Depression and Psychopharm

1. Depression and Psychopharm How Medications work and which to choose

3. Suicide (approximately 1 in 10 of those with depression) Antoine Wiertz (1806-1865) http://www.modjourn.brown.edu/mjp/Image/Wiertz/Wiertz.htm

5. Your client may need a medication consultation for anti-depressants if: • Not so much a characterological depression as a physiological depression • Sleep, sex, and/or appetite disturbance • Fatigue • Agitation or psychomotor retardation • Anhedonia • Dysthymia is really sucking the energy out of them • Grief/heartbreak becomes depression • Psychotherapy isn’t helping • Suicidality • Daily functioning is markedly impaired • Always assess for Hypomania and Mania

6. Anti-depressants Cymbalta No prescription is required as we ship from outside the United States.

7. Antidepressants: Have only been around since the 1950’s Fall into categories: MAOIs TCAs SSRIs Atypical: SNRI, NSRI, etc.

8. MAOIs (antuberculosis) • Powerful Antidepressants that also work with panic disorder and social phobia • The original Antidepressants • Inhibit enzymes that destroy serotonin, norepinephrine, and Dopamine

9. Problems with MAOIs • Foods rich in tyramine are fatal • Avoid aged cheese; aged or cured meats (e.g., air-dried sausage); any potentially spoiled meat, poultry, or fish; broad (fava) bean pods; Marmite concentrated yeast extract; sauerkraut; soy sauce and soy bean condiments; and tap beer. • Listed in book

10. TCAs • Some work as anti OCD and Antipanic • Block reuptake pump for 5HT, NE, and to a lesser extent Dopamine. (level of blockage for each NT is dependent on the medication) BUT ALSO……

11. TCAs: • BLOCK • Muscarinic Cholinergic receptors • Dry mouth, blurred vision, urinary retention, constipation • H1 Histamine receptors • Sedation and weight gain • Alpha 1 adrenergic receptors • Hypotension and dizziness • Sodium channels in the heart and brain • Overdose will cause seizures, cardiac arrest, or arrhythmias

12. Selectivity and the SSRIs • Depending on where the neuron goes and what receptors are blocked will change the effects of the drug • Currently we can’t control where the drug goes in the brain, but selectivity demonstrates better control over which receptors are blocked

13. SSRIs • Block serotonin reuptake selectively-thus limited danger in overdose • Less side effects (only 5HT ones such as nausia, insomnia, headache, gastrointestinal, sweating, anxiety, restlessness • Initial anxiety and difficulty with sleep is common • AND…sexual side effects are a big problem • Additional difficulties into tx of fatigue and apathy should be monitored and treated with adjunct medication…For example Dopamine or NE meds….

14. The current hypothesis is: People may have a NE deficiency and show symptoms of • Poor attention • Poor concentration • Poor working memory • Poor speed of information processing • Psychomotor retardation • Fatigue • Apathy • Depressed mood

15. Or a 5HT deficiency and have symptoms of • Depressed mood • Anxiety • Phobias • Panic • OCD symptoms • Food cravings and Bulimia • How does this knowledge help you help your client?

16. Other antidepressants • SNRIs block 5ht and NE reuptake • NRIs block NE reuptake (not available in US) • Atypical: Welbutrin (works on Dopamine and NE in complex way), Serzone (off the market), BuSpar, Remeron (no sexual, anxiety or nausia, but weight gain and sedation), Effexor (1:30), Milnacipran (1:3) (not in us), and cybalta • 1 + 1 = 3

17. Other notes • Trazodone: For sleep, reduces SSRI side effects of insomnia and agitation and enhances SSRI effect • Can cause priapism in men • Can cause nightmares • What diagnosis would caution the use of this medication Keep in mind that because SSRIs inhibit enzyme 2D6, they increase levels of TCAs in Plasma

18. Some bad mixtures • Luvox with atypical antidepressants, theophylline (for chronic asthma), and even caffeine can lead to seizures • Prozac and Luvox inhibit enzyme 3A4; Xanax, Halcion, and Propulsid (heartburn) are substrates of 3A4 and can become toxic causing cardiovascular trouble or sudden death

19. Other Issues • Drugs can increase (induce) enzymes in the liver too. • For example: Tegretol induces 3A4 and is broken down by 3A4. Thus doses must be monitored and increased to avoid breakthru symptoms • And if Tegretol is stopped, any other drug metabolized by 3A4 will increase their concentration in the plasma (217)

20. Did I cover these topics? Luvox,- addresses ruminations and OCD symptoms Welbutrin and other drugs for sexual side effects Reboxitine Stimulants Providual, Lexapro, Paxil & Luvox (ACH)

21. Poor medication adherence is prevalent 1 out of 3 did not take antidepressant as directed within the first 30 days More than half (56%) did not adhere within four months! Reasons for non-adherence Side effects Belief that meds were not necessary Medication not working Forgot to take meds. Cost ($75 to $250/month) Primary Care Patients with Depression

25. If clinicians closely monitor/manage side effects: • It may enhance compliance with medication • Adequate dosing = better for patient • Patients may not prematurely abandon therapy

27. Sexual Dysfunction During Antidepressant Treatment • Is a huge problem and underreported in studies. Studies are less likely to address effects in women, which are different than in men • Diminished or absent libido • Arousal difficulties • Erectile dysfunction (in men) • Delayed orgasm • Anorgasmia • Or...undesirable sexual arousal and hypersexuality • Sexual partner may not understand

28. Potential Consequences of Sexual Dysfunction • Psychological distress • Reduced quality of life • Self-esteem plummets • Sexual partner still doesn’t understand and relationships may dissolve with blame • Diminished motivation to get intimate with people • Non-compliant with medication

36. A major obstacle in effective treatment of depression (and other disorders) is medication non-adherenece. • What do you do about it? Follow through with your clients! • Tell them what you know • Help them formulate what they’d like to discuss with doctor • Call or ask them to call a doctor and make an appointment • Obtain a release to talk to client’s doctor • Call doctor to introduce self and collaborate treatment

37. So your client has a prescription for anti-depressant medication • Ask client for name and dosage • Assess client’s attitude, feelings, and thoughts about prescription • What is client’s response to meds? • Discuss side effects, discuss research, discuss options…discuss… • Encourage them to keep in contact with physician

38. Race and Anti-depressants • Comparative, two month, pilot study investigating efficacy of Zoloft (Sertraline) found individuals (n=20) with a Chinese heritage: • Responded at a lower dose than Caucasians • One study (Melfi et al. 2000) found that African-Americans/blacks were less likely than whites to receive an antidepressant when their depression was first diagnosed (27% versus 44%). • Of those who did receive antidepressant medications, African Americans were less likely to receive the newer selective serotonin reuptake inhibitor (SSRI) medications than were the white clients. • African-Americans may require lower doses of medication because of metabolic differences (most research has been done on white populations e.g., heart disease study) http://www.depressionet.com.au/articles/251004efod.html

39. Latinos and Mental Health – Study’s show… • Fewer than 1 in 11 contact mental health specialists, while fewer than 1 in 5 contact general health care providers. • Among Latino immigrants with mental disorders, fewer than 1 in 20 use services from mental health specialists, while fewer than 1 in 10 use services from general health care providers (Mental Health, 2001). • One study found that 24 percent of African-American/Blacks, & Hispanics with depression and anxiety received appropriate care, compared to 34 percent of Whites. • Another study found that Latinos who visited a general medical doctor were less than half as likely as Whites to receive either a diagnosis of depression or antidepressant medicine. • Further…..

40. Physician-patient communication and Hispanic ethnicity • Physicians were more likely to state information to patients who started on new anti-depressants • Physicians were more likely to give information about anti-depressants to Whites than to Hispanics • 1 in 5 patients were asked how well their anti-depressants were working • 1 in 10 patients were asked if they were experiencing side effects • Hispanics were less likely than Whites to talk about their anti-depressants • Remember that research is rarely racially specific. • What does this implicate in working with Diverse Populations? Sleath B, Rubin RH, Huston SA Compr Psychiatry. 2003 May-Jun;44(3):198-204

41. Discuss/role-play how these client factors may affect how you communicate about depression and anti-depressants • Sex and Gender • Age • Race • Ethnicity • Nationality • Religion • Learning style • Socio-economic status • Personality and attitude about medication

42. Latinos and Suicide • In 2001, Latinos had a suicide rate of 5 per 100,000 compared to nearly 12 per 100,000 for Whites. • However, in the 2003 Youth Risk Behavioral Surveillance System, Latino students (10.6 percent) were more likely than White students (6.9 percent) to have reported a suicide attempt. • Latino students were more likely to have made a suicide plan (17.6 percent) than White males (16.2 percent). • Latino female students (5.7 percent) were significantly more likely than White female students (2.4 percent) to attempt suicide and require medical attention.