Pychopharm Final 426

8/6/2019 Pychopharm Final 426

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Psychopharmacology:Moods, Medications &

Mental Health

Tanveer A Padder MDMedical Director

Optimum Health & MPB Group

Maryland


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Outline Introduction/Neurochemistry

Depression

Anxiety

Psychosis

Bipolar Disorder

ADHD

Substance Abuse

Insomnia

The Female Patient

Risk Management and other important

issues


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Objectives

Understand brain chemistry and

neurotransmission

Expand your understanding of latestpsychotropic medications

Know common side effects associated withpsychotropic's

Understanding of future and ongoing

treatment modalities Risk Management strategies in your

practice

Improve client outcomes


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Treatment Overview

Different Models of treatment

Current treatment model

Myths about psychiatryBarriers to treatment

Parity issues

How to improve mental healthdelivery


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Diagnostic and Statistical

Manual

Definition of abnormal behavior

Cultural issuesReligious issues

History of DSM

DSM 1-V


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DSM-IV-TR

Axis I: Clinical DisordersDevelopmental Disabilities

Axis II: Personality Disorders

Mental Retardation

Axis III: General Medical Conditions

Axis IV: Contributing Problems

Axis V: Rating of Functioning


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..It is also liketelling a personwho has an

amputated leg torun across theroom.

But a person who has mental health issuehas a broken brain.


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Thalamus

Ventral striatum

Amygdaloid body

Hypothalamus

Olfactory and entorhinal

cortices

Hippocampus

Rostral raphe nuclei

Striatum

Neocortex

Cingulum

To hippocampus

Cerebellar cortex

Caudal raphe nuclei

To spinal cord

Cingulate gyrus


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Neurotransmission

Neurotransmitters- 7 actions

Receptors

Agonist

Antagonist

Stopping Neurotransmission

Reuptake

Enzymatic destruction


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Brain Area Functions

Cerebral Cortex

Prefrontal cortex

Hippocampus Amygdala

Basal Ganglia

nucleus accumbens

thalamus hypothalamus

brainstem


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Neurotransmitters

Serotonin

Nor epinephrine

Dopamine Epinephrine

GABA

Glutamate Acetylcholine


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Serotonin

Synthesized from tryptophan,

Actively transported across BBB

Decreased dietary tryptophan canreduce serotonin.

Oxidized by MAO-a

Most termination through reuptakeMetabolism

Clinical Significance


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Nor epinephrine

Synthesized from tyrosine Functions: attention, emotion

regulation, energy, psychomotor

agitation, tremor, HR, bladderemptying

Termination via reuptake, COMT,

MAO

Clinical significance


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Dopamine

Synthesized from tyrosine

Actions: concentration, energy,

psychosis etc Terminated by dopamine transporter

broken down by COMT, MAO-A and B

Clinical significance

Dopamine receptors


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Other NTs

GABA

Distribution

Synthesis

Receptors


Function

Acetylcholine Primary cell bodies

Termination of action



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Ten leading Causes of Disability inthe World

Type of Disability Cost (in

DALYs)GBD

Unipolar major depression 42,972

Tuberculosis 19,673

Road traffic accidents 19,625

Alcohol use 14,848

Self-inflicted injuries 14,645

Manic-depressive (bipolar)illness

13,189

War 13,134

Violence 12,955

Schizophrenia 12,542

Iron deficiency anemia 12,511


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Mood disorders

Neurotics build castles in the air, psychotics livein them.

Normal Borderline Psychotic

Approximately 20.9 million about9.5 percent

Include those where the primary symptom is adisturbance in mood.

The disorders include Major Depression,Dysthymic Disorder, Bipolar Disorder, andCyclothymia.


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Major Depressive Disorder

Leading cause of disability in the U.S. forages 15-44.

Major depressive disorder affectsapproximately 14.8 million Americanadults, or about 6.7 percent

The median age at onset is 32.

More prevalent in women than in men. Common symptoms include:


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Subtypes of Depression

Melancholic

Atypical

Seasonal

Catatonic

Psychotic


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Major Depression vs. Dysthymia

RecurrentMajor

Depressive

Episodes

Dysthymia


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Likelihood of having another Major

Depressive Episode if youve had

Major

Depressive

Episode

Major

Depressive

Episode

Major

Depressive

Episode

Major

Depressive

Episode

Major

Depressive

Episode

Major

Depressive

Episode

1 episode

50%

2 episodes

70%

3 episodes

90%


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Etiology

Neurotransmitters Deficiency states Depression

States of excess Mania

Down regulation

Risk Factors-

Psychological Theory

Patients have distorted perceptions and

thoughts of themselves, the worldaround them and the future learnedhelplessness

Secondary Depression


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Treatment-Bio-psycho-social

ModelBiologic

Tricylclic antidepressants

Monoamine oxidase inhibitors- Second generation antidepressants

SSRIs, Venlafaxine, bupropion, mirtazapine

Atypical antipsychotics Electroconvulsive therapy


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SSRIs

SSRI Use; Depressive and anxious disorders including:

Dysthymia,

Major Depression, Panic Disorder,

Generalized Anxiety Disorder,

Obsessive Compulsive Disorder,

Posttraumatic Stress Disorder,

Separation Anxiety Disorder, Selective Mutism

Mechanism of Action

Side effects


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Common SSRI;s

Prozac (fluoxetine)-typically activating, sarafem

Paxil (paroxetine)-typically sedating, available in liquidform.

Zoloft (sertraline)-usually neither sedating or activating. Celexa (citalopram)-usually neither sedating or

activating.. Advantage in few drug interactions, verygood choice for medically ill children on multiplemedications.

Most of them are available as a liquid, dosage (child)2.5-40.

Luvox (fluvoxamine)-Can be very sedating in children.Used in OCD


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Methysergide is an antagonist

Buspirone is an agonist

6 LSD isan agonist 7

5

43

2

1

Fenfluramineincreases release

Reserpine depletesvesicular stores

Fluoxetine (Prozac) andtricyclics block reuptake

MAO inhibitorsdecrease degradation

Tryptophan

5-OH-tryptophan

5-HT

5-HIAA

5-HT

5-HT

MAO

5-HT


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SSRI Side-Effects

Side-Effects- Mild nausea, decreased appetite

weight loss, excessive sweating,

insomnia, jitteriness,

sedation, dizziness, sexual dysfunction.

The serotonergic syndrome is a medicalemergency involving muscle jerking, tremor,

high blood pressure, diarrhea and confusion dueto drug interactions primarily with olderantidepressants


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SNRIs

Block both serotonin and nor-epinephrinereuptake

Venlafaxine (Effexor, Effexor XR, PRISTIQ (desvenlafaxine)

(Cymbalta) Duloxetine


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Miscellaneous Antidepressants

Remeron (mirtazapine)-can be used as sleep aid at lower doses.

Wellbutrin/Zyban (Buproprion)-also used for ADHD, smokingcessation and mood difficulties particularly in Bipolar patients. Mayalso be used to augment

Mechanism of action involves increasing dopamine andnorepinephrine turnover in the brain.

Typical doses are between 100-400 mg/twice a day.

Wellbutrin is not often used in young children, more frequently

adolescents due to side effects including, agitation, insomnia, wtloss, constipation and tremor. More problematic in the increased riskfor seizures in those with a seizure disorder, less risk with the slow-release form.


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Tricyclic acid antidepressants

Tricyclic acid antidepressants (TCA) including Tofranil (imipramine),

Pamelor(nortriptyline), Anafranil (clomipramine), Elavil(amytriptyline)-

TCAs are also used for headache prevention and pain syndromes.

These medications have largely been replaced by the SSRIs fortreatment of depressive and anxiety disorders including Obsessive-Compulsive Disorder and PTSD. Anafranil,

Tofranil is approved for bedwetting. Doses vary for each TCA and some canbe measured for actual blood levels.

Side effects


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Monoamine Oxidase Inhibitors

Monoamine Oxidase Inhibitors(MAOI)including):

Nardil (phenylzine),

Marplan (isocarboxazid)

and Parnate (tranylcypromine).

Rarely used medications due to dietaryrestriction.

Never used with SSRI since may precipitate a

serotonergic crisis. Wash out period

Side effects


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MAO-Is: Dietary Restrictions

Avoid food that has undergone aging, fermentation,pickling,

smoking or bacterial contamination

Avoid medications including: dextromethorphan,decongestants,

allergy meds, sinus meds, asthma inhalants, anti-appetite meds,

energy pills, amphetamine, methylphenidate, cocaine,

methyldopa, levodopa, l-tryptophan, l-tyrosine,phenyalanine,

alcohol, bupropion, guanethidine


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Managing Side effects

Sexual dysfunction- holidays, adjunctivemed

Nausea- take with food

Insomnia- take in morning, adjunct Hypersomnia- take at night

Agitation/ akathisia- discontinue, adjunct

Suicidality monitor closely, discontinue


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Serotonin related Syndromes

Serotonin Syndrome

life threateningemergency!

agitationtremor

confusionmuscle jerks

hyperthermiamuscle stiffness

SSRI Withdrawal Syndrome


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Augmentation

of patients dont respond first agent.1/5 dont benefit from a series of trials

Medication response-usually 67%.

Placebo response 33% If initial response to antidep will relapse

at only 10-20% if rx continued for 6-12

Within class switch Out of class switch

Other medications


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Cognitive Behavioral Therapy

At least as effective as antidepressants in reducingsymptoms

More effective than antidepressants in preventing relapseCognitive restructuringIdentify and challenge depressogenic assumption

Identify more adaptive coping mechanisms

Other Therapies- Supportive, IP, Psychodynamic

Psychosocial Intervention: Education Vocational training Case workers Exercise

Psychological


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Depression: AlternativeTreatments

StJohnswort

Dhea

Diet:

Carbohydra

tes, Pro

tein,Tryptophan

Vitamins- b12, b1, b2, b6, ?vitD,

Folate

SAM-E

Melatonin


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Other Therapies

Naturopathic

Hellerwork and Rolfing

Acupressure and Shiatsu

Auricular Therapy

Massage

Aromatherapy

Kinesiology

Reflexology

Spiritual Healing

Hypnosis

Autogenic Training

Bach Flowers

Acupuncture

Ayurveda


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Anxiety

The most prevalent psychiatric disorders

19 million Americans affected each year.

Estimated cost about 42 Billions $ annually

Prevalence 15% Phobia being the most common, 7%, followed

by GAD

Female out number male, but equal for OCD.

Normal anxiety

Pathological Anxiety

Fear


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Types

Phobias:SpecificSocial

Agoraphobia

GAD Panic Disorder OCDAcute stress disorder PTSDAnxiety disorder due to medical Condition Substance induced anxiety disorder

Anxiety disorder NOS


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Etiology Interplay between biological and psychosocial factors.

Biological: Neurotransmitters

Serotonergic

NE

GABA-Benzodiazepine receptors Psychological

Different school of thoughts

Psychoanalytic perspective:

Structural theory (ID, EGO, SUPEREGO)

Cognitive Theory- Focuses on cognitivedistortions which lead to depression andanxiety

Brain Changes


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Management

APA Guidelines recommend use of Medicationsand psychotherapy.

ECT is not affective for anxiety disorders even

though consider for resistantOCD prior tosurgery.

Goal is full sustained remission with improvefunctioning.

Treatment will depend on full response, partialresponse and resistance

SSRI are the first line treatments, Benzo aresecond line even though prescribed more than

antidepressant, BT can be first or second line.45


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Anxiety: Medications

SSRIs

SNRIs

Benzodiazepines Beta blockers

Other medications

Alternative treatments


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Anxiety: Other Medications

Buspirone (Buspar) Betablockers(Propranolol)

Tiagabine (Gabitril)-

Gabapentin: Clonidine

Mood Stabilizer

Antipsychotic

Cypraheptadine

Cytomel

Hydroxyzine


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Anxiety:Alternative Treatments

CBT:. Has the best track record for most phobicdisorders. The most effective and the most studied

Cognitive restructuring

Behavioral component:

A)Exposure therapy:

1) systemic desensitization-imaginal or in vivo; graded vun-graded 2)Flooding

B) Relaxation Technique

C) Role playing

D) Coping skill training

Herbal remedies: kava, valerian, chamomile

Yoga, breathing exercises


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Others

Supportive Psychotherapy

Insight oriented

Group

Family

Social skill training

Hypnosis: Therapist suggest phobic object

is not dangerous, also teaches selfhypnosis for relaxation in event of phobicobject is confronted

49


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Schizophrenia


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NATURAL HISTORY OFSCHIZOPHRENIA

1010 2020 3030 4040 5050

FunctionFunction

Age (y)Age (y)

ProdromalProdromal

ProgressionProgression

PremorbidPremorbid

Stable RelapsingStable Relapsing


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Positive Symptoms

Hallucinations

Delusions

Disorganized Thought

Catatonia

Negative Symptoms

Affective Blunting

Alogia

Avolition

Anhedonia

Cognition

New Learning

Memory

Mood Symptoms

Insight

Demoralization

Suicide

Components Of Psychotic

Disorders

FUNCTION


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Imaging

Schizophrenic brain Normal brain

Ventricles


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Mesolimbic PathwayMesocortical PathwayNigrostriatal Pathway

Tuberoinfundibular Pathway

Brain Pathways

T t t f P h ti Di d


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Treatment of Psychotic Disorders.

Atypical Antipsychotics Risperdal

Zyprexa

Seroquel

Geodon, Invega-Extended release risperdal

Risperdal Consta

Clozapine

Typical antipsychotics- Haldol, Prolixin etc Injectables- Haldol, Prolixin, Risperdal consta

IM formulations


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Side effects

Dopamine Blockade:

NMS

EPS

TD

Histamine blockade

Acetylcholine blockadeAlpha1 blockade


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Atypical Antipsychotics

Clozap

ine (C

lozar

il)

Risperidone (Risperdal)

Olanzapine (Zyprexa)

Quetiap

ine (Seroque

l)

Ziprasidone (Geodon)

Aripiprazole (Abilify)

Paliperidone (Invega) Asenaprine (Saphris)

Iloperidone (Fanapt)

Luras

idone

HCL(La

tuda)


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Atypical Antipsychotics-Mechanisms

antagonize D2receptors

antagon

ize

5ht2arecep

tors

.

bindlooserthanthe typicalsanddissociate

more quickly


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Atypicals

Mechanism of actionAtypical: Side Effects

Weight gain, diabetes:ck BoxWarning

clozaril, olanzapine>>>risperidone,quetiapine>>

ziprasidone, aripiprazole (+/-)

HigherriskofTDwithconventionalthan

cardiometabolicriskwithatypical


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Metabolic Syndrome

Waist circumference: Men>102 cm (>40 in)

Women>88 cm (>35 in)

Triglycerides >150 mg/dL HDL cholesterol:

Men


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Mania

(bipolar disorder)


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What is Bipolar Disorder ?

It is a spectrum ofaffective episodesincluding:

Major depressiveepisode

Manic episode

Mixed episode

Rapid cycling

Hypomanic episode

The DSM-IVcategorizes it into:

Bipolar I Disorder

Bipolar II Disorder

Cyclothymia

Bipolar N.O.S.


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Summary of DSM-IV-TR

Classification of Bipolar Disorders

* Symptoms do not meet criteria for manic and depressive episodes.

Bipolar featuresthat do not meetcriteria for anyspecific bipolardisorders

At least 2 yearsof numerousperiods ofhypomanic anddepressivesymptoms*

One or moremajordepressiveepisodesaccompaniedby at least one

hypomanicepisode

One or moremanic or mixedepisodes,usuallyaccompanied bymajor depressive

episodes

Bipolar DisorderNot Otherwise

SpecifiedCyclothymicBipolar IIBipolar I

First, ed. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text Rev.

Washington, DC: American Psychiatric Association; 2000:345-428.


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Bipolar I Disorder

MajorDepressive

Episode

Manicor MixedEpisode

Manic

or MixedEpisode

One or moremanic episode

OR Depressed andmanic episodes

OR


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Bipolar II Disorder

Major

DepressiveEpisode

Hypomanic

EpisodeHypomanic

Episode

One or morehypomanic episode

OR Depressed andhypomanic episodes

OR


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Mood Episodes

Depression

Mania

Hypomania

Mixed Episode

Normal Mood


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Unipolar vs. Bipolar

Disorder

Bipolar

Unipolar

ElevatedMood

ElevatedMood

DepressedMood

DepressedMood


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Treatment Overview

Diagnostic evaluation

Safety

Referral to psychiatrist

Establish & maintain a strong alliance

Educate

Relapse Prevention

Family involvement Maintenance


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Indicators of TreatmentOutcome

1. Suicidality

2. Presence of a personality disorder

3. Quality of family and social support

4. Substance use5. History of severity of prior episodes

6. Bipolar I type is most severe

7. Treatment onset-the sooner the better

8. Age of onset-the younger the more severe


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Treatment

List of Prognostic Factors

Education and Support

Medication

1. Mood stablizers

2. Atypical antipsychotics

3. Anti-anxiety

4. ECT5. Others


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Course

Acute Episode

Manic - 5 weeks

Depressed - 9 weeks

Mixed - 14 weeks

Long Term

Variable - most cover fully

Mean number of lifetime episodes 8-9

M d St bili


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Mood Stabilizers

Lithium

Anticonvulsants

valproic Acid [Depakote]

carbamazepine [Tegretol]

New Anticonvulsants (?): lamotrigine [Lamictal]

topiramate [Topamax]

gabapentin [Neurontin]

Oxcarbamazepine [Trileptal]

Antipsychotics

Classic (Haloperidol)

Novel (clozapine, olanzapine, aripiperazole, queiepine)


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Lithium

Mechanism of Action

Molecular Biology

Indications

Predictors of good response Predictors of poor response

Side effects

Interactions

Toxicity Workup


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Valproic Acid (Depakote)

More effective than lithium for rapidcycling and

mixed episodes.

Can be used in combination with lithium.

Worup

Dosage

Monitoring

SE


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Others

Lamictal

Topimirate

Gabapentin Tiagabine

Novel Antipsychotics

Others

G l M i i


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General Monitoring

Check levels of lithium, valproate,

carbamazepine at least 1-2 times per year

Check for weight gain, metabolicabnormalities (atypicals)

Risk of Flipping to mania


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MRI (T1-weighted) images of a 58-year-old healthy control patient (left)as compared with a patient of comparable age with bipolar disorder(right)but without any significant medical or substance abuse history.

Although not diagnostic, common findings in neuroimaging researchstudies withbipolar disorder patients include diffuse gray matter loss, enlargement

of the ventricles, and mild prefrontal volume loss.


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ADHD

ADHD


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ADHD


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ETIOLOGY

What is ADHD

Types

No single etiology has been identified for ADHD. Psychosocial stressor

Environmental factors

Neuro-chemical

Neuro-anatomical factors

Familial and genetic factors

ADHD is best viewed as a final common pathway for a

variety of brain developmental processes.


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How ADHD symptoms evolve?

Children Motor HyperactivityAggressiveness

Low Frustration Tolerance

Impulsiveness

Easy to Distract

Inattentiveness

Shifting Of Activities

Easy to Bore

Impatience

Adults Restlessness

Distractibility


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Co- Morbidity


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Co Morbidity


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MEDICATIONS


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MEDICATIONS.

Used 40+ yrs; 350+ studies;thousands of cases

Stimulants (Response rates 75-80%)

Trying all stimulants - 90%+ responserate

Whats new?

Extended release delivery systems

MEDICATIONS


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MEDICATIONS

Most well-studied drugs in psychiatry

Stimulants

Methylphenidate:

Ritalin, Concerta,

Focalin, Medadate CD, Daytrana

Amphetamine:

Dexedrine, Adderall,

Vyvanse

Atomoxetine (Strattera)

Other Nor epinephrine Reuptake Inhibitors(Bupropion) Effexor

Anti-Hypertensives Guanfacine and Clonidine

STIMULANT Side Effects


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STIMULANT Side Effects

Largely benign;


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STIMULANTs Contd.

Behavior Benefits

Stimulants in preschoolers

Stimulants: Common MythsManaging side effects

Nonstimulants


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Nonstimulants

Modafinil:

(Provigil)approved

for narco

lepsy,shift work, OSA.Acts viahistamine, dopamine

Atomoxetine: (Strattera)norepinephrinereuptake inhibitor

Bupropion:norepinephrine anddopamine *Benefits- not schedule 2, refills ok

Adrenergic Agonists

norepinephr

ine

:med

iates

inattent

ive andhyperactive/ impulsive symptoms

Clonidine- Catapresalpha2agonist

Guanfacine-Tenex more selective alpha2

agonist


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Non pharmacologic therapies

Environmental modifications- Identify and minimize or

avoid distractions

- shop in smaller stores- avoid working in cubicles- Practice organization by

assigning specific

Storage spaces for bills,keys etc. Helpful external aids Herbal medications etc


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Substance Abuse


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Substance Abuse

Abuse-

Addiction

Dependence Tolerance

Neurochemisty

Cravings

Dependence


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Dependence

Probability of becoming dependent aftertrying substance once:

nicotine 32%

heroin 23%

cocaine 17%

alcohol 15%

stimulants 11%

cannabis 9%


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Alcohol Intoxication:


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Alcohol Intoxication:

initially blocks glutamate at NMDAreceptors causing

social disinhibition

more alcohol enhances action of GABAcausing

slurring and incoordination

Alcohol Dependence


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Alcohol Dependence

Mechanism

Treatment

NaltrxeoneAcomprosate

Disulfiram

TopamaxOthers

Alcohol Withdrawal


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Alcohol Withdrawal

Definition

Mechanism

SymptomsTreatment

Alcohol seizures

Delirium tremens


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What is a Standard Drink ?


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What is a Standard Drink ?

Opiates Intoxication:


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Opiates Intoxication:

DSM criteria

Symptoms

Clinical presentationRisk

Management

Dependence Treatment:


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Dependence Treatment:

Methadone- opiate receptor agonist

increases opiate level inbrainslowly sodoesntproduce high.

Covers receptors topreventhigh if use

heroin. Buprenorphine- Buprenex, Subutex,

Buprenorphine/ naloxone- Suboxone

opioid receptor agonist- antagonist,decreases cravings, blocks high

Restrictedaccess inUS

Opiate Withdrawal


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Opiate Withdrawal

Mechanism

Symptoms

Management Methadone

Suboxone

Clonidine Benzos

Cocaine


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Cocaine

History Pharmacology/neurobiology

Pychopharmacology

Intoxication Initial symptoms

High dose effects

Overdose Psychiatric manifestations

Management

I t i ti


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Intoxication

Inhalation (7 s onset, 1-5 min peak, 20min duration, 40-60 min half-life)

IV (15 s onset, 3-5 min peak, 20-30 minduration, 40-60 min half-life)

Nasal (3 min onset, 15 min peak, 45-90min duration, 60-90 min half-life)

Oral (10 min onset, 60 min peak, 60 minduration, 60-90 min half-life)


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Smoke > IV > IM sniff >

Withd l


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Withdrawal

Classic physical withdrawal symptoms donot occur

Symptoms often seen after binge periodsinclude: Intense unpleasant feelings ofmarked anergia, dysphoria, irritability,impulsivity and depression - generally requiringseveral days of rest and recuperation

Management

Hallucinogens


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Hallucinogens

Lsd,mescaline,psilocybin,MDMA(ecstasy)

agonistsat5 htsynapseswithin rewardsystem

Tolerance toeuphoriceffectsmaybe dueto

lossof

serotonergicneurons

Other Substances


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Other Substances

GHB- agonist atGHBand GABA-Areceptors

Cannabis- hits endogenous cannabanoidreceptors to trigger dopamine release in n.accumbens

PCPand ketamine: antagonists at NMDAAmphetamines


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Insomnia


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Insomnia___________________________ Insomnia includes difficulty falling asleep, difficulty

staying asleep, and early morning awakening

Insomnia is not defined by the number of hours of

sleep, but rather, by an individuals ability to sleep

long enough to feel healthy and alert during the day.

The normal requirement for sleep ranges between 4

and 10 hours

Insomnia is a symptom, not a disorder by itself


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W k S t


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Wake System

___________________________

Sl S t


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Sleep System

___________________________

119

Sl W k C l


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Sleep Wake Cycle

___________________________

120

Changes in sleep with age


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Changes in sleep with age___________________________

Stages of sleep


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g p______________________

1. NREM Sleep

A. Stage 1

B. Stage 2C. Stage 3

D. Stage 4

2. REM Sleep

Sleep Stages


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Sleep Stages___________________________

REM Sleep

~20% of night

NREM Sleep

~80% of night

Wake

2/3 of life

Causes of insomnia


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Causes of insomnia

Drugs

Psychiatric disorders

Medical disorders

Poor sleep habits Shift work

Other sleep disorders

Circadian rhythm disorders

Restless legs syndrome Periodic limb movement disorder

Sleep apnea

M di ti d i i


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Medications and insomnia

___________________________Type of medication Example

Blood pressure drugs - blockers, - blockers

Decongestants Phenylephine, Pseudoephedrine

Other substances Alcohol, Nicotine, Caffeine

Management of insomnia


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Management of insomnia

___________________________

Good history

Review medications

Treat underlying Medical Condition

Treat underlying Psychiatric Condition

Improve sleep hygiene

Non-Benzo receptor agonists


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Non-Benzo receptor agonists

Zolpidem

Zolpidem CR

Zeleplon

Eszopiclone

Benzodiazepine receptor


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agonists

LorazepamClonezepam

DiazepamFlurazepamQuazepamAlprazolam

TriazolamEstazolam

Benzodiazepines


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Benzodiazepines

MechanismUse

AbuseSide effectsToxicity

Other classes of medications


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Other classes of medications

AntidepressantsTrazadone

Mirtazapine

Doxepin

Amitryptyline

Antipsychotics

Olanzapine

Quitiepine

Melatonin Receptor Agonists

Melatonin

Ramelteon

MiscellaneousValerian

Diphenhydramine

Cyclobenzaprine

Hydroxyzine

Alcohol

Barbiturates


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Barbiturates

____________________________Drug Duration of action Half-life

Phenobarbital Long 24 140 hrs.

Butabarbital Intermediate 34 42 hrs.

Amobarbital Short-intermediate 8 42 hrs.

Pentobarbital Short-intermediate 15 48 hrs.

Secobarbital Short-intermediate 19 34 hrs.


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Female Patients


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PMS

PMDD

Medications in Pregnancy Baby blues

Post Partum Depression

Menopause


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PMDD


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Prevalence- 3-5%

5 or more symptoms:

depression anxiety

Lability, irritability

loss of interest difficulty concentrating

lethargy appetite changes

sleep disturbance feeling out of

control

breast pain headaches

Treatment- fluoxetine (Sarafem)

Pregnancy


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Risk of not treating Depression: Risk of antidepressant

Treatment guidelines in pregnancy

SSRis and pregnancy Mao and pregnancy

TCA and pregnancy

Mood stabilizers in pregnancyAntipsychotics' in pregnancy

Ant-anxiety medications in pregnancy


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Postpartum Depression


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Postpartum Depression

Diagnostic criteria are similar to MDD

Symptomatology: at least 2 weeks

Impaired functioning in important areas

Presence of prominent anxiety symptoms Intrusive thoughts

Feelings of guilt and inadequacy about

mothering Prevalence of PPD is about 13%

Postpartum Psychosis


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p y

Occur in 1-2 women per1000 following delivery ofa child

Constant across culturesOnset within 2 weeks

Marked cognitive

disturbance & Unusualpsychotic symptoms .

Most postpartumpsychosis meet criteriafor mood disordersparticularly bipolar

disordersRisk of PPP

bipolar disordersdepressed type/manictupe

Primiparous women

Postpartum psychosis

Treatment


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Treatment

Aggressively treated with in hospitalsetting

Do not wait while the general medical

workup is underway

Antipsychotics which are more potent andless sedating agents are preferable

Mood stabilizers should be startedimmediately along with antipsychotics

Atypical antipsychotics

Recommendations for treatment of


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during pregnancy

Have them enroll in pregnancy registry

Reduce incidence of neural tube defectsby-Folic acid 4mg/d,monotherapy if

possible, lowest possible dose

Alpha feto protein screen

Ultrasound at 16-20 WKS

Treat depending on severity

Breast feeding

Pharmacological Rx


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P a aco og ca

SSRI

Considered first line Rx forPPD

Sertraline and paroxetineare least detectable innursing infants

Flouxetine may predisposeto accumulation

One report on celexashowed uneasy sleep ininfant

TCAs

Reasonable option fortreatment

Nortriptyline is the leastdetected in breast milkand nursing infants

Doxepin notrecommended

TCAs are not the primarychoice because ofanticholinergic side effectsand toxicity in overdose

Peri/ Menopause


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Fluctuations of estrogen can dysregulateneurotransmitter

projections to hypothal -> vasomotor

symptoms. Depression in 10%

H/o depression increases risk of

depression during menopause (4-9x). If hot flashes, depression 5x more likely

Hormonal Rx


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Hormonal Rx

Data is limited

Sublingual estrogen Rx,

Large doses of progesterone insuppository and oral micronized formsmay be effective but studies have alsoshown that administration of long acting

progesterone 48 hrs after deliveryincreased risk of ppd

Menopause


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The menopause syndrome Irritability, headaches, depression, anxiety, problems of

memory and concentration, loss of libido

Vasomotor symptoms Irregular menstruation accompanied by hot flashes

Hot flashes are felt as rising sensation of heat in the chest, neckand face

Rise in peripheral blood flow and heart rate

Mood Disturbances in Menopause Hormonal changes

Could be secondary to hot flash induced sleep problems

Psychosocial and cultural factors

Treatment


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Symptoms diary

Analysis of TSH

Vitamin supplements & Spironolactone

25mg 50mg daily NSAIDS

Caffeine avoidance

Oral Contraceptives SSRI, TCAs

Treatment


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Alternative therapy

Phytoestrogens

Ginseng

Dong quai

Black cohostChaste tree berry

Vallerian root

Exercise therapyRelaxation therapy

Harmone

EstrogenProgestins

Androgens

Selective estrogen

receptor modulatorsAnitdepressant

moderate or severesymptoms of

depressionConcurrentaugmentation withestrogen may beindicated

Suicide & Clinical Practice


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In any given year:

40,000 psychiatrists in USA

30,000 suicides

10,000 psychiatric care

1500 inpatient 8500 outpatient

Therefore, hypothetically:

Every 4 years one suicide psychiatrists career, 4-8 suicides.

World Data


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Why people kill themselves?

Suicide is a major public health concern worldwide

15-24 year and > 65 years

4 males:1 females

1 million suicide deaths this year

16/100,000 suicide rate 1 suicide every 40 seconds

US- 8th leading cause of death in the US

12/100,000 suicide rate

Translates to 30,000 deaths per year by suicide

81 suicides per day

15 - 24 year olds, suicide is 3rd leading cause of death (afteraccidents and homicides

Risk Factors for Suicide

SADPERSONS Scale


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SADPERSONS Scale

Sex (Male)Age (very young or very old)

Depression

Previous attempt

Ethanol abuse

Rational thinking loss (psychosis)

Social supports lacking

Organized plan No spouse

Sickness (chronic illness)

Suicidal Behavior/ Gestures


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151

Summary


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y

Cocaine Intoxication Dopamine reuptake inhibition

Psychiatric and medical complications

Cocaine Withdrawal Depression with suicidal ideations

Management Supportive stable environment

Etiology


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Biochemical FactorsGenetics and Family variables

Psychiatric diagnosis

Personality traits and disorders

Psychosocial and environmental

factorsChronic medical illness

NeurobiologyPersonality Disorders/Traits

Psychiatric IllnessCo-morbidity


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Severe Medical Illness

Access to Weapons

Life Stressors

Family History

Impulsiveness

Hopelessness

Psychodynamics

Substance Abuse

Suicidal Behavior

Suicide

Psychiatric Illness and SuicideContd


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Contd.

MDD

Bipolar Disorder

Schizophrenia

Alcohol Dependence Borderline PD

Antisocial PD

15% commit suicide

10 - 15%

10%

2% 4 - 9%

5%

Suicide Attempters


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Female Younger

Depression, Alcoholism, Personality D/O

Impulsive Low lethality (overdose)

High availability of help

Suicide Completers


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Male, Older

Depression, Alcoholism, Schizophrenia

Careful planning

High lethality (firearms)

Low availability of help, socially isolated 30% have history of suicide attempts

Approximately 1 in 6 completers leave asuicide note

50% of people who commit suicide have beenseen by a primary care MD

with older suicide victims, this rises to 70%

Outpatient Management


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Sole focus on treatment = safety Be alert to sudden changes in behavior

Consistently involve significant others

Consider day-treatment or other isolation-

reducing activities Document, document, document

National suicidal prevention lifeline1-800-273-talk

Crisis management


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Record-keeping


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Keeping good records is a must.

Never alter a record.

Include discussions with managed-care company

Think out loud about whether to appeal. Get records of past treatment, especially

hospitalizations.

Maintain records per legal requirements (nature

and duration).

Cytochrome P-450


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Liver enzymes metabolize mostmedications

Interactions occur when added other

medication with same pathway. Inducers

Inhibitors

Enzymatic activity affected by genetics

Children


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Many medications not sufficiently studiedin children

Atypical symptoms

Collateral information Careful monitoring required for SSRIs

Black box warning

Risk of Suicide on antidepressantsApproved medications for kids

Elderly


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Start low, go slow

Ultimately require same dose

Decreased metabolism can be dangerous

Often have other medical problems, druginteractions

Depression in elderly

Black box warning Suicide risk assessment

Invasive Treatments


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ECTVNS

TMS

DBS

Future modalities

Electroconvulsive Therapy(ECT)


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History of ECT

How doe sit work

Indications of ECT

Modern ECT

Risks of ECT

SE of ECT

TMS


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How TMS works

Unique experimental design issues

Capabilities and established results Comparison to other techniques

Therapeutic applications

Potential future work


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VNS


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What is VNS

Mechanism of action

Pros Cons

Cost

Indications


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DBS


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History

Interventions

Mechanism

Indications

Advantages and disadvantages

SE

Future Medications


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h k


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Thank You

Documents

Pychopharm Final 426