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.