Psychopharmacology: What You Need To Know About Psychiatric ...
Psychopharmacology: 2019 Medication Management Trends Social Workers Should Know Joe Wegmann, PD, LCSW [email protected] 504.587.9798 www.pharmatherapist.com Are you receiving our free monthly enewsletter? On Tap Review the mental disorders for which psychotropic medications are frequently prescribed Discuss the major psychotropic medication
classes, their clinical indications and the latest trends regarding their use Examine the benefits, risks and side effects of contemporary psychotropics My Approach For All Clients I Treat Help them develop pragmatic skills Understand how to solve problems and the importance of cause The process of motivation Help them overcome an imposter mentality Everyone I see has some sort of a self-esteem or image problem which is at the core of why they came to see me but they dont realize it and dont know what it is Theres a difference between efficacy and self-worth Help them develop a sense of personal autonomy Need for approval Unsolicited feedback Improving in these areas can help clients better overcome unnecessary mood, anxiety and concentration problems that plague them and have them turning
to medications for relief I can help clients better deal with emotional and psychological pain, but if someone is determined to suffer, I cant do much about that Unipolar Depression Etiology Depression is very confusing and there is no general consensus as to whats going on or even whats wrong with the brain Where, in the brain, would we biopsy a depressed person? What specific area? Nobody knows Its cyclical short-term duration for some, extended
for others Depression is likely a number of different illnesses in the future, different nomenclature for different types of depression The more intimate the relationship with the depression, and the greater the gains, the more difficult it will be to give up Assess motivation to get better and Consider context dont depend on checklists, just
let the client tell their story For treatment purposes, focus more on potential Possible Causes Inflammatory Reactive Biological
Medical Medication induced Hormonal Substance abuse Chronic pain
Low selfesteem; poor self-image Classes of Antidepressants First came the Opiates Cyclics: Elavil; Pamelor; Anafranil; Desyrel (trazodone) SSRIs: Prozac Family SNRIs: Effexor; Cymbalta; Pristiq; Fetzima
Atypicals: Wellbutrin; Remeron Work primarily through reuptake inhibition or do they? Approved: MDD; OCD; GAD; PTSD; SAD; Chronic Pain (Cymbalta) None of the above are magic bullets and yet are routinely perceived as an easy way to feel better Antidepressant Selection Particularly For The First-Timer How
the depression presents. Accompanying anxiety and insomnia (high distress factor); Melancholia, hypersomnia, vegetative (low drive factor) Prior history. Use biomarkers to the clients advantage Co-occurring disorders. SSRIs are effective for almost the entire anxiety spectrum. Effexor for pain; Wellbutrin for ADHD Side effects. Most side effects are transient and will abate quickly. Two exceptions: weight gain and sexual problems. Duration. Guideline for an initial trial: 4-6 weeks; some users may respond in 8-10 weeks Dosing. Begin with 1/2 of the minimum recommended effective dose (e.g. Prozac 10mg) then if tolerated, increase to 20mg after a week - then another bump in 3 weeks, if warranted Hottest New Players
Ketamine Infusion Therapy Ketamine is classified as a preoperative general anesthetic for both human and animal use No serotonin, norepinephrine or dopamine effects but instead is an NMDA receptor antagonist, similar to dextromethorphan and methadone If you remember the days of the rave phenomenon, ketamine was a popular psychedelic going by the moniker special K Touted as possessing rather fast-acting antidepressant properties, with many clinicians, predominately psychiatrists, offering ketamine infusion therapy as a alternative for treatment-resistant depression, particularly for those with suicidal tendencies Because ketamine is not FDA approved for depression and is therefore considered an off-label procedure, free market forces enter the picture. Upfront fees can run up to $500 per infusion. Side effects: Possible acute hypertensive crisis; free-floating, hallucinatory sensations So is it possible that dissociation is either a predictor or even possibly responsible for its antidepressant effect? What then? Will the goal be
to induce a psychedelic experience to maximize ketamines benefits? Spravato (esketamine) On March 5, 2019, the FDA approved Spravato (esketamine) nasal spray as additive treatment with antidepressants for treatment-resistant depression Overall response rates after a month of treatment were much higher for esketamine plus an antidepressant, when compared to placebo plus an antidepressant. Also in a long-term maintenance trial, the midpoint time to relapse in stable responders to the esketamine-antidepressant combination was a whopping 635 days Providers of this agent must sign up with the REMS (Risk Evaluation and Mitigation Strategy) system, and the Drug Enforcement Administration (DEA) performs an inspection of a providers office. A provider is mandated to supervise a patient while the intranasal dose is selfadministered, and the supervision must be ongoing for at least 2 hours afterward to monitor for side effects Esketamine is the first, really new and original antidepressant to reach the U.S. market in over 30 years $600 for each 56mg dose and nearly $900 for each 84mg dose
Side effects: Bitter aftertaste; elevated BP; dissociation There is an URGENT need for something new for those suffering from depression particularly treatment-resistant depression Whats next? How about opioids for depression? Side Effects SSRIs and SNRIs Increased anxiety or an activated feeling Sedation Insomnia
Sexual Dysfunction Weight gain (Avg: 4 pounds over six months) Wellbutrin Prominent for anxiety and insomnia Little, if any weight gain No sexual side effects Remeron
Weight gain can be a monster Issues And Controversies Serotonin levels are elevated rapidly by these drugs in daysnot weeks the reuptake inhibition theory for improving depressive symptoms is all but dead Alternative explanation for how antidepressants work: Antidepressants stimulate your nerve cells to grow and branch out, sort of like what fertilizer does for your lawn Neuroprotective benefits Up to 60 percent of antidepressant users dont achieve symptom remission, benefiting only partially Conclusion: Antidepressants on average have modest/small efficacy, although they do outperform placebo Pick one from the list approach little thought given to how each patients many variables are often not
addressed prior to selection Bipolar Disorder Overview Runaway norepinephrine and neurons gone wild Bipolar depressive symptoms far more prevalent than manic symptoms Except for lithium, most treatments for bipolar symptoms were not developed as anti-polar therapies (anticonvulsants; atypical
antipsychotics) Major limitation to novel drug discovery: No consensus on neuropathology Bipolar Mania There is increased emphasis on energy and activity in diagnosing mania, not simply mood Mania is characterized by:
Distractibility Insomnia Grandiosity Flight of ideas Appetite for risk Speech (pressured) Thoughtlessness (risk-taking) Bipolar Depression: Does It Differ From Unipolar Yes, but only a little Depression? Bipolar depressive episodes occur earlier in life and more frequently
Involves more psychomotor slowing Both unipolar and bipolar depression appear essentially the same on functional brain imaging When seeing a depressed patient for the first time, obtain personal AND family history of potential mania; a positive family history of mania is suggestive of bipolarity Mood Stabilizers
Lithium Anticonvulsants: Depakote, Equetro Most second generation antipsychotics are FDA approved for mania Seroquel, Seroquel XR, Symbyax and Latuda are FDA-approved for bipolar depression Traditional antidepressants offer very little for bipolar depression Lithium
Fight/Flight Deactivator Onset of action 5-14 days, its slow Full stabilization up to 3 months Requires blood level monitoring There in NO evidence that lithium raises suicide risk; there is strong evidence that it lowers it Recommended Lithium Monitoring Initiation of treatment Routine Every 3 to 7 days for first several weeks Every 1 to 3 months in stable patient Side Effects of Lithium Most Common
Most Severe Thirst Kidney dysfunction Excessive urination Confusion Weight gain Hypothyroidism Nausea, vomiting, diarrhea Tremor Aggravation of acne in adolescents Depakote
First-line agent for mania, not as effective as lithium Agent of choice for rapid cyclers Lithium ineffective for rapid cycling Treats rage reactions and extreme mood instability Side effects: Fatigue, nausea, weight gain, teratogenic birth defects, PCOS Lamictal Primarily for bipolar depression Works best at reducing the risk of future bipolar depressive episodes in other words, maintenance treatment for bipolar depression
No weight gain; no blood work Stevens-Johnson syndrome Case Example Sally called me regarding her 25-year-old son. Michael (the son), had been prescribed the following: Celexa, Lexapro, Effexor, Pristiq, Cymbalta, and recently, Trintellix. When Michael failed to respond to any one of these antidepressants, it was discontinued and another was prescribed. These were prescribed by a general practice physician over the last couple of years. She stated that Michael showed sparks of improvement vis--vis these medications which eventually
slowed and has now ceased. He has quit graduate school and exhibits depression. Her question for me: Joe, what would you suggest as a next step, really, how should I proceed? Anxiety Generalized Anxiety Chronic low-level anxiety Resolved worries are quickly replaced with new ones, consuming excessive amounts of time These are people who: worry all the time; worry about what they worry about; worry if theyre not worrying Were all often very competent at handling real, identifiable problemsbecause An unambiguous problem invites an unambiguous solution, so
A clear plan of action settles the anxious mind Worriers have trouble distinguishing what is a problem from what might be a problem Medication will numb symptoms only Obsessive-Compulsive Disorder We all have eccentricities, oddities, habits OCD is quite the con artist A disorder of excessive carefulness accompanied by an exaggeration of possible danger
Persistent thoughts and compulsions accompanied by shame and guilt Often incapacitating Having treated it for years, its amazing how many different manifestations present to my office OCD is no longer DSM-classified as an anxiety disorder Antianxiety Agents
Benzodiazepines Generic Name Brand Name Diazepam Valium Chlordiazepoxide Librium Flurazepam Dalmane Clorazepate Tranxene
Clonazapam Klonopin Temazepam Restoril Lorazepam Ativan Alprazolam Xanax Triazolam Halcion Benzodiazepines: After 60 Years,
Are They Still Viable? Benzos are still widely used, but sparsely studied, primarily as a result of their age Benzos are very addictive right? This is a common concern among patients, therapists and prescribers alike The vast majority of those abusing benzos are also abusing other substances like opioids at the same time, as a way to enhance the opioid high The number of people actually abusing benzos alone
is rather small All benzos enhance the actions of the neurotransmitter GABA which has direct anti-anxiety effects Quick rule of thumb: The faster they work, the quicker they wear off; the slower they work, the longer they last Benzos For Specific Anxiety Disorders Panic Disorder: The best choices here are Xanax or clonazepam wafers because of rapid onset. Ive found that for many people, just knowing they have these agents on hand and readily available on a moments notice, can go a long way to minimize attacks
Social Anxiety Disorder: For someone with SAD, taking a benzo 30-60 minutes before an anxiety-triggering event can be beneficial. (Delivering a talk; relaxing on a date; making new acquaintances) Insomnia: Not an anxiety disorder, but in some instances where the insomnia is related to an acute, time-limited stressor (tight work deadline; coping with a sudden loss) benzos are the best choice. Valium is often ideal because of its rapid onset and longacting effects Side Effects of the Benzodiazepines Side effects are generally minimal Little, next-day lethargy or grogginess Enhanced disinhibition with alcohol or
opioids for sure The Psychotic Spectrum: Schizophrenia Second Generation Agents Reduced risk of tardive dyskinesia; overall better tolerability Clozaril is the prototypical agent Abilify Risperdal Rexulti Zyprexa Invega Seroquel Saphris
Vraylar Latuda Fanapt Geodon Clozaril (clozapine) Not a first-line treatment of choice FDA approval for treatment of recurrent suicidal behavior in schizophrenics
Can cause neutropenia (increased risk of opportunistic infection) ANC count monitoring necessary weekly for 6 months, every 2 weeks for 6 months, then monthly Significant weight gain and sedating
Linked to increased risk of Type II diabetes Potential for increasing triglycerides and cholesterol Constipation ADHD ADHD is definitivelya neurodevelopmental disorder
with onset in mid-childhood through early adolescenceperiod Those with ADHD have racecar brains with bicycle brakes CDC: Nearly 20 % of high school age boys in the U.S. and 11% of school-age children have received a diagnosis of ADHD; 53% rise in diagnosis in those 417 this past decade alone Some diagnosticians are hastily viewing any complaints of inattention as ADHD so the diagnosis is poorly established
Parents pressure doctors for pills, instead of challenging and questioning this diagnosis Once started on pills as a child, the now high school Adult ADHD If you have a never-before-diagnosed adult claiming ADHD, probably 95 percent of them have something else People may be feigning symptoms in order to obtain a prescription, but many others are going online searching for a confirmation of ADHD Symptoms must be present before age 12; there is no such thing as new-onset ADHD beyond this age, so the individual either wasnt diagnosed or was diagnosed and decided to fight their way through symptoms
Adults who really have it report significant impairment difficulty driving, job firings, lost relationships, poor credit rating upon questioning If someone has gone say 30-40 years with ADHD, theres going to be a paper trail of impairment, right? Doing It Right Before doing an adult ADHD assessment, keep in mind that most symptoms are nonspecific and can be present in many other psychiatric disorders or even present in people without any disorder at all Note: Positive answers to questions asked cant confirm the diagnosis, but they can provide clues that may prompt
a suspicion of ADHD When an adult patient comes to my office with ADHD-like complaints, the 1st thing I do is assess their motivation Medication How Stimulant Medications Work; Types Of Stimulants The most widely prescribed class of medications for ADHD symptoms is the Psychostimulants Psychostimulants activate the chemicals dopamine and norepinephrine in the frontal and wake up the brain
Norepinephrine improves attention and focus; dopamine improves and lengthens attention span, lessens distractibility and helps decrease impulsivity and excessive movement Two types of stimulants are routinely prescribed in the U.S. The Ritalin (methlyphenidate) products (MPH) The Dexedrine (amphetamine) products (AMP)
The delivery systems: Pills; Pump; Pellets; Patch; Pro-drug The 5 Ps (Psychostimulants) The Pills: Ritalin; Focalin; Adderall The Pump: Concerta The Pellets: Ritalin LA; Focalin XR; Adderall XR The Patch: Daytrana The Pro-Drug Vyvanse The Newest Mydayis (amphetamine) Most of new long-acting versions of Adderall offer little advantages over the original Adderall XR outside of an easierto-swallow delivery Mydayis is an exception
16-hour duration offering a unique advantage for patients whose day is longer than the 12 hours of coverage provided by other extended-release formulations Aptensio XR (methylphenidate) Onset is 2-3 times faster than Concerta with a similar duration Jornay PM ( methylphenidate) To be taken at night, starts working upon awakening 8-10 hours later Aptensio XR and Jornay PM were developed to ease the early morning process when kids are getting ready for school as they are quick to act Psychostimulant Side Effects Appetite suppression in the beginning, but not persistent Insomnia can occur, but usually not a significant issue (sleep improves due to less bedtime rumination) or because of decreased blood
levels of the drug Irritability, particularly with amphetamines Dry mouth The Highest Aim For Psychotropics Is To improve functioning not feelings. Resources Adapted from : Wegmann, J. (2015). Psychopharmacology: Straight Talk on Mental Health Medications. 3rd Edition. Eau Claire, WI: Premier
Publishing & Media Thanks for Attending! Joe Wegmann, PD, LCSW
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