Transcript Depression and Psychopharm

Depression and
Psychopharm
How Medications work and which
to choose
Suicide (approximately 1 in 10 of those
with depression)
Antoine Wiertz (1806-1865)
http://www.modjourn.brown.edu/mjp/Image/Wiertz/Wiertz.htm
Your client may need a medication
consultation for anti-depressants if:
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Not so much a characterological depression as a
physiological depression
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Sleep, sex, and/or appetite disturbance
Fatigue
Agitation or psychomotor retardation
Anhedonia
Dysthymia is really sucking the energy out of them
Grief/heartbreak becomes depression
Psychotherapy isn’t helping
Suicidality
Daily functioning is markedly impaired
Always assess for Hypomania and Mania
Anti-depressants
Cymbalta
No prescription is required as
we ship from outside the United
States.
Antidepressants:
Have only been around since the 1950’s
Fall into categories:
MAOIs
TCAs
SSRIs
Atypical: SNRI, NSRI, etc.
MAOIs (antuberculosis)
 Powerful Antidepressants
that also work
with panic disorder and social phobia
 The
original Antidepressants
 Inhibit
enzymes that destroy serotonin,
norepinephrine, and Dopamine
Problems with MAOIs
 Foods
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rich in tyramine are fatal
Avoid aged cheese; aged or cured meats
(e.g., air-dried sausage); any potentially
spoiled meat, poultry, or fish; broad (fava)
bean pods; Marmite concentrated yeast
extract; sauerkraut; soy sauce and soy bean
condiments; and tap beer.
Listed in book
TCAs
 Some
work as anti OCD and Antipanic
 Block reuptake pump for 5HT, NE, and to
a lesser extent Dopamine. (level of
blockage for each NT is dependent on the
medication)
BUT ALSO……
TCAs:
 BLOCK
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Muscarinic Cholinergic receptors
• Dry mouth, blurred vision, urinary retention,
constipation
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H1 Histamine receptors
• Sedation and weight gain
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Alpha 1 adrenergic receptors
• Hypotension and dizziness
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Sodium channels in the heart and brain
• Overdose will cause seizures, cardiac arrest, or
arrhythmias
Selectivity and the SSRIs
 Depending
on where the neuron goes and
what receptors are blocked will change the
effects of the drug
 Currently we can’t control where the drug
goes in the brain, but selectivity
demonstrates better control over which
receptors are blocked
SSRIs
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Block serotonin reuptake selectively-thus limited danger
in overdose
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Less side effects (only 5HT ones such as nausia,
insomnia, headache, gastrointestinal, sweating, anxiety,
restlessness
Initial anxiety and difficulty with sleep is common
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AND…sexual side effects are a big problem
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Additional difficulties into tx of fatigue and apathy should
be monitored and treated with adjunct medication…For
example Dopamine or NE meds….
The current hypothesis is: People may have
a NE deficiency and show symptoms of
 Poor
attention
 Poor concentration
 Poor working memory
 Poor speed of information processing
 Psychomotor retardation
 Fatigue
 Apathy
 Depressed mood
Or a 5HT deficiency and have
symptoms of
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Depressed mood
Anxiety
Phobias
Panic
OCD symptoms
Food cravings and Bulimia
How does this knowledge help you help your
client?
Other antidepressants
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SNRIs block 5ht and NE reuptake
 NRIs block NE reuptake (not available in US)
 Atypical: Welbutrin (works on Dopamine and NE
in complex way), Serzone (off the market),
BuSpar, Remeron (no sexual, anxiety or nausia,
but weight gain and sedation), Effexor (1:30),
Milnacipran (1:3) (not in us), and cybalta
 1+1=3
Other notes
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Trazodone: For sleep, reduces SSRI side effects
of insomnia and agitation and enhances SSRI
effect
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Can cause priapism in men
Can cause nightmares
What diagnosis would caution the use of this
medication
Keep in mind that because SSRIs inhibit enzyme 2D6,
they increase levels of TCAs in Plasma
Some bad mixtures
 Luvox
with atypical antidepressants,
theophylline (for chronic asthma), and
even caffeine can lead to seizures
 Prozac and Luvox inhibit enzyme 3A4;
Xanax, Halcion, and Propulsid (heartburn)
are substrates of 3A4 and can become
toxic causing cardiovascular trouble or
sudden death
Other Issues
 Drugs
can increase (induce) enzymes in
the liver too.
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For example: Tegretol induces 3A4 and is
broken down by 3A4. Thus doses must be
monitored and increased to avoid breakthru
symptoms
And if Tegretol is stopped, any other drug
metabolized by 3A4 will increase their
concentration in the plasma (217)
Did I cover these topics?
Luvox,- addresses ruminations and OCD
symptoms
Welbutrin and other drugs for sexual side
effects
Reboxitine
Stimulants
Providual, Lexapro, Paxil & Luvox (ACH)
Primary Care Patients
with Depression
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Poor medication
 Reasons for nonadherence is
adherence
prevalent
 Side effects
 1 out of 3 did not take
 Belief that meds were not
antidepressant as
necessary
directed within the
 Medication not working
first 30 days
 Forgot to take meds.
 More than half (56%)
 Cost ($75 to $250/month)
did not adhere within
four months!
If clinicians closely monitor/manage
side effects:
 It
may enhance compliance with medication
 Adequate dosing = better for patient
 Patients may not prematurely abandon
therapy
Sexual Dysfunction During
Antidepressant Treatment
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Is a huge problem and underreported in studies.
Studies are less likely to address effects in
women, which are different than in men
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Diminished or absent libido
Arousal difficulties
Erectile dysfunction (in men)
Delayed orgasm
Anorgasmia
Or...undesirable sexual arousal and hypersexuality
Sexual partner may not understand
Potential Consequences of Sexual
Dysfunction
 Psychological
distress
 Reduced quality of life
 Self-esteem plummets
 Sexual partner still doesn’t understand and
relationships may dissolve with blame
 Diminished motivation to get intimate with
people
 Non-compliant with medication
A major obstacle in effective treatment
of depression (and other disorders) is
medication non-adherenece.
 What
do you do about it? Follow through
with your clients!
• Tell them what you know
• Help them formulate what they’d like to discuss
with doctor
• Call or ask them to call a doctor and make an
appointment
• Obtain a release to talk to client’s doctor
• Call doctor to introduce self and collaborate
treatment
So your client has a prescription for
anti-depressant medication
 Ask
client for name and dosage
 Assess client’s attitude, feelings, and
thoughts about prescription
 What is client’s response to meds?
 Discuss side effects, discuss research,
discuss options…discuss…
 Encourage them to keep in contact with
physician
Race and Anti-depressants
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Comparative, two month, pilot study investigating efficacy of
Zoloft (Sertraline) found individuals (n=20) with a Chinese
heritage:
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One study (Melfi et al. 2000) found that AfricanAmericans/blacks were less likely than whites to receive an
antidepressant when their depression was first diagnosed
(27% versus 44%).
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Responded at a lower dose than Caucasians
Of those who did receive antidepressant medications, African
Americans were less likely to receive the newer selective serotonin
reuptake inhibitor (SSRI) medications than were the white clients.
African-Americans may require lower doses of medication
because of metabolic differences (most research has been
done on white populations e.g., heart disease study)
http://www.depressionet.com.au/articles/251004efod.html
Latinos and Mental Health –
Study’s show…
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Fewer than 1 in 11 contact mental health specialists, while
fewer than 1 in 5 contact general health care providers.
Among Latino immigrants with mental disorders, fewer than 1
in 20 use services from mental health specialists, while fewer
than 1 in 10 use services from general health care providers
(Mental Health, 2001).
One study found that 24 percent of African-American/Blacks, &
Hispanics with depression and anxiety received appropriate
care, compared to 34 percent of Whites.
Another study found that Latinos who visited a general
medical doctor were less than half as likely as Whites to
receive either a diagnosis of depression or antidepressant
medicine.
Further…..
Physician-patient communication
and Hispanic ethnicity
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Physicians were more likely to state information to
patients who started on new anti-depressants
Physicians were more likely to give information about
anti-depressants to Whites than to Hispanics
1 in 5 patients were asked how well their antidepressants were working
1 in 10 patients were asked if they were experiencing
side effects
Hispanics were less likely than Whites to talk about
their anti-depressants
Remember that research is rarely racially specific.
What does this implicate in working with Diverse
Populations?
Sleath B, Rubin RH, Huston SA
Compr Psychiatry. 2003 May-Jun;44(3):198-204
Discuss/role-play how these client factors
may affect how you communicate about
depression and anti-depressants
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Sex and Gender
 Age
 Race
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Ethnicity
Nationality
Religion
Learning style
Socio-economic status
Personality and attitude about medication
Latinos and Suicide
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In 2001, Latinos had a suicide rate of 5 per 100,000
compared to nearly 12 per 100,000 for Whites.
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However, in the 2003 Youth Risk Behavioral Surveillance
System, Latino students (10.6 percent) were more likely
than White students (6.9 percent) to have reported a
suicide attempt.
Latino students were more likely to have made a suicide
plan (17.6 percent) than White males (16.2 percent).
Latino female students (5.7 percent) were significantly
more likely than White female students (2.4 percent) to
attempt suicide and require medical attention.