UPDATE ON THE OUTPATIENT TREATMENT OF PSYCHIATRIC DISORDERS Amanda J. Williams, MD Grayson & Associates Montgomery, AL

UPDATE ON THE OUTPATIENT TREATMENT OF PSYCHIATRIC DISORDERS Amanda J. Williams, MD Grayson & Associates Montgomery, AL

Objectives Differentiate the multiple causes of depressed mood and anxiety, and identify the appropriate treatment for each cause. Understand the most up-to-date literature on psychotropic medications as relevant to clinical practice. Appreciate the importance of psychiatric illness in the geriatric population, knowing the appropriate treatments for delirium, dementia, depression and anxiety. Provide the most evidence-based management of insomnia. Recognize medical sequelae of psychiatric illness ranging from psychosis to eating disorders. Approach addiction treatment through motivational interviewing. Appropriately assess and manage patients with suicidal thoughts.

Mental Health Treatment in Primary Care Settings Depression 67% treated by primary care providers Worsens overall physical health Psychiatric illness accounts for a significant proportion of dermatologic, neurologic and GI complaints

Recovery Oriented Care Autonomy, empowerment, and respect for the person receiving services Shared decision making, focusing on an individual's unique goals and life circumstances Improves engagement

The Depressed Patient Depressive Episode 2 weeks of symptoms SIG E CAPS Hypomania/Mania? Bereavement Other causes TSH, B12, folate, vit D, CBC, UDS

Treatment Options for Unipolar Depression Antidepressant Medications Psychotherapy Combination treatment (medications and psychotherapy) more effective than either alone NICE recommends psychotherapy alone as initial treatment for mild depression Collaborative Care Model Behavioral Changes Supplements: St. John s Wart, 5HTP, SAMe, fish oil, L-theanine ECT, TMS, ketamine infusions, light therapy

Choosing an Antidepressant High placebo response All SSRIs, SNRIs, atypical antidepressants, serotonin modulators appropriate initial treatment What worked in family members?

Citalopram (Celexa) Escitalopram (Lexapro) Sertraline (Zoloft) Fluoxetine (Prozac) Paroxetine (Paxil) Fluvoxamine (Luvox) SSRIs Less drug-drug interactions QTc prolongation (citalopram) Higher rates of diarrhea Cardiac patient Long half-life Weight gain, sedation Helpful for anxious depression Many drug-drug interactions Helpful in OCD

Venlafaxine (Effexor) Duloxetine (Cymbalta) Desvenlafaxine (Pristiq) Levomilnacipran (Fetzima) SNRIs Significant withdrawal Depression and anxiety Fibromyalgia, neuropathic pain Effexor s main metabolite Functional impairment in depression No weight changes

Atypical Antidepressants Mirtazapine (Remeron) Bupropion (Wellbutrin) Vilazodone (Viibryd) Vortioxetine (Trintellix, previously Brintellix) Faster onset Increased appetite, sedation, dry mouth No sexual side effects Helpful in tobacco cessation, ADHD, and hypoactive sexual disorder Less effective in anxiety Contraindicated in eating disorders, seizures, EtOH/benzo abuse Can cause insomnia, dry mouth Weight neutral Theoretically helpful in IBS and anxious depression Headache, GI upset No weight gain or sexual side effects Improves cognitive functioning Studied in geriatric population

Amitriptyline (Elavil) Clomipramine (Anafranil) Doxepin Imipramine Amoxapine Nortriptyline (Pamelor) Desipramine Tricyclic Antidepressants Sedating Most 5HT effect good in OCD Most H1 inhibition tx of gastric ulcers Helpful in psychosis Has therapeutic window Helpful in GI disorders Most NE effect, least ACh best for BPH Phenelzine (Nardil) Selegiline (Emsam) Tranylcypromine (Parnate) Monoamine Oxidase Inhibitors Sedation, weight gain Selective inhibitor of MAO-B at low doses Hypotension

Bipolar Disorder Treatment Lithium Depakote Lamictal Trileptal Tegretol Atypical Antipsychotics Mood Stablizers Decreases suicidality Kidney dysfunction, thyroid dysfunction Sedation, tremor, weight gain, hair loss Do not use with ACE-I, NSAIDs Rapid cycling Significant birth defects Hepatotoxicity, PCOS (7x suicide rate) Bipolar depression No bloodwork monitoring, slow titration Life-threatening rash Depakote will double levels, OCPs will decrease levels Hyponatremia Rapid cycling Stevens Johnson (BBW), agranulocytosis Trigeminal neuralgia, partial seizures Many drug-drug interactions Weight gain, sedation

The Suicidal Patient Risk Factors for Completed Suicide Psychiatric illness and addiction Older age, male sex Living alone, homelessness Unskilled occupations, physicians, military Never married, widowed, separated, divorced Following psychiatric hospitalization Adverse childhood experiences Family discord Family history of suicide Hopelessness and impulsivity Chronic medical illness Access to weapons/firearms Anniversary of a loss Homosexuality Rural areas Social support Connectedness Protective Factors for Suicide Religiosity Pregnancy/Parenthood

The Suicidal Patient Evaluating Suicide Risk Content and duration Changes? Chronic? How are they controlled? What would happen if you died? Do you have a plan? What is it? When would you do it? Are the means readily accessible? Have preparations been made? Management Reduce immediate risk Manage underlying factors Monitoring and follow up

Anxiety Management SSRIs, SNRIs, mirtazapine Buspirone (Buspar) Gabapentin (Neurontin) Hydroxyzine (Vistaril) Benzodiazepines Quetiapine (Seroquel) Propranolol Anxiolytics First-line treatment +/- CBT Few side effects Wide dosing range Neuropathic pain Benzo withdrawal/taper Sedation PRN use Ideally short-term Sedation Performance anxiety

Benzodiazepines

Psychosis Management Assess Safety Diagnosis: Medical cause? Substance use? Medications? Depression, bipolar disorder, PTSD, grief, dementia? Post-partum? Primary psychotic disorder? Treatment Typical vs atypical antipsychotics Psychotherapy, ECT

Insomnia Evaluation Rule out other medical condition, substance use, medications Sleep history and sleep log Behavioral Modifications Behavioral therapies Melatonin Medication Options Sleep Onset Insomnia Zaleplon (Sonata), Zolpidem (Ambien), Lorazepam, Ramelteon (Rozerem melatonin agonist) Sleep Maintenance Insomnia Extended release Zolpidem, Eszopiclone (Lunesta), Temazepam, Estazolam, low dose doxepin (3mg), trazodone, suvorexant (Belsomra)

Post Traumatic Stress Disorder Dissociative, re-experiencing, avoidance, arousal Antidepressants, mood stabilizers, sleep aids, antipsychotics Prazosin nightmares/flashbacks

Pregnancy and Psychotropic Medications No more FDA categories Depression Relapse rates 70% without meds, 30% with meds Avoid Paxil (cardiac defects) Breastfeeding lowest transmission in Zoloft Bipolar Disorder Lithium: tricuspid valve deformities, floppy baby Depakote: neural tube defects, craniofacial defects, cardiac abnormalities, autism (AVOID) Lamictal: good option Sedative-hypnotics may increase the risk of fetal malformations if used during the first trimester. Website: www.womensmentalhealth.org

Geriatric Psychiatry

Dementia Management Cognitive testing MOCA Labs TSH, B12. UA. RPR if high clinical suspicion No imaging unless other reasons to (neuro deficit, younger age, rapid onset of sxs) by most recommendations. Medications Cholinersterase Inhibitors (donepezil, rivastigmine, galantamine) NMDA antagonist (memantine) Vitamin E (2000 IU daily) mild to moderate AD Agitation? Low dose antipsychotics

Addictions Assessment readiness for change Motivational Interviewing Medication Options Opioid agonists: methadone, buprenorphine Alcohol treatments: naltrexone, acamprosate, disulfram Avoid habit forming medications (stimulants, benzos, opioids) as much as possible

Personality Disorders Treatment Plan Medications antidepressants, mood stabilizers, antipsychotics Limit benzos result in subjective improvement, but given abuse potential and possible disinhibition of impulsive behaviors, low dose antipsychotic preferable Fostering compliance by working together in nonjudgmental way

Eating Disorders Nutritional rehabilitation and psychotherapy Monitor for refeeding syndrome (potentially fatal) Medications Avoid bupropion (Wellbutrin) Anorexia Nervosa Bulimia Nervosa Binge Eating Disorder Medications NOT effective Fluoxetine (Prozac) Other SSRIs SSRIs Topiramate (Topamax) Lisdexamfetamine (Vyvanse)

Questions? amandajwilliamsmd@gmail.com

Resources Costa e Silva JA, Chase M, Sartorius N, Roth T. Special report from a symposium held by the World Health Organization and the World Federation of Sleep Research Societies: an overview of insomnias and related disorders--recognition, epidemiology, and rational management. Sleep. 1996 Jun;19(5):412-6. Cuijpers P, Dekker J, Hollon SD, Andersson G. Adding psychotherapy to pharmacotherapy in the treatment of depressive disorders in adults: a meta-analysis. J Clin Psychiatry. 2009;70(9):1219. Dixon, LB. Treatment engagement of individuals experiencing mental illness: review and update. World Psychiatry. 2016 Feb; 15(1): 13 20. Katon WJ. Clinical and health services relationships between major depression, depressive symptoms, and general medical illness. Biol Psychiatry. 2003;54(3):216. Mojtabai R, Olfson M. National patterns in antidepressant treatment by psychiatrists and general medical providers: results from the national comorbidity survey replication. J Clin Psychiatry. 2008 Jul;69(7):1064-74. Murray CJ, Atkinson C, Bhalla K. The state of US health, 1990-2010: burden of diseases, injuries, and risk factors. JAMA. 2013;310(6):591. Ramsberg J, Asseburg C, Henriksson M. Effectiveness and cost-effectiveness of antidepressants in primary care: a multiple treatment comparison meta-analysis and costeffectiveness model. PLoS One. 2012;7(8):e42003. Epub 2012 Aug 2. Solomon DA, Keller MB. Multiple recurrences of major depressive disorder. Am J Psychiatry. 2000;157(2):229.