9/17/2015 DIAGNOSTIC PUZZLES LEARNING OBJECTIVES MENTAL ILLNESS MEDICAL COMORBIDITIES

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1 DIAGNOSTIC PUZZLES MENTAL ILLNESS MEDICAL COMORBIDITES SUBSTANCE ABUSE SPECIAL POPULATIONS IMPROVING COMPLIANCE CASE STUDIES LEARNING OBJECTIVES Learner will be able to identify substance abuse and state 3 medications safe to use for depression, anxiety and insomnia in persons with a substance abuse history. Learner will be able to differentiate between depression and dementia in the elderly and use of medications in this population Learner will be able to state 3 strategies for improving treatment compliance MEDICAL COMORBIDITIES Many medical problems mimic or exacerbate psychiatric symptoms Many medications can have side effects of depression Medications metabolized by Cytochrome P pathways can interact with most psychotropic medications, and drug interactions should always be checked before making any medication changes. There is a high incidence of depression and/or anxiety with many chronic illnesses; heart disease, diabetes, chronic pain 1

2 ASSOCIATION OF COMORBIDITIES Current Depression and Lifetime Diagnosis of Depression and Anxiety by Asthma, Diabetes, and CVD Status Status Current Depression (%) Lifetime Diagnosis of Depression (%) Lifetime Diagnosis of Anxiety (%) Asthma No asthma CVD No CVD Diabetes No diabetes DEPRESSION, SUBSTANCE ABUSE & SUICIDE Over 60 percent of all people who die by suicide suffer from major depression. If one includes alcoholics who are depressed, this figure rises to over 75 percent. Depression affects nearly 10 percent of Americans ages 18 and over in a given year, or more than 24 million people. More Americans suffer from depression than coronary heart disease (17 million), cancer (12 million) and HIV/AIDS (1 million). According to reports published in the Journal of the American Medical Association: Roughly 50 percent of individuals with severe mental disorders are affected by substance abuse. 37 percent of alcohol abusers and 53 percent of drug abusers also have at least one serious mental illness. Of all people diagnosed as mentally ill, 29 percent abuse either alcohol or drugs. SUICIDE RISKS Alcohol and Suicide: Ninety-six percent of alcoholics who die by suicide continue their substance abuse up to the end of their lives. Alcoholism is a factor in about 30 percent of all completed suicides. Approximately 7 percent of those with alcohol dependence will die by suicide. Firearms and Suicide: Although most gun owners reportedly keep a firearm in their home for "protection" or "self defense," 83 percent of gun-related deaths in these homes are the result of a suicide, often by someone other than the gun owner. Firearms are used in more suicides than homicides. Death by firearms is the fastest growing method of suicide. Firearms account for 50 percent of all suicides. Medical Illness and Suicide: Patients who desire an early death during a serious or terminal illness are usually suffering from a treatable depressive condition. People with AIDS have a suicide risk up to 20 times that of the general population. Studies indicate that the best way to prevent suicide is through the early recognition and treatment of depression and other psychiatric illnesses. 2

3 OREGON SUICIDE RATES Compared to the national average, Oregon suicide rates have been higher for the past three decades. The most recently available national data shows Oregon age-adjusted suicide rate of 17.1 per 100,000 in 2010 was 41 percent higher than the national average Oregon ranked 9th place among all US states in suicide incidence. Between 2003 and 2010, Oregon suicide rates were significantly higher than the national average among all age groups except ages and women ages ADDRESSING SUBSTANCE AND ALCOHOL USE PRIOR TO TREATMENT Substance abuse is defined as a pattern of harmful use of any substance for mood-altering purposes. Mental illness refers to disorders generally characterized by dysregulation of mood, thought, or behavior (as recognized by the Diagnostic and Statistical Manual, 5th edition, of the American Psychiatric Association (DSM-5). Dealing with either can be difficult, but it is often more difficult to deal with both. Each disorder has its own unique symptoms that can impair one s ability to function and often interact with each other. IDENTIFYING SUBSTANCE ABUSE CAGE Questions 1. Have you ever felt you should cut down on your drinking? 2. Have people annoyed you by criticizing your drinking? 3. Have you ever felt bad or guilty about your drinking? 4. Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)? CAGE Questions Adapted to Include Drug Use (CAGE-AID) 1. Have you ever felt you ought to cut down on your drinking or drug use? 2. Have people annoyed you by criticizing your drinking or drug use? 3. Have you felt bad or guilty about your drinking or drug use? 4. Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)? 3

4 WHY DO SOME DRUG USERS BECOME ADDICTED, WHILE OTHERS DON T? Risk factors that increase your vulnerability include: Family history of addiction Abuse, neglect, or other traumatic experiences in childhood Mental disorders such as depression and anxiety Early use of drugs Method of administration smoking or injecting a drug may increase its addictive potential WHEN CAN YOU GIVE A NARCOTIC TO SOMEONE WITH A HISTORY OF SUBSTANCE ABUSE? ADHD? Anxiety? Insomnia? Chronic pain? DEPRESSION IN PRIMARY CARE 4

5 TYPES OF TREATMENT ANTIDEPRESSANT MEDICATIONS PSYCHOTHERAPY LIGHT THERAPY, ECT, ALTERNATIVE THERAPIES SSRI S FIRSTLINETREATMENT FOR DEPRESSION AND ANXIETY Fluoxetine (Prozac) Fluvoxamine (Luvox) Sertraline (Zoloft) Paroxetine (Paxil) Escitalopram (Lexapro) Citalopram (Celexa) ATYPICAL ANTIDEPRESSANT GENERIC AND BRAND NAMES Bupropion (Wellbutrin) Duloxetine (Cymbalta) Venlafaxine (Effexor) Mirtazapine (Remeron) Trazodone (Desyrel) 5

6 TRICYCLIC ANTIDEPRESSANTS GENERIC AND BRAND NAMES Amitriptyline (Elavil) Clomipramine (Anafranil) Desipramine (Norpramin) Doxepin (Sinequan) Imipramine (Tofranil) Nortriptyline (Pamelor, Aventyl) Protriptyline (Vivactil) Trimipramine (Surmontil ) MAOI GENERIC AND BRAND NAMES Phenelzine (Nardil) Tranylcypromine (Parnate) Isocarboxazid (Marplan) Selegiline (Emsam) ALTERNATIVE TREATMENTS Herbal remedies; St. Johns Wort, Ginko, Kava to name a few. These may interfer with other medications. Supplements; Vitamins, especially B12, Omega 3 Fatty acids Music, pet therapy, massage, dance and acupuncture. 6

7 DEPRESSION TREATMENT-RISKS Antidepressants can increase suicidal thoughts and behaviors in children, teens, and young adults. (Black Box Warning) Be especially observant within the first few months of treatment or after a change in dose. Over 36,000 people in the United States die by suicide every year, Suicide is the fourth leading cause of death for adults between the ages of 18 and 65 years in the United States. Currently, suicide is the 10th leading cause of death in the United States (2009). INSOMNIA Insomnia is one of the leading symptoms accompanying a variety of somatic and mental health problems. Approximately one-third of Americans experience difficulty sleeping, and in primary care patients the number may be as high as 2/3 of the patients seen. TREATMENTS Medications Alternative/Natural Sleep Remedies Sleep Hygiene Behavioral Techniques 7

8 SLEEP TIPS 1. Establish a Regular Routine: 2. Get an Adequate Amount of Sleep Every Night 3. Go to Bed When You Are Sleepy: 4. Develop Sleep Rituals Before Going to Bed: 5. Avoid Stress and Worries at Bedtime: 6. Use Your Bed for Sleeping and Sex Only: 7. Avoid Heavy Meals Late in the Evening: 8. Reduce Your Intake of Caffeine and Nicotine: 9. Avoid Alcohol 4-6 Hours Before Bedtime: 10. Exercise regularly: 11. Don't nap for more than 30 minutes or after 3 p.m: 12. Keep it Dark and Cool: 13. Use Sleeping Aids Conservatively:. SEDATIVES/HYPNOTICS Flurazepam-Dalmane Temazepam-Restoril Triazolam-Halcion Zolpidem-Ambien Zaleplon-Sonata Lunesta Rozerem (non-narcotic) safe in the elderly SEDATING ANTIDEPRESSANTS Tricyclics-Amitriptyline, Nortriptyline (not FDA approved) Silenor-(Doxepin) 3mg & 6mg FDA approved for insomnia adults, and geriatrics Trazodone-Deseryl-(off label) Mirtazepine-Remeron (off-label) 8

9 OTHERS Antipsychotics-Quetiapine Antihistamines-hydroxyzine, diphenhydramine Antianxiety-lorazepam, diazepam, alprazolam, clonazepam, ect ALTERNATIVE THERAPIES L-Trytophan Melatonin Valerian root Herbal Teas- chamomile ANXIETY Benzodiazepines; use or not use? Benzodiazepines are effective in the treatment of anxiety, especially in panic disorder but have high risk of tolerance, dependence and abuse 9

10 BENZODIAZEPINES Intermediate Acting- alprazolam, lorazepam, Long Acting- chlordiazepoxide, clonazepam, diazepam, clorazepate ALTERNATIVE TREATMENTS Buspirone FDA Approved for anxiety, non narcotic, most helpful in patients with medical comorbidities, poor tolerance to medications, and in geriatrics. Hydroxyzine Pamoate- can be helpful as a prn but can be very sedating for some, and has significant anticholinergic effects Antidepressants-SSRI s, SNRI s, Trazodone, Mirtazapine Atypical s- Seroquel, zyprexa, very sedating and risk of metabolic syndrome, but can be very effective in small doses. WHAT IS OFF-LABEL PRESCRIBING? Off-label is the use of a drug outside the terms of its license Prescribing a dose in excess of that specified by the FDA Prescribing for an unlicensed indication Prescribing for a patient group outside of that specified by the FDA, such as children or the elderly 10

11 DEPRESSION IN THE ELDERLY Depression and dementia share many of the same symptoms. This can make it difficult to identify depression in people with dementia. Recognition and treatment of depression has the potential to improve functioning and quality of life in spite of the presence of other medical comorbidities. Also they often present with somatic complaints, or non-adherence to treatment versus complaints of depression Increase risk of suicide SCREENING TOOL ELDERLY PRESCRIBING Usually need much lower doses, and can become toxic over time especially with benzodiazepines, and become delirious. Impaired kidney or hepatic function need to decrease dose of most medications, (some psych meds can cause liver or kidney problems) Antipsychotics have black-box warnings in elderly. Increased risk for drug-drug interactions secondary to complex medication regimes for medical co-morbidities 11

12 ANTIDEPRESSANTS IN THE ELDERLY Usually start with lower doses Choose ones with best side effect profiles Avoid tricyclics if possible Watch for drug-drug interactions DEPRESSION, DELIRIUM, DEMENTIA? In order to make a diagnosis of dementia, delirium must be ruled out. However, patients with dementia are at increased risk of delirium and may have both. Delirium is an acute disorder of attention and global cognition (memory and perception) and is treatable. The diagnosis is missed in more than 50% of cases. Clients with dementia can also have depression DEPRESSION VERSUS DEMENTIA In depression, even when severe, other impairments typical of dementia (such as in speech, powers of reasoning and ability to orientate themselves in time and space) are unusual. In contrast, in a person with dementia these abilities are likely to be impaired. A depressed person will occasionally complain of an inability to remember things but will remember when prompted, whereas a person with dementia will be forgetful and will often try to cover up memory lapses. In severe depression, the powers of reasoning and memory may be very badly impaired, and it is this state that is most easily confused with dementia. This impairment is mainly due to poor concentration, and the condition is reversible with treatment or when the depression lifts. This is not the case with dementia. 12

13 DELIRIUM VERSUS DEMENTIA Acute onset Acute illness Disorientation Early Variable moment to moment Short Attention span Disturbed sleep-wake cycle Tactile hallucinations most common, may have visual also Gradual onset Chronic illness Disorientation Late Generally stable Attention reduced Sundowner s syndrome Hallucinations later and more likely visual DELIRIUM PREVENTION Avoidance of psychoactive drugs, medication assistance as to prevent incorrect dosing of medications; structured daytime activity, dark and quiet at night (for good sleep), visual and hearing assistive devices, orientation devices PSYCHOSIS AND DEMENTIA Although some atypical antipsychotic medications are modestly helpful for some patients, they are not effective for the majority of Alzheimer's patients with psychotic symptoms. Good clinical practice requires that medical or environmental causes for Alzheimer's-related agitation and aggression be ruled out and that behavioral interventions be considered before turning to antipsychotic medications. If an antipsychotic medication then is warranted, clinicians should closely monitor their Alzheimer's patients for intolerable side effects and potential safety concerns 13

14 TREATMENT OF NON-EMERGENT AGITATION IN DEMENTIA Start treatment with a cholinesterase inhibitor. Add memantine if the patient is moderate to severely demented. If agitation persists, try an SSRI antidepressant. If the SSRI antidepressant is unhelpful, trial trazodone. If these strategies are unhelpful, try either risperidone or aripiprazole. If both trials fail, use quetiapine. If quetiapine trial fails, use olanzapine. If olanzapine trial fails, use either divalproex or carbamazepine. If all the monotherapy trials fail, only then use combination therapy.* Avoid benzodiazepines! STRATEGIES TO ENHANCE PATIENT ADHERENCE Studies have shown that in the United States alone, non-adherence to medications causes 125,000 deaths annually and accounts for 10% to 25% of hospital and nursing home admissions. This makes non-adherence to medications one of the largest and most expensive disease categories. Moreover, patient non-adherence is not limited to medications alone. It can also take many other forms; these include the failure to keep appointments, to follow recommended dietary or other lifestyle changes, and to follow other aspects of treatment or recommended preventive health practice KEEP IT SIMPLE - SIMPLIFYING REGIMEN CHARACTERISTICS 1. Adjusting timing, frequency, amount, and dosage 2. Matching to patients' activities of daily living 3.Using adherence aids, such as medication boxes and alarm 14

15 IMPARTING KNOWLEDGE: Discussion with physician, nurse, or pharmacist Distribution of written information or pamphlets Accessing health-education information on the Web MODIFYING PATIENT BELIEFS: Assessing perceived susceptibility, severity, benefit, and barriers Rewarding, tailoring, and contingency contracting PATIENT AND FAMILY COMMUNICATION Active listening and providing clear, direct messages Including patients in decisions Sending reminders via mail, , or telephone Convenience of care, scheduled appointments Home visits, family support, counseling 15

16 LEAVING THE BIAS Tailoring the education to patients' level of understanding EVALUATING ADHERENCE Self-reports (most commonly used) Some possible questions- 1.Do you ever forget to take your medications? 2.Are you careless at times about taking medications? 3.When you feel better, do you sometimes stop taking medications? 4.Sometimes, when you feel worse, do you stop taking your medicine? Pill counting, measuring serum or urine drug levels CASE STUDY #1 45 yo hispanic female with CHF, Diabetes II, morbid obesity presents with complaints of severe anxiety, and insomnia Medications: O2 continuously 2lpm; spirolactone 50mg daily, seroquel 100mg TID, amitriptyline 200mg QHS, enalapril 20mg ii dily, metformin 500mg daily, celexa 40mg daily, valium 5mg TID, ultram i-ii q4-6h prn pain, albuteral inhaler prn What would you do? 16

17 CASE STUDY #2 35 yo married caucasian male presents with history of episodes of anxiety with paranoia multiple stressors, unable to hold a job, moves frequently, alcohol abuse, currently presents as depressed with low energy, fatigue, low energy, nightmares of physical abuse as a child; drinks 2-3 beers or whiskey every night. Current Medications: Bupropion XL 300mg, lorazepam 1mg prn anxiety Diagnosis? Medication changes? REFERENCES Texas Medication algorithm project(tmap) NIMH website: Innovations in clinical neuroscience on-line at: Facts and Figures/National Statistics: iewpage&page_id=050fea9f-b b1135c3a70de1fda ADDITIONAL REFERENCES Current Psychiatry free journal also available on-line Texas Medication algorithm project(tmap) and others NIMH website: Innovations in clinical neuroscience on-line at: Clinical Handbook of psychotropic drugs 19 th ed. Clinical Handbook of psychotropic drugs for children and adolescents by Normand J. Carrey, Barry A. Martin, Aidan Stokes, and Umesh Jain 17

18 REFERENCES CONTINUED Differentiating between Depression & Dementia Dementia Today June 17,2015: Depression and Comorbid Illness in Elderly Primary Care Patients: Impact on Multiple Domains of Health Status and Well-Being Polly Hitchcock Noël, PhD; John W. Williams, Jr, MD, MHS; Jürgen Unützer, MD, MPH; Jason Worchel, MD; Shuko Lee, MS; John Cornell, PhD; Wayne Katon, MD; Linda H. Harpole, MD, MPH; Enid Hunkeler, MA Ann Fam Med. 2004;2(6) SUBSTANCE Abuse and mental illness: Strategies to Enhance Patient Adherence: Making it Simple Ashish Atreja, MD, MPH, Fellow, Naresh Bellam, MD, MPH, Resident Physician, and Susan R. Levy, PhD, Professor Emeritus 18