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Hot Topics Blog

Adding mirtazapine to SSRIs or SNRIs....does it work?

Simon Curtis - 13 Dec, 2018

What is the point of evidence? Sometimes it can help to leap medicine forward. Just think of all those strokes and heart attacks we save now with evidence-based interventions. But, just as usefully, sometimes it can help to put the brakes on, to give us time to pause and reflect on interventions that have become widespread in practice ahead of an evidence base. The use of vaginal MESH is a classic recent example of this, but in the field of therapeutics what about using mirtazapine in combination with SSRIs for ‘treatment resistant depression’?

So, imagine you have been treating Sue for depression. She has not responded despite talking therapy and two different SSRIs at maximum dose. What next? Should we try adding in mirtazapine?

Now I have to admit I never been a big fan of mirtazapine. It has always struck me as a bit of a ‘sledge hammer’ drug. People often seem to be over sedated on it, weight gain is common and people complain of feeling sluggish. That said I have some patients, like you, who do brilliantly on it, it is a useful choice in agitated depression with severe insomnia and despite my misgivings it came out well in this year’s big Lancet comparative meta-analysis as monotherapy in acute major depression, with a higher response rate and lower drop-out rate than many other antidepressants.

But I have been concerned to see how rapidly it has become used in recent years in addition to SSRIs or SNRIs as augmentation therapy in treatment resistant cases. This has become common practice in no time and without an evidence base to support it. There is a pharmacological rationale for combining it, in that it has a different mode of action to SSRI or SNRI with the potential for an additive and possible synergistic action (I once heard a psychiatrist describe the combination as ‘rocket fuel’). However, does it actually work in practice? Previous studies have shown mixed results, so a recent high quality RCT is welcome BMJ2018;363;k4218. This excellent study was based in primary care and looked at 500 patients like Sue, with major depression that had not responded despite 6 weeks of an SSRI or SNRI. They were then randomised in a blinded RCT to adding in mirtazapine 30mg or placebo. At 12 weeks there was no clinically significant benefit for adding mirtazapine compared to placebo, and yet an increased chance of adverse effects.

So, time to pause and reflect before reaching for the prescription tab and adding mirtazapine. The evidence informs us it doesn’t work and increases adverse effects. But where does that leave us with poor Sue? How can evidence usefully inform what we should do next to help her?

With our recent Hot Topics Autumn series just finished, we are already working on our next edition for Spring 2019 and treatment resistant depression will be one of the Hot Topics we examine. It’s the sort of clinically relevant topic, important to try to help our patients lives, that we love. We hope you will join us!

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Do you know your Vagifem from your vajazzle?

Stephanie de Giorgio - 20 Dec, 2018

Do you know your Vagifem from your vajazzle? Confused between Femodette and Femosten? Does discussing menopause bring you out in a cold sweat? Well, NB Medical have the answer in the form of our Women’s Health Course and by the end of the day, these mysteries and many others will be solved for you. So far, we have had great feedback from delegates and look forward to another year travelling the country talking about vulvae and uteri.

Writing and presenting this course for NB Medical, alongside Zoe Norris has been one of the most fun things I have done in my career to date. Getting the grey matter working again whilst researching the literature and evidence and then getting lost down You Tube rabbit holes of funny videos for the breaks has been both academically challenging and deeply pleasing respectively. Sarah Millican reading Fifty Shades of Grey was a particular highlight of the You Tube experience and was a must for one of the breaks, borderline inappropriate, but hysterically funny!

One of the challenges of designing and presenting a Women’s Health Course has been ensuring that we make it useful for all those who attend, whatever their level of expertise on the subject at hand. We learn a lot from what delegates need from the questions they ask and the feedback they give, and we are using this to further design the course for the future and plan to include more scenario-based learning formed from questions asked during the courses and give people a chance to ask questions during the day to form these bespoke scenarios.

So, what do we try and cover to make sure everyone takes something from the day? The fundamentals of menopause, HRT, contraception are covered comprehensively, because you have told us those are most important. Then we move onto other areas such as the vulval dermatology section “It’s not always thrush”, perinatal mental health, early pregnancy problems and pelvic floor dysfunction amongst many other topics. We include latest evidence and guidelines and really practical tips you can bring to change your practice the day after the course.

Make 2019 the year you add women’s health to your PDP and come and join the NB presenters, even and perhaps especially if you are one of the doctors whose offices I sometimes locum in, where there is one lonely speculum from circa 1994 gathering dust in the cupboard under the sink. Demystification of the vulva and vagina awaits. For those who seem to get through hundreds of speculae in clinics, we are suitable for recertification for DFSRH and LoC for coils and implants. There are face to face courses, webcasts and webinars available for you to choose from to suit your learning needs. You can sit at home on the sofa in your PJs or come to a course (preferably not in your PJs, but it could be a new course variable perhaps – would be way more comfy than presenting in my heels).

The current courses booked are in Belfast on the 27th Feb and Manchester on the 28th Feb and the webcasts and webinars are available HERE.

We look forward to seeing you. 

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Where's the evidence....?

Ahmed Rashid - 6 Dec, 2018

It can sometimes feel like people use the word ‘evidence’ as a stick to beat us healthcare professionals with. Whether it’s university academics, guideline producers, governmental departments, or senior politicians, we’re often told that we’re doing something wrong and that they have some ‘evidence’ to discredit what we’re doing and force us to toe their line. Regardless of what our years of experience and common sense tell us, we must immediately change our practice or else the evidence stick will be used to beat us down until we repent.

But it doesn’t have to be like this. Although evidence-based healthcare has been a movement that has transformed the way we care for our patients - mostly for the better - it has also received much criticism. Clearly, the best available scientific evidence needs to inform our clinical decisions, but that doesn’t mean that it should dictate them. Many of the studies that form the evidence base, for example, come from secondary care populations, and the types of patients are often far different from the patients we see in general practice.

Just as importantly, each and every patient and family we see is unique, and have their own particular circumstances, which we can and should take into account. There may be events going on in their lives that completely change their goals and priorities, and it’s our job to understand those and react appropriately. Sometimes the science will be trumped by the things that matter most to our patients, and that’s just good, holistic practice.

The evidence stick is brutal because it can be hard to respond to. If we’re told confidently and definitively that there’s evidence to support or reject an intervention, it can be difficult to challenge it, and intimidating to try and do so. But in actual fact, a lot of the evidence that we’re presented with has big holes in it, and can very much be challenged or critiqued with some careful reading.

The problem is, as busy healthcare workers in a pressurised system, we don’t always have time for the reading. Even when we do make time to read the journals and guidelines, it can be difficult to contextualise new findings within all the mountains of other pieces of information that are published each year, month, week, and even day. How can we synthesise all the new information that we’re given and make sense of how it will apply to us in our real-life consultations with patients every day?

At NB Medical Education, we get this. We get the challenges, we get the need for balance and common sense, and above all, we get how difficult it is to keep up with all the latest developments.

Over the last twenty years, we’ve been delivering courses to frontline healthcare staff across the NHS. Our ethos throughout this time has been to empower delegates to go back to their practices and be able to skilfully interpret and use the latest evidence in a productive and balanced way, taking into account all the nuances and context that comes with it. In healthcare, it sometimes feels like everything is a priority. And the problem with that, as we all know, is that when everything is a priority, then nothing is!

Our educational courses take our delegates through the most important topics in primary care at the moment, and highlight the key practice points for real-world practice. Perhaps most importantly though, they shine a light on the subtleties and limitations of the evidence, so delegates can go back to their practices fully equipped to use it in a constructive way to improve the lives of their patients.

For more information on our Spring 2019 course dates, click HERE

Find this blog useful? You can quickly add CPD to your account by writing a reflective note about the post you have read.

Log in to your NB Dashboard and use the 'Add Reflective Note' button at the bottom of a blog entry to add your note.