PIPC ® Psychiatry In Primary Care Medications Robert K. Schneider, MD Departments of Psychiatry,...

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