Uncovering the Mysteries of Psychiatry

1. Uncovering the Mysteries of Psychiatry Nancy Gerrard June 8, 2014

2. Today’s review: • Alternative treatments for depression • 3 new medications • Drugs of abuse

3. OUR clientele • Young adult years have also been called the • AGE of INSTABILITY • EMERGING ADULTHOOD • Children and adolescents increasingly take antidepressants (1/13 on psych meds) • Thin line between diagnosing depression and teaching youth to view any emotional upset as pathological • NY Times, Iarovici, April 2014

4. OUR Clientele • Patients I see at the University Health Center: • Anxiety • Depression • Bipolar disorder • First episode psychosis • Obsessive Compulsive Disorder • Eating disorders • ADHD • Transgender clients

5. Depression Alternative therapies

6. Depression • Depressed mood most of day • Diminished interest in pleasurable activities • Decrease or increase in appetite • Insomnia or hypersomnia • Psychomotor agitation or retardation • Fatigue or loss of energy • Feelings of worthlessness or excessive guilt

7. Depression (cont) • Diminished ability to think or concentrate • Recurrent thoughts of death, recurrent suicidal thoughts or attempts • These symptoms occur nearly every day and they cause clinically significant distress or impairment in social, occupational or other important areas of functioning.

8. Depression – what causes it?? • Genetics • Situational (life events and environmental stress) • Personality or temperament • Biological/medical factors • Drug/alcohol induced

9. Standard treatment for depression • Therapy • Medications • Combination of therapy and medication • Hospitalization

10. Medications for depression • Prozac • Paxil • Zoloft • Celexa • Lexapro • Cymbalta • Effexor • Pristiq • Wellbutrin

11. Treatments for depression Sleep Healthy diet No alcohol or drugs Limit caffeine use Get outside for natural light at least 20 minutes per day Exercise daily Socialize with positive people

13. Bright light therapy Hastens the effects of antidepressant drugs Rapid onset of antidepressant action Antidepressant effects mediated through eyes Useful as a nonpharmacological intervention during pregnancy

14. Bright light therapy Use a light box with full spectrum light – 10, 000 lux Time with patient’s circadian phase of melatonin secretion (7.5-9 hrs after evening melatonin secretion Rare side effects such as: headache, eyestrain, nausea, and agitation

15. Transcranial Magnetic Stimulation • Approved for treatment resistant depression • Electromagnetic coil placed against scalp and delivers pulses • Session is between 30-50 minutes • Treatments are 5x week for 4-6 weeks • Occasional headache after treatment • Some insurance coverage

16. Alternative Treatments Deep brain stimulation (same as what is used for Parkinsons) Electroconvulsive therapy (ECT) Sleep Deprivation (still being studied)

17. Alternative Therapies • L- methylfolate or Deplin • A form of folate that can cross blood brain barrier • 70% of depressed persons have a genetic factor that limits their ability to convert folic acid or folate in food to l-methylfolate. • L-methylfolate regulates neurotransmitter production • Used as an adjunct to antidepressant medications

18. Alternative Therapies • St John’s wort – antidepressant effects (mild to modest effects) • SAMe – possible benefit for depression • Omega 3 – possible benefit for depression • Melatonin- possible benefit for depression but can improve sleep

19. Mind Body Therapies • Psychotherapy • Visualization • Journaling • Meditation • Acupuncture

20. New Medications

21. 3 New Medications

22. New medications Fetzima – antidepressant Works on norepinephrine and serotonin In same family as cymbalta, pristiq, effexor

23. New medications Latuda– atypical antipsychotic Using for mood stabilization, psychosis, adjunct for depression Same family as Abilify, Geodon, Zyprexa, Seroquel

24. New medications Brintellex – antidepressant Works on serotonin but several different receptors involved. Less weight gain and less sexual side effects reported

25. Drugs of Abuse

26. Alcohol • Most frequently used drug by teens • ½ of jr high students drink monthly • 14% of teens intoxicated at least 1x in past yr. • 8% of teens who drink, drink 5+ drinks

27. Alcohol • Underage drinking attracts many developing adolescents • Peer pressure • Increased independence • Easy access • Increased stress

28. Alcohol Dangers • Lowers attention/car accidents • Decreases memory • Tend to mix with other drugs – DANGER • Intoxication associated with suicides and suicide attempts • Males tend to complete less yrs of education if abusing alcohol • Drinking increases risk of engage in unsafe sexual practices, or victimization • Brain is still developing in adolescents

29. Students at risk with alcohol • Family history of alcoholism • Genetics • Environment • Family problems • Peers abusing alcohol • Psychiatric problems • Personality (risk takers)

30. Marijuana • Dried flowers, leaves, stems, seeds from hemp plant Cannabis Sativa which contains THC • Most common illicit drug used in US • Hand rolled in cigarettes or used in pipes or water pipes (bongs). • Can also be mixed in food or brewed as a tea

31. Marijuana effects on body • THC rapidly passes through lungs into blood which carries chemical to brain and other organs • Influences pleasure, memory, thinking, concentration, sensory, and time perception • Can affect brain development in young people – affects thinking and memory • Increases HR by 20-100% which can last 3 hrs. • Increased risk of heart attack

32. Marijuana effects on body • High doses of marijuana can cause a temporary psychotic reaction (hallucinations and paranoia) • Possible link between marijuana and later development of psychosis • Long term marijuana users trying to quit have irritability, sleeplessness, decreased appetite, anxiety, drug craving

33. Potency of marijuana • In 1980, the concentration of THC in marijuana was 4% • In 2012, the concentration of THC in marijuana was around 15%

34. Stimulant abuse • Big problem on college campuses • Stimulants cannot make you smarter! • Persons like to go after the “rush” or the “high” that stimulants can give • Also allow to stay awake all night to study • Statistics are hard to find for the amount of abuse

35. Synthetic/Designer Drugs

36. Synthetic/designer drugs Labeled as not for human consumption Camouflaged under names such as stain remover, insect repellant Active ingredients are a moving target Grown in popularity due to representation as legal and their limited detection by standard tests May present with s/s that resemble psychiatric disorders such as schizophrenia, anxiety, depression Longterm consequences relatively unknown

37. Bath salts First used in US in July 2010 Cheap ($20-50 per 50mg packet) Users predominantly young and male Often coingested with marijuana, alcohol, opiods

38. Bath Salts Contain ingredients similar to ecstasy, methamphetamine, cocaine Contains cathinone in khat plant Increase in serotonin, dopamine, norepinephrine

39. Bath Salts Names • Purple wave • Zoom • Cloud Nine • Lunar Wave • White Lightening • Scarface • Vanilla Sky • Bloom

40. Bath Salts • Cause a surge in dopamine • Also surge in norepinephrine

41. Bath Salts Desired effects: Euphoria Alertness Increased sociability Increased empathy Intensification of sensory experiences Sexual arousal

42. Bath Salts Adverse effects Tachycardia Hypertension Hyperthermia/sweating Mydriasis Seizures/spasms Respiratory distress Death

43. Bath Salts Behavioral side effects Panic attacks Agitation Hallucinations/psychosis/paranoia Aggression Self mutilation Insomnia Depression

44. Bath Salts May be inhaled, injected, snorted, swallowed , or inserted into rectum or vagina Effects occur with doses of 2-5mg Typical dose is 5-20mg Effects occur 10-20 minutes after ingestion Desired effects last 2-4 hrs

45. Bath Salts Addiction potential: strong urge to re-dose occurs 20-30” after ingestion May be 10x more addictive than methamphetamine in rat studies

46. Bath Salts What to look for: May mimic a psychiatric disorder Disorientation/agitation Dilated pupils with nystagmus Lockjaw and teethgrinding Rapid, loud, incoherent speech Emotional, verbal, physical abuse Negative results on standard urine toxicology but developing new testing

47. Bath Salts Treatment Mainly supportive Sedatives (benzodiazepines) Monitor for respiratory depression Antipsychotics Physical restraints may be necessary Lab work may show elevated liver enzymes Inderal for BP, tachycardia, tremors, sweating

48. Molly • Pure form of MDMA or Ecstacy • Many more times potent than MDMA • Popular • Makes it feel as if “everything is right with the world”, euphoria • Usually taken as tablet or capsule • Surge of serotonin – emotional closeness, sexual arousal • Negative: confusion, depression, sleep problems, anxiety

49. Spice/K2 Synthetic cannabinoids

50. Spice/K2 Designed to mimic THC (tetrahydrocanninol) Carry a higher risk of causing psychois 1st appeared in US in 2008 77% of users are male Inhalation most common route of administration $10-20 per gram (usual dose is 0.3g)