Dr James Ovens Consultant Psychiatrist Tandridge CMHRS Medication Update Dr James Ovens Consultant Psychiatrist Tandridge CMHRS

Overview Antipsychotics- updates, developments Antidepressants- new developments Antidepressants- therapeutic options Questions and queries

Antipsychotics-Developments New depots: -Paliperidone -Aripirazole Lurasidone

Paliperidone First pass metabolite of Risperidone Oily base depot Oral rarely used Once monthly administration Side effect profile similar to that of Risperidone: Metabolic syn, ^Prolactin, Switch from existing regime or use loading doses

Aripiprazole depot Once monthly administration Oral trial Single dosing 400mg injection Plasma level equivalent to 10mg oral Side effect profile similar to oral- generally favourable, little metabolic syn, occasional EPSE’s, akathisia Treatment failure main drawback

Lurasidone New antipsychotic High affinity for D2, 5-HT2a, 5-HT7 receptors High efficacy Data suggesting cognitive benefits Low chance metabolic syndrome Can reduce weight gained with other antipsychotics EPSE chief unwanted effect, can be severe akathisia

Antidepressants- developments Vortioxetine 2018 Meta analysis of Antidepressants

Vortioxetine

Vortioxetine New multimodal antidepressant Multiple 5-HT receptor agonist, partial agonist and antagonist actions Produced with aim of replicating binding profiles of drugs known to be useful in treatment resistant depression Yet has good side effect profile, absent discontinuation symptoms Aimed at 2nd line choice after SSRI

Vortioxetine On all formularies, Nice recommended Simple dosing regime Suggested use as 2nd line use in Depressive illness Easy swapping and stopping regimes Developing use in Surrey

Antidepressants- Therapeutic Options First Antidepressant- SSRI Second Choice- Alternative SSRI, Venlafaxine Now Vortioxetine an option (tolerable, no switchover concerns) Alternative options include augmentation strategies

Antidepressants- Augmentation strategies If SSRI’s poorly tolerated: -Mirtazapine -Duloxetine -Agomelatine -Reboxetine

Antidepressants- No response Always: Clarify diagnosis; Personality disorder, OCD, Anxiety disorder, Neurodevelpomental disorder, exclude intercurrent medical cause. Venlafaxine Vortioxetine 2nd SSRI Augmentation strategy

Antidepressants- Augmentation Buspirone Anxiolytic antipsychotic: Quetiapine, Olanzapine, Aripiprazole, Flupentixol Mirtazapine Bupropion (not with Venlafaxine) Lithium, Lamotrigine, TCA’s under sec. care ECT Ketamine

Buspirone Anxiolytic in BNF coding Potentiates Serotonin release Dose titration to 30mg daily StarD shows good data Well tolerated Anxiolytic effect is helpful Good experiences

Anxiolytic Antipsychotics Quetiapine Olanzapine Aripiprazole Flupentixol Low doses Anxiolytic, improved sleep Unwanted effects

Mirtazapine Good evidence base on StarD In combination with SSRI or Venlafaxine Well tolerated Experience less encouraging!

Bupropion SSRI, NARI, Dopaminergic activity In combination or as lone agent Highest rate of response in StarD Generally well tolerated Off label in UK Encouraging responses in experience Evidence of harmful effects in combination with Venlafaxine

Mood stabilisers Generally in secondary care Lamotrigine widely used with some success, evidence base not that strong Lithium less widely used in recent times but good evidence base

Others ECT Ketamine

2018 Meta Analysis Lancet published Meta Analysis Favourable findings: Escitalopram Sertraline Paroxetine Agomelatine Mirtazapine

2018 Meta Analysis Less favourable: Reboxetine Trazadone Fluvoxamine Vortioxetine (!)

Thank you… ……any questions?