Medication Management. Dr Ajith Weeraman MBBS, MD (Psychiatry), FRANZCP Consultant Psychiatrist Epworth Clinic Camberwell 14 th March 2015

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1 Medication Management Dr Ajith Weeraman MBBS, MD (Psychiatry), FRANZCP Consultant Psychiatrist Epworth Clinic Camberwell 14 th March

2 Medication Management Objectives: 1. Principles of psycho-pharmacology 2. Common mental health conditions 3. Frequent issues in general practice 4. Risks related to medication 5. Cases 2

3 Principles of psycho-pharmacology - Principle Diagnosis, Co-morbid conditions - Treatment options for the condition: Bio-Psycho-Social approach - Informed consent - Medication selection Evidence based, Treatment Guidelines Age, sex, body weight, special groups 3

4 Principles of psycho-pharmacology- cont. When are medication used? What is the optimal dose? What the maintenance dose? Monitoring of mental and physical state Regular risk assessment Failure to respond to treatment, Why? Discontinuation of medication 4

5 The phase of Treatment Subside acute symptoms Relieve symptoms Restore previous level of function (REHABILITATION) Maintain stabilization Prevent return of acute symptoms Continue Rx for the duration of the episode E.g. Depression 6/12 First Episode Psychosis 2 years Recurrent relapses- many yrs, lifelong Relapse prevention 5

6 Common mental health issues Mood disorders Anxiety disorders Psychotic disorders Drug and alcohol disorders Personality disorders 6

7 Cases and possible interventions: 1. Commencement of medication 2. Titration of medication 3. Change of medication 4. Combination of medications/ Poly-pharmacy 5. Interaction of medication 6. Interaction of medication and substances/ alcohol: 7. Non-adherence of medication 7

8 Commencement of medication Case 1: 45 year old professional, female, single, lives alone Diagnosis: severe OCD, no acute risks, affecting her work and social life, became unemployed due to ongoing symptoms and secondary depression Never treated with antidepressant medication, not willing to see a psychologist, but willing to see a psychiatrist Not happy to take antidepressants Group Discussion 8

9 Case 1, Management: Had initial assessment and provided treatment options. Fluctuated her insight, fear of medication side effects and questioning possible improvement. Took 3 months to convince her pharmacological treatment. Commence Paroxetine 10mg mane and titrate up to 20mg after few months. Tolerated side effects well, improved significantlymentally, socially, professionally. No relapses for the last 3 years. Take home message psycho-education ++++, provide options, engage, develop trust, support the patient to understand the nature of illness, titrate medication up slowly, monitor regularly 9

10 Titration of medication Case 2: 78 year old lady, lives with husband, previous psychiatric history +, no drug and alcohol history Diagnoses: Generalized Anxiety Disorder with secondary depression, Eating Disorder NOS, Cluster C Personality traits (dependent, avoidant, anxious) GP commenced Escitalopram 5mg mane few weeks ago, Zolpidem 10mg nocte 12 months ago Issues: extremely fearful of increasing the dose, slowly deteriorating for more than 2 years- physically, socially, psychologically, not safe at home, can not increase medication due to her fears Group Discussion 10

11 Case 2: Management: GP referred the patient to a private psych inpatient unit. Admitted to a private psychiatric unit, educated the patient and family, engage, assess regularly, titrated the dose of Escitalopram by 2.5mg increments up to 15mg at night, not developed any side effect, started reducing the dose of Zolpidem Incorporated CBT, regular day leave with the family and prepare for discharge Take home message- Psycho-education ++++, support the patient and family to understand the nature of illness, titrate slowly, monitor regularly Avoid long-term use of hypnotics/ Benzodiazepine Get specialist opinion early 11

12 Change of medication Case 3: 35 year old gentleman, single, stressed at work due to work load, on medical leave and subsequently lost his job. Diagnoses: Major Depressive Disorder, Cluster C personality traits Was on Mirtazapine 60mg nocte for few months, worsening depressive symptoms and suicidal ideation Mirtazapine was ceased abruptly and commenced Paroxetine 20mg mane Became extremely anxious and depressed, sleep disturbances, Emergency Dept, Crisis team involvement Group Discussion 12

13 Case 3: cont. Issues related to medication change: - Abrupt discontinuation of highest dose of Mirtazapine and commencement of Paroxetine - Possible short term use of Diazepam - Regular reviews Management: Regular MSEx, Reassurance, adding Diazepam. Later reduce and ceased diazepam Involvement of a clinical psychologist Take home message: educate the patient, involve family, wean of the medication, review the patient regularly, private admission +/-, involve Crisis Team 13

14 Interaction of medication and substances/ alcohol: Case 4: 68 year old businessman, lives with wife, adult children Diagnoses: Major Depressive Disorder, Alcohol Dependence, relationship difficulties, sexual dysfunction Issues: ongoing depressive symptoms for years, risk of suicide as father also committed suicide, Work long hours- 7 days a week Medication: Mirtazapine 90mg nocte, Venlafaxine XR 150mg mane, Diazepam 5-10mg PRN Group Discussion 14

15 Case 4, Management: Assessed regularly, educate patient and wife, treatment options explained (including Lithium Carbonate therapy as an adjunct) Counsel in relation to effects of alcohol ---- ceased alcohol use completely Regular phone discussions with the GP only one prescriber Cease Mirtazapine and diazepam Titrated up Venlafaxine XR 300mg mane Life style modifications: work (Mon-Fri), encourage to engage in his previous pleasure activities Significant improvement in all domains, no relapses Take home message: address alcohol and substance abuse, simplify medication regimen to minimize interaction, avoid poly-pharmacy, better communication bet therapists/ patient/ family, consider Lithium Carbonate 15

16 Non-adherence of medication Case 5: 30 year old, single man, lives alone, work 3-4 days a week, could not Diagnoses: Paranoid Schizophrenia, alcohol abuse Medication: Risperidone 3mg nocte, good response to medication when he takes them daily Issues: ongoing Persecutory delusions, alcohol abuse, poor adherence to medication, could not attend work regularly due to persecutory delusions, risk of harming others and self, risk of resistance to medication, emerging negative symptoms Group Discussion 16

17 Case 5, Plan of management: Psycho-education, Address alcohol abuse Engagement with the treatment plan, Introduce Webster/ Blister pack Commencement of Risperidone Consta (depot medication) fortnightly instead of oral Risperidone to improve medication adherence Take home message: Address non-adherence the medication, Treat co-morbid alcohol/ substance abuse, get specialist opinion in early phase of psychotic disorders to prevent negative symptoms, multiple relapses 17

18 Thank you. Dr Ajith Weeraman 18

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