Start Low, Go Slow but Treat to Target

Transcription

1 Start Low, Go Slow but Treat to Target Pharmacotherapy for Depression, Anxiety and At-Risk Alcohol Use in Late Life September 29, 2014

2 Audio and Control Panel instruction On the phone? Raise your hand and we will open up your lines for you to ask your question to the group. (Right) Using computer speakers? Type into the question box and we will address your questions. (Left)

3 Gary J. Kennedy MD Director, Division of Geriatric Psychiatry, Montefiore Medical Center Professor of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine

4 Statistics show a great increase during the last few decades in the number of patients suffering from mental diseases. The time has come for the general practitioner to have a better understanding of mental diseases

5 If early in the cases of beginning mania and melancholia patients could be placed under the firm, careful management of nurses trained properly to care for them, there would often not be serious outbreaks of mental disturbance that eventually develops under present conditions.

6 Mental Disorders and General Practice Journal of the American Medical Association 1906;46: Reprinted June 7, 2006 JAMA vol. 295 no. 21 page 2547

7 JAMA, 19 June 2013 vol. 309 no. 23

8 Treat to Target 50% of patients do not achieve remission with the first prescription Slow response predicts recurrence Residual symptoms predict recurrence Greater disability Caregiver burden Nonadherence Greater use of health care resources

9 Behavioral Activation - 1 Behavioral approach to counter patterns of avoidance and withdrawal from interpersonal situations, daily-life demands, distressing thoughts or feelings. Recognition that avoidance may minimize shortterm distress, but in the long-run it promotes difficulty by reducing opportunities to elevate mood (positive reinforcement)

10 Behavioral Activation 2 Activities and social contexts that are positively reinforcing are identified and encouraged Self-monitoring, scheduling and structuring of daily activities, rating the pleasure and sense of accomplishment experienced during an engaged activity, exploring alternatives to counter perceived behavioral obstacles Rumination targeted to move attention away from the content of ruminative thoughts toward direct, immediate behavior.

11 Evidence Base for Treating Geriatric Depression in Primary Care Detection and Screening Collaborative / Care Management Models PROSPECT (Bruce et al, 2004, JAMA) IMPACT (Unützer et al, 2002, JAMA) PRISM-E (Bartels et al, 2004, AJP) RESPECT(Dietrich et al, 2004, BMJ)

12 Change from Baseline Treatment Response Within the First Two weeks HAM-D 17 (ITT Group - LOCF Approach) * * * * * Mirtazapine (n = 187) Fluoxetine/paroxetine (n = 186) * p 0.05 Weeks

13 MEYERS et al. Arch Gen Psychiatry. 2009;66(8):

14 Apathy, retardation PHARMACOLOGIC ALGORITHM Initiate citalopram or sertraline If response is inadequate, switch or augment SSRI, OR switch class based on symptom profile Insomnia, anxiety, anorexia Pain Atypical, melancholic, anxious bupropion mirtazapine duloxetine venlafaxine If inadequate response Atypical anxious MAOI Melancholic, TCA

15 STAR*D Pharmacologic Switch Algorithm N Engl J Med 2006;354: Initiate citalopram (60 mg maximum dose) If intolerant or inadequate response switch to buproprion SR sertraline venlafaxine ER (400mg) (200mg) (375mg)

16 STAR*D Pharmacologic Augment Algorithm N Engl J Med 2006;354: Initiate citalopram (60 mg maximum dose) If inadequate response add Best choice buproprion SR (400mg) Second best choice buspiron (60mg)

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18 Pooled Analysis of Aripeprazole as a Therapeutic Adjunct

19 Pharmacotherapy vs. ECT Depression with Psychotic Features CORE study of 253 patients found over half experienced a 50% reduction in symptoms within the first week or the third ECT. By the 10 th treatment 65% achieved remission. With added treatments 75 % reached remission; of those aged 65 and over, 90% achieved remission (O Connor et al, 2001; Husain et al, 2004) Meyers et al (2009) randomized 259 adults with psychotic depression to olanzepine/sertraline or olanzepine/placebo. The mean age of the 142 aged 60 and over was 71 yrs. The mean doses were 13 mg olanzepine, 165 mg sertraline. 12 week remission rate with olanzepine/sertraline was 41.9% vs. 23.9% for olanzepine only. By week two 10% had remitted; by week four 20% remitted. Rates of remission, tolerability were similar between the young and old. Both experienced significant increases in cholesterol, triglycerides, body weight (14 lbs younger vs. 7 lbs older).

20 Meyers se al. Arch Gen Psychiatry. 2009;66(8):

21 Pharmacotherapy of Bipolar Depression and Mixed Mania with Depression

22 Treatment of Anxiety Take Away First Medications: Consider existing medications possibly causing anxiety for d/c Older adults have more variable response to certain dose and less equipped to mitigate adverse effects Reduce polypharmacy Benzodiazepines Some agents are longer lasting than others Alprazolam<Lorazepam<Clonzepam Longer lasting agents may accumulate and lead to intoxication or adverse events Metabolism differences Some agents require less involvement of the liver Lorazepam (Ativan) Oxazepam (Serax) Are efficacious BUT

23 Anxiety what works for older adults? Relaxation training; efficacious and low cost progressive muscle relaxation, including imaginal relaxation deep breathing meditation education about tension and stress Supportive therapy-reflective listening and validation of feelings Cognitive therapy-does not include the relaxation component of CBT Cognitive-Behavioral Therapy Ayers CR, Sorrell JT, Thorp SR et al: Evidenced based psychological treatments for late life anxiety. Psychology and Aging 2007; 22:8-17

24 Anxiety what works for older adults? SSRIs: Older adults with GAD given escitalopram had a greater response rate vs placebo at 12 weeks However, response rates were not significantly different using an intention-to-treat analysis Generally well tolerated. Side effects: fatigue, sleep disturbance, urinary sx Venlafaxine: Equally safe and well tolerated in older adults Shows similar efficacy in older adults in the treatment of GAD. Those with comorbid depression may exhibit decreased rates of response to anxiolytics Lenze EJ, et al: Escitalopram for older adults with generalized anxiety disorder: a placebo controlled trial. JAMA 2009; 301(3) Katz IR, et al: Venlafaxine ER as a treatement for generalized anxiety disorder in older adults:pooled analysis of five randomized placebo-controlled clinical trials. J Amer Geriatr Soc (1)18-25

25 BENZODIAZEPINES Choose a short-acting agent without active metabolites (eg, lorazepam or oxazepam) Limit use to <6 months Long-term use is fraught with multiple complications: Motor incoordination and falls Cognitive impairment Depression Potential for abuse and dependence

26 Treatment Medications: Adverse effects Increased risk of falling Cognitive impairment Can interfere with therapy (learning, memory) Can occur at lower doses than for younger patient Can carefully consider short term use earlier in treatment Avoid: Anti-histamines, sedatives, atypical antipsychotics

27 PHARMACOTHERAPY for ANXIETY (1 of 2) Disorder First-line treatments Second-line treatments Panic disorder with or without agoraphobia SSRIs, SNRIs, CBT Benzodiazepines Social phobia, generalized SSRIs plus CBT Benzodiazepines Social phobia, specific β-blockers OL plus CBT Buspirone Specific phobia CBT or benzodiazepines β-blockers Obsessive-compulsive disorder SSRIs, SNRIs, CBT Clomipramine OL = off label

28 PHARMACOTHERAPY for ANXIETY (2 of 2) Disorder First-line treatments Second-line treatments Posttraumatic stress disorder Generalized anxiety disorder Anxiety and medical disorders SSRIs or SNRIs SNRIs, SSRIs, CBT Identify and treat underlying cause, use SSRIs or SNRIs in primary anxiety disorder CBT Benzodiazepines Benzodiazepines

29 BUSPIRONE Studies suggest efficacy in treating generalized anxiety disorder treatment, but clinical experience is less positive Appears to be safer than benzodiazepines for patients taking several other medications or needing treatment for longer periods Clinical response is delayed for ~4 weeks, so concomitant use of short-term benzodiazepine may be useful for some patients

30 Follow-up Frequent follow-up Especially after medication or dose change Start low, go slow but go! Addressing focus on side effects Addressing this by: Avoid laundry list of side of effects Focus on established efficacy and tolerability for most Physical symptoms tend to DECREASE not increase Involve family Listen to concerns

31 Pharmacotherapy for Alcohol Use Disorders in Late Life Why substitute one substance for another? DSM-5 criteria do not capture the majority of older adults at risk for adverse consequences of excess alcohol use Even moderate alcohol intake will halve the benefits of antidepressants in major depressive disorders When social or health consequences have already occurred, abstinence rather than reduced intake is the goal Relapse after a period of abstinence is the norm for heavy users

32 Most Common Psychiatric Comorbidities Common Dual Diagnoses seen in Older Alcoholics Depression (20-30%) Cognitive loss (10-40%) Anxiety disorders (10-20%)

33 The Spectrum of Interventions for Older Adults A Not Drinking B Light-Moderate Drinking C Heavy Drinking D Alcohol Problems E Mild Dependence F Chronic/Severe Dependence Prevention/ Education Brief Advice Brief Interventions Pre-Treatment Intervention Formal Specialized Treatments

34 Workbooks Patients given workbooks containing elder specific content containing the following steps: 1. Identifying future goals-how the older person would like his/her life to improve, be different in the future (focus on hobbies, relationships, social life, finances) 2. Customized feedback (in the form of a health profile) 3. Discuss types of drinkers in the U.S and where the elders drinking pattern fits in to their age group ex: telling someone they fall into the at-risk group based on national guidelines 4. Introduce/educate the concept of standard drinks (ie, alcohol content of various beverages) 5. Reasons for drinking, weighing pros and cons, reasons to cut down

35 Workbooks 6. Considering change: quitting or cutting down on drinking 7. Sensible drinking limits, how to cut down (getting reacquainted with hobbies or activities from earlier life, pursuing volunteering) 8. Drinking agreement in the form of a prescription - negotiating limits 9. Coping with risky situations-boredom, social isolationrole playing 10. Summary of the session-including drinking limits, encouragement, drinking diary cards to be completed for the next month.

36 Naltrexone in the Treatment of Alcohol Dependence Cumulative Relapse Rate Naltrexone HCl (N=35) 0.1 Placebo (N=35) No. of Weeks Receiving Medication Volpicelli et al. Arch Gen Psychiatry. 1992;49:

37 Treatment Relapse prevention Naltrexone: competitive opioid antagonist, reduces the high of intoxication, reduces amount someone drinks. Acamprosate: GABA-A receptor agonist, NMDA receptor antagonist; received FDA approval for treatment alcohol dependence in abstinent drinkers. Reduces cravings. Renal metabolism. Disulfiram: Dangerous in older adults.

38 Available March 2015 from Guilford Press with extensive coverage on Diet and exercise Psychotherapeutic and psychosocial interventions Suicide prevention Medications

39 Thank you!