Psychiatry Curbside Top 10 April 27, 2018 Laurel Ralston, DO Staff Psychiatrist Director of Psych-Oncology, Taussig Cancer Institute
Objectives Review current diagnostic and prescribing guidelines for depression and anxiety disorders Discuss non-pharmacologic treatment alternatives Recognize patients at risk for psychiatric crisis
#1.Why are primary care doctors responsible for providing most mental health services in the US?
https://jamanetwork.com/data/journals/jama/936400/jig170002fa.png In 2017, 60% of psychiatrists were 55 or older
https://jamanetwork.com/data/journals/jama/936400/jig170002fa.png Boston Med Surg J 1923; 189:965-969. DOI: 10.1056/NEJM192312131892401 The importance of psychiatry to the medical profession may be measured with a fair degree of accuracy by the prominence of the part played by mental diseases as a factor in public health problems.
Depression & Anxiety Screening Assess further if: PHQ-2= 3 or higher or GAD-2= 3 or higher www.phqscreeners.com
#2. Is DSM-5 relevant for the primary care provider? 600 500 DSM Diagnoses (1952-2013) 541 400 410 300 265 200 100 128 182 0 DSM-I DSM-II DSM-III DSM-IV DSM-5
DSM-5 Depression Specifiers Depression specifiers: - Mixed features - Atypical features - Psychotic features - Anxious distress - Melancholic features - Peripartum onset - Seasonal onset Add mood stabilizer? Bupropion? Activating SSRI/SNRI? Add antipsychotic?
DSM v NIMH Symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century symptoms alone rarely indicate the best choice of treatment. Patients with mental disorders deserve better. NIMH has launched the Research Domain Criteria (RDoC) project to transform diagnosis by incorporating genetics, imaging, cognitive science, and other levels of information to lay the foundation for a new classification system. -Thomas Insel, NIMH Director 2002-2015 https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2013/transforming-diagnosis.shtml
Psychiatry On the Horizon Imaging Biomarkers -CRP, IL-6, TNF-α Glutamate - ketamine Glial Cells PET Scan: depressed brain (top), treated depression (bottom) PET Scan: normal (left), manic phase (right) -Ashwell, Ken W. S. & Restak, Richard M. (2012). The brain book : development, function, disorder, health. South Yarra, Vic : Palgrave Macmillan -Carter, R., Aldridge, S., Page, M. (., Parker, S., Frith, C. D., Frith, U., & Shulman, M. B. (2009). The human brain book.1st American ed. London [England]: New York, N.Y.
#3. When Should I Prescribe a Medication? Image: http://blogs.discovermagazine.com/neuroskeptic/files/2018/02/lol.png
Prescribing considerations Past medication trials (personal, family) Psychiatric co-morbidities Medical co-morbidities Age Drug interactions (eg tamoxifen) Cost Pregnant/Breastfeeding - https://womensmentalhealth.org
#4. Which antidepressants work best?
SSRIs Medication Approved Indication Usual Dosage Max (mg/day) Zoloft (sertraline) MDD Social anxiety disorder 50-200 mg/day 50-200mg/day 200 200 Panic disorder 50-200mg/day 200 OCD 50-200mg/day 200 PTSD 50-200mg/day 200 PMDD 50-150mg/day 150 Paroxetine (Paxil) MDD GAD 20-50mg/day (12.5-37.5) 20-50mg/day 50 (62.5) 50 Social Anxiety Disorder 20-60mg/day (12.5-37.5) 60 (37.5) Panic disorder 20-40mg/day (12.5-75) 60 (75) PTSD 20-60mg/day 60 PMDD (12.5-25mg/day) (25)
SSRIs Medication Approved Indication Usual Dosage Maximum (mg/day) Citalopram (Celexa) Escitalopram (Lexapro) Fluoxetine (Prozac) MDD 20-40mg/day 40 MDD GAD MDD OCD 10-20mg/day 10-20mg/day 20-80mg/day qam or BID 20-60mg/day, qam or BID 20 20 80 80 Panic disorder 20-60mg/day 60 Bulimia 20-60mg/day 60 PMDD 20-60mg/day 60 Fluvoxamine (Luvox) OCD 100-300mg/day, divided BID 300
SNRIs Medication Approved Indication Usual Dosage Maximum Duloxetine (Cymbalta) Venlafaxine (Effexor) Desvenlafaxine (Pristiq) Milnacipran (Savella) Levomilnacipran (Fetzima) MDD GAD Fibromyalgia MDD GAD Social Anxiety Panic Disorder 40-60mg/daily 60mg/day 60 mg/day 75-225mg/day 75-225mg/day 75mg/day 75-225mg/day 120mg 120mg 60mg 225mg 225mg 75mg 225mg MDD 50mg/day 50mg Fibromyalgia 100mg/day 200mg MDD 40-120mg/day 120mg
Medication Approved Indications Usual Dosage Maximum Vilazodone (Viibryd) Vortioxetine (Trintellix) Trazodone Multimodal 5HT Antagonists MDD 20-40mg/day 40mg MDD 20mg/day 20mg MDD Insomnia* (off label) 150-300mg/day (divided BID or TID) 25-100mg qhs 400mg 200mg Noradrenergic-specific serotonin antidepressant Medication Approved Indications Usual Dosage Maximum Mirtazapine (Remeron) MDD 15-45mg/qhs 45mg
NDRI Medication Approved Indications Usual Dosage Maximum Bupropion (Wellbutrin) MDD 300mg (divided TID) (IR) 300mg (divided BID) (SR) 450mg 400mg BupropionXL MDD, SAD 300mg/day 450mg Aplenzin MDD, SAD 348mg/day 522mg
#5. What do I tell my patient about risks & side effects?
Suicidal thoughts and behaviors FDA black box warning (2004) - Adolescents and young adults Based on 24 studies; 4400 patients - Prevalence of suicidal thinking and behavior in first few months of starting antidepressant? 4% in antidepressant group; 2% in placebo group No actual suicides
Addressing Sexual Side Effects Patients are unlikely to initiate conversation dose or switch to bupropion, mirtazapine Augment with bupropion, sildenafil Anita H. Clayton, Harry A. Croft & Lata Handiwala (2014) Antidepressants and Sexual Dysfunction: Mechanisms and Clinical Implications, Postgraduate Medicine, 126:2, 91-99.
Serotonin syndrome
#6. What augmentation or alternative treatments are available? Medications Bright light therapy Nutrition/Exercise Brain Stimulation Pharmacokinetic gene testing
Drug Augmentation in Treatment Resistant Depression Huynh NN, McIntyre RS. What Are the Implications of the STAR*D Trial for Primary Care? A Review and Synthesis. Primary Care Companion to The Journal of Clinical Psychiatry. 2008;10(2):91-96.
Bright light therapy Proven efficacy in depression with seasonal onset Relatively inexpensive ($100-200), sometimes lighbox is covered by insurance Negligible side effects, but can potentially evoke manic symptoms in bipolar patients
Nutrition Vitamin B6 - Needed to produce serotonin Omega 3 FA (DHA) - Promotes production of brain derived neurotrophic factor (BDNF); protect neurons, birth of new brain cells Jacka et al. A randomised controlled trial of dietary improvement for adults with major depression (the 'SMILES' trial). BMC Medicine (2017) 15:23
Nutrition Role of Inflammation - Prebiotics Food for good gut bacteria - Probiotics Live bacteria and yeast; replenish good gut bacteria Vitetta, L., Bambling, M., & Alford, H. (2014). The gastrointestinal tract microbiome, probiotics, and mood.inflammopharmacology, 22(6), 333-339.
Electroconvulsive therapy Treatment option with highest remission rates (80%) Frequently M/W/F x3 weeks, then maintenance monthly as needed Risk of memory impairment No absolute contraindications National Institutes of Health: National Institute of Mental Health. Brain Stimulation Therapies. Accessed April 26, 2018.
Transcranial Magnetic Stimulation 50% remission rates Pros: non-invasive, negligible side effects Cons: time intensive, unreliable insurance coverage, limited number of clinicians offering TMS Cress K, Brown K, Landry B, Zotyka R. Treatment of unipolar, non-psychotic major depressive disorder with transcranial magnetic stimulation: a retrospective evaluation examining acute and long-term efficacy of TMS during routine clinical practice. Poster presentation at: 2016 Annual Meeting of the American Psychiatric Association; May 14-18, 2016; Atlanta, GA.
Psychopharmacologic gene testing Identify CYP450 variant metabolizers - Most psych medications metabolized via 3A4, 2D6, 1A2 Presence of specific genes associated with medication adverse effects - Serotonin transporter gene promoter polymorphism (5-HTTLPR)
#7. Is it okay to prescribe benzos? Lack of data on best practice guidelines Increased risk for adverse effects in patients that are elderly, have pulmonary disease or history of substance abuse Set clear expectations with patient at onset re: anticipated duration of treatment Relationship between benzos and dementia is unclear
Benzo Equivalency Chart Approx Oral Equivalency (mg) Time to peak level, hours Alprazolam (Xanax) 0.5-1 1-2 12 Lorazepam (Ativan) 1-2 1-4 15 Diazepam (Valium) 5-10 1-2 100 Clonazepam (Klonopin) 0.25-0.5 34 Tempazepam (Restoril) 10-20 2-3 11 Half-life, hours
#8. Is there evidence-based psychotherapy? Cognitive behavioral therapy Dialectical behavioral therapy Behavioral activation Motivational interviewing Mobile apps Depression/Anxiety Borderline PD Depression Depression/Substance Limited Evidence
Not Just Talk Effective psychotherapy can elicit a biological response - Changes on neuroimaging - Changes in cortisol, oxytocin - Biofeedback parameters
Mirror Neurons Common activation of emotionally significant parts of the cortex, whether the emotion is personal or a third-person observation, may be the anatomical basis for empathy In this PET scan, the same sets of nerve cells in the cerebral cortex are activated when watching an action as when performing it, evidence of mirror neurons at work
#9. How can I identify patients at suicide risk?
https://www.nimh.nih.gov/health/statistics/suicide.shtml
Patients with suicidal thoughts MYTH: Asking about suicide makes patients suicidal (it does not!) Screening tool: Columbia Suicide Scale Know the guidelines for involuntary hospitalization in your state Have a written office protocol for how to handle an actively suicidal patient
Patient Resources National Suicide Prevention Lifeline, 1-800-273-TALK (8255) or Live Online Chat SAMHSA Treatment Referral Helpline, 1-877-SAMHSA7 National Alliance for Mental Illness (NAMI)
#10. How Can We Improve PCP and MH Provider Collaboration? Telemedicine Project ECHO (Extension of Community Health Outcomes) Collaborative Care Models