Why Blog? Bupropion Vs SSRI, If you can't beat them, join them.

Guidelines based on evidence!

I wasn’t too excited with my assignment to blog about epidemiology.  It seemed like an assignment that would consume a lot of my time and I wouldn’t necessarily learn much more then I would with traditional methods of teaching. 

I saw a patient this week that definitely changed my mind though. She has been battling with depression for many years. She has been going to counseling for 2 years with little improvement of her symptoms.  Thanks to “reading tons of blogs” she came to the conclusion that it’s not “bad” to take medications for depression.  Through the blogs she learned that depression is a chemical imbalance in the brain and there is treatment for it. She also had a thorough knowledge of available medications for depression and their side effects.

Reading these blogs was obviously more effective in getting her the treatment she needed than her counselor or her primary care doctor!

I recommended we start a SSRI (selective serotonin reuptake inhibitor) a type of medication used for depression.  She also had some symptoms of anxiety and SSRIs are also used to treat anxiety.  I thought this would be the best option for her.  Many bloggers apparently had horrible things to say about SSRIs.  After reading personal experiences from other bloggers she wanted nothing to do with SSRIs and wanted to try Bupropion, another medication used for depression.  So that’s what we started her on.

Should patients be making medical decision based on personal experiences that people blog about though? How about the millions of people that responded well to SSRIs and just didn’t blog about it?  Maybe an SSRI would have been better for her. A pooled meta-analysis of 10 randomized studies from 1991 through 2006 found that in patients with high levels of anxiety “there appears to be a modest advantage for the SSRIs compared to Bupropion in the treatment of anxious depression (6% difference in response rates).”¹ This meta analysis looked at the experience of 1,275 patients with anxious depression to come to that conclusion. 

So why did I still prescribe Bupropion? Shared decision-making.  At one point she apologized for asking for a different medication then the one I recommended.  I let her know I would never prescribe something I did not feel comfortable with and Bupropion is a good choice! No need to apologize.  “The American College of Physicians recommends that when clinicians choose pharmacologic therapy to treat patients with acute major depression, they select second-generation antidepressants on the basis of adverse effect profiles, cost, and patient preferences (Grade: strong recommendation; moderate-quality evidence).” ² That’s exactly what we did.  Bupropion is a second-generation antidepressant.  Thanks to other bloggers she was very familiar with the side effect profile of all the available antidepressants.  That was her preference. 

Whether we like it or not, this is where our patient’s are getting their medical information.  If you can’t beat them, join them!

Bibliography:

1.  Papakostas GI, Stahl SM, Krishen A, Seifert CA, Tucker VL, Goodale EP, Fava M. Efficacy of bupropion and the selective serotonin reuptake inhibitors in the treatment of major depressive disorder with high levels of anxiety (anxious depression): a pooled analysis of 10 studies. J Clin Psychiatry. 2008 Aug;69(8):1287-92. PubMed PMID: 18605812.

2.  Qaseem A, Snow V, Denberg TD, Forciea MA, Owens DK; Clinical Efficacy Assessment Subcommittee of American College of Physicians. Using second-generation antidepressants to treat depressive disorders: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2008 Nov 18;149(10):725-33. Erratum in: Ann Intern Med. 2009 Jan 20;150(2):148. PubMed PMID: 19017591.

Now that the sun is out…should I forgive Erik?

“Back at the hotel in Columbia, MO. After laughing at dinner like I haven't laughed in a long time! De regreso en el hotel en Columbia, MO, Despues de reirme en la cena como no lo habia hecho en mucho tiempo!”

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    June 10, 2010 at 11:45pm · Friends Only ·

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That was my FB status after going out to dinner with Erik (my program director), his wife, and a couple friends during my interview process at MU.  After that dinner my decision was made:  I would do my fellowship at MU.  It seamed like a fun group of people to work with.  The scenery was beautiful and I clearly remember Erik saying the winters where mild, “Snow never sticks.”  You can imagine my surprise during the historic snowstorm this month.  I didn’t leave my apartment for 3 days!!  I felt deceived!  Could not seeing the sun for 3 days really reduce my chances of being happy?

In a personal view article in the BMJ it mentions “Research has shown that people are happier, more energetic, and less likely to be sick in the longer and brighter days of summer, whereas their mood tends to decline—and anxious and depressive states to intensify—during the shorter and duller days of winter.” ¹ They didn’t reference these studies though.

I found one study done in nurses working at Akdeniz University Hospital in Antalya, Turkey where “exposure to daylight at least 3 h a day was found to cause less stress and higher satisfaction at work.” ² Can these results apply to me?  Is a study done in Turkey useful for people that live in the sates?

To complicate things even more. A study in the Netherlands found NO association between mean daily temperature, duration of sunshine and duration of rainfall to major depression and sad mood in the general population. ³

Bottom line for now:  this epidemiology thing and using in to make decisions in our everyday life is kinda of complicated!  One of the biggest decisions I will have to make in the near future is deciding where I should live.  There are so many things to take in to consideration when making this decision.  Looking at studies that have researched what things effect quality of life and Job satisfaction will be on my list of things to do.  But may give no definite answer! 

In the meantime, now that the sun is out and the temperature today is in the 40s, should I forgive Erik?

Bibliography:

1.   Hillman, Mayer; More daylight, better health: why we shouldn’t be putting the clocks back this weekend. BMJ 2010; 341:c5964 

2.   Alimoglu, Mustafa Kemal; Levent Donmez, Levent; Daylight exposure and the other predictors of burnout among nurses in a University Hospital. International Journal of Nursing Studies, Volume 42, Issue 5, July 2005, Pages 549-555

3.   Huibers MJ, De Graaf LE, Peeters FP, Arnts A. Does the weather make us sad? Meteorological determinants of mood and depression in the general population;  Psychiatry Research, Volume 180, Issues 2-3 December 2010, Pages 143-146

Is epidemiology the answer to finding true happiness?

 My main goal in life is to be happy. Is that not everyone’s goal?  Even if your goal is to save the world, deep down it’s because you think this will make you happy! I’ve had ups and down in achieving this goal.  This trimester I will explore epidemiology as the possible answer to achieving a perpetual state of happiness. 

Now you’re thinking what does epidemiology have anything to do with happiness? Well here is my reasoning:

Epidemiology studies the distribution of disease in populations with the goal of finding everything that can influence or cause a disease to ultimately intervene and prevent disease all together.  Making everyone healthier.

The world health organization defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” That sounds like happiness to me!

According to the Epidemiology text by Leon Gordis fourth edition: “The premise underlying epidemiology is that disease, illness, and ill health are not randomly distributed in human populations.” So, if the lack of “a state of complete physical, mental and social well-being” is not random, neither is the presence of it. I just have to find what interventions I need to take to increase my chances of achieving this state.  Epidemiology I think will give me the best chances of succeeding at this.

I welcome comments and suggestion. Keep in mind though, for those that will argue that the answer to happiness is God, and may suggest I read the bible rather then Gordis…. this blog is part of my epidemiology assignment. I might take a theology class next semester if epidemiologically speaking this increases my chances of being happy....