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

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

3. Antipsychotics-Developments
New depots:
-Paliperidone
-Aripirazole
Lurasidone

4. 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

5. 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

6. 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

7. Antidepressants- developments
Vortioxetine
2018 Meta analysis of Antidepressants

8. Vortioxetine

9. 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

10. 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

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

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

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

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

15. 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

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

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

18. 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

19. 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

20. Others
ECT
Ketamine

21. 2018 Meta Analysis Lancet published Meta Analysis Favourable findings:
Escitalopram
Sertraline
Paroxetine
Agomelatine
Mirtazapine

22. 2018 Meta Analysis Less favourable: Reboxetine Trazadone Fluvoxamine
Vortioxetine (!)

23. Thank you…
……any questions?