49th Annual Meeting Psychiatry for the Non-Psychiatry Specialist Jacintha Cauffield, PharmD, BCPS, CDE Associate Professor of Pharmacy Practice Lloyd L. Gregory School of Pharmacy Palm Beach Atlantic University Disclosure I do not have a vested interest in or affiliation with any corporate organization offering financial support or grant monies for this continuing education activity, or any affiliation with an organization whose philosophy could potentially bias my presentation OWNING CHANGE: Taking Charge of Your Profession Objectives: Pharmacist Objectives: Technician Differentiate amongst common psychiatric conditions Determine medication treatment for the various discussed psychiatric conditions Prevent adverse effects and drug interactions related to treatment Explore the psychosocial and societal challenges and misconceptions with psychiatric disorders and their treatment Differentiate amongst common psychiatric conditions Identify common medications used to treat the psychiatric disorders discussed Recognize potential adverse effects and drug interactions related to treatment Explore the psychosocial and societal challenges and misconceptions with psychiatric disorders and their treatment The Face of Mental Illness Diagnostic and Statistical Manual (DSM-V) Standard classification of mental disorders Based upon signs and symptoms Diagnostic criteria developed to increase reliability No reliable objective methods for psychiatric diagnosis Symptoms + Severity (impairment of normal function) 1
Commonly Seen Psychiatric Conditions in Adults Attention Deficit Hyperactivity Disorder (ADHD) Anxiety* Generalized Anxiety Disorder (GAD) Panic Disorder Agoraphobia Social Anxiety Disorder (SAD) Bipolar Disorder Depression Schizophrenia *Obsessive Compulsive Disorder (OCD) and Posttraumatic Stress Disorder (PTSD) are now classified separate from Anxiety Disorders Schizophrenia: Diagnosis NOT a split personality Major symptoms (> 2 for at least 1 month) Delusions Hallucinations Disorganized speech Grossly disorganized or catatonic behavior Negative symptoms Must have at least one of these three symptoms Depression Diagnosis: DSM-V Depressed mood Anhedonia Significant weight loss or gain Change in sleep habits Psychomotor agitation or retardation Fatigue or loss of energy Feelings of worthlessness/inappropriate guilt Decreased ability to think/concentrate; indecisive Recurrent thoughts of death/suicidal ideation Bipolar Disorder Elevated mood AND ed goal directed activity Mania Hypomania Diagnosis Bipolar Disorder Type I Bipolar Disorder Type II Major Depression? Not necessarily Yes-Hallmark Duration >1 week > 4 days Severity Marked impairment Hospitalization Psychosis possible Impairment, if present, is mild Noticed by others Identification Hallmark Can be missed What Is an Elevated Mood? 3 symptoms (elation) or 4 symptoms (irritability): Decreased need for sleep Distractibility Excessive involvement in high risk pleasurable activity Flight of ideas Grandiosity Increase in energy, goal-directed activity or psychomotor agitation Pressured speech Attention Deficit Hyperactivity Disorder (ADHD) Inattentive Hyperactive/Impulsive Careless mistakes/unable to give close Fidgets and squirms attention Leaves seat when inappropriate Difficulty keeping attention Runs about or climbs when Doesn t listen inappropriate Fails to finish tasks (loses focus) Unable to play quietly Difficulty organizing On the go / Driven by a motor Avoids tasks that require mental effort Talks excessively over long periods of time Blurts out answers before question Loses things often completed Easily distracted Difficulty waiting turns Forgetful in daily tasks Interrupts or intrudes on others Combined: symptoms of both inattentive and hyperactive/impulsive 2 or more settings Before age 12 For at least 6 months 2
Anxiety Disorders Anxiety Disorders How do I know if it s pathological? Excessiveness Intensity Duration (chronicity) Impairment Significant physical element Underdiagnosed Waxes and wanes Low remission rate Worsens prognosis of comorbid psychiatric conditions Uncontrollable worry about several areas Generalized Anxiety Disorder Uncued/ Spontaneous Panic Disorder Symptom Focus Fear of exposed places Agoraphobia Intermittent panic/anxiety symptoms and avoidance Fear of social scrutiny Social Anxiety Disorder Discrete object or situation Specific Phobia How does bipolar disorder differ from depression? A. Decreased sleep B. Elevated mood C. Loss of appetite D. Decreased concentration Correct Diagnosis Leads to Effective Treatment Matching Medications to Conditions Medication Anxiety Bipolar Disorder Depression Schizophrenia Anticonvulsants Adjunct Yes No Adjunct Antidepressants Yes? Yes No Antipsychotics Adjunct Yes Adjunct Yes Benzodiazepines Yes No No No Lithium No Yes Adjunct No ADHD Stimulants (amphetamine salts, dextroamphetamine, dexmethylphenidate, lisdexamfetamine, methylphenidate) Atomoxetine Clonidine Guanfacine Which medications am I most likely to see: 2013 IMS Data Class Medication Antidepressants Bupropion (SR, L) Citalopram Desvenlafaxine Duloxetine Escitalopram Antipsychotics Aripiprazole Olanzapine Benzodiazepines Alprazolam Diazepam Lorazepam Stimulants Other Amphetamine salts (immediate and ER) Lisdexamfetamine Methylphenidate (generic, Concerta ER) Buspirone Hydroxyzine Paroxetine Sertraline Trazodone Venlafaxine ER Quetiapine 3
Treatment Conundrums: Antipsychotics in Schizophrenia SGAs: Other Indications First generation Antipsychotics (FGA) (Typical) (e.g. chlorpromazine, haloperidol) More uniform class low potency anticholinergia high potency More movement disorders (EPS) EPS is a class effect Hyperprolactinemia vs. Second Generation Antipsychotics (SGA) (Atypical) (e.g. aripiprazole, olanzapine) More effective against negative symptoms? More diverse class Differing side effect profiles Metabolic syndrome Not devoid of movement disorders Aripiprazole Clozapine Lurasidone Olanzapine Quetiapine Ziprasidone Anxiety (Adjunct-SAD) (SAD; Adjunct-GAD) (GAD, SAD) (Adjunct-GAD, SAD) Depression (Adjunct) Bipolar DO (Mania) Bipolar DO (Depression) Not effective (likely) (with fluoxetine) ER only (- Monotherapy) (with fluoxetine) Addressing FGA ADRs SGAs: Metabolic Syndrome Switch agents if possible Acute Dystonias: treat/prophylax with anticholinergic Benztropine Parkinsonian syndromes: anticholinergic Akathisia: Lipophilic beta blocker (propranolol) Tardive dyskinesia: no known treatment Weight Gain Clozapine = olanzapine (26.3%) Low potency FGAs Quetiapine (17%) (9%)=paliperidone High potency FGAs Lurasidone Ziprasidone (5.8%) Aripiprazole (4.9%) *FDA considers >7% clinically significant Worst Least Glucose Intolerance Clozapine=olanzapine Quetiapine=risperidone=paliperidone Lurasidone > Ziprasidone=aripiprazole ADA: consider a change in antipsychotics if >5% weight gain SGAs: Selected ADRs ADR High Low Akathisia Aripiprazole, lurasidone Quetiapine Agranulocytosis Clozapine ---- EPS (>6 mg/day) Clozapine, quetiapine Hyperprolactinemia ---- QTc prolongation Ziprasidone (aripiprazole, clozapine, olanzapine, risperidone, quetiapine) * ---- Sedation Clozapine, olanzapine, Aripiprazole quetiapine Seizures Clozapine ---- SGAs can be used to treat: (Choose all that apply!) A. ADHD B. Depression C. Mania D. Schizophrenia *www.crediblemeds.com 4
Antidepressants in Depression Antidepressant Classes No definitive first-line agent Side effect profile Previous response Family member response Class Serotonin Selective Reuptake Inhibitors (SSRIs) Serotonin Norepinephrine Reuptake Inhibitor (SNRIs) Mixed Serotonergic Activity Other Agents Citalopram, escitalopram, fluoxetine, paroxetine, sertraline Desvenlafaxine, duloxetine, levomilnacipran, venlafaxine Vortioxetine, vilazodone Bupropion, mirtazapine Antidepressant-Patient Matches Bipolar Depression: Antidepressants Symptom (that is present) Weight loss Weight gain Insomnia Hypersomnia Suicidal ideation Antidepressant (counteract symptom) Mirtazapine, paroxetine, TCAs Bupropion, duloxetine, SSRIs (except paroxetine), venlafaxine Mirtazapine, TCAs, paroxetine, trazodone Bupropion, duloxetine, fluoxetine, sertraline, vilazodone NOT TCAs, avoid bupropion; use SSRIs Neuropathic pain Duloxetine, TCAs (amtitriptyline (?), desipramine, nortriptyline) Sexual dysfunction Bupropion, mirtazapine, nefazodone, vilazodone? Pregnancy, sertraline, bupropion? Evidence for efficacy weak Can cause a switch to mania (TCAs, venlafaxine) Monotherapy Bipolar I Bupropion, fluoxetine, paroxetine: little to no switching Use: h/o positive response Relapses off of antidepressant Bipolar II? Bipolar Depression: Alternatives Lamotrigine (not acutely) Lurasidone Olanzapine + fluoxetine Other SSRI/SGA combinations? Quetiapine Lithium (partial relief) Pharmacotherapy: Anxiety DO Often a balancing act Antidepressants (SSRIs) Benzodiazepines Cornerstone of pharmacotherapy Short term use Treat cognitive and behavioral Treat somatic and autonomic symptoms symptoms Effective across anxiety DO Effective only for GAD, panic DO; spectrum avoid in SAD Take 2-4 weeks to manifest Immediate relief benefits Can initially worsen symptoms Symptom relief Buspirone takes 2-4 weeks of scheduled dosing for relief 5
Pharmacotherapy: PTSD and OCD Benzodiazepines ineffective PTSD: therapy tailored to symptoms SSRIs central Additional treatments added based upon symptoms OCD: antidepressant with serotonergic activity necessary SSRIs, clomipramine Adjunctive antipsychotics Medication Interactions Pharmacokinetic Pharmacodynamic Substrate Psychiatric Medication Interactions: Pharmacokinetic 1A2 2C19 2D6 3A4 Caffeine Clozapine Olanzapine Ramelteon Citalopram Diazepam Escitalopram Sertraline Vilazodone Inhibitor Fluvoxamine Amitriptyline Fluvoxamine Imipramine Inducer Carbamazepine Smoking Barbiturates St. John s Wort Aripiprazole Atomoxetine Some FGAs Paliperidone SSRIs Trazodone TCAs Venlafaxine Vortioxetine Paroxetine Benzodiazepines Buspirone Desvenlafaxine Guanfacine Levomilnacipran Lurasidone Quetiapine TCAs (some) Vilazodone Z drugs Fluvoxamine Nefazodone Barbiturates Carbamazepine St. John s Wort Additional Pharmacokinetic DDIs Valproic acid (VPA) and Lamotrigine (LTG) VPA inhibits LTG metabolism through UGT LTG concentrations Stevens Johnson Syndrome Low doses of VPA (125-250 mg/day) Cut LTG by half A physician wishes to add an antipsychotic to a patient s regimen. He is taking fluoxetine concomitantly. Which is best? A. Aripiprazole B. Haloperidol C. Quetiapine D. Pharmacodynamic: Serotonin Syndrome What is it? Altered Mental Status Neuromuscular Hyperactivity Autonomic Instability Hunter s criteria Spontaneous clonus Agents Dextromethorphan Linezolid Monoamine Oxidase Inhibitors Opioids (fentanyl, meperidine) SNRIs SSRIs Stimulants Tramadol Triptans? Inducible clonus + agitation or diaphoresis Ocular clonus + agitation or diaphoresis Tremor AND hyperreflexia ONLY Hypertonia AND temp > 38 o C AND ocular or inducible clonus 6
Pharmacodynamic: QTc Prolongation* and Torsade des Pointes (TdP) 92%: additional risk factor (e.g. overdose, drugdrug interaction) Known TdP Risk Possible TdP Risk Conditional TdP Risk Chlorpromazine Citalopram Escitalopram Haloperidol Mesoridazine (d/c ed) Thioridazine Aripiprazole Atomoxetine Clozapine Iloperidone Lithium Mirtazapine Olanzapine Paliperidone Quetiapine TCAs (most) Venlafaxine Ziprasidone *QTC >460-500 msec; www.crediblemeds.com Amitriptyline Doxepin Paroxetine Sertraline Living with a Psychiatric Condition (Mental Illness) Which statement is true with regard to people who have psychiatric conditions? A. They can t live productive lives. B. Self- advocacy is difficult when they are sick. C. Pharmacotherapy is usually adequate to achieve and maintain remission. D. They are prone to violence and are commonly a danger to others. Mental Illness and the Criminal Justice System 2012: Patients with severe mental illness in jail: 356,268 Patients in psychiatric hospitals: 35,000 Rate of violent crime low Substance Abuse Crimes of survival http://www.tacreports.org/storage/documents/treatment-behind-bars/treatmentbehind-bars.pdf; accessed 6/26/2015; Law Human Behav 2014;38:439. Barriers to Treatment Can t advocate for self Patients unable to articulate symptoms Lack of energy Inability to concentrate Inability to organize Lack of insight Communication blocks Aren t We Overmedicating Patients? Medication is only part of the solution Medication improves patient ability to participate in nonpharmacologic measures Psychotherapy and psychoeducation are essential Better long term outomes Treat early to prevent complications Consider step down therapy 7
Supporting the Patient who has a Psychiatric Condition: Resources Unusual behavior may be a symptom Offer support National Alliance on Mental Illness www.nami.org National Institute of Mental Health www.nimh.gov College of Psychiatric and Neurologic Pharmacists www.cpnp.org 8