There may be more drug interactions with some of the SSRIs. The risks differ with SSRIs, and none are free of risk. Among non-SSRIs, the costs of mirtazapine and the tricyclics are low; however, the generic versions of venlafaxine and bupropion SA are very expensive, and their price is much higher than even the branded SSRIs. Their unique mechanisms, along with a small market share that discourages competition, has enabled the generic manufacturers to keep prices up.
Check for potential drug-drug interactions (DDIs) before prescribing. Computerized, frequently updated drug interaction information is available. It is impossible to remember all the known interactions much less keep up with all of the new evidence being published. It is particularly difficult when the patient is taking multiple drugs.
DDI information will someday be built into electronic order entry systems. For now, if you have access to fast Internet service, there are excellent applications that enable you to examine the entire regimen at once and the potential impact of adding or subtracting drugs. They are available on-line by subscription from www.genelex.com (GeneMedRx) and www.micromedex.com (Drug REAX). However, the time it takes to do these checks is a barrier. In addition, it should be noted that, though recommended by many19 and despite high face validity, the value of formal checking for DDIs is unproven. Adequate studies with sufficient numbers of patients have not been done.
Use lithium in preference to valproate as first-line treatment for bipolar disorder. Marketing influence, personal heuristics, and deficiencies in training20 have resulted in an unwarranted preference for agents other than lithium in the United States.21 Fear of the adverse effects of lithium and the inconvenience of monitoring for them is the usual objection. However, most guidelines and algorithms suggest these concerns do not outweigh the clinical advantages of this product. Psychiatrists may also be overlooking the significant risks associated with the alternatives to lithium. For example, valproate has exceptional teratogenicity, resulting in a recommendation by epilepsy treatment experts that it be avoided as a first-line treatment for all women of childbearing potential.22 Lithium is also a cost-effective choice that may have the best chance of sustained effectiveness as a monotherapy.21
Approach insomnia as a symptom that requires diagnosis and treatment specific to the diagnosis.Many of the algorithms and guidelines discuss insomnia as a common symptom in patients with the disorder under discussion. However, the guidelines consistently recommend diagnosing the cause of the insomnia first, then treating. Often the cause is multifactorial. This evaluation requires extra time, and the impulse is to go to the faster solution of adding a favored hypnotic; however, patients may be using excess caffeine or other stimulants, or they may be waking to have a cigarette because of nicotine dependence.
In addition, some patients have symptoms suggestive of sleep apnea or restless legs syndrome. Conditioned insomnia is a common component, often involving preoccupation with watching the clock, worrying about whether one will be able to sleep, and inability to redirect one's thoughts to more restful topics. Cognitive-behavioral approaches can be very helpful for this. Patients may be on polydrug therapy that includes activating medications that might best be switched to less stimulating alternatives, rather than adding one more drug to the regimen.
Comments and conclusions
Guidelines and algorithms will be of more practical value when their most important advice—specifically the advice that differs from usual practice and may give better results—can be provided efficiently and just at the point of decision making. Input of this kind may someday be considered a necessary contributor to, but never a sufficient basis for, clinical decision making.