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

2. Goal
Examine Psychopharmacology in Primary Care: Ethics & Evidence

3. 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

4. Ethics
State Laws/Scope of Practice
Competency
Consult

5. Psychopharmacology 101
Overview
Terms
Medication Classes

6. 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

7. 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

8. 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

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

10. Pharmacokinetics
Absorption · Bioavailability · Distribution · Excretion · Metabolism

11. 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

12. 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.
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

13. 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

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

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

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

17. 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)

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

19. Medication Classes Antidepressants Anxiolytics Stimulants
Antipsychotics
Anticonvulsants
Alzheimer’s

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

21. Sedating Antidepressants
trazodone (Desyrel)
mirtazepine (Remeron) Z

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

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

24. 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)

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

26. 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)

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

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

29. 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

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

31. 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)

32. Depression 2

33. TMAP

34. 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

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

37. 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

39. 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

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

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

43. TMAP

44. TMAP

45. 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)

46. Dementia
Targets
1st line
2nd line
Common Errors
Tips

47. Text
Stern, Herman, Slavin (2004)

48. Text
Stern, Herman, Slavin (2004)

49. Stern, Herman, Slavin (2004)

50. Online References
(bilingual pt handouts for disease and medications)
UTDOL.com (subscription evidence-based, peer-reviewed information resource)
(online free version has meds, disease, interactions)

51. 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,
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, Madrid España-Spain
epocrates.com
Stahl's Essential Psychopharmacology: Neuroscientific Basis and Practical Applications (Essential Psychopharmacology Series) Stephen M. Stahl (Author), Nancy Muntner (Illustrator)
TMAP-