a few years, and at best the rest of your life.
http://www.docguide.com/news/content.nsf/news/8525697700573E1885256B84006FB998 -- "Lexapro (Escitalopram) Significantly More Effective Than Placebo in Social/Generalized Anxiety and Panic Disorders"
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9184626&dopt=Abstract -- "Role of serotonin drugs in the treatment of social phobia."
Here are some interesting studies on the use of benzodiazepines, Klonopin (clonazepam) in particular, in SP:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8120156&dopt=Abstract -- "Treatment of social phobia with clonazepam and placebo."
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=1757453&dopt=Abstract -- "Long-term treatment of social phobia with clonazepam."
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=2228982&dopt=Abstract -- "Clonazepam for the treatment of social phobia."
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=2372756&dopt=Abstract -- "Social phobia and clonazepam."
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=2186023&dopt=Abstract -- "Clonazepam in the treatment of social phobia: a pilot study."
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11043885&dopt=Abstract -- "A comparison of the efficacy of clonazepam and cognitive-behavioral group therapy for the treatment of social phobia."
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8994456&dopt=Abstract -- "A 2-year follow-up of social phobia. Status after a brief medication trial."
Here are some more studies you may find interesting, which pertain to the use of all sorts of drugs in treating SP:
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12607230&dopt=Abstract -- "A review of 19 double-blind placebo-controlled studies in social anxiety disorder (social phobia)."
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=11206035&dopt=Abstract -- "Benzodiazepines and anticonvulsants for social phobia (social anxiety disorder)."
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=7782272&dopt=Abstract -- "Social phobia: a pharmacologic treatment overview."
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12900950&dopt=Abstract -- "Pharmacological treatment of social anxiety disorder: A meta-analysis."
http://www.socialfear.com/ -- This page goes into a fair amount of detail on social phobia, and discusses many medications commonly used to treat SP.
Finally, here's an interesting article I thought you'd like to read that kind of ties in with what I'm saying (Note, citalopram, but not escitalopram, is mentioned in this article; this is because the article was written before Lexapro was released last September / Also note, this article mentions the generic names of several drugs, and here's what they are -- paroxetine=Paxil, sertraline=Zoloft, citalopram=Celexa, fluoxetine=Prozac, clonazepam=Klonopin, buspirone=BuSpar, gabapentin=Neurontin, bupropion=Wellbutrin/Zyban, phenelzine=Nardil):
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Choosing the Right SSRIs for Social Phobia
Carl Sherman
Contributing Writer
In May 1999, paroxetine became the first medication to be approved by the Food and Drug Administration as a treatment for social phobia.Although selective serotonin reuptake inhibitors (SSRIs) are a standard first-line treatment among prescribing physicians, paroxetine is not at the top of the list. Nor, for that matter, is any single agent sufficient in many cases.
"The greatest amount of available data at this point is with paroxetine, but it's likely all SSRIs are similarly effective," said Dr. Mark Pollack, director of the anxiety disorders treatment and research program at Massachusetts General Hospital, Boston. "We don't have data, such as head-to-head trials, that say one [SSRI] is better than another for social phobia."
Dr. Bruce Lydiard, director of the mood and anxiety program at the Medical University of South Carolina, Charleston, said he tailors the drug to the patient. For patients who have sleep problems, paroxetine is a likely option; if lethargy is an issue, a more activating agent such as sertraline or citalopram may be more appropriate.
Although Dr. Lydiard uses fluoxetine, he is likely to opt for an agent with a shorter half-life if the patient has had no prior experience with SSRIs.
In addition to their apparent efficacy in social phobia itself, SSRIs have a broad spectrum to recommend them, Dr. Lydiard said. "You see a fair amount of comorbid major depression, posttraumatic stress disorder, or panic in these patients."
"Start low, go high" seems to be a common plan. Although intolerance to stimulation and other SSRI side effects is less pronounced than when the drugs are used for panic disorder, some patients may be exquisitely sensitive to bodily sensations or "quite hypochondriacal" and require a slow escalation of the dose, Dr. Lydiard said. He said he often begins with one-fourth the dose he'd use for depression (for example, 5 mg of fluoxetine or 12.5 mg of sertraline), but may end 1˝ times higher, he said.
"I'm pretty cautious," agreed Dr. Franklin R. Schneier, associate director of the anxiety disorders clinic at New York State Psychiatric Institute in New York, who says he typically initiates social phobia treatment with half the usual starting dose for depression (for example, 10 mg of paroxetine), reaching the antidepressant level in 3-4 weeks. "At that point, if I'm not seeing any benefit or side effects, I might go up some more.
"For most people with social phobia, the situation is very chronic. They've had it for 5-10 years and are not in an immediate crisis, so there's no pressure to push the dose and make a quick decision. You have the luxury of a reasonably full trial."
But this may require some patience. "It may take weeks or months to get a full, comprehensive reduction in distress," Dr. Pollack said. "It takes a while [for the patient] to trust the anxiolytic effects of the medication and to expose himself to difficult situations."
Although there are not much data defining the length of an adequate trial, Dr. Pollack will consider a substantial dose increase if there has been no progress after 4 weeks, and then augmentation if not much has happened 2-3 weeks after that.
In the long run, augmentation often is necessary. "The target is getting the patient as close to well as possible. We want to push patients until they're pretty comfortable in social situations and able to do whatever they want to," he said. At least half will not achieve this goal with SSRIs alone.
Most often, this means an anxiolytic. "Sixty percent of the people I treat get some benzodiazepines," Dr. Lydiard said. "Sometimes just knowing it's in his pocket keeps the patient from panicking."
Among the benzodiazepines, clonazepam is a typical first choice. Dr. Pollack said that he may add the drug at the outset of treatment—before the SSRI—or use it to cover stimulant effects of the SSRI in a patient who is unusually sensitive. Buspirone is an alternative when a benzodiazepine is contraindicated. A more recent option is gabapentin. "My experience with this drug has been quite positive. ... It's a useful addition," he said.
Dr. Lydiard noted that he may use bupropion to augment an SSRI if improvement is inadequate or to manage sexual side effects.
Switching rather than augmentation has its place, particularly if the response to the first drug is negligible. Dr. Lydiard is likely to go to another SSRI, while Dr. Schneier will more often chose a different class altogether, either clonazepam (if comorbid depression or dependence is not an issue) or an MAO inhibitor, particularly phenelzine. That will depend on how amenable the patient is to following a diet and how trustworthy the person is. "I wouldn't be comfortable [giving an MAO inhibitor] if a patient is too impulsive or has a history of noncompliance," he said.
The efficacy of drugs shouldn't obscure the role of cognitive-behavioral therapy (CBT) in the role of social phobia. Dr. Schneier, who is trained in this modality, said he often recommends it as a first-line approach for someone who has not had it before. Those patients for whom he prescribes medication will also be getting some CBT, "in a formal or informal way," perhaps through his encouraging exposure to difficult situations.
In Dr. Schneier's experience, the response to CBT is less dramatic than to medication, but it tends to be longer lasting. And when an SSRI alone is inadequate, the addition of CBT may make adjunctive medication unnecessary, he said.
~~~
This article brings up another quite important topic -- cognitive behavioral therapy. CBT combined with medication is always the best way to go, and gives you a much better chance of achieving complete remission and even one day being able to discontinue medication.
Any more questions, I'm here! :-)
poster:Ame Sans Vie
thread:250509
URL: http://www.dr-bob.org/babble/20030812/msgs/250799.html