pipc ® psychiatry in primary care medications robert k. schneider, md departments of psychiatry,...

35
PIPC® P sychiatry I n P rimary C are Medications Robert K. Schneider, MD Departments of Psychiatry, Internal Medicine and Family Practice The Medical College of Virginia at the Virginia Commonwealth University Richmond, Virginia

Upload: jennifer-warren

Post on 31-Dec-2015

215 views

Category:

Documents


0 download

TRANSCRIPT

Page 1: PIPC ® Psychiatry In Primary Care Medications Robert K. Schneider, MD Departments of Psychiatry, Internal Medicine and Family Practice The Medical College

PIPC® Psychiatry In Primary Care

MedicationsRobert K. Schneider, MD

Departments of Psychiatry, Internal Medicine

and Family Practice

The Medical College of Virginia at

the Virginia Commonwealth University

Richmond, Virginia

Page 2: PIPC ® Psychiatry In Primary Care Medications Robert K. Schneider, MD Departments of Psychiatry, Internal Medicine and Family Practice The Medical College

PIPC® Goals

• Effectively recognize, diagnose and treat mental illness in primary care

• Bring the psychiatry skills and knowledge base of the primary care physician on par with other medical specialty knowledge bases

Page 3: PIPC ® Psychiatry In Primary Care Medications Robert K. Schneider, MD Departments of Psychiatry, Internal Medicine and Family Practice The Medical College

Outline

• PIPC 1– Introduction

– PIPC® Interview– MAPS-O®

– Mood Disorders

– Suicide

Page 4: PIPC ® Psychiatry In Primary Care Medications Robert K. Schneider, MD Departments of Psychiatry, Internal Medicine and Family Practice The Medical College

Outline

• PIPC 2– Anxiety Disorders

• PIPC 3– Neurotransmitters

– The 3 Phases and the 5Rs

– Medications

– Cases and Discussion

Page 5: PIPC ® Psychiatry In Primary Care Medications Robert K. Schneider, MD Departments of Psychiatry, Internal Medicine and Family Practice The Medical College

NEUROTRANSMITTERS

Page 6: PIPC ® Psychiatry In Primary Care Medications Robert K. Schneider, MD Departments of Psychiatry, Internal Medicine and Family Practice The Medical College

Decreased state due to up-regulation of receptors

Neurotransmitter Receptor Hypothesis Neurotransmitter Receptor Hypothesis of Antidepressant Actionof Antidepressant Action

6-2 Stahl S M, Essential Psychopharmacology (2000)

Page 7: PIPC ® Psychiatry In Primary Care Medications Robert K. Schneider, MD Departments of Psychiatry, Internal Medicine and Family Practice The Medical College

6-5 6-6

Stahl S M, Essential Psychopharmacology (2000)

Antidepressant blocks the reuptake pump, causing more

NT to be in the synapse

Neurotransmitter Receptor Hypothesis Neurotransmitter Receptor Hypothesis of Antidepressant Actionof Antidepressant Action

Increase in NT causes receptors to down-regulate

Page 8: PIPC ® Psychiatry In Primary Care Medications Robert K. Schneider, MD Departments of Psychiatry, Internal Medicine and Family Practice The Medical College

receptor sensitivity

6-1 Stahl S M, Essential Psychopharmacology (2000)

amount of NT

clinical effect

antidepressant introduced

Page 9: PIPC ® Psychiatry In Primary Care Medications Robert K. Schneider, MD Departments of Psychiatry, Internal Medicine and Family Practice The Medical College

The 3 Phases and 5 Rs

• Acute

• Continuation

• Maintenance

• Response

• Remission

• Relapse

• Recovery

• Recurrence

Page 10: PIPC ® Psychiatry In Primary Care Medications Robert K. Schneider, MD Departments of Psychiatry, Internal Medicine and Family Practice The Medical College

DEPRESSION

NORMAL MOOD

RECOVERY OR REMISSION

EPISODE OF DEPRESSIONEPISODE OF DEPRESSION

TIME6 - 24 months

5-1 Stahl S M, Essential Psychopharmacology (2000)

Page 11: PIPC ® Psychiatry In Primary Care Medications Robert K. Schneider, MD Departments of Psychiatry, Internal Medicine and Family Practice The Medical College

acute 6 - 12 weeks

continuation4-9 months

maintenance1 or more years

REMISSION

RECOVERY

DEPRESSION

NORMAL MOOD

100%

5-3 Stahl S M, Essential Psychopharmacology (2000)

TIME

Page 12: PIPC ® Psychiatry In Primary Care Medications Robert K. Schneider, MD Departments of Psychiatry, Internal Medicine and Family Practice The Medical College

5-4 Stahl S M, Essential Psychopharmacology (2000)

acute 6 - 12 weeks

continuation4-9 months

maintenance1 or more years

TIME

DEPRESSION

NORMAL MOOD RELAPSE RECURRENCE

Page 13: PIPC ® Psychiatry In Primary Care Medications Robert K. Schneider, MD Departments of Psychiatry, Internal Medicine and Family Practice The Medical College

Acute Phase Treatment• Focus is response and full remission

• establish target symptoms

• patient preference, “collaborative approach”

• Psychotherapy especially helpful in chronic

depression or depression exacerbated by recent

stressors

• Acute phase is over ONLY after a remission is

achieved

Page 14: PIPC ® Psychiatry In Primary Care Medications Robert K. Schneider, MD Departments of Psychiatry, Internal Medicine and Family Practice The Medical College

DEPRESSION

NORMAL MOOD

RESPONSE

RESPONSE

5-2 Stahl S M, Essential Psychopharmacology (2000)

Page 15: PIPC ® Psychiatry In Primary Care Medications Robert K. Schneider, MD Departments of Psychiatry, Internal Medicine and Family Practice The Medical College

Changing the Medication• “Pseudoresistance”

– Verifying Compliance (“like an antibiotic”)– “Too little, too late”– Inadequate duration– Correct diagnosis (undetected comorbid diagnosis)

• Worsening Condition– severity escalating

– new symptoms developing (destructive impulses)

• Partial Remission vs. Full Remission

Page 16: PIPC ® Psychiatry In Primary Care Medications Robert K. Schneider, MD Departments of Psychiatry, Internal Medicine and Family Practice The Medical College

Continuation Phase Treatment• Focus is to prevent relapse

• Period of time following full remission during

which discontinuation of treatment will result

in relapse

• Don’t stop before 6-9 months of therapy

• Don’t decrease the dosage

• Full Dosage, for the Full Period of Time

Page 17: PIPC ® Psychiatry In Primary Care Medications Robert K. Schneider, MD Departments of Psychiatry, Internal Medicine and Family Practice The Medical College

5-4 Stahl S M, Essential Psychopharmacology (2000)

acute 6 - 12 weeks

continuation4-9 months

maintenance1 or more years

TIME

DEPRESSION

NORMAL MOOD RELAPSE RECURRENCE

Page 18: PIPC ® Psychiatry In Primary Care Medications Robert K. Schneider, MD Departments of Psychiatry, Internal Medicine and Family Practice The Medical College

Maintenance Phase Treatment

• Focus is to prevent recurrence

• Recurrence can only occur after the

recovery from a previous episode

• Therefore only recurrent major

depression is considered

• Maintain Full Dosage

Page 19: PIPC ® Psychiatry In Primary Care Medications Robert K. Schneider, MD Departments of Psychiatry, Internal Medicine and Family Practice The Medical College

Termination vs. Maintenance

• Degree of Functional Impairment

• Additional non-affective mental disorder

• Chronic medical disorder

• Prior history of depressive episode

1 episode: 50-80%

2 or more episodes: 80-90%

• Persistence of dysthymic symptoms

Page 20: PIPC ® Psychiatry In Primary Care Medications Robert K. Schneider, MD Departments of Psychiatry, Internal Medicine and Family Practice The Medical College

5-4 Stahl S M, Essential Psychopharmacology (2000)

acute 6 - 12 weeks

continuation4-9 months

maintenance1 or more years

TIME

DEPRESSION

NORMAL MOOD RELAPSE RECURRENCE

Page 21: PIPC ® Psychiatry In Primary Care Medications Robert K. Schneider, MD Departments of Psychiatry, Internal Medicine and Family Practice The Medical College

MEDICATIONS

Page 22: PIPC ® Psychiatry In Primary Care Medications Robert K. Schneider, MD Departments of Psychiatry, Internal Medicine and Family Practice The Medical College

General Considerations

• Three Neurotransmitters– Serotonin– Norepinephrine– Dopamine

• Three major sites of action– Reuptake pump– Post-synaptic receptor– MAO enzyme inhibition

Page 23: PIPC ® Psychiatry In Primary Care Medications Robert K. Schneider, MD Departments of Psychiatry, Internal Medicine and Family Practice The Medical College

Common Classes

• TCAD– NE and 5HT Reuptake inhibition

• SSRI– 5HT Reuptake inhibition

• “Less Selective” Reuptake inhibition– DA and NE (buproprion)– 5HT and NE (venlafaxime)

• Post synaptic receptor blockade– Trazodone, nafazodone

Page 24: PIPC ® Psychiatry In Primary Care Medications Robert K. Schneider, MD Departments of Psychiatry, Internal Medicine and Family Practice The Medical College

Norepinephrine and Serotonin Reuptake Inhibitors: TCAD

• Classic Tricyclic Antidepressants–amitriptyline (Elavil)

–clomipramine (Anafranil)

–desipramine (Norpramin)

–imipramine (Tofranil)

–nortriptyline (Pamelor)

Page 25: PIPC ® Psychiatry In Primary Care Medications Robert K. Schneider, MD Departments of Psychiatry, Internal Medicine and Family Practice The Medical College

Norepinephrine and Serotonin Reuptake Inhibitors: Effects

• Primarily blocks reuptake of norepinephrine, serotonin and weakly dopamine

• Effective in severe depression and anxiety disorders

• Sedating properties, reduces pain and stimulates appetite

• Nortriptyline level is a meaningful measurement

Page 26: PIPC ® Psychiatry In Primary Care Medications Robert K. Schneider, MD Departments of Psychiatry, Internal Medicine and Family Practice The Medical College

Norepinephrine and Serotonin Reuptake Inhibitors

• Side Effects– urinary retention, constipation, blurred vision,

dry mouth, weight gain, sexual dysfunction

– orthostatic hypotension, delayed cardiac conduction

• Cautions– the elderly

– cardiac patients

Page 27: PIPC ® Psychiatry In Primary Care Medications Robert K. Schneider, MD Departments of Psychiatry, Internal Medicine and Family Practice The Medical College

Selective Serotonin Reuptake Inhibitors

• Classic SSRIs

–sertraline (Zoloft)

–fluoxetine (Prozac)

–paroxetine (Paxil)

–citralopam (Celexa)

Page 28: PIPC ® Psychiatry In Primary Care Medications Robert K. Schneider, MD Departments of Psychiatry, Internal Medicine and Family Practice The Medical College

Selective Serotonin Reuptake Inhibitors: Effects

• Selectively blocks the serotonin reuptake pump

• Mild to moderate depression (max doses in severe)

• Safer in overdose

• Indicated for anxiety disorders

Page 29: PIPC ® Psychiatry In Primary Care Medications Robert K. Schneider, MD Departments of Psychiatry, Internal Medicine and Family Practice The Medical College

Selective Serotonin Reuptake Inhibitors: Side Effects• Side Effects

– nausea, headache– jitteriness and insomnia (especially early)– sexual dysfunction– “Discontinuation Syndrome”

• Cautions– very few – notable exception: Serotonin Syndrome

Page 30: PIPC ® Psychiatry In Primary Care Medications Robert K. Schneider, MD Departments of Psychiatry, Internal Medicine and Family Practice The Medical College

Less Selective Reuptake Inhibitors

• Serotonin, Norepinephrine and mild

Dopamine Reuptake Inhibitor

–venlafaxine (Effexor)• Dopamine, Norepinephrine and mild

Serotonin Reuptake Inhibitor

–bupropion (Wellbutrin)

Page 31: PIPC ® Psychiatry In Primary Care Medications Robert K. Schneider, MD Departments of Psychiatry, Internal Medicine and Family Practice The Medical College

Serotonin, Norepinephrine & Mild Dopamine Reuptake Inhibitor

• venlafaxine (Effexor)– Effects

• blocks reuptake of serotonin, norepinephrine and dopamine (mildly)

• antidepressant effects and anxiolytic properties

– Side Effects• nausea, somnolence, dry mouth, constipation,

nervousness, dizziness• risk of increased blood pressure

Page 32: PIPC ® Psychiatry In Primary Care Medications Robert K. Schneider, MD Departments of Psychiatry, Internal Medicine and Family Practice The Medical College

Dopamine, Norepinephrine & Weak Serotonin Reuptake Inhibitor• bupropion (Wellbutrin)

– Effects• moderate dopamine reuptake inhibition,

norepinephrine reuptake inhibitor (bupropion metabolite), and weak serotonin reuptake inhibition

• antidepressant, antismoking, NOT ANXIOLYTIC– Side Effects

• agitation, tremor, insomnia, headache, constipation• increased risk of seizures at doses above 450mg/day• minimal sexual dysfunction, cardiac complications,

or weight gain– Cautions

• history of seizures or previous head trauma

Page 33: PIPC ® Psychiatry In Primary Care Medications Robert K. Schneider, MD Departments of Psychiatry, Internal Medicine and Family Practice The Medical College

Postsynaptic Serotonin Inhibition

• Serotonin (postsynaptic 5HT-2 inhibition)– trazodone (Desyrel)– nafazodone (Serzone)

Page 34: PIPC ® Psychiatry In Primary Care Medications Robert K. Schneider, MD Departments of Psychiatry, Internal Medicine and Family Practice The Medical College

Postsynaptic Serotonin Inhibition

• trazodone (Desyrel)– Effects

• sedating, good hypnotic• Post synaptic receptor blockade, weak SSRI

– Side Effects• difficult to get to high enough doses for depression• sedation, dry mouth, orthostasis, priapism (very rare)

• nafazodone (Serzone)– Effects

• effective antidepressant• good anxiolytic, effective in the anxious depressed• Post synaptic blockade, moderate SSRI

– Side Effects• sedation (much less than trazodone), nausea, visual

disturbances, lightheadedness

Page 35: PIPC ® Psychiatry In Primary Care Medications Robert K. Schneider, MD Departments of Psychiatry, Internal Medicine and Family Practice The Medical College

CASES