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 America 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
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.)
