UpToDate and the Rx Transitions in Mental Health

 

For the nonphysicians reading this UpToDate is a comprehensive online resource for physicians that has essentially replaced internal medicine texts. Before it existed, most physicians who practiced adult clinical medicine could purchase a new internal medicine text every 4 or 5 years for $200-300. UpToDate (UTD) requires an annual subscription that is roughly double that cost. Many large groups of physicians provide access to their medical staff free of charge. In my last years of practice, I had an out-of-pocket subscription but I let it lapse 2 years ago. I renewed it just last week.

My rationale for the subscription comes down to several factors.  First, I need access to the best current information on complex diseases and their treatment.  The counterargument is that you can access it online – but that information is often not balanced or realistic.  UTD is carefully edited by experts in the field who often comment on what they do in their clinics.  There are several levels of editing.  Second, continuing medical education credit is available just from studying what you are interested in.  I can do a deep dive into a subject on UTD and end up with several hours of CME credit that is necessary for licensing.  The free CME credit I can access is often low in quality and requires too much time – like needing to watch an hour-long video to get 1 hour of CME credit. I really have a hard time understanding why anyone would watch or listen to a program when reading is much faster.  The only useful exception is listening while driving.  Third, there is a drug interaction program.  After extensively researching hundreds of polypharmacy combinations – I still like running those analyses.  Fourth, researching my own medical problems.  A colleague pointed out that was one of the main reasons he subscribes.  In today’s world of brief medical appointments, it is good to have some expert backup.  And if any medication is suggested I always do my own drug interaction checks and do not assume the prescribing physician or pharmacists has.  I have suggested modifications of prescriptions to my physicians on that basis.  Fifth, as a reference for my blog.  UTD references are in many of my posts.

When I renewed this time there was an option for Rx Transitions in Mental Health.  I have positively mentioned UTD in the past as a source for physicians on antidepressant tapering and transitions.  Any experienced psychiatrist has done hundreds of these transitions or tapers.  The original UTD chapters were written by senior psychopharmacology experts and they were approaches I had used many times in the past.  It was also a reminder that contrary to some recent discussions about antidepressant withdrawal – psychiatrists have been aware of these issues and have addressed them for decades.

The Rx Transitions interface is sparse. It is explicit about the intent: “to provide clinicians with information about switching antidepressant medications”.   There is a column on the left of antidepressant to be stopped SSRIs (citalopram, escitalopram, fluoxetine, sertraline), SNRIs (duloxetine venlafaxine ER) and DNRIs (bupropion ER).  After selecting the drug and the dose – a drop-down menu appears with a brief list of important information including a link to the drug interaction program.  A more expanded list of antidepressants being started pops up that includes paroxetine, milnacipran and levomilnacipran, mirtazapine, vortioxetine, and vilazodone.  Once that is checked three different schedules are provided for an immediate, rapid or standard switch.  That roughly translates to switches on day 1, week 1 or week 2 respectively.  Several paragraphs of additional information are shown and the entire summary can be printed.

I have included a graphic at the top of this post to illustrate the possible transitions. The possibilities are illustrated for the starting prescription of citalopram and ending the transition with any of the 12 antidepressants on the right side of the diagram.  That is 12 possible transitions x 3 starting doses or 36 possible transitions. If we made similar connections for all the drug and dosages on the left side of the diagram there would be a total of 346.  All would ask about immediate, rapid, or standard switches and all would show additional information about the switch is subsequent windows.

The question is whether this add on would be useful for you in your clinical practice. The first consideration is that UTD has had sections about how to do this in the main resource for years.  They are written by expert psychopharmacologists.  When I have looked at them as a reference, they back up what experienced psychiatrists do in practice.  Secondly, do you treat much depression and should you?  There has been movement in the past 20 years to suggest that antidepressant prescribing should be a function in primary care.  Both the American College of Physicians (ACP) and the American Academy of Family Physicians (AAFP) have guidelines about this.  Collaborative care models have been suggested but many if not most primary care MDs have inadequate psychiatric back up. Context is very important since I doubt that getting a prescription in a primary care clinic is the same as seeing a psychiatrist. As an example – if I am discussing an antidepressant transition, I have asked that patient if they have ever stopped the medication and if they have ever had withdrawal symptoms. Some primary care physicians tell me they see minimal withdrawal symptoms because people tend to just stop the medication if they get side effects.  In that case starting a new medication is starting from scratch.

In psychiatric practice it is common to see people on the max doses of antidepressant monotherapy or polypharmacy.  In those cases, I would typically see people much more often until I was sure they had made the transition without side effects or withdrawal.  That might include initial tapering and close monitoring of depressive symptoms.  A final variable is whether the person can be counted upon to self-monitor.  I always told my patients to call me at the earliest sign of a side effect and further that I did not ever expect they would get used to side effects.  That did not prevent many from not reporting side effects until they came in for the follow up visit.  That is another reason for scheduling close follow up during these transitions.

Rx Transitions in Mental Health may be useful for physicians who have not had a lot of experience making these transitions.  It is an outline for what is possible in both the time domain and end results based on the list of medications that are used.  I think the choices could be further simplified.  For example, I do not see the utility for transitioning to paroxetine – an antidepressant with the highest withdrawal and drug interaction risk from any other medication in the diagram.  Similarly, I do not see the utility in including both citalopram and escitalopram as antidepressants to transition to, especially now that they are both generic drugs. Escitalopram is preferred because it has a lower effective dosage and better side effect profile. Using this program assumes a knowledge of antidepressants in general.  There are still many prescribed for other indications like sleep, headaches, and chronic pain.  Depression specialty clinics still prescribe tricyclic antidepressants and monoamine oxidase inhibitors that require special considerations.  There are also augmenting therapies (aripiprazole brexpiprazole, buspirone) that factor into the transitions. For the basic cases listed and with all the qualifications posted in the software – many will find the suggestions useful.

An easy thought experiment is possible to assist in the decision to get Rx Transitions.  Just look at the above diagram and think about each transition listed.  If you have done it many times before without any complications and are aware of all the considerations and precautions - you probably don't need it.  

The written chapter in UpToDate (2) is more comprehensive than the antidepressant switching tool.  It discusses concepts like antidepressant equivalent doses, pharmacokinetics, antidepressant withdrawal/discontinuation, and has links to specific classes of antidepressants, general approaches to treating depression, and treatment resistant depression.   Even at that level – psychiatric training should provide the clinical psychiatrist with what they need.  If you are a psychiatrist, I would encourage you to read this chapter first if you are considering subscribing to UTD for the psychiatric content only.  I hope that you know all this information cold including how to set up the medication transitions and monitor them.  As previously stated, there are many other reasons for psychiatrists to subscribe to UTD.

Primary care physicians will probably find this chapter to be very useful – especially if you have been nominated in your group to treat anxiety and depression.  I would recommend reading the chapter (2) first.  If your group provides access, they might also consider the switching tool but I would not consider it a necessity. If you have been using UTD for years you are probably aware of this chapter.     

 

George Dawson, MD, DFAPA      

 

Supplementary:

I have had UpToDate staff comment on this blog before.  If you are an UTD staff member please post a reference to the very first chapter on antidepressants transitions in UTD.  I think the original chapter was written by Ross J. Baldessarini, MD.  I would appreciate knowing how long that content has been in UTD.  

References:

1:  Rx Transitions for Mental Health: Antidepressant switching tool. In: UpToDate, Connor RF (Ed), Wolters Kluwer. (Accessed on October 2, 2025.)

2:  Hirsch N, Birnbaum RJ.  Switching antidepressant medications in adults.  In: UpToDate, Connor RF (Ed), Wolters Kluwer. (Accessed on October 2, 2025.)

What Can The APA Learn From UpToDate?

By way of introduction UpToDate is a highly successful online internal medicine text.  It has associated features such as handouts for patients on medications, procedures, and medical conditions.  It also has an online drug interaction feature that allows a limited set of preferences on the part of the physician.  CME credits are available for reading online.  The text covers a broad range of diseases and conditions.  I have asked them for more specific data on the extent of their coverage and total number of pages, but they refused to give it to me citing that it was proprietary information.  I noticed that they currently say that they have 77,000 pages updated by 5100 physicians.

I have been a subscriber to this service for a number of years and the subscription rate is currently about $500/year.  To illustrate how important that number is I need to compare UpToDate to what it replaced.  Ever since graduation from medical school I purchased a new internal medicine textbook about every 4 - 5 years.  I was also a 20+ year subscriber the the Medical Clinics of North America.  I considered it all a part of keeping up on general medicine while practicing psychiatry.  The cost of a typical medicine text like the last one I purchased Textbook of Internal Medicine (William N. Kelley, MD, ed) was somewhere in the $200+ range.  Searching Amazon it looks like my text is out of print by the two comprehensive texts are available for $224 (Harrison's) and $151 (Goldman-Cecil).  Doing the math shows that for $200 you can get a serviceable text that might last you for 5 years (it goes without saying that you always have to do additional reading) and at the end of the day - you still have text in your hand and a valuable reference.  That same 5 year period as a subscriber to UpToDate will provide you with online access of updated data and at the end of that time unless you renew - it is all gone.  Granted it is handy to have this available online if you are working in a hospital setting on different units and the CME feature is very nice - but the cost is about $2500 or twelve and a half times as much as a text every 5 years.

The premium cost in UpToDate relative to a medicine text probably has many things driving it.  The advent of the hospitalist in combination with the electronic health record are probably two of the most significant factors.  If you have internists working 10 hour days 7 days on and 7 days off across large hospitals suddenly there is not time to go to libraries and do research.  All of the information needs to be available as they are essentially word processing documents in the EHR at computer terminals.  In case you haven't tried it, it is also much easier to electronically search a textbook than to heft its considerable weight and keeping flipping flimsy pages back and forth from the index.  Many large groups now provide UpToDate online to their hospitalists and medical specialists in order to keep them working right at those word processing terminals.  These same hospitalists consulting on my inpatient psychiatric unit introduced me to UpToDate when it first came out.

How does all of this this apply to the currently dated and I am guessing infrequently used American Psychiatric Association (APA) Practice Guidelines?  Just looking at the dates of these guidelines shows that applying my approach to internal medicine by purchasing a new text every 4 or 5 years, would have left me more up to date with a psychiatry text than the current APA Practice Guidelines.  What about content in UpToDate?  There are 13 chapters on the major psychiatric disorders that psychiatrists treat.  There are several subheadings under the major headings.  For example, under the heading Anxiety Disorders there are chapters on acute procedure anxiety, acute stress disorder, agoraphobia, combat operational stress,  comorbid anxiety and depression, co-occurring substance use disorder and anxiety, generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, and social anxiety disorder.  There are separate chapters on the pharmacotherapy and psychotherapy of these disorders including fairly esoteric approaches to treatment like deep brain stimulation for obsessive-compulsive disorder.   The sections are all detailed and frequently updated.  Not only that but the recommendations section is essentially written as treatment guidelines.  As an example from that section (1):

"We recommend that patients with obsessive-compulsive disorder (OCD) be treated with cognitive-behavioral therapy (CBT), a selective serotonin reuptake inhibitor (SSRI) medication, or both (Grade 1A)."

Their definition of  Grade 1A Recommendation is:

"A Grade 1A recommendation is a strong recommendation, and applies to most patients in most circumstances without reservation. Clinicians should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present."

This is the general outline of the psychiatric disorders section in UpToDate.  From the sections I have read their literature review and section updates are all within the last 1-2 months and some of the sections are written by top experts in the field.  The detail is well above what an internist or family physician would need but I would not say it is less than what most psychiatrists need.  It gives practical advice on what is known about the treatment of psychiatric disorders and it is condensed down to about 4 - 12 bullet points at the end of each section.  Solid recommendations are made on management where possible and the recommendation is also graded as to whether or not there is good research to back it up.

What is the importance of these developments for psychiatrists, organized psychiatry, and medicine in general?  I think there are a number of important points.  First, psychiatry is represented in a text that is read by internists and family physicians to a greater extent and in more detail than ever in the past.  This is good for several reasons.  It provides some guidance to primary care physicians in considering the treatment of patients with complicated psychiatric problems at time when there may be fewer psychiatrists covering their patients.  It provides them with technical details that are needed to provide care.  It makes it easier for them to assume the care of patients who have be correctly diagnosed but can no longer be followed by a psychiatrist.  Overall it is good for the idea that psychiatry is a mainstream speciality in the field of medicine.  Second, it brings up the critical question of why the APA has a web page with the APA Practice Guidelines listed at all?  Most are hopelessly out of date.  They have little public visibility.  There have been some opinions that the time for practice guidelines by professional organizations are a thing of the past.  After all, managed care organizations and governments write the guidelines now don't they?  A secondary question is what is the purpose of a professional organization?  In my most read post on this blog, I suggest that it is to propose and disperse state-of-the-art treatments to its membership ("There is a responsibility to establish professional standards for patients referred to psychiatrists for the assessment and treatment....").  Certainly there was a recent opportunity.  An expensive effort bringing together top experts in all fields from around the world was done to compile the DSM-5.  The public was clearly confused about this project when the press and several critics equated the DSM-5 to treatment rather than diagnosis and misread the DSM-5 as being something more than it really is - a guidebook to the International Classification of Diseases.  I have seen experts from that collaboration speak at two conferences now and they happen to also be experts in the treatments of these conditions.  Would it have been wise to update the treatment guidelines in the manner of UpToDate rather than leaving the effort at the level of the DSM-5?  I think that it probably would have.

I brought this issue up recently and was told by people at decision making levels in the APA that they are rethinking the Practice Guidelines from a cost effectiveness standpoint.  My thinking on this is very clear.  If the APA does not want to represent the membership as a union dedicated to advancing the rights and interests of the members from that perspective then it really needs to present itself as a professional organization.  APA members certainly don't enjoy the benefits typically seen when businesses or unions lobby Congress.  If anything psychiatry and medicine has been in an unchecked downward spiral of overregulation and exploitation from businesses for about 30 years now.  The argument is typically made that we are a professional organization and focus on professional education and accountability.  Practice guidelines demonstrate that you have the expertise and wisdom to make that claim.  The APA can no longer say that.  There are more succinct treatment recommendations written by experts and more frequently updated in an online text that targets nonpsychiatrists.

I will be the first to suggest that  this is bad for the profession for a number of reasons and further evidence that the APA is doing very little to advance the profession and the plight of its members.  The current guidelines should be removed (at least the dated ones) and the organization needs to think about a streamlined process to construct new ones or get out of the practice guideline field.  



George Dawson, MD, DFAPA    

References:

1:  Simpson HB, Stein MB, Hermann R.  Pharmacotherapy for obsessive-compulsive disorder.  In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on February 21, 2015.)