For: NEON Primary Healthcare Providers By: Michelle Romero, DO June 2013

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1 For: NEON Primary Healthcare Providers By: Michelle Romero, DO June 2013

2 This power point is only a guideline for recommendations in the treatment of psychiatric disorders. This is not comprehensive. Please refer to the Psychiatric Medication Guide power point for more in depth information regarding specific medications.

3 Start with an SSRI. Fluoxetine, Sertraline, Citalopram Paroxetine generally not well tolerated Escitalopram is expensive Titrate dose up every 4 weeks as needed to target symptoms. An adequate trial is maximized dosing for 12 weeks. At a minimum dosing should be maximized for at least 6 weeks before saying it s a failed trial.

4 If the first trial did not work: try a 2 nd SSRI. May cross-titrate (decreasing the first one while starting and increasing the new one). If the second SSRI failed: If absolutely no response to the SSRI: switch to another class, either an SNRI or a Novel Medication If some response, may consider adding on a second medication: Another anti-depressant from a different class Aripiprazole or Quetiapine

5 Combination Treatment: Add on Buproprion if having trouble with increased sleep, low energy, poor concentration, increased appetite. Add on Mirtazapine if having trouble with decreased sleep, decreased appetite, anxiety. Add on Aripiprazole if having trouble with low energy, lack of interest, psychosis. Add on Quetiapine if having trouble with decreased sleep, decreased appetite, anxiety, psychosis, anger.

6 Switching anti-depressant classes usually better than adding on a 2 nd medication for better adherence. If needing to add on, adding a 2 nd antidepressant is generally the first step, before adding on an anti-psychotic due to the metabolic risks. May consider starting with Duloxetine if depression in combination with neuropathic pain.

7 Sexual side-effects may be experienced with the SSRI and SNRI medications. Decreasing the dose may help if still effective. Adding on Buproprion generally helps this side effect. Duloxetine is equal to Placebo in causing sexual side effects. Mirtazapine does not have this side effect. If male, can use erectile dysfunction medication to help with side effect.

8 Start with an SSRI. Fluoxetine, Sertraline, Citalopram Paroxetine generally not well tolerated Escitalopram is expensive Titrate dose up every 4 weeks as needed to target symptoms. An adequate trial is maximized dosing for 12 weeks. At a minimum dosing should be maximized for at least 6 weeks before saying it s a failed trial.

9 If the first trial did not work: try a 2 nd SSRI. May cross-titrate (decreasing the first one while starting and increasing the new one). If the second SSRI failed: If absolutely no response to the SSRI: switch to another class, either an SNRI, Mirtazapine, or Buspirone. If some response, may consider adding on a second medication (low-dose SNRI, Mirtazapine, or Buspirone). Consider Mirtazapine if having trouble with sleep.

10 In the first 2 weeks, anxiety may increase as the medications can often cause restlessness. May use brief, up to 3 month, trial of a benzodiazepine if no history of substance abuse/dependence. Avoid Buproprion: does not help anxiety and may increase anxiety for some. For PTSD: use Prazosin at bedtime for nightmares.

11 As Needed Medications: Propranolol: for performance based anxiety Helps with the physical symptoms of anxiety. Hydroxyzine: for panic attacks or sleep Gabapentin: as add-on therapy or sleep Can also help to stabilize out the mood. Limit the use of Benzodiazepines!!!

12 Must have a mood-stabilizer on board Lithium Depakote Lamotrigine Quetiapine Aripiprazole

13 Lamotrigine does not require any monitoring, but needs to be titrated up slowly to avoid the risk for a rash and requires adherence. Good for Bipolar d/o, type II Use Lithium for patients with multiple past suicide attempts. Avoid Depakote in fertile females. Add on birth control if prescribing.

14 Lamotrigine Lithium Quetiapine Aripiprazole Buproprion is safer in Bipolar Depression than the other anti-depressant medications. Less likely to cause switching. Avoid all anti-depressant medications if not on a mood-stabilizer. May de-stabilize: cause manic episode.

15 Any of the anti-psychotics will work equally well. Haloperidol is a good older, cheap alternative to the newer anti-psychotics. The older, first-generation, anti-psychotics have more movement related side effects. Add on Cogentin to help with this. The newer, second-generation, antipsychotics, have more metabolic side effects. Requires monitoring of metabolic risk factors.

16 First, treat the primary mental health disorder. Poor sleep is a symptom of most mental health disorders: depression anxiety bipolar d/o (manic or depressed) psychosis Second, discuss and utilize sleep hygiene. Third, try medications.

17 The average adult should aim for 7-9 hours of sleep per night. Go to bed and wake up at the same time every day. Use the bed only for sleep and for sex. Make sure bedroom is dark, quiet, and cool. If in bed longer than 30 minutes without falling asleep, get out of bed. Get out of bed and do something calming/relaxing, such as light reading.

18 Do not have the TV on throughout the night. The flashing light keeps the brain awake. If noise helps to distract thoughts, may set a sleep timer on the TV or use another form of noise: classical music nature sounds white noise Regular exercise can help improve sleep. Do not exercise too close to bedtime. Limit caffeine to at/before lunchtime. Don t eat to close to bedtime.

19 Melatonin Safe, non-addictive, over-the-counter herbal that can help to re-set the sleep cycle. Benadryl Safe, non-addictive, over-the-counter option. Hydroxyzine Safe, non-addictive, prescription option especially useful for those with anxiety. Trazodone Safe, non-addictive, prescription option. If Bipolar d/o, make sure a mood stabilizer is being used.

20 Medications used to treat primary mental health disorder, that may also help with sleep: Mirtazapine Gabapentin Depakote Seroquel Avoid other sleeping medications. Ambien, Lunesta, Restoril, Rozarem, etc. If sleep is a continuous problem, may want to consider a sleep study.

21 First, treat the underlying mental health disorder. Lack of focus and restlessness are symptoms of most mental health disorders: depression anxiety bipolar d/o (manic or depressed) psychosis

22 MUST have been diagnosed and/or had symptoms existing in childhood. NOT new onset in adulthood. May want to start treatment with nonstimulants: Wellbutrin Straterra Intuniv/Guanfesin

23 Recommend Concerta or Vyvanse Longer lasting, smoother on-off, less mood lability. Lower risk of abuse/dependence. Concerta: 18mg to 72mg Generally lasts 8-10 hours. Vyvanse: 20mg to 70mg Generally lasts hours. Monitor vitals: Weight, BP, Pulse, Height (in children) Patient Assistance Programs Available.

Psychiatric Medication Guide

Psychiatric Medication Guide F O R : N E O N P R I M A R Y H E A L T H C A R E P R O V I D E R S B Y : M I C H E L L E R O M E R O, D O M A Y, 2 0 1 3 Anti-depressants TCA s & MAOI s (Tricyclic Antidepressants