Practical Psychopharmacology Hunter Hansen, PsyD, MSCP Certificate in Integrated Primary Care Fairleigh Dickinson University

Goal Examine Psychopharmacology in Primary Care: Ethics & Evidence

Objectives Review Ethical Considerations Psychopharmacology 101 Examine Evidence Based Approaches to Medication Co- management: A. Depression B. Anxiety C. Bipolar disorder D. ADHD E. Dementia F. Schizophrenia

Ethics State Laws/Scope of Practice Competency Consult

Psychopharmacology 101 Overview Terms Medication Classes

Overview Primary Care- The de facto mental health system, prescribes 3/4 of all psychotropic prescriptions1. Historically, not equipped with mental health specialty training. Common Problems Misdiagnosis -> Inappropriate Tx Discomfort Underdosing Poor Education

Overview Primary Care- The de facto mental health system, prescribes 3/4 of all psychotropic prescriptions. Historically, not equipped with mental health specialty training. Common Problems Misdiagnosis -> Inappropriate Tx Discomfort Underdosing Poor Education Underutilization of Combined Treatment Drug Interactions Family History Anecdotal Pharma Influence

Terms Psychopharmacology- psychotropics targeting CNS, affecting multiple systems. Rx for other med probs can affect CNS as well (Adverse Reactions) Pharmacodynamics Pharmacokenetics Half Life Adverse Reactions (Side Effects) Other Terms

Pharmacodynamics mechanisms of action- how they work for many psychotropic meds, they target receptors (blocking, activating) or blocking the recycling or destruction of neurotransmitters

Pharmacokinetics Absorption · Bioavailability · Distribution · Excretion · Metabolism

Metabolism Drugs have to be excreted from the body, and many have to be broken down to do so. Mainly done by the liver (enzymes) and kidneys. converted Kidney activate Liver deactivate Fig leaf for modesty

methylphenidate (Ritalin) Half Life The period of time necessary for one half of a substance introduced to a living system or ecosystem to be eliminated or disintegrated by natural processes. www.seagrant.umn.edu It takes 6 half live for a drug to be eliminated. Examples: fluoxetine (Prozac) methylphenidate (Ritalin) alprazolam (Xanax) 4-6 days 2-3 hours 11.2 hours 36 days 18 hours 66 hours

Adverse Reactions AKA Side Effects Unexpected, unwanted, and/or dangerous effects Can be mild <-> severe Usually short lived and dose dependent More serious can involve: cardiac changes dangerous skin rashes breathing changes changes in blood (low white blood cell count) worsening sx (e.g. suicidally) others

Other Terms PRN QD, BID, TID medication | dose | route | timing | number fluoxetine | 20mg | PO | qam | #30 (pills) scheduled drugs

Safety Safety Patrol Black Box Warnings Pregnancy Breastfeeding Liver (hepatic)/Kidney (renal) impaired.

Drug Interactions Medicines can interact in the way that they are distributed (pharmokinetics) and the way they act (pharmodynamics) Food/Herbal interactions

Drug Development Some newer meds are reformulations of older meds: “Something Old, Something New, Something Borrowed, Something Blue” Some newer meds are reformulations of older meds: escitalopram (Lexapro) < - citalopram (Celexa) dexmethylphenidate (Focalin) < - methylphenidate (Ritalin)

Ways to Classify Medications Treatment Category (Antipsychotic) Pharmacodynamics ( SSRI, DNRI) DEA Schedule (I, II, III, ...) Pregnancy Risk (A, B, C ...) others

Medication Classes Antidepressants Anxiolytics Stimulants Antipsychotics Anticonvulsants Alzheimer’s

Antidepressants Z (more than antidepressants) Sedating Antidepressants Activating Antidepressants Stimulating Antidepressants Z

Sedating Antidepressants trazodone (Desyrel) mirtazepine (Remeron) Z

Activating Antidepressants Selective Seritonin Reuptake Inhibitors (SSRI) fluoxetine (Prozac) sertraline (Zoloft) citalopram (Celexa) escitalopram (Lexapro) paroxetine (Paxil)- most sedating SSRI

Stimulation Antidepressants SNRIs (serotonin & Norepinephrine Reuptake Inhibitor) venlafaxine (Effexor) desvenlafaxine (Pristiq) duloxetine (Cymbalta) DNRIs (Dopamine and Norepinephrine Reuptake Inhibitor) bupropion (Wellbutrin)

Other ADs Tricyclic antidepressants (TCA) amitriptyline (Elavil), amoxapine, clomipramine (Anafranil), desipramine (Norpramin), doxepin (Sinequan), imipramine (Tofranil, Tofranil-PM), nortriptyline (Pamelor) Monoamine oxidase inhibitor- MAOI Phenelzine (Nardil), Tranylcypromine (Parnate), Isocarboxazid (Marplan), Selegiline (Emsam)

Anxiolytics benzodiazipines- enhancing gamma-aminobutyric acid: chlordiazepoxide (Librium) diazepam (Valium) alprazolam (Xanax) lorazepam(Ativan) clonazepam (Klonopin) azapirones- buspirone (BuSpar) antihistamines: hydroxyzine (Vistaril)

Stimulants Increasing Dopamine in Frontal Lobe methylphenidate Concerta (long-acting) Metadate CD (long-acting) ER (intermediate-acting) Methylin ER (intermediate-acting) Ritalin (short-acting) LA (long-acting) SR (intermediate-acting) Dexmethylphenidate (Focalin & Focalin XR) amphetamine Adderall (intermediate-acting) XR (long-acting) Dexedrine (short-acting) spansule (intermediate-acting) (lisdexamfetamine) Vyvanse (Pro Drug)

Mood Stabilizers lithium (Eskalith) valproic acid (Depakote, Depakene) carbamazepine (Tegretol) oxcarbazepine (Trileptal)

Antipsychotics dopamine receptor blockade Atypical-aripiprazole, asenapine, iloperidone, olanzapine, paliperidone, quetiapine, risperidone, or ziprasidone Typical- Chlorpromazine (Thorazine) Haloperidol (Haldol) Perphenazine (Trilafon) Fluphenazine (Prolixin).

Alzheimer's acetyl cholinesterase (Ach E) inhibitors & NMDA antagonist Mild to Mod ALZ: Razadyne (galantamine), Exelon (rivastigmine), and Aricept (donepezil) Mod to Severe ALZ: Namenda (memantine) & Aricept (donepezil) Dr. Alzheimer 1906

Rx Review medications are not disorder specific review only examines Rx not psychotherapy, which in some cases is superior to Rx.

Depression Targets- depressed mood, anhedonia, low energy, insomnia 1st Line- SSRIs (Selective Serotonin Reuptake Inhibitors), also SNRI (Serotonin–Norepinephrine Reuptake inhibitors), NDRI (Norepinephrine-Dopamine Reuptake Inhibitors) 2nd Line- TCA, MAOI! Common Errors- Underdosing, Short Trials, Rx for mild conditions. Tips- Keep Titrating Up Until Remission or Adverse Reaction. MDD + Psychotic (olanzapine + fluoxetine (OFC) combination)

Depression 2

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Anxiety Common Errors- Start too high, overuse of benzo’s, underutilize combined tx, not titrating to discontinue. Tips- Start Low, Go Slow Caution if comorbid/hx of substance abuse

Anxiety Disorders Generalized Anxiety Disorder Panic Disorder Obsessive Compulsive Disorder Acute Stress/Posttraumatic Stress Disorder Specific Phobia Social Phobia

Bipolar Targets- mood instability (e.g. elevated, expansive, irritable, depressed) Common Errors- treatment with AD monotherapy, noncompliance, not monitoring BLs Tips- monitor blood levels for lithim

Schizophrenia Targets- Positive Symptoms 1st line- Atypicals Common Errors- noncompliance, failure to monitor for metabolic syndrome (atypicals), one drug (clozapine) is particularly dangerous but effect and pt must have CBC draws to monitor for agranulocytosis Tips- Side Effects are Dose Dependent

AD Spectrum Sedating Activating mirtazapine (Remeron) trazadone (Desyrel) paroxetine (Paxil) sertraline (Zoloft) citalopram (Celexa)escitalopram (Lexapro) fluoxetine (Prozac) bupropion (Wellbutrin) venlafaxine (Effexor) Sedating Activating

Bipolar 1st Line- depakote, lithium, SGA 2nd Line, SGA Common Errors- using antidepressant for depressed episode Tips-

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ADHD Targets- inattention, impulsivity, hyperactivity Sir George Frederic Still 1902 Targets- inattention, impulsivity, hyperactivity 1st line- stimulants 2nd line- SNRI (Strattera), guanfacine Common Errors- underdosing, not clearing for cardiac risks Tips- many options for delivery (patch, liquid, sprinkel beads)

Dementia Targets 1st line 2nd line Common Errors Tips

Text Stern, Herman, Slavin (2004)

Text Stern, Herman, Slavin (2004)

Stern, Herman, Slavin (2004)

Online References www.nlm.nih.gov/medlineplus/ (bilingual pt handouts for disease and medications) UTDOL.com (subscription evidence-based, peer-reviewed information resource) www.epocrates.com (online free version has meds, disease, interactions)

Reference Norquist, G.S. Regier, D.A. (1996). The Epidemiology Of Psychiatric Disorders And The De Facto Mental Health Care System. Annual Review of Medicine, 47, 473-479 PRACTICE GUIDELINE FOR THE Treatment of Patients With Major Depressive Disorder Second Edition, Karasu, Gelenberg, Merriam, and Wang (2000) and Watch Update (2005) utdol.com Clinical Practice Guideline for Treatment of Patients with Anxiety Disorders in Primary Care Published Agencia Laín Entralgo. Unidad de Evaluación de Tecnologías Sanitarias Gran Vía, 27 28013 Madrid España-Spain epocrates.com Stahl's Essential Psychopharmacology: Neuroscientific Basis and Practical Applications (Essential Psychopharmacology Series) 2008 Stephen M. Stahl (Author), Nancy Muntner (Illustrator) TMAP- www.dshs.state.tx.us/mhprograms/disclaimer.shtm