Transcript Pearls for practitioner`s: Anti-depressants

PEARLS FOR PRACTITIONER'S:
ANTI-DEPRESSANTS, ANXIOLYTICS
AND HISTORY TAKING
AMY NEWSTROM, CNP
NURSE PRACTITIONER ASSOCIATION OF SOUTH DAKOTA
ANNUAL CONFERENCE 2016
LEARNING OBJECTIVES
• Discuss importance of history taking in regards to psychotropic medications
• Increase understanding of commonly used anti-depressants: mechanism of
action, side effects, and titration
• Increase understanding of commonly used anxiolytics: mechanism of action,
side effects, and titration
• Discuss referral points
• Discuss alternative therapy: Transcranial Magnetic Stimulation
HISTORY TAKING & CHOOSING THE RIGHT MEDICATION
• Identify the symptoms the client wants
treated
• Listen for a clear history
• Know medical background
• In general, the first line treatment for
depressive symptoms, in the absence
of mood instability, is selective
serotonin reuptake inhibitors (SSRI)
TARGETED SYMPTOMS OF ALL ANTIDEPRESSANTS
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Depressed mood
Sleep disturbance
Appetite disturbance
Fatigue
Decreased sexual drive
Psychomotor agitation or retardation
Impaired concentration
Loss of ability to experience pleasure (anhedonia)
Atypical depression is depression exhibited by
hypersomnia, hyperphagia, low energy and mood
reactivity
SELECTIVE SEROTONIN REUPTAKE INHIBITORS
SELECTIVE SEROTONINS REUPTAKE INHIBITORS
(SSRI’S)
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Citalopram (Celexa)
Escitalopram (Lexapro)
Fluoxetine (Prozac)
Fluvoxamine (Luvox)
Paroxetine (Paxil)
Sertraline (Zoloft)
COMMON SIDE EFFECTS OF SSRI’S
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Sexual dysfunction
Decreased spontaneity (emotional flattening)
Weight gain
Diarrhea
Initial increase in anxiety
Insomnia
Tremors
Headache
Dizziness
SEROTONIN NOREPINEPHRINE REUPTAKE INHIBITORS:
• Same as SSRI but acting on norepinephrine and serotonin
SEROTONIN NOREPINEPHRINE REUPTAKE INHIBITORS
(SNRI’S)
• Atomoxetine (Strattera)
• Desvenlafaxine (Pristiq)
• Duloxetine (Cymbalta)
• Levomilnacipran (Fetzima)
• Milnacipran (Savella)
• Venlafaxine (Effexor)
COMMON SIDE EFFECTS OF SNRI’S
• NAUSEA
• VOMITING
• CONSTIPATION
• HYPERHIDROSIS
• TACHYCARDIA
• ERECTILE DYSFUNCTION
• URINARY HESITANCY OR
RETENTION
• SEDATION
• HYPONATREMIA
• INCREASE IN BLOOD PRESSURE
NOREPINEPHRINE DOPAMINE REUPTAKE INHIBITOR
BUPROPION (WELLBUTRIN)
• Often used as an augmenting
agent
• Can reduce fatigue
• Off label use for ADHD
• Frequently abused
• No sexual side effects
ALPHA 2 ANTAGONIST: MIRTAZAPINE (REMERON)
• DUAL SEROTONIN AND NOREPINEPHRINE AGENT
• Notable side effects:
-dry mouth
-constipation
-increased appetite/ weight gain
-hypotension
-flu-like symptoms
-change in urinary function
SEROTONIN PARTIAL AGONIST REUPTAKE INHIBITOR
(SPARI): VILAZODONE (VIIBRYD)
• Onset of action may be sooner than
other SSRI’s
• Essentially same side effects as SSRI
but less potential for sexual side
effects and weight gain
• First member of this new antidepressant class
MULTIMODAL ANTI-DEPRESSANT
VORTIOXETINE (BRINTELLIX)
• May have less sexual side effects
• Shown effective specifically in
elderly patients with depression
• Long half life
• Can be costly
STAR*D STUDY (SEQUENTIAL TREATMENT ALTERNATIVES
TO RELIEVE DEPRESSION)
• Took place over a 7 year period and enrolled 4,041 outpatients. 1,165 participants were excluded,
leaving 2,876 outpatients, ages 18-75 from 41 clinical sites around the United States.
• Patients were referred to the trial by their doctor and all were diagnosed with Major Depressive
Disorder (NIH, 2016)
• 4 levels of treatment:
-Level 1: Citalopram for 12-14 weeks
-Level 2: Divided into the “switch” or “add-on” groups
-Level 3: Divided into the “switch” or “add-on” groups
-Level 4: Considered to have treatment-resistant depression
National Institute of Mental Health (2006)
https://www.psychologytoday.com/blog/mad-in-america/201008/the-stard-scandal-new-paper-sums-it-all
THE EMPIRIC APPROACH TO DIAGNOSING BIPOLAR DISORDER
• Many patients have never had full mania
• Many patients have poor recollections of past mood states
• “Bipolar” is a current fad and may influence patient recollection
• Patient may like their hypomania and dislike their depression, whereas
spouse may like the patient’s depression and dislike their hypomania
• Diagnosis often has more to do with reconstructing past history than
assessing current symptoms
• Everybody has a temperament and a personality but not all are pathological
PRESENTATION IN CLINICAL PRACTICE: BIPOLAR I
Percent Time Spent in Symptom Categories
% Time (Hypo)manic
% Time
Cycling/Mixed
9.3 5.9
31.9
52.7
% Time Depressed
Judd et al. Arch Gen Psychiatry 2002.
% Time
Asymptomatic
PRESENTATION IN CLINICAL PRACTICE: BIPOLAR II
Percent Time Spent in Symptom Categories
% Time Pure
Hypomanic
% Time
Cycling/Mixed
1.3 2.3
50.3
% Time Pure Depressed
46.1
% Time
Asymptomatic
Judd et al. Arch Gen Psychiatry 2003.
ASKING THE RIGHT QUESTIONS
• Symptom history
• Ask patient about any hypomanic symptoms
immediately before or after depressed period
• Ask patient if others have noticed any symptoms
of mania spectrum
• Don’t just focus on mood—consider over-activity
as a core feature
• Behavior history
• Ask about impulsive behaviors,
divorce/separation, job changes
Akiskal et al. J Affect Disord 2000. Bowden. Psychiatr Serv 2001.
DIAGNOSTIC ISSUES FOR DEPRESSION:
IS IT UNIPOLAR OR BIPOLAR?
• In a survey of 600 bipolar patients, more than 1/3 of
respondents sought help within one year of symptom
onset
• 69% were not diagnosed as bipolar—most frequent
diagnosis was major depression
• Mean physicians consulted before correct Dx: 4
• 1/3 did not receive a bipolar diagnosis for 10 years
WERE THEY MISDIAGNOSED OR DID THEY
PROGRESS TO BIPOLAR DISORDER?
Hirschfeld et al. J Clin Psychiatry 2003.
STATISTICAL SIGNIFICANCE
• A Swedish national cohort study found that people (both women and
men diagnosed with bipolar disorder died approximately 9 years
earlier than the general population (Crump, Sandquist, Winkleby, &
Sundquist, 2013).
• Both genders had an 8-10 fold increase risk of suicide (Crump,
Sandquist, Winkleby, & Sundquist, 2013).
• The lifetime prevalence of alcohol misuse in bipolar I disorder is
34.1%: One out of five women and two out of five men (DiFlorio,
Craddock, & van de Bree, 2014).
BENZODIAZEPINES
• Symptoms targeted by
benzodiazepines:
*Anxiety
*Insomnia
*Agitation
*Withdrawal
BENZODIAZEPINES: HOW THEY WORK
 Facilitate the binding of GABA to GABA A receptors (GABA agonist)
 Facilitates the flow of chloride into the neuron to decrease excitability
Alprazolam (Xanax)
Lorazepam (Ativan)
Chlordiazepoxide (Librium)
Midazolam (Versed)
Clonazepam (Klonopin)
Oxazepam (Serax)
Diazepam (Valium)
Quazepam (Doral)
Estazolam (Prosom)
Temazepam (Restoril)
Flurazepam (Dalmane)
Triazolam (Halcion)
BENZODIAZEPINES: COMMON SIDE EFFECTS
BUSPIRONE (BUSPAR)
• A serotonin 1A partial agonist
• FDA approved for management of anxiety
disorders
• Usually well-tolerated
• Side effects can include: dizziness,
headache, nervousness, sedation,
excitement, nausea and restlessness
• Lack of dependence and withdrawal
• Lack of sexual dysfunction and weight gain
REFERRAL POINTS
• Mood instability
• Psychosis
• Treatment-resistant
depression
• Questions of safety
TRANSCRANIAL MAGNETIC STIMULATION
• Non-invasive option
• FDA approved for the treatment of Major Depressive Disorder in adult patients who
have failed to achieve satisfactory improvement from one prior antidepressant
medication at or above the minimal effective dose and duration in the current
episode (U.S. Food and Drug Administration, 2011).
• Works by applying a highly concentrated magnetic field, switched rapidly on and off,
to the left prefrontal cortex. The left prefrontal cortex is thought to play a role in
mood regulation.
• Magnetic fields concentrated in this area produce very small electric currents that
reach 2-3 centimeters into the brain directly beneath the treatment coil. It is
thought that the electrical currents activate cells that release neurotransmitters like
serotonin, norepinephrine and dopamine to treat depression (Clinical TMS Society,
2016).
RESOURCES
• Akiskal, H.S., Bourgeois, M.L., Angst, J., Moller, H., Hirschfeld, R. (2000). Re-evaluating the prevalence of and diagnostic
composition within the broad clinical spectrum of bipolar disorders. Journal of Affective Disorders, 59(Suppl 1). S5-S30.
• Bachhuber, M.A., Hennessy, S., Cunningham, C.O. and Starrels, J.L. (2016). Increasing benzodiazepine prescriptions and
overdose mortality in the United States, 1996-2013. American Journal of Public Health, 106(4). 686-688.
• Bowden, C.L. (2001). Strategies to reduce misdiagnosis of bipolar depression. Psychiatric Services, 52(1). 51-55.
• Clinical TMS Society (2016). TMS Therapy. Retrieved on February 18, 2016 at
http://www.clinicaltmssociety.org/left/clinicaltmssociety/
• Crump, C., Sundquist, K., Winkleby, M.A., & Sundquist, J. (2013). Comorbidities and mortality in bipolar disorder: a
Swedish national cohort study. Journal of the American Medical Association Psychiatry, 70(9). 931-939.
• DiFlorio, A., Craddock, N., & van de Breen, M. (2014). Alcohol misuse in bipolar disorder: A systematic review and
meta-analysis of comorbidity rates, European Psychiatry, 29(3). 117-124.
• Frye, M.A., Gitlin, M.J. & Altchuler, L..L.. (2004). Unmet needs in bipolar depression. Depression and Anxiety, 19(4),
199-208.
• Goldberg, J.F., Hansow, M. & Whiteside, J.E. (2001). Risk for bipolar illness in patients initially hospitalized for unipolar
depression, American Journal of Psychiatry, 158(8), 1265-1270.
• Harvard Health Publication. (2010). Transcranial magnetic stimulation. Harvard Mental Health Letter, September 2010.
• Hirschfeld, R. M. et al. (2003). Screening for bipolar disorder in the community. Journal of Clinical Psychiatry, 64 (1),
53-59.
• Ingersol, E. & Rak, C. (2016). Psychopharmacology for mental health professionals: An integrative approach. (2nd Ed.).
Boston, MA: Cengage Learning.
RESOURCES
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Judd LL, Akiskal HS, Schettler PA, Coryell W, Endicott J, Maser JD, et al. (2003). A prospective investigation of the natural history of the
long-term weekly symptomatic status of bipolar II disorder. Archives of General Psychiatry, 60. 261-269.
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National Institute of Mental Health. (2010). Magnetic Stimulation Scores Modest Success as Antidepressant. Retrieved on February
18, 2016 at http://www.nimh.nih.gov/news/science-news/2010/magnetic-stimulation-scores-modest-success-asantidepressant.shtml
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National Institute of Mental Health. (2006). Questions and answers about for NIMH sequenced treatment alternatives to relieve
depression (STAR*D) study- all medication levels. Retrieved on September 14, 206 at http://www.nimh.nih.gov/funding/clinicalresearch/practical/stard/allmedicationlevels.shtml
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Rush. A. J. et al. (2006). Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: A
STAR*D report. American Journal of Psychiatry, 163(11), 1905-1917.
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Scrandis, D.A. (2015). Identification and management of bipolar disorder. The Nurse Practitioner, 39(10). 31-37.
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Stahl, S.M. (2013). Stahl’s essential psychopharmacology: neuroscientific basis and practical applications. (4th Ed.). Cambridge, UK:
Cambridge University Press.
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Stahl, S.M. (2014). Prescriber’s guide. (5th Ed.). Cambridge, UK: Cambridge University Press.
•
U.S. Food and Drug Administration Center for Devices and Radiological (2011). Health Guidance for Industry and FDA Staff - Class II
Special Controls Guidance Document: Repetitive Transcranial Magnetic Stimulation (rTMS) Systems. Retrieved on February 22, 2016
at http://www.fda.gov/RegulatoryInformation/Guidances/ucm265269.htm
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Valente, S. & Fisher, D. (2012). Transcranial magnetic stimulation for major depression. The Journal of Chi Eta Phi Sorority, 56(1): 2325.
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Whitaker, R. (2010). The STAR*D scandal: a new paper sums it all up. Psychology Today. Retrieved on August 30, 2016 at
https://www.psychologytoday.com/blog/mad-in-america/201008/the-stard-scandal-new-paper-sums-it-all
•
World Health Organization. (2015). Depression: Fact Sheet No 369. Retrieved on February 22, 2016 at
http://www.who.int/mediacentre/factsheets/fs369/en/.
QUESTIONS