Psych meds: taking my doctor at face value
May 14, 2013 3:25 PM   Subscribe

My pdoc wants to decrease the dosage of a medication that has proven to work well for me, while increasing the dosage of an expensive designer drug that the jury is still out on. I'm skeptical.

You are not my psychiatrist. You do not know my medical history. You do not have x-ray goggles to see inside my brain. Right, sorted.

I am in the U.S., insured on an HMO plan that is affiliated with my state's high-risk program.

I've been on Lexapro for depression and anxiety issues since late 2006. I've found it to be very effective in helping me function with day-to-day stuff -- it hasn't made all the depressive feelings go away, it just allows me to live my life and be productive, which is the most important thing for me. For a long, long time, it was expensive and not available as a generic. It finally went generic and I was thrilled. Finally, a happy nexus of efficacy and affordability!

It was right around that time that the pdoc added a small amount of Abilify into the mix -- I gave it a shot, although I didn't really notice a change. I continued to take Abilify until my insurance plan year started over and I had a new annual deductible to pay down. I got to the pharmacy to pick up my prescription, and all the blood drained out of my face when they told me my cost for a one-month supply would be $500 (out of pocket; my benefits won't start until I've paid off the deductible). So... no thanks, I've already proven I can survive just fine without it.

But: I just checked in with my pdoc and he thinks the Abilify was working GREAT for me, wants to put me on even more of the stuff, while halving my dosage of the Lexapro. The same Lexapro that has been crucial to my emotional well-being for 6 1/2 years. I expressed concerns, and he said that the only alternative he could come up with was to try me on Wellbutrin, but he didn't want the weight-gain side effect for me. I already struggle with my weight.


1) Like I said, you're not my doctor, but should I take at face value that this pdoc has my best interests in mind here? Now that Lexapro is generic, is he under pressure from drug reps to push the Hot New Thing on every patient that walks in? Do drug reps basically have doctors by the balls these days?

2) I honestly don't notice much of a difference with the added Abilify, although my doctor says he does. If I can survive with the level of depression and anxiety I have at present -- some bad days, but no suicidal ideation or anything -- is it worth the dent in my finances to be marginally happier? I know the cost will come down once the benefits kick back in, but I still feel like I'm being robbed of my ability to enjoy being on my nice little generic and the system is laughing at me and saying "screw you."

Anecdata welcome.
posted by mirepoix to Health & Fitness (27 answers total) 2 users marked this as a favorite
The huge benefit of having drug reps around is that they give doctors free samples. Can your psychiatrist give you some samples of Abilify so that you can try out the suggested doses?
posted by jaguar at 3:42 PM on May 14, 2013 [1 favorite]

I expressed concerns

Tell him straight up that you feel that lexapro worked well for you and that it's simply not possible for you to afford Abilify, and that you wish to go back to taking lexapro only.

If he won't listen to you on that, find a new pdoc, or just talk to your GP and let them know you had been taking lexapro and need a refill.
posted by yohko at 3:42 PM on May 14, 2013 [11 favorites]

Do drug reps basically have doctors by the balls these days?

Some hospitals don't allow them in.

Drug companies will hire doctors at a good rate to give free educational presentations to other doctors on their drug. Inevitably these things are held at either a very nice restaurant or very nice resort, depending on how long the seminar is.

Whether your doctor is involved with this, who knows.

Doctors often don't know how much drugs cost.
posted by yohko at 3:45 PM on May 14, 2013

Do you have anyone else who knows your history who can give you feedback about your moods when you're on Abilify? It's sometimes hard to tell yourself, and psychiatrists don't generally see patients super regularly, so you're both working at a little bit of a disadvantage here.
posted by jaguar at 3:47 PM on May 14, 2013 [2 favorites]

It is OK (and wise, and a good way of practicing your anxiety-control skills) to say:

"I feel that Lexapro is working really well as far as controlling my symptoms is concerned, and I cannot afford Abilify. Could you please give me some specific reasons as to why you want to change my dosages? What do you believe Wellbutrin would achieve that isn't being taken care of by the Lexapro?"

This man is a service provider, not a god. You pay him to help you, and it's supposed to be a collaborative process. So, collaborate.

(I also agree that getting third-party insights, preferably from people who see you in your daily life, is helpful. It was my sisters' testimony that got me off of Abilify in particular.)
posted by Fee Phi Faux Phumb I Smell t'Socks o' a Puppetman! at 3:52 PM on May 14, 2013 [16 favorites]

Oh, also, using a mood diary may help give him (and maybe you) a reason to reevaluate your functional level. If you want I can give you a bunch of other mood diary resources (there are loads out there - paper, app, website...)
posted by Fee Phi Faux Phumb I Smell t'Socks o' a Puppetman! at 3:54 PM on May 14, 2013 [2 favorites]

Ask if you are eligible for any patient assistance programs from the makers of Abilify. Abilify generics should be available in mid-2015, so it's not terribly long to wait if you feel like you're doing well on the Lexapro for now.

Nthing getting feedback from 3rd parties about how you've been on your current regimen. The fact that he says he's willing to give you Wellbutrin (generic) as an alternative suggests that this isn't just industry influence and that he really thinks you need a change in your meds. Surely you must be describing symptoms you find problematic to your doctor for him to be so interested in changing your regimen?
posted by treehorn+bunny at 3:56 PM on May 14, 2013

Before I'd even clicked the "more inside", I knew you were going to be talking about an SSRI you liked, versus Abilify, The New Thing.

This same scenario has played out among several of my friends -- they have an SSRI they're satisfied with, the doc has them add Abilify, they can't afford it/don't like it/whatever, and want to drop it. Then the doctor gives them grief about it, and says, "but you're doing so much better!" -- even though the patients disagree. I dropped a psychiatrist, in part, because she was doing the same thing to me. I am not at all anti-psych-meds, but this Abilify push is really gross to me.

Useless Anecdote: I've spent a lot of time with one of my friends during her transitions on and off Abilify. From a third-party stance, Abilify really doesn't seem to help her at all. She didn't like it, and there was no observable change in her life, depression, or behaviour - although her psychiatrist insisted there was. This friend also had the perception the Abilify was messing with her diabetes, as well. Her psychiatrist was very dismissive of that worry.

Some people like Abilify, but you don't appear to be one of them. Your opinion matters, and if you really think it's 1) not helping, and 2) too expensive, then you have the right to not take it. If you're happy with your Lexapro, there's no point in adding Abilify. Maybe you need to add or change something, but you don't have to do Abilify if it's both useless and expensive.
posted by Coatlicue at 4:02 PM on May 14, 2013 [9 favorites]

YMMV, but I wouldn't worry about weight gain when switching from Lexapro to Wellbutrin. I lost 25 pounds when I first started Wellbutrin, and when I went from Wellbutrin to Lexapro, I gained back the 25 pounds. Wellbutrin under another name is actually used as a weight loss aid, or at least as the drug that keeps you from putting on weight when you quit smoking.

Frankly, I hated Lexapro, which gave me a really bad case of "Don't give a fuck," but I know how individual the reactions to these drugs can be.
posted by mneekadon at 4:07 PM on May 14, 2013

Anecdata: Wellbutrin caused me to lose weight.
Compound anecdata: I understand weight loss (or at least usually not causing weight gain) to be one of the things that makes Wellbutrin appeal to folks (that and it can amp up your libido a little instead of dampening it like many antidepressants).

What percentage of people taking Wellbutrin gain weight and how much do they gain on average? What percentage of people taking Abilify gain weight and what is the average amount of weight gain? It seems to me that if weight gain is his primary concern, those should be the things he is comparing. You should be more concerned about the seizure risk associated with Wellbutrin at higher doses.
Gut reaction: Your doc is not as informed about meds as would be ideal, and keeping yourself independently educated (as you are doing here) is advised.
Isn't Abilify potentially really bad for people with diabetes or who are at a high risk for diabetes?
posted by tllaya at 4:08 PM on May 14, 2013

Yeah, unfortunately there are doctors like this. The regulations have tightened but they still exist. I had one do something similar. I wanted to get *off* SSRIs completely because they were causing more problems than they were solving (I'm not anti-meds, it just wasn't the right solution for me anymore). He insisted on switching me to "the next hot thing" (Viibryd) which ended up giving me horrible nightmares. He switched me quickly back to whatever I was previously taking, but it took a lot of pushing for me to convince him that I needed to be off meds entirely. I realized that he had his pocketbook as his first priority, not my health.
posted by radioamy at 4:09 PM on May 14, 2013

First, what reason did your doctor give you when he added the Abilify? Second, what reason is he giving you now for reducing the Lexapro? You've been upfront and clear with your reasoning (Lexapro works, Abilify is $$$), so what is his?

Do drug reps basically have doctors by the balls these days?
Not anecdata: Yeah. You can use this convenient list to look up your doctor and see how much he has personally pocketed, and from whom.

Anecdata: I went through an experience where I was told that since the maximum dosage of the generic drug I had been prescribed (citalopram/Celexa) was not working, I should not discontinue it, but simply go up to the maximum dosage of the wildly expensive non-generic drug I had been prescribed (quetiapine/Seroquel) AND try the all-new, long-lasting Seroquel XRtm!
And I took it, I did, like a good patient, even as I watched my doctor write my prescription for Seroquel XR with her shiny new Seroquel XR-branded pen. I was not warned about anything remotely like tardive dyskinesia, neuroleptic malignant syndrome, serious weight gain, or the sudden onset of intense/psychotic suicidal ideation (thankfully, I only experienced the latter two; however, all of these are also known side effects of Abilify).
Thanks to that ProPublica list, I found out that the manufacturers of Seroquel, AstraZeneca, had been lining my doctor's pocketbook for years! And the year after my totally awesome Seroquel-induced psychotic break, the Department of Justice fined AstraZeneca $520 million for off-label marketing... of Seroquel!

The fact that psychiatric drugs are marketed with cartoons and commercials on TV does not instill a great deal of confidence that your average prescribing doctor's ultimate concern is anything but maximizing the financial gain they are likely to receive as a kickback for writing the 'right' prescriptions.

I honestly don't notice much of a difference with the added Abilify, although my doctor says he does.
From a purely logistical stance, your doctor's point doesn't make sense; your psychiatrist is only able to observe your mood and behavior once every few weeks. What do your friends and family see -- did they notice a change when you started Abilify? I think you should trust your gut, your self, your own mind. I do not think you should take any mind-altering substances that you do not want to take, or that you feel coerced into taking because Reasons.
Abilify is getting shoved in patients' faces as an add-on to EVERYTHING right now. It was developed and initially approved by the FDA for use in patients diagnosed with schizophrenia, but it's developed a massive new following as an add-on over the last few years. Nowadays, they want you to take Abilify so much that the manufacturers will help you pay for it -- out of the kindness of their hearts, I imagine -- and their advertisements run night and day. They just want to help, you know? Never mind the wonky stuff their product does to your blood sugar levels, or the fact that it can drastically increase your risk for developing diabetes, or the fact that if you take it for too long you can develop permanent shivers, shakes, and tics (TD).

More anecdata: CrazyMeds is a great resource for learning about things like this. Good luck! You are your own best advocate!
posted by electroshock blues at 4:28 PM on May 14, 2013 [7 favorites]

Wellbutrin is a stimulant! What is your doctor talking about? My resting heart rate was like 100bpm when I was on that shit. I would talk to your doctor in more detail about Wellbutrin as a possible alternative to Abilify. There's a cheap generic, and if he's willing to go that route it's worth considering.

A second opinion is rarely a bad idea.
posted by baby beluga at 4:43 PM on May 14, 2013

For what it's worth, I did a stint on welbutrin years ago and it did not make me gain weight at all.

And for what it's worth, you need to speak up and tell your doc that you cannot afford the new med and that if he wishes you to be medcompliant he needs to work with that constraint in mind. If not, then get a referral to a new doc. While you are at it, i'd drop in and have a word with a pharmacist and see what he or she has to say about your med cocktail.
posted by St. Alia of the Bunnies at 4:47 PM on May 14, 2013 [1 favorite]

Not a doctor, just a patient with lots of med miles.

Agree with others that Abilify is way more likely to make you gain weight or be more likely to become insulin resistant than Wellbutrin. (I've taken both, at different times, and done lots of research on my own.) Abilify did nothing but give me side effects on top of my anxiety and depression. Wellbutrin has not made me gain weight at all, doc suggested it partly because of that.

More Abilify (an atypical antipsychotic, for heaven's sake) probably won't help. Reducing the Lexapro is insane, if it works well enough for you. There are other adjunct drugs to try. Adding Wellbutrin makes way more sense, and even a smaller dose can help (I'm only on 200 mg a day, which is 2/3 the normal dosage). Wellbutrin can be stimulating, but it makes me sleepy. The generic extended release is cheap. If you want something different, Risperdal is generic now, and adding a small dose for a short time actually does help some people with resistant depression.

I hate docs that push more expensive "new" meds, especially when they aren't prescibing them correctly or there isn't enough info about them in the real world to make a good case for it. (Idiot doc who told a friend that it was fine to take double the Vioxx because it was so much safer than aspirin or ibupfrofen.) It is so important to research everything they want to give you yourself, especially if they've demonstrated that they aren't doing any research themself but hearing about meds from drug company reps.

A little off topic but: A cheap generic blood pressure drug called guanfacine has recently been re-branded and reapproved for use in ADHD, called Intuniv. They added a time release for a drug that was once a day dosing anyway and now charge about ten times the price for it. Over $200.00 a month for a flipping $4 generic.

On preview above: Crazy Meds is one of the best sources for info on these meds.
posted by monopas at 4:48 PM on May 14, 2013 [2 favorites]

1) Like I said, you're not my doctor, but should I take at face value that this pdoc has my best interests in mind here? Now that Lexapro is generic, is he under pressure from drug reps to push the Hot New Thing on every patient that walks in? Do drug reps basically have doctors by the balls these days?

My experience with this sort of thing is that there's a tradeoff between (1) staying comfortable, sane and happy in the short run and (2) doing the tinkering and experimentation that it takes to find The Perfect Combination of meds in the long run.

Psychiatrists tend to be more interested in #2. I think it's just the nature of the profession — your neurochemistry is a fascinating puzzle and they want to solve the damn thing. As a patient I tend to be a lot more interested in #1, because any tinkering we do carries the risk that we'll try something that doesn't work and I'll have to live through another bad week/month/year as a result. No thanks.

It's not necessarily just the drug rep/big money thing, though that may be relevant too. My pdoc's latest Big Idea was to add lithium to my regimen, and nobody is getting rich off of lithium. He just likes to tinker with shit, and as long as I'm not 100% symptom free he's gonna keep doing it.

Long story short: he may well have your best interests in mind here — and just have a different set of priorities than you do. It's not necessarily "You want to get better; he wants boatloads of cash." It might be more like "You want to guarantee you'll stay above 95%; he wants to try and get you to 100% eventually, even if you end up dipping down to 75% along the way."
posted by Now there are two. There are two _______. at 4:50 PM on May 14, 2013 [3 favorites]

Response by poster: Thanks for all the insight. So far, the common thread here is "be your own advocate," which I think is probably the way to proceed.

Re diabetes -- I am at risk for it but I've had blood tests done in the past year that show my sugar is good and I have to worry more about cholesterol. Abilify has the possible side effect of rasing LDL levels.

First, what reason did your doctor give you when he added the Abilify? Second, what reason is he giving you now for reducing the Lexapro?

I came to him a while back wondering if I could increase the Lexapro dosage slightly. The Lexapro was working but I felt like I might have been plateauing after being on that dosage for a long time. We added the Abilify because my Lexapro dosage is already higher than the typically prescribed amount and I guess it's not recommended to raise it any further. As far as reducing the Lexapro, the end result would ostensibly be a reduction in some side effects I'd mentioned to him. In truth, though it'd be swell to be free of those side effects, I think the positives of the medication outweigh the negatives.

That ProPublica list is great. I didn't see my doctor's name on it, but it's an Asian name and could have alternate spellings.
posted by mirepoix at 4:50 PM on May 14, 2013

electroshock blues: Awesome resource on the pharmaceutical payments thing - I feel remarkably better now that I see my treatment team members aren't on the lists. Thank you for sharing!

mirepoix: I was taken off of Lexapro for exactly the same reason your doctor is hesitant to increase your dose; we switched me to Cymbalta (SNRI) and Lamictal (anticonvulsant/mood stabilizer known for antidepressant effects) and it's been amazingly better. The headaches and nightmares were bad with Lamictal, but when I switched to the extended release (which is JUST NOW FINALLY generic, as of seriously like three months ago) all that went away.

I also just did a genetic analysis thing that basically said "everything works on you other than SSRIs," which was darned funny considering how many SSRIs I've been on. Something to consider, anyway. The only reason we're not trying to use it to "perfect" my med combo right now is that I'm under a ton of stress and we do not want to taper down on anything that's sort of halfway working, given how bad the last two years have been.

Oh, and all the atypical antipsychotics are pretty freaking awful on the weight gain, sleepiness, and diabetes/insulin stuff, as far as I know. I'm 0 for 2 on the things (Abilify & Geodon,) and thanks to Geodon I now take Metformin.
posted by Fee Phi Faux Phumb I Smell t'Socks o' a Puppetman! at 5:35 PM on May 14, 2013 [1 favorite]

One good way to tell how you're doing is to fill out a depression/anxiety quiz or questionnaire now and then and see how your answers stack up. (On preview, it's pretty much a mood log with specifics.) Unfortunately, you won't be able to compare your answers to what was going on before.. but maybe you can try to remember how you would have answered a couple of months ago. At least do something like that if you make a change in your medications.

Because of my own anxiety, For several years I was reticent about questioning my doctor...but of course it's so easy for me to see what you should do. I suggest that you say something like, "You told me you've seen improvement in my moods. Can you tell me specifically what you've noticed." If you feel hesitant, you can say that it's not easy for you to ask. You're there because of depression and anxiety, and it's pretty much a rule that whatever mistrust and worries you have "in real life" are going to show themselves in your relationship with your psychiatrist. Trust develops gradually, and if you're suspicious, give yourself a break. It's part of how your mind works.

I didn't do well on Lexapro, but its cousin Celexa has helped me for many years. The side affects of slow thinking, forgetfulness, and emotional numbness created big problems in the early days. I got a lot better when Wellbutrin was added. The cognitive and memory effects lessened a great deal, and I felt like I had more physical energy and was able to enjoy a few things. I gained weight with Wellbutrin, but my doctor was hugely surprised because in his long career he hadn't seen weight gain from that drug...when there was a change, it was weight loss.

I know nothing about Abilify, but I think it's normal when someone takes a psychiatric drug and notices no benefits they're asked to take more of the new drug, as long as there are no troublesome adverse effects. So your doctor isn't out of line in wanting to add more. If you don't believe in it, there's less of a chance it would help your mood (according to what 2 doctors have told me).

There's no reason why you can't decline to increase it, and you're fully entitled to discontinue it. It's not even a permanent decision; if things change for you later on, you can try it again. (Maybe by then they're be more information about patients' experiences.) Cost is absolutely a valid reason not to choose a drug, by the way. I like the idea of asking for samples, if you decide to give Abilify more of a trial run.

Doctors can feel hopeful when they hear about a promising drug, and they can experience anxiety when they're not able to help a patient as much as they'd like to. They're not supposed to let those feelings interfere, but you know, they're just people. So see if you can start a conversation that's only about how you feel, about your reluctance, and about what you feel comfortable doing.
posted by wryly at 6:39 PM on May 14, 2013

Just nthing the "Wellbutrin will make you gain weight? Say what?" sentiment. I've heard Wellbutrin described as "one of the speedier antidepressants", and my own experience definitely supports that characterization. (Thank goodness the "Wow! Zoomy!" feeling died down after the first week.) And although I don't have a citation to point to, my understanding is that it's not supposed to be prescribed to people with eating disorders, in part because it has an appetite suppressing effect.
posted by Lexica at 6:43 PM on May 14, 2013 [2 favorites]

This stuck out to me.

>I honestly don't notice much of a difference with the added Abilify, although my doctor says he does.

Who has the better ability to tell?
posted by megatherium at 7:32 PM on May 14, 2013

Psychiatrists frequently dance around this little fact... but it's technically your call. Just tell him you're sticking with the old stuff, thanks.

My professional opinion is that Seroquel and Ability are horseshit.
posted by hobo gitano de queretaro at 7:37 PM on May 14, 2013

Anecdata... when I started taking Abilify, under the same doctor justifications, I immediately had a serious side effect: I simply. could. not. sleep. For days on end. I went from never having any sleep problems to having extraordinary and crippling insomnia. The effect before and after Abilify was so sudden as to be impossible to see as anything other than Abilify. (Frustratingly, the sleep problems continued after stopping Abilify, though they eventually faded away.)

(Note -- insomnia is not one of the most common side effects of Abilify.)

I mention this not because it's particularly relevant (you haven't mentioned any key side effects for you personally) but because one should stress that anti-psychotics are *very* powerful drugs that are frankly not that well understood, and I am very skeptical of the current push of using these antipsychotics alongside antidepressants for their supposed auxiliary antidepressant qualities. Long term use of high doses of Abilify could have who-knows-what consequences.

If Lexapro has been truly crucial to your emotional well-being for years, then you need to put your foot down.
posted by lewedswiver at 7:43 PM on May 14, 2013 [1 favorite]

My meds are not your meds. My doc is not your doc. I am not a doc.

One of the things I value about my doc is that she is generally very conservative about meds, in both the "if it's workin', stick until it don't" sense and the "let's start with the cheap, work for most people meds." It does not sound like your doc ascribes to those principles. I would probably have a problem with it in your place.

On a purely logistical, 'can I say no?' sense: Yeah, you can say no. I guess there's some chance he could like, not write a new script for the Lexapro? But that'd be super weird and I strongly suspect that you'd be able to relate the circumstances to basically anyone with a pad (what I actually mean is GP/other psych/maybe urgent care place?) and get one.
posted by PMdixon at 8:23 PM on May 14, 2013

My professional opinion is that Seroquel and Ability are horseshit.
I think this is very much dependent on the person. The difference between me being given carbamazepine and being given Seroquel is huge - I couldn't think straight on carbamazepine as I was so tired and confused, whereas the Seroquel seems to work perfectly for me in combination with sertraline. It's not perfect - I get tired more easily, it affects my sex drive and, weirdly, ability to follow novels/fictional films, and there has been weight gain which I didn't particularly need - but it does enough for me to want to continue with it. Someone more cynical will probably disagree with me, but as my medication is prescribed on the NHS there is no real financial incentive for pdocs here to prescribe one drug over another, unless there is an issue with central funding (as happens with some cancer medications).

Abilify doesn't seem to be common here - I've never had it prescribed, but then I am bipolar II - but this list of side effects is unusual to say the least. I've never seen warnings about compulsive gambling on drugs before...
posted by mippy at 4:25 AM on May 15, 2013

Ok, I'll be the odd one out, since you asked for anecdata. Abilify is my miracle drug. It took me from not exactly depressed but still basically blanked out and unable to focus on anything and made me an actual productive working scientist again. (I also have OCD, and Abilify is the only thing I've tried so far that even touches it.) I find it a little sedating, but I take it at bedtime and it's fine.

The catch was that I had to be prescribed a relatively sizable dose -- 10 mg, which I understand is not the norm for first prescriptions. My current pdoc says that a lot of docs are reluctant to prescribe clinically relevant dosages, and he doesn't believe the more typical dosages of 3-5 mg are actually useful.

That said, it is a pretty burly drug and if you're not comfortable with it, that's totally your call and you wouldn't be alone. I've had none of the scarier side effects that I didn't already have from something else (Effexor has gifted me with hand tremors, thanks Effexor), but the possibility does exist.
posted by dorque at 8:39 AM on May 15, 2013

Oh my goodness, why switch if what you have is working? All else aside, you want to keep some tricks up your sleeve in case what you have *stops* working.
posted by mskyle at 9:15 AM on May 15, 2013

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