1. Like Tylenol ® for Tumors The role of medications in complex bio-psycho-social situations himanshua@nwpltd.org

4. Family history Conception

5. Family history Conception In-utero exposure Birth

6. Family history Conception In-utero exposure Birth Psychological Abuse

7. Family history Conception In-utero exposure Birth Psychological Abuse Drugs

8. Family history Conception In-utero exposure Birth Psychological Abuse Drugs

9. The BioPsychoSocial Model of Treatment Biological Factors Genes, Chemicals, Cells and Molecules Social Factors Family, Friends, Employment, Finance, Housing, Community Psychological Factors Defenses, ego strengths, temperament, trauma, insight

10. Brain Stuff

11. DOPAMINE Aggression Schizophrenia Parkinsonism Chemical Dependency Huntington’s Disease

12. SEROTONIN Rigid Thinking Depression & Anxiety Sleep Disorders Amotivational Syndrome Sexual Side Effects Gastrointestinal Tract

13. NOR-ADRENALINE ADHD Anxiety ‘Fight or Flight’ response

14. Under the Microscope – Neurons

16. No Cure YET ! ADHD DEPRESSION ANXIETY DISORDERS SCHIZOPHRENIA BIPOLAR DISORDER

17. No Cure YET ! ADHD DEPRESSION ANXIETY DISORDERS SCHIZOPHRENIA BIPOLAR DISORDER DIABETES HYPERTENSION CANCER ASTHMA

18. General Principles With All Meds No ‘Brain Biopsy’ services available….yet Double Edged Sword - Risk vs. Benefit Start Low, Go Slow - Lowest possible effective dose

19. General Principles With All Meds Keep assessing – Is it doing what it’s supposed to be doing ? 3 meds,3 times a day - goodbye compliance! Meds are often used for symptoms, not just illnesses

20. Treat the Symptoms !

21. ADHDBPADDepressionAnxiety d/o Irritability++++ Increased activity +++ Emotional Outbursts ++++ Poor Sleep+++ Distractibility+++ Impulsivity+++ Talkativeness++ Crying spells+++ Suicidal thoughts +++

22. Special Considerations Celexa (Citalopram)

23. Special Considerations

24. Celexa (Citalopram)

25. Special Considerations Celexa (Citalopram)

26. Special Considerations Lexapro (Escitalopram)

27. “How does this affect my depression, Willis?”

28. “Practice-based evidence*” * Presenter’s subjective opinion- please don’t sue me Forest Pharmaceuticals !

31. Mood StabilizersMedication Why you might choose it LithiumClassic bipolar I Suicide risk Very inexpensive valproate/DepakoteRapid cycling, BPAD –II, Cyclothymia carbamazepine/TegretolRapid cycling Severe sleep problems Can't take Depakote,Can't afford Trileptal, oxcarbazepine/TrileptalAlternative to Depakote as a starting place Low long-term risk is appealing lamotrigine/LamictalDepression is the dominant symptom Afraid of weight gain olanzapine/ZyprexaEmergency-level symptoms Can use "as-needed", fast acting clozapineTried everything else for severe symptoms one of the most effective medications we have

32. Specific principles during crisis evaluations Drug intoxication – New meds – Recent increase Drug withdrawal – Recent reduction Drug interactions Drug compliance – Do not accept ANY vague answers

33. Here we go…

34. Wellbutrin Zoloft Lexapro Celexa Effexor Cymbalta Buspar Paxil Remeron

35. Lithium Anticonvulsants Haldol Seroquel Zyprexa Abilify Geodon Risperidone Wellbutrin Zoloft Lexapro Celexa Effexor Cymbalta Buspar Paxil Remeron

36. Lithium Anticonvulsants Haldol Seroquel Zyprexa Abilify Geodon Risperidone Wellbutrin Zoloft Lexapro Celexa Effexor Cymbalta Buspar Paxil Remeron Ritalin Adderall Dexedrine Focalin Concerta Vyvanse Strattera Clonidine Tenex Intuniv

37. Lithium Anticonvulsants Haldol Seroquel Zyprexa Abilify Geodon Risperidone Wellbutrin Zoloft Lexapro Celexa Effexor Cymbalta Buspar Paxil Remeron Trazodone Lorazpam Propranolol Cogentin Ritalin Adderall Dexedrine Focalin Concerta Vyvanse Strattera Clonidine Tenex Intuniv

38. Where should we start ?

40. Attention Deficit /Hyperactivity Disorder

41. If treatment is working… Improved attention and ability to concentrate Reduced hyperactivity Fewer behavioral problems and outbursts Improved performance at school

42. Two major groups 1. Stimulants 2. Non- Stimulants

43. Stimulants Dosing Long acting - take once in morning Short acting - may be taken up to three times/day Out of your system within the day (Drug holidays?) Indications ADHD Narcolepsy

44. Generic classBrand names Methylphenidate, short-actingRitalin® Methylin® Methylphenidate, intermediate- acting Ritalin SR Metadate® ER Methylin ER Methylphenidate, long-actingConcerta® Daytrana (9 hrs) Ritalin LA Dextroamphetamine, short- acting Dexedrine® Dextrostat® Dextroamphetamine, long- actingDexedrine spansule Vyvanse Mixed Amphetamine Salt (MAS), intermediate-acting Adderall® MAS, long-actingAdderall-XR Duration 2-4 hours 5 hours 8 -12 hours 5 hours 6-12 hours 5 hours 9 hours

45. Specific Stimulants Ritalin (Methylphenidate) – Short Acting (2-4 hrs) – Generic – Available in solution form Adderall – Stronger efficacy, stronger side effects (headaches, loss of appetite, stomachaches) – Generic

46. Concerta - OROS technology

47. Specific Stimulants Daytrana (Methyphenidate transdermal patch system) – Absorbed by the skin gradually over 9 hours – Effect lasts for 3 hours after patch removed

48. Specific Stimulants Vyvanse (Lis-dexamfetamine) – Dexedrine with an amino acid (Lysine) attached to it – The amphetamine is inactive until the amino acid gets detached by liver – Smoother effect – Theoretically, one cannot get ‘high’

49. Stimulants Side effects Reduced appetite, Weight Loss Rebound Headache Jittery feeling, Irritability, “Zombie”, “loss of personality” Gastrointestinal upset Difficulty with sleep Tics and repetitive movements May precipitate crisis calls

50. Stimulants Contraindication Eating Disorder Caution Psychosis Bipolar disorder Anxiety FAS Autism

51. Non stimulants Atomoxetine Clonidine, Tenex and Intuniv Wellbutrin Atypical Antipsychotics

52. Atomoxetine (Strattera) a Selective Nor Epinephrine Reuptake Inhibitor. Indications – ADHD – ? Adjunct in Depression Dosage – Needs to be taken everyday – Takes weeks to start working – target = 1.2 mg/kg in one/two doses Side Effects – Nausea - Try Eggs, Peanut Butter, Pepto bismol – Sleepiness – Urinary Retention

53. Alpha-2 agonists Clonidine (Catapres) Up to two divided doses 9 times more potent than Tenex Sedation Withdrawal may precipitate crisis Guanfacine (Tenex) May give up to three divided doses Less sleepiness

54. Alpha-2 agonists Guanfacine Extended Release (Intuniv) Brand new Once a day dosing 1-4 mg daily dose

55. Aggression

56. Atypical Antipsychotics Clonidine and Tenex Lithium Anti- Seizure medications

57. If treatment is working… – Calmer, less disruption, fewer outbursts – Improved concentration, restlessness – Improvement in irritability, behavioral problems – Better Grades – Fewer Time Outs

58. Atypical Antipsychotics Clozapine Clozaril Risperidone Risperdal Risperdal M-tab Risperdal Consta Olanzapine Zyprexa Zyprexa Zydis Quetiapine Seroquel Ziprasidone Geodon Aripiprazole Abilify Paliperidone Invega

59. General Side Effects Dry Mouth Blurry Vision Weight Gain Constipation Diabetes / Increased Blood Sugars Increased Cholesterol Note- smoking reduces blood levels

60. Acute Dystonic Reactions Sudden Dramatic, frightening Very uncommon with 2 nd generation antipsychotics Quickly reversible

61. Pseudo- Parkinsonism ‘Zombie’ ? Very uncommon with SGAs Reversible Treatable Always weigh risk vs benefits

62. Akathisia A subjective feeling Restlessness, ‘I feel like I want to jump out of my skin’ May precipitate crisis call Very uncomfortable but it can be managed

63. Tardive Dyskinesia Slow, writhing Involuntary movements Usually affect face, neck, hands & feet Risk increases with duration of treatment Risk lower with newer meds Monitor- DISCUS/AIMS (5 min) Always weigh risks vs benefits

64. Clozapine (Clozaril) Potent but toxic If you need to stop, Gradually taper over 1-2 weeks Weekly CBC Sedation, Drooling, Constipation Smoking reduces Clozaril Levels

65. Risperidone (Risperdal – M tab - Consta) Available in many forms Risperdal Consta – 12.5 -25 mg / 2 weeks; takes 3-6 weeks to start acting Sleepiness, Milky discharge, Problems with Menses More likely to cause Dystonia & Parkinson’s-like side effects

66. Quetiapine ( Seroquel - Seroquel XR) Wide range of dosage (25 mg to 1400mg) Helpful for anxiety Sleepiness Reduced Blood Pressure

67. Ziprasidone (Geodon) Sleepiness OR restlessness/activation Get an EKG before starting Take with Food

68. Olanzapine (Zyprexa - Zyprexa Zydis) Tablet, Orally disintegrating tab, Intramuscular shot Sleepiness, Weight gain Diabetes

69. Aripiprazole (Abilify – Discmelt) May be Activating in certain pts.

70. Paliperidone (Invega) OROS Related to Risperdione New baby on the block

71. BIPOLAR DISORDER

74. If treatment is working… Fewer, less severe periods of mania (or hypomania) and depression Fewer day to day emotional lability, mood swings Less disruption, better functioning

76. Lithium ( Eskalith – Eskalith CR - Lithobid - Lithium Carbonate - Lithium Citrate Solution ) Main Indication – Bipolar Disorder Dose :Target Li level 0.8 – 1.4 mEq/L :Start 300 mg, usually up to 1800 mg in two divided doses Precautions –Avoid dehydration, NSAIDS (Tylenol, Sulindac OK), Many BP meds Regular blood tests

77. Common Side Effects Increased frequency of urination Fine Tremor Cognitive Slowing Diarrhea Nausea, Vomiting

78. Valproic acid syrup - Depakote delayed release tab - Depakote sprinkle caps Depakote EC tab Main Indication – Bipolar Disorder Dose :Target Depakote level 40 -100 mcg /ml Extended release form available –once a night Regular Blood Tests Beware –Failure of BCP

79. Common Side effects tiredness dizziness Nausea, vomiting tremor hair loss, acne weight gain

80. Lamotrigine (Lamictal) Very Gradual increase (over weeks) to avoid Rash Taper over 2 weeks Caution – Depakote, Tegretol & BCPs may increase levels of Lamictal Any rash with Lamictal should be taken seriously

81. Topiramate (Topamax) Neutralizes / Negates weight gain – used in combos ‘Dope-a-max’

82. Other Mood Stabilizers… Carbamazepine (Tegretol) Oxcarbamazepine (Trileptal) Gabapentin (Neurontin)

83. ANXIETY DISORDERS

84. Anti Anxiety Meds First Line – SSRIs, SNRIs Others - Benzodiazepines - Antihistamines Benadryl, Vistaril - Propranolol, Atenolol

85. If treatment is working… Improvement in mood and sense of well being Less fixated / rigid / preoccupied Improved sleep and appetite Better functioning at school and home

86. SNRIs Act on Nor Epinephrine in addition to Serotonin - ? Better for anxiety Main Indications – Anxiety, Depression, Diabetic Neuropathy, ? ADHD May cause increase in blood pressure Withdrawal may precipitate crisis call

87. SNRIs Venlafaxine Effexor Effexor XR Capsules Usual Dose 37.5 mg -225 mg in up to two doses Taper slowly to avoid Withdrawal Pristiq (Desvenlafaxine) Metabolite of Venlafaxine Single daily dosage of 50 mg Taper slowly to avoid Withdrawal Duloxetine Cymbalta Capsules Usual Dose -40 to 60 mg in two divided doses

88. Benzodiazepines Main Indications - Panic Disorder - Social Phobia - Generalized Anxiety Disorder - Used as Sleep Aid Use for short periods to avoid tolerance Taper slowly - Sudden withdrawal is dangerous (Seizures, arrhythmias)- may precipitate crisis call

89. Benzos SHORT ACTINGHalf LifeUsual Dose Triazolam Halcion2 Hours0.125 -0.5 mg at bedtime Temazepam Restoril87.5 – 30 mg at bedtime MEDIUM ACTING Alprazolam Xanax60.25 -0.5 mg TID (Max 4mg) Lorazepam Ativan101 – 6 mg in 2 or 3 div doses LONG ACTING Clonazepam Klonopin180.5 – 2 mg up to 2 div doses Alprazolam Xanax XR123 – 6 mg once a day Diazepam Valium302 -10 mg

90. Beta Blockers Block Physical symptoms of anxiety Use with Caution in Diabetics, asthmatics Side Effects – lower blood pressure & heart rate, sleepiness, ? Depression Taper slowly to avoid rebound increase in BP Propranolol Inderal Usually 20 mg BID, or as needed Atenolol Tenormin 50 -100 mg in up to two divided doses

91. Buspirone (Buspar) Indication –Generalized Anxiety Disorder Common Side Effects –light headedness, Insomnia, Headache

92. SSRIs

96. SSRIs - Indications Mood disorders Depression Anxiety disorders PTSD, GAD, OCD, Elective mutism, Social phobia, Separation anxiety Developmental disorders Autism, FAS All developmental disorders with repetitive behaviors

97. If treatment is working… Autism, FAS Improvement in perseveration /rigidity/ compulsive behavior Better with transitions, calmer Depression Improvement in mood and sense of well being less irritable fewer headaches and stomachaches Improved sleep and appetite Resolution/improvement of suicidality Better grades, invested in relationships

98. Trade name GenericAvailable AsDose Range (mg) Comments CelexaCitalopramTab, Solution2.5 -40generic ProzacFluoxetineTab, Solution5 - 40Longest half life; PaxilParoxetineTab, liquid5 - 40Withdrawal, sleepy, weight gain ZoloftSertralineTab, Concentrate 25 - 200Sexual side effects LexaproEscitalopramTab, Solution2.5 - 20Newest SSRI LuvoxFluvoxamineTab25 – 300Headache, insomnia

99. Other Antidepressants

100. Bupropion (Budeprion - Wellbutrin SR – Wellbutrin XL- Zyban) Main Indications –Depression, ADHD, Smoking Cessation Aid Common Side Effects – agitation, Insomnia. Good Sexual Side Effect Profile – used as adjunct to SSRIs

101. Tricyclic Antidepressants Commonly Used Ones  Clomipramine (OCD) (Anafranil)  Amitriptyline (Elavil )  Nortriptyline (Pamelor- Aventil)  Desipramine Main Indications – Adjuncts to depression, as Sleep aids, Bed Wetting, Chronic Pain “Dirty Drugs” – dangerous in overdose

102. Selegiline Transdermal system ( Emsam) MAO inhibitors make a come back ! Safe in lower dose (6 mg), dietary restrictions with higher dose May be better for ‘atypical depression’ (weight gain, oversleeping)

103. Mirtazapine (Remeron) Tab, Orally disintegrating tab Main Indication – Depression, Sleep Aid Usual Dose 7.5 mg – 45 mg at night Side Effects - Sleepiness and weight gain, especially with lower doses!

104. Antidepressants and crisis calls Suicidality (FDA black box warning) Manic switching – Decreased Need for sleep – Rages/ severe irritability – Grandiosity, disinhibition, hypersexuality – Change in distractibility, talkativeness – Family history of BPAD FAS, Autism, MR

105. Alzheimer’s Dementia Beware of drug-drug interactions Donepezil (Aricept) – For all stages of dementia – 5-10 mg daily – Nausea Memantine (Namenda) – For moderate to severe dementia – Titrate up to 10 mg BID – Dizziness

106. Meds to counteract side effects from other meds!

107. Insomnia Techniques to ensure good sleep hygiene Benadryl / Melatonin (if difficulty falling asleep) Trazodone /Melatonin SR/ Ambien – CR (if difficulty staying asleep) Clonidine/Seroquel / Remeron / Paxil (Two birds, one stone)

108. Trazodone Weak Antidepressant in higher doses Used for side effect of sleepiness Watch out for early morning grogginess Rare - priapism in males - take to ER!

109. SGA –induced Extra Pyramidal Side Effects Cogentin (Benztropine) – Dry mouth, constipation, urinary retention, confusion Benadryl – Dry mouth, sedation Lorazepam – Sedation, agitation

110. Lithium-induced tremor Lorazepam/ Clonazepam – Sedation, agitation Propranolol

111. SGA induced weight gain Metformin – Diarrhea, nausea – Lactic acidosis

112. “Is there a Generic for that?” Depression/ Anxiety Celexa Wellbutrin SR and XL Prozac Zoloft Paxil Effexor XR Inderal Remeron ADHDAdderall Dexedrine spansule Ritalin Ritalin SR Tenex Metadate ER Clonidine Mood Stabilizers Depakote ER Eskalith LamictalTopamax TegretolTrileptal AntipsychoticsRisperdal

113. Thank You himanshua@nwpltd.org