Educational Objectives:
|
|
- Martin Kelly
- 5 years ago
- Views:
Transcription
1 Managing Depression in Primary Care Primary Care Medicine: Principles and Practice October 2011 Descartes Li, M.D. Clinical Professor University of California, San Francisco Educational Objectives: By the end of the presentation, a participant will be able to: 1) Choose antidepressant based on side effect profile 2) Manage common antidepressant related side effects 3) Understand risks of Osteoporosis, GI bleeding, QTc prolongation, and Suicide with antidepressants Outline Relevant Disclosures none Current Controversies Overview of Antidepressants Antidepressants: Selection and Side Effect Management Non-pharmacological treatments Osteoporosis, GI bleeding, QTc, and Suicide Questions and Summary 1
2 Outline The Crazy State of Psychiatry, by Marcia Angell Current Controversies Overview of Antidepressants Antidepressants: Selection and Side Effect Management Non-pharmacological treatments Osteoporosis, GI bleeding, QTc, and Suicide Questions and Summary How generalizable are study findings? In one study of psychiatric outpatients, only 41 (12%) of 346 patients would have been eligible for typical research studies. Zimmerman M et al. Are subjects in pharmacological treatment trials of depression representative of patients in routine clinic practice? Am J Psychiatry. 2002;159(3): Turner E et al. Selective Publication of Antidepressant Trials and Its Influence on Apparent Efficacy. NEJM (3): 252 2
3 In Defense of Antidepressants American Psychiatric Association Practice Guidelines for Depression Agency for Health Care Policy and Research, Clinical Practice Guidelines Cochrane Review ab html In Defense of Antidepressants, by Peter Kramer (The New York Times, July 9, 2011) Bottom Line: For mild depression, watchful waiting is a reasonable option Outline Current Controversies Overview of Antidepressants SSRIs Other Antidepressants TCAs MAOIs Antidepressants: Selection and Side Effect Management Non-pharmacological treatments Osteoporosis, GI bleeding, QTc and Suicide Questions and Summary SSRI s (selective serotonin reuptake inhibitors) First line Fairly safe in OD 9m minimum duration of treatment Fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), citalopram (Celexa), escitalopram (Lexapro) SSRI: Side Effects Categories Early and frequently transient Early and persist: sexual dysfunction Gradually and accrue: weight gain 3
4 Early and Transient Examples: Nausea or dull headache Jitteriness Gi upset Early and Transient Strategies: Start low and go slow Reassurance For anxiety/nervousness: add lowdose benzodiazepines For sedation: see later Furukawa, T A, Streiner, D L, & Young, L T. (2001). Is antidepressant-benzodiazepine combination therapy clinically more useful? A meta-analytic study. Journal of affective disorders, 65(2), Second Generation Antidepressants Buproprion (Wellbutrin): Low rate of sexual side effects or wt gain, Assoc. w/ increased rate of seizures, not for pts w/ eating d/o or prior sz d/o Second Generation Antidepressants Duloxetine (Cymbalta): mixed NE and 5HT activity, Alleviates pain of diabetic neuropathy and fibromyalgia Kajdasz DK et al, Clin Ther 2007;29 Suppl:
5 Second Generation Antidepressants Second Generation Antidepressants Mirtazapine (Remeron): sedation and weight gain Nefazodone (Serzone): 5-HT2 blocker,?for anxious depression black box for liver failure (1/250K pt-yrs) low rate of sexual se s Second Generation Antidepressants Second Generation Antidepressants Trazodone (Desyrel): usually prescribed as a hypnotic Warn about priapism Venlafaxine (Effexor): Mixed NE and 5HT activity increases BP similar side effect profile to ssri s significant withdrawal syndrome 5
6 Tricyclic Antidepressants (TCA s ) NE reuptake inhibitors anticholinergic side effects, orthostatic hypotension, tremor, weight gain, sexual side effects, cardiac conduction delay (quinidine like effect) Note: Duloxetine, a newer dual action antidepressant, has more equal 5HT and NE effects across its dosage range. Examples [not a complete list]: amitriptyline (Elavil), doxepin (Sinequan), imipramine (Tofranil), desipramine (Norpramin), nortriptyline (Pamelor, Aventyl), maprotiline (Ludiomil) Monoamine-oxidase inhibitors (MAOIs) Who was Libby Zion? Prevalence of MAOI usage Psychiatrists who had prescribed MAOIs Never 12 Not for at least three years 27 Between one to three years ago 17 Between three and 12 months ago Percentage (N=573) 14 Within last 3 months 30 Balon R et al. A Survey of Prescribing Practices for Monoamine Oxidase Inhibitors. Psychiatric Services 50: ,
7 Monoamine-oxidase inhibitors (MAOIs) Important: dietary restrictions! (b/o hypertensive crisis) Also drug-drug interactions Side effects: sedation, sexual side effects, weight gain phenelzine (Nardil), trancylopramine (Parnate), [selegiline (Eldepryl) for Parkinson s] MAOI Diet 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. Wine and domestic bottled or canned beer are considered safe when consumed in moderation. Refer to article and give handout to patient J Clin Psychiatry 1996 Mar;57(3): The making of a user friendly MAOI diet. MAOI Summary Make sure you look up dietary restrictions! SSRI s SGA ( Other ) Tricyclics MAOI s Antidepressants 7
8 Outline Current Controversies Overview of Antidepressants Antidepressants: Selection and Side Effect Management Sedation Sexual Dysfunction Weight Gain Non-pharmacological treatments Osteoporosis, GI bleeding, QTc and Suicide Questions and Summary As you write that Rx Patients told to stay on ADs for at least 6 months were three times more likely to continue their meds Discussing side effects was also associated with staying the course longer Bull SA et al. Discontinuation of use and switching of antidepressants: influence of patient-physician communication. JAMA 2002;288 (11): Case Vignette Depressed for 2 months, No medical problems, No comorbidities Which ONE of the following is the best medication intervention? a. Bupropion 150mg twice daily b. Duloxetine 40mg daily c. Fluoxetine 20mg daily d. Imipramine titrated up to 100mg at bedtime e. Venlafaxine 300mg daily How to pick antidepressant? 8
9 Current evidence does not warrant the choice of one antidepressant over another on the basis of differences in efficacy and effectiveness. Other differences with respect to onset of action and adverse events may be relevant for the choice of a medication. Gartlehner et al. Comparative Benefits and Harms of Second-Generation Antidepressants. Ann Intern Med. 2008;149: Choosing an Antidepressant is Not Based on Efficacy? Clinically important differences exist for both efficacy and acceptability in favour of escitalopram and sertraline. Sertraline might be the best choice Cipriani et al. Comparative efficacy and acceptability of 12 new-generation antidepressants: a multiple-treatments meta-analysis. Lancet 2009; 373: Do No Harm How to pick antidepressant? SSRI s and SGA s Safer than: Tricyclics MAOI s Patient preference Patient or Family history of response Clinician familiarity Comorbidities--Side effect profile 9
10 The person who takes medicine must recover twice, once from the disease and once from the medicine. Attributed to William Osler, MD The Maze of Mood Medications How do you choose? Food Fast Good Cheap Meds Sedation Sexual dysfunction Weight gain (Cheap) Of 401 out- patients taking SSRIs: Most Common drowsiness (38%) dry mouth (34%) sexual dysfunction (34%) Most Bothersome drowsiness (17%) sexual dysfunction (17%) weight gain (11%) N.B. Good side effect management means good follow-up! Hu, X H, Bull, S A, Hunkeler, E M, et al. (2004). Incidence and duration of side effects and those rated as bothersome with selective serotonin reuptake inhibitor treatment for depression: patient report versus physician estimate. J Clin Psychiatry, 65(7), Choosing an Antidepressant Side Effects Sedation/activation Sexual dysfunction Weight gain (Cost) 10
11 Case Vignette No medical problems Depressed for 2 months Hypersomnia Insomnia or anxious Activating Neutral or mixed Mildly to Moderately Sedating Strongly sedating Relative activation vs. Sedation modern antidepressants psychostimulants Bupropion Fluoxetine, Sertraline Venlafaxine, Escitalopram Citalopram Paroxetine, Fluvoxamine Nefazodone Tricyclics Trazadone Mirtazapine Kelly, K, Posternak, M, & Alpert, J E. (2008). Toward achieving optimal response: understanding and managing antidepressant side effects. Dialogues in clinical neuroscience, 10(4), Sedation Management Strategies Review other meds Switch from am to hs dosing Reduce dosage Switch to another AD?Consider psychostimulant: methylphenidate or dextroamphetamine or modafinil (this is off-label) Fava M et al, Ann Clin Psychiatry 2007;19 (3): Choosing an Antidepressant Side Effects Sedation/activation Sexual dysfunction Weight gain (Cost) 11
12 Case Vignette No medical problems Depressed for 2 months Fears loss of libido Sexual dysfunction is common Women: 43% total, 22% low libido, 14% sexual arousal problems, 7% pain Men: 31% total, 21% premature ejaculation, 5% erectile dysfunction, 5% low libido Remember to ask about sexual functioning beforehand Laumann EO et al, JAMA 1999;281(6): SEXUAL DYSFUNCTION Effect on sexual functioning DEPRESSION DECREASED LIBIDO AROUSAL DISORDER ANTIDEPRESSANT ORGASM DYSFUNCTION Increased? Neutral or mixed Common Psychostimulants Bupropion Nefazadone Mirtazapine Duloxetine Tricyclics Maoi s Ssri s,venlafaxine Segraves. J Clin Psychiatry Monogr Kelly, K, Posternak, M, & Alpert, J E. (2008). Toward achieving optimal response: understanding and managing antidepressant side effects. Dialogues in clinical neuroscience, 10(4),
13 Sexual Dysfunction Strategies Dose reduction Timing of sexual activity Drug holiday Anti-dote therapy: (off-label) Sexual Dysfunction Strategies anti-dote therapy: (off-label) buspirone 45mg qd dopamine (DA) agonists: amantadine bupropion 300mg qd α 2 -adrenergic receptor antagonists: yohimbine psychostimulants: methylphenidate 5-20mg PDE-5 inhibitors: Sildenafil mg qd Choosing an Antidepressant Side Effects Sedation/activation Sexual dysfunction Weight gain (Cost) Case Vignette No medical problems Depressed for 2 months Obesity Weight loss 13
14 Impact on weight Weight loss (?) Neutral or mixed mild to moderate Significant psychostimulants Bupropion Nefazadone Ssri s (fluoxetine < paroxetine) Maoi s Tricyclics mirtazapine Weight Management strategies Kelly, K, Posternak, M, & Alpert, J E. (2008). Toward achieving optimal response: understanding and managing antidepressant side effects. Dialogues in clinical neuroscience, 10(4), Sample Year End Diary Entry Alcohol units 3836 (poor) Cigarettes 5277 Calories 11,090,265 (repulsive) Fat units 3457 (approx.) (hideous idea in every way) Weight gained 74 lbs. Weight lost 72 lbs (excellent) Bridget Jones Diary, by Helen Fielding. Penguin Books Weight Management strategies (off label) Life style interventions : Eat healthy, exercise more Get the right amount of sleep and reduce stress* Address dry mouth Switch or add bupropion Add psychostimulants *Elder, C R, Gullion, C M, Funk, K L, et al. (2011). Impact of sleep, screen time, depression and stress on weight change in the intensive weight loss phase of the LIFE study. International journal of obesity, 2011 Mar 29. [Epub ahead of print] 14
15 Weight Management strategies (Off-Label) Choosing an Antidepressant Side Effects Sibutramine (Meridia): removed from US market b/o CV risks Orlistat (Xenical): 120mg tid w meals Bupropion + Naltrexone (Contrave): also rejected b/o increased P and BP (N16mg+B200mg BID) Metformin, studied in patients on atypical antipsychotics Topiramate mg daily Sedation/activation Sexual dysfunction Weight gain Cost Case Vignette No medical problems Depressed for 2 months No money Cost of some psychiatric meds Drug & Strength # Cost Unit cost Budeprion XL 150MG Tabs 180 $ $1.64 Wellbutrin SR 150MG Tab 180 $ $3.62 Clonazepam 2mg tab 90 $23.99 $0.27 Citalopram Hydrobromide 20mg Tab 90 $89.97 $1.00 Diazepam 5mg tab 90 $13.97 $0.16 Escitalopram 10MG Tab 90 $ $3.50 Fluoxetine HCl 20MG Cap 90 $50.97 $0.57 Mirtazapine 15mg Tab, 30mg 90 $ $1.67 Sertraline HCl 100MG Tab* 90 $29.97 $0.33 Venlafaxine HCl 75mg Cap 90 $ $1.88 Zolpidem Tartrate 10mg tab 90 $45.97 $0.51 from Drugstore.com 7/16/11, prices subject to change, about 50% cheaper than local drugstore *Descartes Li Best Buy! 15
16 Outline Current Controversies Overview of Antidepressants Antidepressants: Selection and Side Effect Management Non-pharmacological treatments Osteoporosis, GI bleeding, QTc and Suicide Questions and Summary Case Vignette Depressed for six months No medical hx, no comorbidities Wants psychotherapy, but can t afford it Okay to prescribe meds? Yes Mergl et al. Are treatment preferences relevant in response to serotonergic antidepressants and cognitive-behavioral therapy in depressed primary care patients? Results from a randomized controlled trial including a patients' choice arm. Psychother Psychosom 2011;80: Depressed for six months No medical hx, no comorbidities Wants meds, should you recommend psychotherapy? No. Case Vignette Other options Psychotherapy Bibliotherapy Self-help organizations Exercise Light therapy Complementary/alternative medications Mergl et al. Are treatment preferences relevant in response to serotonergic antidepressants and cognitive-behavioral therapy in depressed primary care patients? Results from a randomized controlled trial including a patients' choice arm. Psychother Psychosom 2011;80:
17 Bibliotherapy Feeling Good, by David Burns Self Help organizat ions Mind Over Mood, by Greenberger and Padefsky Outline Current Controversies Overview of Antidepressants Antidepressants: Selection and Side Effect Management Non-pharmacological treatments Osteoporosis, GI bleeding, QTc and Suicide Questions and Summary GI Bleeding 17
18 SSRIs and GI bleeding Two potential mechanisms: platelet aggregation, gastric acidity Overall risk is low: 1 per 8000 SSRI prescriptions Associated also with increased blood loss during surgical procedures. TCAs, mirtazapine, and bupropion NOT associated with bleeding What s the bottom line? You should mention this risk in the following situations: history of stomach ulcers or bleeding disorders. about to have surgery (consider stopping SSRI a few days in advance). taking NSAIDs, aspirin, warfarin, or antiplatelet drugs (clopidogrel). SSRIs and osteoporosis Osteoporosis Two observational studies in Archives of Internal Medicine: Women on SSRIs lost double the bone density of those either on tricyclics or on no antidepressants Diem SJ et al., 2007;167(12): Haney EM et al. 2007;167(12):
19 SSRIs and osteoporosis More recent study, with longer followup, found association with: wrist fracture (HR = 1.30, 95% CI ), but not with first hip fracture (HR = 1.01, 95% CI ) The bottom line Warn your elderly patients about osteoporosis, even though the findings are still preliminary. Diem SJ et al. Use of Antidepressant Medications and Risk of Fracture in Older Women. Calcif Tissue Int (2011) 88: QTc and Citalopram QTc and Citalopram trial of 119 adults showed that QTc is increased in a dose-dependent fashion with citalopram Dosage QT prolongation CI (msec) 20mg 8.5msec mg 18.5msec mg 12.6msec inferred 19
20 Bottom Line Check EKG before you go higher than 40mg, then again after they have been on a higher dose If they're already on a higher dose, just check the EKG If QTc in men over 450 and women over 500, consider decreasing dosage or switching to escitalopram Review other risk factors for increased QTc Antidepressants and Suicide Risk Suicide Risk and Antidepressants In 2004, FDA issued a black box warning for children and adolescents warning of a risk of suicidal events. In 2007, another black box warning issued for adults up to 25 years of age. (based on an odds ratio, 1.55; 95% confidence interval, 0.91 to 2.70) Suicide Risk and Antidepressants Furthermore, benefit of antidepressants in pediatric patients is controversial Bridge JA et al. Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment: a meta-analysis of randomized controlled trials. JAMA 2007;297: Friedman RA and Leon AC. Expanding the black box - depression, antidepressants, and the risk of suicide. NEJM 2007 Jun 7;356(23): Epub 2007 May 7. 20
21 Suicide Risk and Antidepressants Increase in suicidal ideation in children up to age 18, but not actual suicide. Probably suicide neutral or slightly beneficial in yr age range Hammad et al. Suicidality in pediatric patients treated with antidepressant drugs. Arch Gen Psychiatry 2006;63: Stone M et al. Risk of suicidality in clinical trials of antidepressants in adults: analysis of proprietary data submitted to US Food and Drug Administration. BMJ 2009 Aug 11;339:b2880. Odds Ratios for Suicidal Behavior and Ideation among Patients Treated with Antidepressants for Psychiatric Indications, as Compared with Placebo. Data are from the Summary Comments of the December 13, 2006, meeting of the FDA's Psychopharmacologic Drugs Advisory Committee. CI denotes confidence interval. Bottom line Questions In younger patients (<25years) Suicide risk is increased Risk decreases with increasing age Warn younger patients (and their families) to monitor for increased suicidality 21
22 Outline Current Controversies Overview of Antidepressants Antidepressants: Selection and Side Effect Management Non-pharmacological treatments Questions Summary (Good Side Effect Management means good follow up) 22
Educational Objectives: Outline. Relevant Disclosures. Managing Depression in Primary Care Lake Tahoe, August 2011
Managing Depression in Primary Care Lake Tahoe, August 2011 Descartes Li, M.D. Clinical Professor University of California, San Francisco descartes.li@ucsf.edu Educational Objectives: By the end of the
More informationEducational Objectives:
Managing Depression in Primary Care Controversies in Women's Health December 2011 Descartes Li, M.D. Clinical Professor University of California, San Francisco descartes.li@ucsf.edu Educational Objectives:
More informationBRIEF ANTIDEPRESSANT OVERVIEW. Casey Gallimore, Pharm.D., M.S.
BRIEF ANTIDEPRESSANT OVERVIEW Casey Gallimore, Pharm.D., M.S. Antidepressant Medication Classes First Generation Tricyclic Antidepressants (TCAs) Monoamine Oxidase Inhibitors (MAOIs) Second Generation
More informationPHYSICIAN REFERENCE ANTIDEPRESSANT DOSING GUIDELINES
PHYSICIAN REFERENCE ANTIDEPRESSANT DOSING GUIDELINES Table of Contents Print TABLE OF CONTENTS Drug Page Number Anafranil... 2 Asendin... 4 Celexa... 4 Cymbalta... 6 Desyrel... 8 Effexor...10 Elavil...14
More informationCommon Antidepressant Medications for Adults
(and Citalopram (Celexa) Escitalopram (Lexapro) Fluoxetine (Prozac) Fluoxetine Weekly (Prozac Weekly) 20 in AM w/ food (10 mg in elderly or those w/ panic disorder) 20 40 40 (If age >60yo, max 20) 10 10
More informationAntidepressant Medication Strategies We ve Come a Long Way or Have We? Who Writes Prescriptions for Psychotropic Medications. Biological Psychiatry
Antidepressant Medication Strategies We ve Come a Long Way or Have We? Joe Wegmann, PD, LCSW The PharmaTherapist Joe@ThePharmaTherapist.com 504.587.9798 www.pharmatherapist.com Are you receiving our free
More informationPresentation is Being Recorded
Integrated Care for Depression & Anxiety Psychotropic Medication Management for Primary Care Providers Los Angeles County Department of Mental Health September 20, 2011 Presentation is Being Recorded Please
More information9/20/2011. Integrated Care for Depression & Anxiety: Psychotropic Medication Management for PCPs. Presentation is Being Recorded
Integrated Care for Depression & Anxiety Psychotropic Medication Management for Primary Care Providers Los Angeles County Department of Mental Health September 20, 2011 Presentation is Being Recorded Please
More informationDiagnosis & Management of Major Depression: A Review of What s Old and New. Cerrone Cohen, MD
Diagnosis & Management of Major Depression: A Review of What s Old and New Cerrone Cohen, MD Why You re Treating So Much Mental Health 59% of Psychiatrists Are Over the Age of 55 AAMC 2014 Physician specialty
More informationManagement of SSRI Induced Sexual Dysfunction. Serotonin Reuptake Inhibitors*
Management of SSRI Induced Sexual Dysfunction John J. Miller, M.D. Medical Director, Center for Health and WellBeing Exeter, NH Serotonin Reuptake Inhibitors* fluoxetine clomipramine sertraline paroxetine
More informationPrimary Care Management of Depression. John Briles, MD, Medical Director October 11, 2017
John Briles, MD, Medical Director October 11, 2017 Molina Healthcare of Michigan uses a HEDIS measure for Antidepressant Medication Management (AMM) to measure how well treating providers (PCPs) appropriately
More informationQuick Guide to Common Antidepressants-Adults
Quick Guide to Common Antidepressants-Adults Medication Therapeutic Range (mg/day) Initial Suggested Serotonin Reuptake Inhibitors (SSRIs) All available as generic FLUOXETINE (Prozac) CITALOPRAM (Celexa
More informationTreating Depression in Adults
Treating Depression in Adults By Deborah Christensen, Ph.D., M.S.C.P. Depressive Disorders represent a broad and heterogeneous group of commonly diagnosed psychological disorders. The DSM adequately describes
More informationRealities of Depression in Primary Care Setting
Realities of Depression in Primary Care Setting Jaroslava Salman, MD Department of Supportive Care Medicine Division of Psychiatry Click to edit Master Presentation Date August 4 th 2018 Disclosure I have
More informationEducational Objectives: Outline. Epidemiology Assessment and Diagnosis Treatment. Depression in Primary Care Essentials of Primary Care 2009
Depression in Primary Care Essentials of Primary Care 2009 Descartes Li, M.D. Associate Clinical Professor University of California, San Francisco descartes.li@ucsf.edu Educational Objectives: By the end
More informationChildren s Hospital Of Wisconsin
Children s Hospital Of Wisconsin Co-Management Guidelines To support collaborative care, we have developed guidelines for our community providers to utilize when referring to, and managing patients with,
More informationOutline. Depression in Primary Care Role Impairment in Depression. Epidemiology Assessment and Diagnosis Treatment Suicide
Depression in Primary Care 2008 Descartes Li, M.D. Associate Clinical Professor University of California, San Francisco descartes.li@ucsf.edu Outline Epidemiology Assessment and Diagnosis Treatment Suicide
More informationThe Use of Antidepressants in the Treatment of Irritable Bowel Syndrome and Other Functional GI Disorders What are functional GI disorders?
The Use of Antidepressants in the Treatment of Irritable Bowel Syndrome and Other Functional GI Disorders Christine B. Dalton, PA-C Douglas A. Drossman, MD and Kellie Bunn, PA-C What are functional GI
More informationMajor Depressive Disorder
Major Depressive Disorder HEDIS Measures And Clinical Practice Guidelines Jennifer Highley, PMHNP-BC Behavioral Health West Point Healthcare Effectiveness Data and Information Set (HEDIS) Performance measures
More informationSUTTER PHYSICIANS ALLIANCE (SPA) 2800 L Street, 7 th Floor Sacramento, CA 95816
SUTTER PHYSICIANS ALLIANCE (SPA) 2800 L Street, 7 th Floor Sacramento, CA 95816 SPA PCP Treatment & Referral Guideline Managing Depression in Older Adults Developed March 1, 2003 Revised September 21,
More informationMedications and Children Disorders
Mental Health Comprehensive Services Providing Family Stability and Developing Life Coping Skills Medications and Children Disorders Psychiatric medications can be an effective part of the treatment for
More informationReducing the Anxiety of Pediatric Anxiety Part 2: Treatment
Reducing the Anxiety of Pediatric Anxiety Part 2: Treatment Lisa Lloyd Giles, MD Medical Director, Behavioral Consultation, Crisis, and Community Services Primary Children s Hospital Associate Professor,
More informationPartners in Care Quick Reference Cards
Partners in Care Quick Reference Cards Supported by the Agency for Healthcare Research and Quality MR-1198/8-AHRQ R This project was funded by the Agency for Healthcare Research and Quality (AHRQ), formerly
More informationPsychobiology Handout
Nsg 85A / Psychiatric Page 1 of 7 Psychobiology Handout STRUCTURE AND FUNCTION OF THE BRAIN Psychiatric illness and the treatment of psychiatric illness alter brain functioning. Some examples of this are
More informationAntidepressant Selection in Primary Care
Antidepressant Selection in Primary Care Rebecca D. Lewis, DO OOA Summer CME Oklahoma City, OK 6 August 2017 Objectives Understand the epidemiology of depression. Recognize factors to help choose antidepressants.
More informationANTI-DEPRESSANT MEDICATIONS
ANTI-DEPRESSANT MEDICATIONS This information is not intended to be a substitute for medical advice. It s purpose is solely informative. If your client or yourself are taking antidepressants, do not change
More informationChange Your Brain, Change Your Life. The Breakthrough Program for Conquering Anxiety, Depression, Obsessiveness, Anger, and Impulsiveness
Change Your Brain, Change Your Life The Breakthrough Program for Conquering Anxiety, Depression, Obsessiveness, Anger, and Impulsiveness Daniel G Amen Three Rivers Press New York Appendix Medication 1.
More informationPrepared by: Elizabeth Vicens-Fernandez, LMHC, Ph.D.
Prepared by: Elizabeth Vicens-Fernandez, LMHC, Ph.D. Sources: National Institute of Mental Health (NIMH), the National Alliance on Mental Illness (NAMI), and from the American Psychological Association
More informationDepression: Identification, Evaluation and Management in Primary Care
Depression: Identification, Evaluation and Management in Primary Care Primary Care Medicine: Update 2012 Rena K. Fox, M.D. Associate Professor of Clinical Medicine University of California, San Francisco
More information90 dosage units per 90 days OR. Extended-release Formulations Ultram ER 90 dosage units per 90 days OR
Pre - PA Allowance 12 years of age or older Quantity Immediate-release Formulation Ultracet 720 dosage units per 90 days OR Ultram 720 dosage units per 90 days Extended-release Formulations Ultram ER 90
More informationDepression: Identification, Evaluation and Management in Primary Care
Depression: Identification, Evaluation and Management in Primary Care Primary Care Update: 2013 I have nothing to disclose Rena K. Fox, M.D. Associate Professor of Clinical Medicine University of California,
More informationDementia Medications Acetylcholinesterase Inhibitors (AChEIs) and Glutamate (NMDA) Receptor Antagonist
Dementia Medications Acetylcholinesterase Inhibitors (AChEIs) and Glutamate (NMDA) Receptor Antagonist Medication Dosage Indication for Use Aricept (donepezil) Exelon (rivastigmine) 5mg 23mg* ODT 5mg Solution
More informationDuragesic Patch (fentanyl patch) Prior authorization is not required if prescribed by an oncologist
Pre - PA Allowance Quantity 30 patches every 90 days Prior-Approval Requirements Prior authorization is not required if prescribed by an oncologist Age 2 years of age or older Diagnosis Patient must have
More informationAntidepressants Choosing the Right One
Antidepressants Choosing the Right One Dr Lim Boon Leng Consultant Psychiatrist Dr BL Lim Centre For Psychological Wellness #09-09, Gleneagles Medical Centre, 6 Napier Rd, S258499 www.psywellness.com.sg
More informationPsychiatry curbside: Answers to a primary care doctor s top mental health questions
Psychiatry curbside: Answers to a primary care doctor s top mental health questions April 27, 2018 Laurel Ralston, DO Psychiatrist, Taussig Cancer Institute Objectives Review current diagnostic and prescribing
More informationMedications Guide: Public Speaking And Social Anxiety
AnxietyHub.org Dr. Cheryl Mathews Medications Guide: Public Speaking And Social Anxiety Copyright 2016 AnxietyHub Medications Specifically for Public Speaking and Social Anxiety This is not intended to
More informationA Brief Overview of Psychiatric Pharmacotherapy. Joel V. Oberstar, M.D. Chief Executive Officer
A Brief Overview of Psychiatric Pharmacotherapy Joel V. Oberstar, M.D. Chief Executive Officer Disclosures Some medications discussed are not approved by the FDA for use in the population discussed/described.
More informationPart 2: Pain and Symptom Management Depression
Guidelines & Protocols Advisory Committee Part 2: Pain and Symptom Management Depression Effective Date: February 22, 2017 Key Recommendations Before diagnosing and treating major depressive disorder,
More informationMORPHINE IR DRUG CLASS Morphine IR, Dilaudid IR (hydromorphone), Opana IR (oxymorphone)
Pre - PA Allowance Tablets & Suppositories Morphine sulfate tablets Morphine sulfate suppositories Oxymorphone tablets Hydromorphone tablets Hydromorphone suppositories 360 tablets per 90 days OR 360 suppositories
More informationSchedule FDA & literature based indications
Psychotropic Medication List Recommended dosages are intended to serve only as a guide for children. Recommended doses are literature based. Clinicians should consult package insert of medications for
More informationPsychiatry in Primary Care: What is the Role of Pharmacist?
Psychiatry in Primary Care: What is the Role of Pharmacist? Benjamin Chavez, PharmD, BCPP, BCACP Clinical Associate Professor Director of Behavioral Health Pharmacy Services January 12, 2019 Disclosure
More informationFamily Medicine Forum November 10, 2017 Montreal., Quebec. Jon Davine, CCFP, FRCP(C) Associate Professor, McMaster University
APPROACH TO DEPRESSION IN PRIMARY CARE Family Medicine Forum November 10, 2017 Montreal., Quebec. Jon Davine, CCFP, FRCP(C) Associate Professor, McMaster University DISCLOSURE Speaker/Presenter Disclosure
More informationOXYCODONE IR (oxycodone)
RATIONALE FOR INCLUSION IN PA PROGRAM Background Oxycodone hydrochloride, a pure opioid agonist, is used in the treatment of moderate to severe pain (1-2). The precise mechanism of action is unknown; however,
More informationWellbutrin/Wellbutrin-SR/ Wellbutrin-XL (bupropion)
Wellbutrin/Wellbutrin-SR/ Wellbutrin-XL (bupropion) Generic name: Bupropion Available strengths: 75 mg, 100 mg immediate-release tablets; 100 mg, 150 mg, 200 mg sustained-release tablets (Wellbutrin-SR);
More informationAntidepressant Selection in Primary Care
Antidepressant Selection in Primary Care R E B E C C A D. L E W I S, D O O O A S U M M E R C M E B R A N S O N, M O 1 5 A U G U S T 2 0 1 5 Objectives Understand the epidemiology of depression. Recognize
More informationReview of Psychotrophic Medications. (An approved North Carolina Division of Health Services Regulation Continuing Education Course)
Review of Psychotrophic Medications (An approved North Carolina Division of Health Services Regulation Continuing Education Course) Common Psychiatric Disorders *Schizophrenia *Depression *Bipolar Disorder
More informationHYSINGLA ER (hydrocodone bitartrate) Prior authorization is not required if prescribed by an oncologist.
Pre - PA Allowance None Prior authorization is not required if prescribed by an oncologist. Prior-Approval Requirements Age 18 years of age or older Diagnosis Patient must have the following: 1. Pain,
More informationPre - PA Allowance. Prior-Approval Requirements LEVORPHANOL TARTRATE. None
Pre - PA Allowance None Prior-Approval Requirements Prior authorization is not required if prescribed by an oncologist and/or the member has paid pharmacy claims for an oncology medication(s) in the past
More informationDepression. There are several forms of depression (depressive disorders). Major depressive disorder and dysthymic disorder are the most common.
Depression Depression is a state of low mood and aversion to activity that can affect a person's thoughts, behavior, feelings and sense of well-being. People with depressed mood can feel sad, anxious,
More informationXartemis XR (oxycodone / acetaminophen extended release)
RATIONALE FOR INCLUSION IN PA PROGRAM Background Xartemis XR is a combination of oxycodone and acetaminophen in a dosage formulation to deliver both immediate pain relief, in less than an hour, and extended-release
More informationPSYCHIATRY INTAKE FORM
Please complete all information on this form. PSYCHIATRY INTAKE FORM Name Date Date of Birth Primary Care Physician Current Therapist/Counselor What are the problem(s) for which you are seeking help? 1.
More informationMedications for Anxiety & Behavior in Williams Syndrome. Disclosure of Potential Conflicts. None 9/22/2016. Evaluation
Medications for Anxiety & Behavior in Williams Syndrome Christopher J. McDougle, M.D. Director, Lurie Center for Autism Professor of Psychiatry and Pediatrics Massachusetts General Hospital and MassGeneral
More informationStudy Guidelines for Quiz #1
Annex to Section J Page 1 Study Guidelines for Quiz #1 Theory and Principles of Psychopharmacology, Classifications and Neurotransmitters, Anxiolytics/Antianxiety/Minor Tranquilizers, Stimulants, Nursing
More informationDepression and Anxiety. What is Depression? What is Depression? By Christopher Okiishi, MD Spring Not just being sad A syndrome of symptoms
Depression and Anxiety By Christopher Okiishi, MD Spring 2016 What is Depression? Not just being sad A syndrome of symptoms Depressed mood Sleep disturbance Decreased interest in usual activities (anhedonia)
More informationDepression & Anxiety in Adolescents
Depression & Anxiety in Adolescents Objectives 1) Review diagnosis of anxiety and depression in adolescents 2) Provide overview of evidence-based treatment options 3) Increase provider comfort level with
More informationBELBUCA (buprenorphine buccal film)
RATIONALE FOR INCLUSION IN PA PROGRAM Background Belbuca is indicated for the management of chronic pain severe enough to require daily, aroundthe-clock, long-acting opioid treatment for which alternative
More informationLinda Sobeski Farho, PharmD, BCPS Assistant Professor, Pharmacy Practice UNMC College of Pharmacy Critical Issues in Geriatrics June 24, 2010
Pharmacologic Treatment of Depression Linda Sobeski Farho, PharmD, BCPS Assistant Professor, Pharmacy Practice UNMC College of Pharmacy Critical Issues in Geriatrics June 24, 2010 1 Disclosure I have no
More informationTreatment of Major Depressive Disorder
Treatment of Major Depressive Disorder Sarah Mullowney, MD PGY3 Psychiatry Resident, University of Utah Paula Gibbs, MD Medical Director of 5 West at UUMC Clerkship Director MS III Psychiatric Rotation
More informationReviews/Evaluations. Use of Selective Serotonin Reuptake Inhibitors in Pediatric Patients. Pharmacotherapeutic Options
Reviews/Evaluations Use of Selective Serotonin Reuptake Inhibitors in Pediatric Patients Childhood major depressive disorder (MDD) has become recognized as a serious and common illness affecting between
More informationMental Health Nursing: Mood Disorders. By Mary B. Knutson, RN, MS, FCP
Mental Health Nursing: Mood Disorders By Mary B. Knutson, RN, MS, FCP A Definition of Mood Prolonged emotional state that influences the person s whole personality and life functioning Adaptive Functions
More informationNortriptyline vs amitriptyline in elderly
Nortriptyline vs amitriptyline in elderly Amitriptyline (Elavil ) vs other antidepressants - comparative analysis amitriptyline vs divalproate, amitriptyline vs trazodone. Learn what other patients are
More informationPharmacotherapy of depression
Pharmacotherapy of depression Stuff you already know Stuff you probably know Stuff you possibly don t know Stuff you thought you knew but are mistaken about How long does it take for antidepressants
More informationCOMMONLY PRESCRIBED PSYCHOTROPIC MEDICATIONS NAME Generic (Trade) DOSAGE KEY CLINICAL INFORMATION Antidepressant Medications*
COMMONLY PRESCRIBED PSYCHOTROPIC MEDICATIONS NAME Generic (Trade) DOSAGE KEY CLINICAL INFORMATION Antidepressant Medications* Bupropion (Wellbutrin) Start: IR-100 mg bid X 4d then to 100 mg tid; SR-150
More informationIMPORTANT NOTICE. Changes to dispensing of some Behavioral Health Medications for DC Healthcare Alliance members
IMPORTANT NOTICE Changes to dispensing of some Behavioral Health Medications for DC Healthcare Alliance members These changes apply only to members covered under the DC Healthcare Alliance program Alliance
More informationPharmaceutical Interventions. Collaborative Model of Mental Health Care for Older Iowans Des Moines May 18, 2007
Pharmaceutical Interventions Collaborative Model of Mental Health Care for Older Iowans Des Moines May 18, 2007 Outline Overview Overview of initial workup and decisions in elderly depressed individual
More informationRichard Heidenfelder M.D. Child, Adolescent and Adult Psychiatry 447 9th Ave San Diego, CA
*We are not accepting any New Patients who are currently taking any controlled pain medications *We are *Note: not completion accepting of the any following New Patients paperwork who and Initial are Screening
More informationOptimal Use of Antidepressants: Focusing on SNRI, NDRI and SSRE
Optimal Use of Antidepressants: Focusing on SNRI, NDRI and SSRE Chan-Hyung Kim, MD Severance Mental Health Hospital Institute of Behavioral Science in Medicine Diagnostic Criteria Pyramid Etiologic Pathophysiologic
More informationNorthSTAR. Pharmacy Manual
NorthSTAR Pharmacy Manual Revised October, 2008 Table of I. Introduction II. III. IV. Antidepressants New Generation Antipsychotic Medications Mood Stabilizers V. ADHD Medications VI. Anxiolytics and Sedative-Hypnotics
More informationMentoring Session: Participant Cases
Handout for the Neuroscience Education Institute (NEI) online activity: Mentoring Session: Participant Cases The Case: 55-year-old patient with depression and anxiety The Question: What to do when antidepressants
More informationNorpramin (desipramine)
Generic name: Desipramine Available strengths: 10 mg, 25 mg, 50 mg, 75 mg, 100 mg, 150 mg tablets Available in generic: Yes Drug class: Tricyclic antidepressant General Information Norpramin (desipramine)
More informationDrugs for Emotional and Mood Disorders Chapter 16
Drugs for Emotional and Mood Disorders Chapter 16 NCLEX-RN Review Question 1 Choices Please note Question #1 at the end of Ch 16 pg 202 & Key pg 805 answer is #4 1. Psychomotor symptoms 2. Tachycardia,
More informationThe Context: Why is this so important to treat?
Depression for PG1s Ian A. Cook, M.D. UCLA Department of Psychiatry Laboratory of Brain, Behavior, and Pharmacology Semel Institute for Neuroscience & Human Behavior DepressionLA.com PsychiatryGuidelines.com
More informationRATIONALE FOR INCLUSION IN PA PROGRAM
RATIONALE FOR INCLUSION IN PA PROGRAM Background hydromorphone (Exalgo, Dilaudid) and oxymorphone (Opana and Opana ER) are Schedule II narcotics prescribed to treat moderate to severe pain. Morphine produces
More informationObjectives. Sexual dysfunction (SD) SD in the general population. Assessment of sexual functioning ANTIDEPRESSANT-INDUCED SEXUAL DYSFUNCTION
Objectives To appreciate the relationship between major depressive disorder, its treatment and sexual dysfunction To review the assessment of sexual function An approach to the clinical management of antidepressant
More informationMAJOR DEPRESSION CLINICAL PRACTICE GUIDELINE
MAJOR DEPRESSION CLINICAL PRACTICE GUIDELINE Reviewed and Updated by the Behvioral Health Subcommittee 7/20/2017 Topic Purpose Access Assessment 7/2017 Recommendations SummaCare Health Plan bases its Clinical
More informationAnti- Depressants, Mood Stabilizers: What Works Best For Bipolar Disorder? Date: March 30, 2007 Source: NIH/National Institute of.
30-3-2007 Anti- Depressants, Mood Stabilizers: What Works Best For Bipolar Disorder? Date: March 30, 2007 Source: NIH/National Institute of. 30-3-2018 C. Psychiatric drugs: controlled trial demonstrated
More informationTREATMENT OF DEPRESSION IN LATE LIFE. Robert Kohn, MD
TREATMENT OF DEPRESSION IN LATE LIFE Robert Kohn, MD WHY TREAT ELDERLY PERSONS Major depression is not a normal part of aging The rates are lower than younger cohorts The prevalence rates are still high
More informationRuby Williams, M.D. Drugs, Alcohol and Sleep February 24, 2018
Ruby Williams, M.D. Drugs, Alcohol and Sleep February 24, 2018 Objectives Describe pharmacology of commonly prescribed drugs for stimulants and hypnotics Brief review of common drugs that affect sleep
More informationLevorphanol. Levorphanol Tartrate. Description
Federal Employee Program 1310 G Street, N.W. Washington, D.C. 20005 202.942.1000 Fax 202.942.1125 5.70.59 Subject: Levorphanol Page: 1 of 8 Last Review Date: March 17, 2017 Levorphanol Description Levorphanol
More informationGuidelines MANAGEMENT OF MAJOR DEPRESSIVE DISORDER (MDD)
MANAGEMENT OF MAJOR DEPRESSIVE DISORDER (MDD) Guidelines CH Lim, B Baizury, on behalf of Development Group Clinical Practice Guidelines Management of Major Depressive Disorder A. Introduction Major depressive
More informationOverview and Update on Current Psychopharmacological Medications, Including New Medications in Clinical Trials
SPEAKER NOTES Overview and Update on Current Psychopharmacological Medications, Including New Medications in Clinical Trials Summarized by Thomas T. Thomas New psychotropic medications are coming on the
More informationIlluminating the Black Box: Antidepressants, Youth and Suicide
Illuminating the Black Box: Antidepressants, Youth and Suicide David H. Rubin, M.D. Executive Director, MGH Psychiatry Academy Director, Postgraduate Medical Education Director, Child and Adolescent Psychiatry
More informationAntidepressant Pharmacology An Overview
Figure 1. Antidepressant Pharmacology An Overview Source: NEJM 2005;353:1819-34 Figure 2. 1 Figure 3: Antidepressant Pharmacology pictures: Weak inhibition Bupropion NOTE: CYP enzymes noted are those inhibited
More informationDepression: Identification, Evaluation and Management in Primary Care
Depression: Identification, Evaluation and Management in Primary Care Primary Care Medicine: Update 2010 Rena K. Fox, M.D. Associate Professor of Clinical Medicine University of California, San Francisco
More informationAdult Depression - Clinical Practice Guideline
1 Adult Depression - Clinical Practice Guideline 05/2018 Diagnosis and Screening Diagnostic criteria o Please refer to Attachment A Screening o The United States Preventative Services Task Force (USPSTF)
More informationAffective or Mood Disorders. Dr. Alia Shatanawi March 12, 2018
Affective or Mood Disorders Dr. Alia Shatanawi March 12, 2018 Affective or Mood Disorders Reactive Depression. Secondary: Medical Neurological Drugs Major (Endogenous) Depression = Unipolar: Depressed
More informationPsychotropic Medication Use in Dementia
Psychotropic Medication Use in Dementia Marie A DeWitt, MD Diplomate of the American Board of Psychiatry and Neurology, Specialization in Psychiatry & Subspecialization in Geriatric Psychiatry Staff Physician,
More informationPsychotropic Medications Archana Jhawar, PharmD, BCPP Clinical Faculty of UIC Pharmacy Practice Clinical Psychiatric Pharmacist Jesse Brown VA
Psychotropic Medications Archana Jhawar, PharmD, BCPP Clinical Faculty of UIC Pharmacy Practice Clinical Psychiatric Pharmacist Jesse Brown VA Goals of Medications Use least number at lowest dose to get
More informationTreat mood, cognition, and behavioral disturbances associated with psychological disorders. Most are not used recreationally or abused
Psychiatric Drugs Psychiatric Drugs Treat mood, cognition, and behavioral disturbances associated with psychological disorders Psychotropic in nature Most are not used recreationally or abused Benzodiazepines
More informationANTIDEPRESSANT MEDICATION & RISK OF DEMENTIA
ANTIDEPRESSANT MEDICATION & RISK OF DEMENTIA A Nationwide Cohort Study in Taiwan / Speaker: Chee-Kin Then / Advisor: Prof. Shing-Chuan Shen / Unit: Graduate Institute of Medical Sciences / Date: 2017.04.
More informationPamelor (nortriptyline)
Generic name: Nortriptyline Available strengths: 10 mg, 25 mg, 50 mg, 75 mg capsules; 10 mg/5 ml oral solution Available in generic: Yes Drug class: Tricyclic antidepressant General Information Pamelor
More informationTreatment of Depression in the Primary Care Office
Treatment of Depression in the Primary Care Office Paul E.A. Glaser, MD, PhD Departments of Psychiatry, Pediatrics and Anatomy & Neurobiology University of Kentucky November 5, 2010 Disclosures of Potential
More informationTofranil and Tofranil-PM (imipramine)
Tofranil and Tofranil-PM (imipramine) Generic name: Imipramine Available strengths: 10 mg, 25 mg, 50 mg tablets; 75 mg, 100 mg, 125 mg, 150 mg capsules (Tofranil-PM) Available in generic: Yes Drug class:
More information1 1 Evidence-based pharmacotherapy of major depressive disorder. Michael J. Ostacher, Jeffrey Huffman, Roy Perlis, and Andrew A.
1 1 Evidence-based pharmacotherapy of major depressive disorder Michael J. Ostacher, Jeffrey Huffman, Roy Perlis, and Andrew A. Nierenberg Massachusetts General Hospital and Harvard University, Boston,
More informationDaniel Suzuki, MD Adjunct Clinical Associate Professor of Psychiatry, USC Keck School of Medicine Clinical Adjunct Professor/Faculty, Graduate School
Daniel Suzuki, MD Adjunct Clinical Associate Professor of Psychiatry, USC Keck School of Medicine Clinical Adjunct Professor/Faculty, Graduate School of Psychology, Fuller Theological Seminary Medical
More information11. Psychopharmacological Intervention
11. Psychopharmacological Intervention 11.1 Goals of Psychopharmacology The goal of psychopharmacology is to ensure that patients with more severe forms of depression and those who fail to benefit adequately
More informationGuide to Psychiatric Medications for Children and Adolescents
Guide to Psychiatric Medications for Children and Adolescents by Glenn S. Hirsch, M.D. The following guide includes most of the medications used to treat child and adolescent mental disorders. It lists
More informationALAMEDA COUNTY BEHAVIORAL HEALTH CARE SERVICES MEDICATION FORMULARY
ANTIDEPRESSANTS Serotonin Selective Reuptake Inhibitors citalopram 10, 20, 40 mg, 10 mg/5cc $ 0.40 No escitalopram 10, 20 mg $ 2.60 Yes fluoxetine 10, 20 mg, 20 mg/5 ml $ 0.40 Yes fluvoxamine 25, 50, 100
More informationClinical Guideline / Formulary Document Pharmacy Department Medicines Management Services
Clinical Guideline / Formulary Document Pharmacy Department Medicines Management Services DEPRESSION Pharmacological Treatment of Depression NICE guidelines suggest the following stepped care model also
More informationPRACTICAL MANAGEMENT OF DEPRESSION IN OLDER ADULTS. Lee A. Jennings, MD MSHS Assistant Professor Division of Geriatrics, UCLA
CASE #1 PRACTICAL MANAGEMENT OF DEPRESSION IN OLDER ADULTS Lee A. Jennings, MD MSHS Assistant Professor Division of Geriatrics, UCLA OBJECTIVES Epidemiology Presentation in older adults Assessment Treatment
More information