Brief Overview of Common Psychotropic Medications --and-- The Role of the Complex Care Clinician in Supporting Psychiatric Medications Marc Avery, MD, Psychiatrist University of Washington School of Medicine

Objectives Participants in this training will: 1. Be familiar with the classes of common psychiatric medications. 2. Learn of some important basic concepts about how psychiatric medications are used effectively. 3. Understand the role of The complex care clinician In supporting psych meds.

Psychiatric Medications – only a few classes: Antidepressants Antianxiety Anti-Psychotics Mood Stabilizers MAT Sure, there are ADHD meds and a bunch of other spurious meds, but these are less common.

Deliver Coordinated Services Antidepressants How do they work? How effective are they? What can patients expect? Can work as soon as 48 hours, but usually takes 1 -6 weeks. The PHQ is a great tool for judging improvement. Do they have side effects? Startup side effects (nausea, sweating, sedation). Ongoing side effects (sweating, sexual dysfunction) Dangerous side effects (suicidality, mania, serious allergy) How does a prescriber choose an antidepressant? All just as likely to work. Different people respond differently, but you can’t tell ahead of time. Often need to try 2 or 3 different ones to find the best match. It does appear that medications can stop working over time.. but…. Typically use side effects to guide Engage Clients in their whole health Actively engage each client/patient in his/her Care Planning: Collaborate with the client/patient/family to develop a whole health service plan including services from agencies outside the partnership Deliver Coordinated Services Develop Shared Care Plans across primary care, mental health and substance use : Develop and use processes for the collecting and updating shared goals among client/patient and providers Develop and use processes for communicating and supporting client’s shared goals among providers

Antianxiety Sleeping Medications SSRI antidepressants Treatment of choice Benzodiazepines Are habit forming. Must take them often Sleeping Medications Many are also benzodiazepines, and don’t work long term very well. Not habit forming meds don’t work as well. Sleep counseling is the treatment of choice.

PTSD Prazosin for nightmares Prazosin is a blood pressure medication – so some patients can experience LOW blood pressure when taking it.

Abilify (aripiprazole), Clozaril (clozapine), Geodon (ziprasidone), Latuda (lurasidone) Risperdal (risperidone), Saphris (asenapine), Seroquel (quetiapine), Zyprexa (olanzapine) Antipsychotics There are about a dozen of them. They also all “work” about the same, but often with VERY different side effect profiles. Onset of action is much faster than antidepressants. Many have: Metabolic side effects: diabetes, weight gain, increased cholesterol. Neurologic side effects: akathesia, tremor, dyskinesia. Generally treat the symptoms of psychosis: hallucination, delusion, ideas of reference, etc. Less good at the “negative” symptoms of psychosis Also treat mania, ‘resistant depression’, anxiety, but high side effects.

Mood Stabilizers So what is bipolar disorder? What is a ‘mood stabilizer’? Medication Choices – the big 4:  LITHIUM – need labs. Depakote (Valproate) – need labs. Lamictal – need to take reliably Antipsychotics – side effects “Mood stabilization” takes more time to treat than depression or psychosis Often using meds that are more difficult to use.

MAT Opiates Suboxone – (Buprenorphine/Naloxone) needs waivered. – needs induction. Buprenorphine (Subutex) Both the above need ‘induction treatment’ Methadone – treatment program. Naltrexone – Long Acting Injectable (Vivitrol) every four months.   Alcohol: Antabuse –Acamprosate –Naltrexone –  Smoking: Chantix – Bupropion - Gum/Patches

What is the role of care manager, care coordinator, BH clinician in supporting effective medication treatment? You can do as at least as much with the patient as they (or their family) might do for themselves. Inquire about what they heard or learned when they met with their prescriber. Help patients formulate (and write down) medication questions for their prescriber. Ask about side effects and how they have adjusted to them. Educate patients about what to expect from medication. Celebrate any benefits! Look up medications on the internet (WebMD is my fave). Look up medication interactions (the AARP drug interaction checker is my fave).

What if patients don’t want to take psychiatric medication?

Medication Reconciliation – What and why? What is? Prescribed Dispensed Purchased Mixed, traded, stolen, tossed, flushed Taken Prescriptions, OTCs, herbs, remedies. Why bother? Medication Errors are COMMON!!! Sharing of information Patient Education

MEDICATION ADHERENCE The sobering facts: 75% of all patients are non-adherent in some way. 30% of Rx’s never filled at all 50% of Rx’s filled not taken correctly Non-adherence following hospitalization for schizophrenia approach 50% during the first year post discharge 10% of all hospitalizations are due to non-adherence Est. cause of 125,000 deaths annually  http://www.epill.com/statistics.html

Predictors of Poor Adherence Homelessness, other social factors Adjustment to daily routine Lack of family involvement  Confusion Depression (doubles risk of non-adherence) Psychosis Cognitive impairment Poor insight and denial Lack of perceived efficacy Side Effects Complexity (QID dosing alone reduces adherence from 80% to 50%) Duration Stigma Fear of dependency  Cost / loss of benefits / availability  Clinician–patient relationship issues Inadequate follow-up The Take Home: Side effects and lack of efficacy are high on the list! Mitchell, Selmes Adv Psych Tr (2007) 13: 336-346 Lars Osterberg, M.D., and Terrence Blaschke, M.D., N Engl J Med 2005; 353:487-497August 4, 2005, http://www.nejm.org/doi/full/10.1056/NEJMra050100

MEDICATION ADHERENCE Tips for improving medication adherence   Tips for improving medication adherence ACTUALLY TALK ABOUT IT! Work out how they GET their medication Help patients get organized – pill boxes, medisets, medication lists Keep meds in a familiar place Pull in family Peers! Peers! Peers! Associate with another daily task.

AARP drug interaction checker AIMS Center COMMONLY If you’re like me: you’ll forget most of this information after a while – so where to get info when you need it? Resources: WebMD GoodRx AARP drug interaction checker AIMS Center COMMONLY PRESCRIBED PSYCHOTROPIC MEDICATIONS HANDOUT Aims.uw.edu https://aims.uw.edu/sites/default/files/PsychotropicMedications_0.pdf Above provided courtesy of the AIMS Center, University of Washington – sharing is permissible with appropriate reference.