PSYCHOPHARM PRESENTATION revised newest
- 1. 1 Understanding the Basics of Psychopharmacology Andrew Blalock, Ph.D. Positive Impact, January 2015 WHY THIS TRAINING? Depression inhighrisk populations,>2foldincrease PTSD high-riskpopulations:women,prisoners,minorities Dementia decreased withART,butprevalence of MCMD andHAD? Bipolar primary& secondary, 10 x higher Schizophrenia inat-riskpopulation, 2-10x higher PRIMARY NEUROTRANSMITTER SYSTEMS PARTI: Commonly PrescribedMedications (listsare not exhaustive) ANTIDEPRESSANTS Oldermedicationslike tricyclicantidepressants (TCAs) and monoamineoxidase inhibitors (MAOIs)are rarelyused anymore,though TCAsare nowusedfornon-specificorpsychogenicpaindisorders. We typicallydonotsee these meds regularly here atPI. *= lowestrates of studiedinteractionswith various HIV meds;some are insufficientlystudiedtodate Selectiveserotoninreuptakeinhibitors (SSRIs)workbyincreasingthe amountof serotonin,the neurotransmittermost associatedwithmood. Citalopram(Celexa)* Escitalopram(Lexapro)* Paroxetine (Paxil) Fluoxetine (Prozac) Fluvoxamine (Luvox)
- 2. 2 Sertraline (Zoloft)* Side Effects:Sexual problemsincludinglow sexdrive,ED, orinabilitytohave anorgasmare commonbut often reversible,dizziness,headaches,nausearightafteradose,insomnia,feelingjittery;some inducedmania(rare) Serotonin-norepinephrine reuptake inhibitors (SNRIs);increase the levelsof the neurotransmittersserotoninand norepinephrineinthe brain. Desvenlafaxine (Pristiq) Duloxetine (Cymbalta) Venlafaxine(Effexor) Side Effects:drowsiness,fatigue,blurredvision,lightheadedness, strange dreams,constipation,fever/chills, headache,drymouth,nausea,+/- appetite,sweating,BPchange (Cymbalta) Serotonin modulatorsandstimulators (SMSs);thesedrugsactpartly as serotoninreuptakeinhibitors andagonize or antagonize various serotoninreceptors. Vilazodone(Viibryd) Vortioxetine(Brintellix) Others Remeron(Mirtazapine) Wellbutrin(Buproprion) Buspar (Buspione) Ketamine Almostanymedicationinvolvedwithserotoninregulationhasthe potentialtocause serotonintoxicity (serotonin syndrome) –markedbysome of the following: mania,restlessness,agitation,emotionallability, insomniaandconfusion. Althoughserious,itisnotcommon,generallyonlyappearingathighdosesorwhile on othermedications. Pregnancycontraindications –determiningextentisdifficultaspregnanciesduringdepressionare atsome risk anyway. Discontinuationsyndrome –veryrare withnewermedications(v.TCAsandMAOIs). Suicidal thoughts/behaviors –rare, butreported,esp.inthose under24yo;overall though,+ outweigh -. MOOD STABILIZERS These are usedto treat mooddisorders characterizedbyintense andsustainedmoodshifts, typically bipolardisorder, but alsoother/similarcyclicmooddisturbances.AlsousedintreatingborderlinePDandschizoaffective disorder.Mood stabilizers includemineral,anticonvulsant,andantipsychoticmedications. Lithium-- needlabworkforlevels (therapeuticrange:0.6or 0.8-1.2 mEq/L) Lamictal (Lamotrigine) Tegretol (Carbamazepine) Depakene (Valproicacid),Depakote (divalproex sodium) Trileptal (Oxcarbazepine) Atypical Antipsychotics -- refertosubsequentsection Side effects:verymedspecificrangingfromlithiumtoxicityto skinconditionsandWBC. Combinationtherapy(atypical antipsychoticwithlithiumorvalproate) showsbetterefficacyovermonotherapy inthe manicphase. Most moodstabilizersare primarilyanti-manicagents,meaningthattheyare effective attreating maniaand moodcyclingand shifting,butare noteffectiveattreatingacute depression.Exceptions (becausetheytreat both) include lithium, Lamictal,andSeroquel. Still,antidepressants are oftenprescribedinadditiontomoodstabilizersduringdepressivephases.
- 3. 3 ANXIOLYTICS Whenyouare anxious,yourbrainbecomesmore active andnaturallyproducesachemical called gamma-aminobutyric acid (GABA) tomake youfeel calmer.Mostanxiolyticsworkbyboostingthisprocesshelpingtoproduce a feelingof calm,peace and overall safety. Alcohol alsoworksonGABA whichiswhyitis a primaryself-medicatingchoice for anxiety. Benzodiazepines Alprazolam(Xanax) - avoid Chlordiazepoxide(Librium) Clonazepam(Klonopin)* Clorazepate (Tranxene) Diazepam(Valium) Lorazepam(Ativan)* Oxazepam(Serax)* Temazepam(Restoril)* Triazolam(Halcion) –avoid Also,some SSRIs,Hydroxyzine,BetaBlockers,Neurontin;5-6othersrarelyusedandoftennot inUS Shiftseemstobe awayfrom benzos due todependenceissues (especiallythose thatactquicklylike Xanax) otherthan foracute anxietyorinlowerdoses orin some alcohol detox protocols;Rx prn longterm? More commonside effects,especiallyof highdoses, include drowsiness,headaches,memoryproblems(inhigh dosescan cause amnesticsyndromes),dizziness,feeling‘numb’,depersonalization/derealization,and dependence oraddiction. There isariskof a benzodiazepine withdrawalandreboundsyndromeafter continuoususage forlongerthantwoweeks,andtolerance anddependencemayoccurif patientsstayunder thistreatmentforlonger ANTIPSYCHOTICS Antipsychoticsworkbyalteringthe effectof neurotransmitters:serotonin,noradrenaline,andacetylcholine;however, dopamine isthe mainchemical thatthese medicines affect.Theycansuppressorprevent positive symptomslike a/v hallucinations,delusions,thoughtdisorder(associatedwithpsychoticspectrumdisorders),andextreme moodswings (associatedwithbipolardisorder).Firstgenerationones,introducedin1950s and used until early1990s were powerful tranquilizersassociatedwithadverse neurologicalside effects(TDandEPS – postural andmovementdisorders). Nowin additiontotreatingpsychoticsyndromes,theyare alsousedasadjunctive therapies(usuallyinlowerdoses) withan antidepressantformooddisorders. Atypicals - second generation Aripiprazole(Abilify) Lurasidone (Latuda) Olanzapine (Zyprexa) Quetiapine (Seroquel) Risperidone(Risperdal) Ziprasidone (Geodon) Asenapine (Saphris) Paliperidone (Invega) Side Effects: all atypical antipsychoticscarrythe possible riskforcausingweightgainandraisingbloodsugar, cholesterol,andtriglyceride levels,whichmustbe periodicallymonitoredduringtreatment. Some antipsychotics -- typical and atypical -- can cause heartrhythm problemsthatmayrequire monitoringbyadoctor.
- 4. 4 HYPNOTICS(sleep) Alsocalledsoporificdrugs,thisisa classof psychoactive drugs whose primaryfunctionisto induce sleep andtobe used inthe treatmentof insomnia,earlyandmiddle. Include barbituates,quinazolinones,benzodiazepines,atypical antipsychotics,antidepressants,antihistamines,andthese more familiar: Zolpidem(Ambien);Zolpidem(Intermezzo) Zalepon(Sonata) Eszopiclone (Lunesta) Ramelteon(Rozerem) Rozeremisdifferentinthatisdoesnot bindtoGABA like the others,butratherto melatoninreceptors. Adverse side effectsincludedrowziness,dizziness,hangover,anddependence.Some of these,especiallyAmbien,are molecularly verysimilartobenzos,thusriskof misuse anddependence.Controversyre:forshorttermrelief ormaintenanceinlong term. PARTII: HIV-PSYCHOTROPIC INTERACTIONS Beginswithhepatic(liver) metabolism;InPhase I, Cytochrome P450 isthe mostcrucial. Cytochrome P450 systemisaffectedbyage,hormones,nutrition,drughalf-life,stress,drugdosages,hepatic bloodflow,andliverdisease In HIV care, Norvir(ritonavir) isthe biggestoffender(causesmostinteractions) Three importantterms: Substrate - any drug metabolizedbyP450 enzymes Inhibitor- anydrug that inhibitsthe metabolismof aP450 substrate (strong,moderate,weak) Inducer- anythingthatincreasesthe amountof P450 enzymes(strong,moderate,weak) Three waysinteractionsoccur: Addinhibitororinducertoexistingregimencontainingasubstrate drug Withdraw inhibitororinducerfromexistingregimencontainingasubstrate drug Addsubstrate drugto a regimencontaininganinhibitororinducer Thisarea of clinical researchandknowledge isvastandgrowing.Forus,we needtorememberthatmostinteractions are notclinicallysignificant;however,theydooccurandare oftenhighlyidiosyncratic/individualistic.Itis Impossibleto memorize all interactions,sowe refertoexcellentresourcessuchas: www.madisonclinic.org http://hivinsite.ucsf.edu/arvdb?page=ar-00-02 http://www.columbia.edu/cu/hivmentalhealthtraining/pdf/Drug_Interactions.pdf http://nynjaetc.org/documents/2013_PsychGuide_WEB.pdf
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- 6. 6 PARTIII: QUESTIONS FOR COUNSELORS AND THERAPISTS Often,the firstmentionof psychotropicmedicationcomesfromthe counselorortherapistwhoknowsthe client’s historyandcurrent symptompicture best.Inthisrole,the counselorortherapistservesasthe bridge orliaisoninthe relationshipbetweenthe clientandthe prescribing physician.Thus,we are ina positiontobe askeda lotby clients,but alsoto be helpful andfacilitative tophysicians. Some waystoenhance these skills: Be able topresentan accurate and concise case presentation,if able.(Thistakestrainingandpractice,butis very appreciatedbythe doc…).Or if not referringinperson,be able tostate specificclinical issues, emotional/cognitive/behavioral disturbances thatyoufeel maybenefitfromfurtherevaluation.Avoid phrasing referralsvaguely,forexample:“seemsdepressed,please evaluate…” Take time to followupwiththe prescribingphysician,atminimumtothankhim/herforthe assistance,butalso to reportwhat changesyouare noticinginthe clientovertime. You don’tneedtoplayphysician,PA,ornurse,butit’sveryhelpful tobe an informativetherapistwithgood knowledge of history,especiallyprior medications,adherencehistory/pattern,andanysubstance abuse/addictionissuesthatthe clientislikelytominimize oravoidintheirconsultation withthe physician. Consultthe pharmacist;oftenmore knowledgeable andlesstime-pressured thanphysicians;notcriticizing,just theirtraining/FTjob.Underutilizedresource! Expandor include youreducationaboutmulticultural issuesastheyrelate topsychiatryandmedications. Dependingonnationality,culture,orlevelof acculturation,some clientsperceive psychiatristsasa lastresort for “crazy people”andyouwill encounterresistance. Alternatively,some culturestendtodescribe their psychological paininsomaticorphysical terms.Inthiscase,providingaconsultationwitha“real doctor”could be helpful andavaluable in-road. It’s importantforus to be readyto facilitate answeringquestionsclientsmighthave aboutmedications,especiallyif they are unfamiliarwithpsychiatry orare relativelyuneducatedorbiasedagainst psychotropicmedications. There are no specific,completelyrightor wrong answers to the questions below,and each clientisunique.But there are some good responses.Let’swork togetherto see how we might approach them. Why doI needmedication?AmI thatbad/crazy? How doesthismedicationwork;howwillithelpme? Will thismedicine allowme tofeel atall?Idon’twant to be a robot or “un-feeling.” How longdoI have totake it?I don’twant to be on psychmedicationforthe restof my life. What are the side effectsof thismedicine?Will itmake myHIV (orother medical condition) worse? What if it doesn’twork/help?ThenwhatdoIdo? Can I stopit if I want to? Isthismedicationaddictive? What if the doctor justkeepsaddingother medicinestotreatthe side effectsof the original one? Is itexpensive?HowamI goingto payfor this? Aren’tthere more natural or homeopathicthingsforme totake? Othersyouhave encountered?... Acknowledgements: Murray Bennett, MD, FRCPC; Director Psychiatry Madison Clinic and Harborview Medical Center Karina K. Uldall, MD, MPH; Department of Psychiatry, UW School of Medicine Neil E. Whicker, MD, Grady Infectious Disease Program, Emory University