In December 2006 I participated in a survey of psychiatrists by a pharmaceutical company. They asked me if I could have only five medications to prescribe which ones would I choose? Since I have a cash only practice I have to go with the most effective medications long term.
Most medication studies are to meet FDA requirements, which means short studies (6-8 weeks), and they only have to show 50% improvement in symptoms and be statistically better than placebo (that may be associated with only 30-40% improvement). These studies do not represent real world treatment – patients can’t be given any counseling and can only be on one medication.
It is only through extensive clinical experience that we can learn which medications are best.
I think of the best medications as the ones that patients come back and say are great….that they have changed their life – side effects are minimal, and the highest standard is that they are still saying it after 6 months, 1 year, 5 years, etc. If the medication starts working on day one that is a bonus.
Great medications help you feel better, function better, be less stressed and help protect your overall health. Great medications also enable you to focus on your life – career, relationships, hobbies, and not be constantly preoccupied by symptoms and survival. You think – I wish I had this medication a long time ago.
The main problem with the best meds is cost – especially if you don’t have good insurance – but usually there’s a way to get the medications you need or at least to find generics that are close to the best branded meds.
In my experience stimulants as a group have the highest batting average (the highest percent of the time a particular med works great). I have patients that have taken them for over three decades. I haven’t seen any long term problems from taking them.
I was initially trained in the 60’s. One of the most helpful things I was taught – “if what you are doing isn’t working, do something else. Even if it is wrong it will get you unstuck.” This led me to trial and error and eventually to appreciate the value and relative safety of stimulants.
Amphetamines have been available for over 70 years and methylphenidate over 50 years so we have more experience with them than any other medication that we currently use in psychiatry. Ironically, stimulants aren’t included in the top 10 most often prescribed meds by psychiatrists in the first quarter of 2008. Despite the fact we have much safer delivery systems the FDA still regulates all the stimulants at a higher level – requiring a written prescription and maintaining a record of each prescription. This creates practical problems, inconvenience, etc., not to mention a certain intimidation is felt by doctors. By contrast, the most abused prescription medications – pain meds – such as Hydrocodone – are much less regulated.
My top 5 list has changed some since 12/06 and hopefully will keep changing as we get even better medications. For now it consists of the following:
#1 Stimulants – Vyvanse (preferred by 3/4’s of my patients who prefer amphetamines) and Adderall XR (preferred by 1/4 of my patients who prefer amphetamines). 15% of patients prefer one of the methylphenidates such as Concerta, Focalin XR, or Daytrana.
#2 Benzodiazepines – Alprazolam (Xanax and Niravam are my first choice). Clonazepam, especially Klonopin wafers are a close second.
Alprazolam, in a recent study was the #1 med prescribed for stress symptoms by primary care physicians. Psychiatrists in 2008 used Clonazepam #1, then Seroquel #2, and Alprazolam #3 for stress symptoms.
#3 Sleeping medication – Ambien CR/Lunesta (I rated Ambien CR first in 06 only because 15-20% of patients have a bad taste the next day from Lunesta – but using a mouthwash with whitener morning and night usually prevents significant taste problems). Both of these meds work great for most people. They are both approved for long term use and provide normal sleep. Short acting Ambien is still preferred by some patients and some take it because it is in generic and they can’t afford CR or Lunesta. Short acting may not keep you asleep more than 5 hours and has some risk of side effect issues.
No sleep medications were in the top 10 meds prescribed by doctors in 2008.
#4 Antidepressants – Pristiq/Effexor XR – I don’t have enough experience with Pristiq (son of Effexor) to be confident that the majority of patients will end up preferring it to Effexor XR, but in theory it’s better, safer to use, easier to dose, easier to combine with other meds, especially Wellbutrin. Wellbutrin is the only antidepressant that almost never has weight gain or sexual side effect issues (except for infrequent uses of MAOI’s like Emsam patch). But Wellbutrin doesn’t have efficacy for the whole range of anxiety and depression symptoms so it would not be the preferred med if you could only use one antidepressant.
Cymbalta is the other antidepressant in this category. It has more FDA approved uses including fibromyalgia, and generalized anxiety disorder and is very similar to Pristiq in its ratio of effect on serotonin and norepinephrine. I rank Pristiq first because it has much lower protein binding and therefore gets into the brain faster and works faster. Prestiq has essentially no drug drug interactions whereas Cymbalta inhibits metabolism of certain medications that can either result in unexpected side-effects or interfere with the activation of pain medications like codeine or hydrocodone.
#5 Mood stabilizers – Abilify/Seroquel. There is no perfect choice in this category. I use these two the most but I also use a lot of Lamictal, Zyprexa (Symbyax) and Lithium.
