pipc ® psychiatry in primary care medications robert k. schneider, md departments of psychiatry,...
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PIPC® Psychiatry In Primary Care
MedicationsRobert K. Schneider, MD
Departments of Psychiatry, Internal Medicine
and Family Practice
The Medical College of Virginia at
the Virginia Commonwealth University
Richmond, Virginia
PIPC® Goals
• Effectively recognize, diagnose and treat mental illness in primary care
• Bring the psychiatry skills and knowledge base of the primary care physician on par with other medical specialty knowledge bases
Outline
• PIPC 1– Introduction
– PIPC® Interview– MAPS-O®
– Mood Disorders
– Suicide
Outline
• PIPC 2– Anxiety Disorders
• PIPC 3– Neurotransmitters
– The 3 Phases and the 5Rs
– Medications
– Cases and Discussion
NEUROTRANSMITTERS
Decreased state due to up-regulation of receptors
Neurotransmitter Receptor Hypothesis Neurotransmitter Receptor Hypothesis of Antidepressant Actionof Antidepressant Action
6-2 Stahl S M, Essential Psychopharmacology (2000)
6-5 6-6
Stahl S M, Essential Psychopharmacology (2000)
Antidepressant blocks the reuptake pump, causing more
NT to be in the synapse
Neurotransmitter Receptor Hypothesis Neurotransmitter Receptor Hypothesis of Antidepressant Actionof Antidepressant Action
Increase in NT causes receptors to down-regulate
receptor sensitivity
6-1 Stahl S M, Essential Psychopharmacology (2000)
amount of NT
clinical effect
antidepressant introduced
The 3 Phases and 5 Rs
• Acute
• Continuation
• Maintenance
• Response
• Remission
• Relapse
• Recovery
• Recurrence
DEPRESSION
NORMAL MOOD
RECOVERY OR REMISSION
EPISODE OF DEPRESSIONEPISODE OF DEPRESSION
TIME6 - 24 months
5-1 Stahl S M, Essential Psychopharmacology (2000)
acute 6 - 12 weeks
continuation4-9 months
maintenance1 or more years
REMISSION
RECOVERY
DEPRESSION
NORMAL MOOD
100%
5-3 Stahl S M, Essential Psychopharmacology (2000)
TIME
5-4 Stahl S M, Essential Psychopharmacology (2000)
acute 6 - 12 weeks
continuation4-9 months
maintenance1 or more years
TIME
DEPRESSION
NORMAL MOOD RELAPSE RECURRENCE
Acute Phase Treatment• Focus is response and full remission
• establish target symptoms
• patient preference, “collaborative approach”
• Psychotherapy especially helpful in chronic
depression or depression exacerbated by recent
stressors
• Acute phase is over ONLY after a remission is
achieved
DEPRESSION
NORMAL MOOD
RESPONSE
RESPONSE
5-2 Stahl S M, Essential Psychopharmacology (2000)
Changing the Medication• “Pseudoresistance”
– Verifying Compliance (“like an antibiotic”)– “Too little, too late”– Inadequate duration– Correct diagnosis (undetected comorbid diagnosis)
• Worsening Condition– severity escalating
– new symptoms developing (destructive impulses)
• Partial Remission vs. Full Remission
Continuation Phase Treatment• Focus is to prevent relapse
• Period of time following full remission during
which discontinuation of treatment will result
in relapse
• Don’t stop before 6-9 months of therapy
• Don’t decrease the dosage
• Full Dosage, for the Full Period of Time
5-4 Stahl S M, Essential Psychopharmacology (2000)
acute 6 - 12 weeks
continuation4-9 months
maintenance1 or more years
TIME
DEPRESSION
NORMAL MOOD RELAPSE RECURRENCE
Maintenance Phase Treatment
• Focus is to prevent recurrence
• Recurrence can only occur after the
recovery from a previous episode
• Therefore only recurrent major
depression is considered
• Maintain Full Dosage
Termination vs. Maintenance
• Degree of Functional Impairment
• Additional non-affective mental disorder
• Chronic medical disorder
• Prior history of depressive episode
1 episode: 50-80%
2 or more episodes: 80-90%
• Persistence of dysthymic symptoms
5-4 Stahl S M, Essential Psychopharmacology (2000)
acute 6 - 12 weeks
continuation4-9 months
maintenance1 or more years
TIME
DEPRESSION
NORMAL MOOD RELAPSE RECURRENCE
MEDICATIONS
General Considerations
• Three Neurotransmitters– Serotonin– Norepinephrine– Dopamine
• Three major sites of action– Reuptake pump– Post-synaptic receptor– MAO enzyme inhibition
Common Classes
• TCAD– NE and 5HT Reuptake inhibition
• SSRI– 5HT Reuptake inhibition
• “Less Selective” Reuptake inhibition– DA and NE (buproprion)– 5HT and NE (venlafaxime)
• Post synaptic receptor blockade– Trazodone, nafazodone
Norepinephrine and Serotonin Reuptake Inhibitors: TCAD
• Classic Tricyclic Antidepressants–amitriptyline (Elavil)
–clomipramine (Anafranil)
–desipramine (Norpramin)
–imipramine (Tofranil)
–nortriptyline (Pamelor)
Norepinephrine and Serotonin Reuptake Inhibitors: Effects
• Primarily blocks reuptake of norepinephrine, serotonin and weakly dopamine
• Effective in severe depression and anxiety disorders
• Sedating properties, reduces pain and stimulates appetite
• Nortriptyline level is a meaningful measurement
Norepinephrine and Serotonin Reuptake Inhibitors
• Side Effects– urinary retention, constipation, blurred vision,
dry mouth, weight gain, sexual dysfunction
– orthostatic hypotension, delayed cardiac conduction
• Cautions– the elderly
– cardiac patients
Selective Serotonin Reuptake Inhibitors
• Classic SSRIs
–sertraline (Zoloft)
–fluoxetine (Prozac)
–paroxetine (Paxil)
–citralopam (Celexa)
Selective Serotonin Reuptake Inhibitors: Effects
• Selectively blocks the serotonin reuptake pump
• Mild to moderate depression (max doses in severe)
• Safer in overdose
• Indicated for anxiety disorders
Selective Serotonin Reuptake Inhibitors: Side Effects• Side Effects
– nausea, headache– jitteriness and insomnia (especially early)– sexual dysfunction– “Discontinuation Syndrome”
• Cautions– very few – notable exception: Serotonin Syndrome
Less Selective Reuptake Inhibitors
• Serotonin, Norepinephrine and mild
Dopamine Reuptake Inhibitor
–venlafaxine (Effexor)• Dopamine, Norepinephrine and mild
Serotonin Reuptake Inhibitor
–bupropion (Wellbutrin)
Serotonin, Norepinephrine & Mild Dopamine Reuptake Inhibitor
• venlafaxine (Effexor)– Effects
• blocks reuptake of serotonin, norepinephrine and dopamine (mildly)
• antidepressant effects and anxiolytic properties
– Side Effects• nausea, somnolence, dry mouth, constipation,
nervousness, dizziness• risk of increased blood pressure
Dopamine, Norepinephrine & Weak Serotonin Reuptake Inhibitor• bupropion (Wellbutrin)
– Effects• moderate dopamine reuptake inhibition,
norepinephrine reuptake inhibitor (bupropion metabolite), and weak serotonin reuptake inhibition
• antidepressant, antismoking, NOT ANXIOLYTIC– Side Effects
• agitation, tremor, insomnia, headache, constipation• increased risk of seizures at doses above 450mg/day• minimal sexual dysfunction, cardiac complications,
or weight gain– Cautions
• history of seizures or previous head trauma
Postsynaptic Serotonin Inhibition
• Serotonin (postsynaptic 5HT-2 inhibition)– trazodone (Desyrel)– nafazodone (Serzone)
Postsynaptic Serotonin Inhibition
• trazodone (Desyrel)– Effects
• sedating, good hypnotic• Post synaptic receptor blockade, weak SSRI
– Side Effects• difficult to get to high enough doses for depression• sedation, dry mouth, orthostasis, priapism (very rare)
• nafazodone (Serzone)– Effects
• effective antidepressant• good anxiolytic, effective in the anxious depressed• Post synaptic blockade, moderate SSRI
– Side Effects• sedation (much less than trazodone), nausea, visual
disturbances, lightheadedness
CASES