pychopharm final 426
TRANSCRIPT
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Psychopharmacology:Moods, Medications &
Mental Health
Tanveer A Padder MDMedical Director
Optimum Health & MPB Group
Maryland
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Outline Introduction/Neurochemistry
Depression
Anxiety
Psychosis
Bipolar Disorder
ADHD
Substance Abuse
Insomnia
The Female Patient
Risk Management and other important
issues
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Objectives
Understand brain chemistry and
neurotransmission
Expand your understanding of latestpsychotropic medications
Know common side effects associated withpsychotropic's
Understanding of future and ongoing
treatment modalities Risk Management strategies in your
practice
Improve client outcomes
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Treatment Overview
Different Models of treatment
Current treatment model
Myths about psychiatryBarriers to treatment
Parity issues
How to improve mental healthdelivery
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Diagnostic and Statistical
Manual
Definition of abnormal behavior
Cultural issuesReligious issues
History of DSM
DSM 1-V
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DSM-IV-TR
Axis I: Clinical DisordersDevelopmental Disabilities
Axis II: Personality Disorders
Mental Retardation
Axis III: General Medical Conditions
Axis IV: Contributing Problems
Axis V: Rating of Functioning
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..It is also liketelling a personwho has an
amputated leg torun across theroom.
But a person who has mental health issuehas a broken brain.
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Thalamus
Ventral striatum
Amygdaloid body
Hypothalamus
Olfactory and entorhinal
cortices
Hippocampus
Rostral raphe nuclei
Striatum
Neocortex
Cingulum
To hippocampus
Cerebellar cortex
Caudal raphe nuclei
To spinal cord
Cingulate gyrus
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Neurotransmission
Neurotransmitters- 7 actions
Receptors
Agonist
Antagonist
Stopping Neurotransmission
Reuptake
Enzymatic destruction
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Brain Area Functions
Cerebral Cortex
Prefrontal cortex
Hippocampus Amygdala
Basal Ganglia
nucleus accumbens
thalamus hypothalamus
brainstem
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Neurotransmitters
Serotonin
Nor epinephrine
Dopamine Epinephrine
GABA
Glutamate Acetylcholine
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Serotonin
Synthesized from tryptophan,
Actively transported across BBB
Decreased dietary tryptophan canreduce serotonin.
Oxidized by MAO-a
Most termination through reuptakeMetabolism
Clinical Significance
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Nor epinephrine
Synthesized from tyrosine Functions: attention, emotion
regulation, energy, psychomotor
agitation, tremor, HR, bladderemptying
Termination via reuptake, COMT,
MAO
Clinical significance
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Dopamine
Synthesized from tyrosine
Actions: concentration, energy,
psychosis etc Terminated by dopamine transporter
broken down by COMT, MAO-A and B
Clinical significance
Dopamine receptors
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Other NTs
GABA
Distribution
Synthesis
Receptors
Clinical Significance
Function
Acetylcholine Primary cell bodies
Termination of action
Clinical Significance
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Ten leading Causes of Disability inthe World
Type of Disability Cost (in
DALYs)GBD
Unipolar major depression 42,972
Tuberculosis 19,673
Road traffic accidents 19,625
Alcohol use 14,848
Self-inflicted injuries 14,645
Manic-depressive (bipolar)illness
13,189
War 13,134
Violence 12,955
Schizophrenia 12,542
Iron deficiency anemia 12,511
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Mood disorders
Neurotics build castles in the air, psychotics livein them.
Normal Borderline Psychotic
Approximately 20.9 million about9.5 percent
Include those where the primary symptom is adisturbance in mood.
The disorders include Major Depression,Dysthymic Disorder, Bipolar Disorder, andCyclothymia.
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Major Depressive Disorder
Leading cause of disability in the U.S. forages 15-44.
Major depressive disorder affectsapproximately 14.8 million Americanadults, or about 6.7 percent
The median age at onset is 32.
More prevalent in women than in men. Common symptoms include:
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Subtypes of Depression
Melancholic
Atypical
Seasonal
Catatonic
Psychotic
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Major Depression vs. Dysthymia
RecurrentMajor
Depressive
Episodes
Dysthymia
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Likelihood of having another Major
Depressive Episode if youve had
Major
Depressive
Episode
Major
Depressive
Episode
Major
Depressive
Episode
Major
Depressive
Episode
Major
Depressive
Episode
Major
Depressive
Episode
1 episode
50%
2 episodes
70%
3 episodes
90%
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Etiology
Neurotransmitters Deficiency states Depression
States of excess Mania
Down regulation
Risk Factors-
Psychological Theory
Patients have distorted perceptions and
thoughts of themselves, the worldaround them and the future learnedhelplessness
Secondary Depression
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Treatment-Bio-psycho-social
ModelBiologic
Tricylclic antidepressants
Monoamine oxidase inhibitors- Second generation antidepressants
SSRIs, Venlafaxine, bupropion, mirtazapine
Atypical antipsychotics Electroconvulsive therapy
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SSRIs
SSRI Use; Depressive and anxious disorders including:
Dysthymia,
Major Depression, Panic Disorder,
Generalized Anxiety Disorder,
Obsessive Compulsive Disorder,
Posttraumatic Stress Disorder,
Separation Anxiety Disorder, Selective Mutism
Mechanism of Action
Side effects
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Common SSRI;s
Prozac (fluoxetine)-typically activating, sarafem
Paxil (paroxetine)-typically sedating, available in liquidform.
Zoloft (sertraline)-usually neither sedating or activating. Celexa (citalopram)-usually neither sedating or
activating.. Advantage in few drug interactions, verygood choice for medically ill children on multiplemedications.
Most of them are available as a liquid, dosage (child)2.5-40.
Luvox (fluvoxamine)-Can be very sedating in children.Used in OCD
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Methysergide is an antagonist
Buspirone is an agonist
6 LSD isan agonist 7
5
43
2
1
Fenfluramineincreases release
Reserpine depletesvesicular stores
Fluoxetine (Prozac) andtricyclics block reuptake
MAO inhibitorsdecrease degradation
Tryptophan
5-OH-tryptophan
5-HT
5-HIAA
5-HT
5-HT
MAO
5-HT
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SSRI Side-Effects
Side-Effects- Mild nausea, decreased appetite
weight loss, excessive sweating,
insomnia, jitteriness,
sedation, dizziness, sexual dysfunction.
The serotonergic syndrome is a medicalemergency involving muscle jerking, tremor,
high blood pressure, diarrhea and confusion dueto drug interactions primarily with olderantidepressants
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SNRIs
Block both serotonin and nor-epinephrinereuptake
Venlafaxine (Effexor, Effexor XR, PRISTIQ (desvenlafaxine)
(Cymbalta) Duloxetine
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Miscellaneous Antidepressants
Remeron (mirtazapine)-can be used as sleep aid at lower doses.
Wellbutrin/Zyban (Buproprion)-also used for ADHD, smokingcessation and mood difficulties particularly in Bipolar patients. Mayalso be used to augment
Mechanism of action involves increasing dopamine andnorepinephrine turnover in the brain.
Typical doses are between 100-400 mg/twice a day.
Wellbutrin is not often used in young children, more frequently
adolescents due to side effects including, agitation, insomnia, wtloss, constipation and tremor. More problematic in the increased riskfor seizures in those with a seizure disorder, less risk with the slow-release form.
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Tricyclic acid antidepressants
Tricyclic acid antidepressants (TCA) including Tofranil (imipramine),
Pamelor(nortriptyline), Anafranil (clomipramine), Elavil(amytriptyline)-
TCAs are also used for headache prevention and pain syndromes.
These medications have largely been replaced by the SSRIs fortreatment of depressive and anxiety disorders including Obsessive-Compulsive Disorder and PTSD. Anafranil,
Tofranil is approved for bedwetting. Doses vary for each TCA and some canbe measured for actual blood levels.
Side effects
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Monoamine Oxidase Inhibitors
Monoamine Oxidase Inhibitors(MAOI)including):
Nardil (phenylzine),
Marplan (isocarboxazid)
and Parnate (tranylcypromine).
Rarely used medications due to dietaryrestriction.
Never used with SSRI since may precipitate a
serotonergic crisis. Wash out period
Side effects
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MAO-Is: Dietary Restrictions
Avoid food that has undergone aging, fermentation,pickling,
smoking or bacterial contamination
Avoid medications including: dextromethorphan,decongestants,
allergy meds, sinus meds, asthma inhalants, anti-appetite meds,
energy pills, amphetamine, methylphenidate, cocaine,
methyldopa, levodopa, l-tryptophan, l-tyrosine,phenyalanine,
alcohol, bupropion, guanethidine
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Managing Side effects
Sexual dysfunction- holidays, adjunctivemed
Nausea- take with food
Insomnia- take in morning, adjunct Hypersomnia- take at night
Agitation/ akathisia- discontinue, adjunct
Suicidality monitor closely, discontinue
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Serotonin related Syndromes
Serotonin Syndrome
life threateningemergency!
agitationtremor
confusionmuscle jerks
hyperthermiamuscle stiffness
SSRI Withdrawal Syndrome
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Augmentation
of patients dont respond first agent.1/5 dont benefit from a series of trials
Medication response-usually 67%.
Placebo response 33% If initial response to antidep will relapse
at only 10-20% if rx continued for 6-12
Within class switch Out of class switch
Other medications
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Cognitive Behavioral Therapy
At least as effective as antidepressants in reducingsymptoms
More effective than antidepressants in preventing relapseCognitive restructuringIdentify and challenge depressogenic assumption
Identify more adaptive coping mechanisms
Other Therapies- Supportive, IP, Psychodynamic
Psychosocial Intervention: Education Vocational training Case workers Exercise
Psychological
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Depression: AlternativeTreatments
StJohnswort
Dhea
Diet:
Carbohydra
tes, Pro
tein,Tryptophan
Vitamins- b12, b1, b2, b6, ?vitD,
Folate
SAM-E
Melatonin
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Other Therapies
Naturopathic
Hellerwork and Rolfing
Acupressure and Shiatsu
Auricular Therapy
Massage
Aromatherapy
Kinesiology
Reflexology
Spiritual Healing
Hypnosis
Autogenic Training
Bach Flowers
Acupuncture
Ayurveda
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Anxiety
The most prevalent psychiatric disorders
19 million Americans affected each year.
Estimated cost about 42 Billions $ annually
Prevalence 15% Phobia being the most common, 7%, followed
by GAD
Female out number male, but equal for OCD.
Normal anxiety
Pathological Anxiety
Fear
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Types
Phobias:SpecificSocial
Agoraphobia
GAD Panic Disorder OCDAcute stress disorder PTSDAnxiety disorder due to medical Condition Substance induced anxiety disorder
Anxiety disorder NOS
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Etiology Interplay between biological and psychosocial factors.
Biological: Neurotransmitters
Serotonergic
NE
GABA-Benzodiazepine receptors Psychological
Different school of thoughts
Psychoanalytic perspective:
Structural theory (ID, EGO, SUPEREGO)
Cognitive Theory- Focuses on cognitivedistortions which lead to depression andanxiety
Brain Changes
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Management
APA Guidelines recommend use of Medicationsand psychotherapy.
ECT is not affective for anxiety disorders even
though consider for resistantOCD prior tosurgery.
Goal is full sustained remission with improvefunctioning.
Treatment will depend on full response, partialresponse and resistance
SSRI are the first line treatments, Benzo aresecond line even though prescribed more than
antidepressant, BT can be first or second line.45
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Anxiety: Medications
SSRIs
SNRIs
Benzodiazepines Beta blockers
Other medications
Alternative treatments
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Anxiety: Other Medications
Buspirone (Buspar) Betablockers(Propranolol)
Tiagabine (Gabitril)-
Gabapentin: Clonidine
Mood Stabilizer
Antipsychotic
Cypraheptadine
Cytomel
Hydroxyzine
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Anxiety:Alternative Treatments
CBT:. Has the best track record for most phobicdisorders. The most effective and the most studied
Cognitive restructuring
Behavioral component:
A)Exposure therapy:
1) systemic desensitization-imaginal or in vivo; graded vun-graded 2)Flooding
B) Relaxation Technique
C) Role playing
D) Coping skill training
Herbal remedies: kava, valerian, chamomile
Yoga, breathing exercises
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Others
Supportive Psychotherapy
Insight oriented
Group
Family
Social skill training
Hypnosis: Therapist suggest phobic object
is not dangerous, also teaches selfhypnosis for relaxation in event of phobicobject is confronted
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Schizophrenia
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NATURAL HISTORY OFSCHIZOPHRENIA
1010 2020 3030 4040 5050
FunctionFunction
Age (y)Age (y)
ProdromalProdromal
ProgressionProgression
PremorbidPremorbid
Stable RelapsingStable Relapsing
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Positive Symptoms
Hallucinations
Delusions
Disorganized Thought
Catatonia
Negative Symptoms
Affective Blunting
Alogia
Avolition
Anhedonia
Cognition
New Learning
Memory
Mood Symptoms
Insight
Demoralization
Suicide
Components Of Psychotic
Disorders
FUNCTION
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Imaging
Schizophrenic brain Normal brain
Ventricles
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Mesolimbic PathwayMesocortical PathwayNigrostriatal Pathway
Tuberoinfundibular Pathway
Brain Pathways
T t t f P h ti Di d
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Treatment of Psychotic Disorders.
Atypical Antipsychotics Risperdal
Zyprexa
Seroquel
Geodon, Invega-Extended release risperdal
Risperdal Consta
Clozapine
Typical antipsychotics- Haldol, Prolixin etc Injectables- Haldol, Prolixin, Risperdal consta
IM formulations
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Side effects
Dopamine Blockade:
NMS
EPS
TD
Histamine blockade
Acetylcholine blockadeAlpha1 blockade
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Atypical Antipsychotics
Clozap
ine (C
lozar
il)
Risperidone (Risperdal)
Olanzapine (Zyprexa)
Quetiap
ine (Seroque
l)
Ziprasidone (Geodon)
Aripiprazole (Abilify)
Paliperidone (Invega) Asenaprine (Saphris)
Iloperidone (Fanapt)
Luras
idone
HCL(La
tuda)
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Atypical Antipsychotics-Mechanisms
antagonize D2receptors
antagon
ize
5ht2arecep
tors
.
bindlooserthanthe typicalsanddissociate
more quickly
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Atypicals
Mechanism of actionAtypical: Side Effects
Weight gain, diabetes:ck BoxWarning
clozaril, olanzapine>>>risperidone,quetiapine>>
ziprasidone, aripiprazole (+/-)
HigherriskofTDwithconventionalthan
cardiometabolicriskwithatypical
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Metabolic Syndrome
Waist circumference: Men>102 cm (>40 in)
Women>88 cm (>35 in)
Triglycerides >150 mg/dL HDL cholesterol:
Men
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Mania
(bipolar disorder)
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What is Bipolar Disorder ?
It is a spectrum ofaffective episodesincluding:
Major depressiveepisode
Manic episode
Mixed episode
Rapid cycling
Hypomanic episode
The DSM-IVcategorizes it into:
Bipolar I Disorder
Bipolar II Disorder
Cyclothymia
Bipolar N.O.S.
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Summary of DSM-IV-TR
Classification of Bipolar Disorders
* Symptoms do not meet criteria for manic and depressive episodes.
Bipolar featuresthat do not meetcriteria for anyspecific bipolardisorders
At least 2 yearsof numerousperiods ofhypomanic anddepressivesymptoms*
One or moremajordepressiveepisodesaccompaniedby at least one
hypomanicepisode
One or moremanic or mixedepisodes,usuallyaccompanied bymajor depressive
episodes
Bipolar DisorderNot Otherwise
SpecifiedCyclothymicBipolar IIBipolar I
First, ed. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text Rev.
Washington, DC: American Psychiatric Association; 2000:345-428.
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Bipolar I Disorder
MajorDepressive
Episode
Manicor MixedEpisode
Manic
or MixedEpisode
One or moremanic episode
OR Depressed andmanic episodes
OR
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Bipolar II Disorder
Major
DepressiveEpisode
Hypomanic
EpisodeHypomanic
Episode
One or morehypomanic episode
OR Depressed andhypomanic episodes
OR
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Mood Episodes
Depression
Mania
Hypomania
Mixed Episode
Normal Mood
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Unipolar vs. Bipolar
Disorder
Bipolar
Unipolar
ElevatedMood
ElevatedMood
DepressedMood
DepressedMood
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Treatment Overview
Diagnostic evaluation
Safety
Referral to psychiatrist
Establish & maintain a strong alliance
Educate
Relapse Prevention
Family involvement Maintenance
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Indicators of TreatmentOutcome
1. Suicidality
2. Presence of a personality disorder
3. Quality of family and social support
4. Substance use5. History of severity of prior episodes
6. Bipolar I type is most severe
7. Treatment onset-the sooner the better
8. Age of onset-the younger the more severe
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Treatment
List of Prognostic Factors
Education and Support
Medication
1. Mood stablizers
2. Atypical antipsychotics
3. Anti-anxiety
4. ECT5. Others
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Course
Acute Episode
Manic - 5 weeks
Depressed - 9 weeks
Mixed - 14 weeks
Long Term
Variable - most cover fully
Mean number of lifetime episodes 8-9
M d St bili
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Mood Stabilizers
Lithium
Anticonvulsants
valproic Acid [Depakote]
carbamazepine [Tegretol]
New Anticonvulsants (?): lamotrigine [Lamictal]
topiramate [Topamax]
gabapentin [Neurontin]
Oxcarbamazepine [Trileptal]
Antipsychotics
Classic (Haloperidol)
Novel (clozapine, olanzapine, aripiperazole, queiepine)
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Lithium
Mechanism of Action
Molecular Biology
Indications
Predictors of good response Predictors of poor response
Side effects
Interactions
Toxicity Workup
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Valproic Acid (Depakote)
More effective than lithium for rapidcycling and
mixed episodes.
Can be used in combination with lithium.
Worup
Dosage
Monitoring
SE
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Others
Lamictal
Topimirate
Gabapentin Tiagabine
Novel Antipsychotics
Others
G l M i i
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General Monitoring
Check levels of lithium, valproate,
carbamazepine at least 1-2 times per year
Check for weight gain, metabolicabnormalities (atypicals)
Risk of Flipping to mania
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MRI (T1-weighted) images of a 58-year-old healthy control patient (left)as compared with a patient of comparable age with bipolar disorder(right)but without any significant medical or substance abuse history.
Although not diagnostic, common findings in neuroimaging researchstudies withbipolar disorder patients include diffuse gray matter loss, enlargement
of the ventricles, and mild prefrontal volume loss.
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ADHD
ADHD
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ADHD
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ETIOLOGY
What is ADHD
Types
No single etiology has been identified for ADHD. Psychosocial stressor
Environmental factors
Neuro-chemical
Neuro-anatomical factors
Familial and genetic factors
ADHD is best viewed as a final common pathway for a
variety of brain developmental processes.
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How ADHD symptoms evolve?
Children Motor HyperactivityAggressiveness
Low Frustration Tolerance
Impulsiveness
Easy to Distract
Inattentiveness
Shifting Of Activities
Easy to Bore
Impatience
Adults Restlessness
Distractibility
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Co- Morbidity
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Co Morbidity
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MEDICATIONS
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MEDICATIONS.
Used 40+ yrs; 350+ studies;thousands of cases
Stimulants (Response rates 75-80%)
Trying all stimulants - 90%+ responserate
Whats new?
Extended release delivery systems
MEDICATIONS
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MEDICATIONS
Most well-studied drugs in psychiatry
Stimulants
Methylphenidate:
Ritalin, Concerta,
Focalin, Medadate CD, Daytrana
Amphetamine:
Dexedrine, Adderall,
Vyvanse
Atomoxetine (Strattera)
Other Nor epinephrine Reuptake Inhibitors(Bupropion) Effexor
Anti-Hypertensives Guanfacine and Clonidine
STIMULANT Side Effects
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STIMULANT Side Effects
Largely benign;
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STIMULANTs Contd.
Behavior Benefits
Stimulants in preschoolers
Stimulants: Common MythsManaging side effects
Nonstimulants
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Nonstimulants
Modafinil:
(Provigil)approved
for narco
lepsy,shift work, OSA.Acts viahistamine, dopamine
Atomoxetine: (Strattera)norepinephrinereuptake inhibitor
Bupropion:norepinephrine anddopamine *Benefits- not schedule 2, refills ok
Adrenergic Agonists
norepinephr
ine
:med
iates
inattent
ive andhyperactive/ impulsive symptoms
Clonidine- Catapresalpha2agonist
Guanfacine-Tenex more selective alpha2
agonist
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Non pharmacologic therapies
Environmental modifications- Identify and minimize or
avoid distractions
- shop in smaller stores- avoid working in cubicles- Practice organization by
assigning specific
Storage spaces for bills,keys etc. Helpful external aids Herbal medications etc
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Substance Abuse
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Substance Abuse
Abuse-
Addiction
Dependence Tolerance
Neurochemisty
Cravings
Dependence
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Dependence
Probability of becoming dependent aftertrying substance once:
nicotine 32%
heroin 23%
cocaine 17%
alcohol 15%
stimulants 11%
cannabis 9%
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Alcohol Intoxication:
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Alcohol Intoxication:
initially blocks glutamate at NMDAreceptors causing
social disinhibition
more alcohol enhances action of GABAcausing
slurring and incoordination
Alcohol Dependence
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Alcohol Dependence
Mechanism
Treatment
NaltrxeoneAcomprosate
Disulfiram
TopamaxOthers
Alcohol Withdrawal
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Alcohol Withdrawal
Definition
Mechanism
SymptomsTreatment
Alcohol seizures
Delirium tremens
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What is a Standard Drink ?
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What is a Standard Drink ?
Opiates Intoxication:
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Opiates Intoxication:
DSM criteria
Symptoms
Clinical presentationRisk
Management
Dependence Treatment:
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Dependence Treatment:
Methadone- opiate receptor agonist
increases opiate level inbrainslowly sodoesntproduce high.
Covers receptors topreventhigh if use
heroin. Buprenorphine- Buprenex, Subutex,
Buprenorphine/ naloxone- Suboxone
opioid receptor agonist- antagonist,decreases cravings, blocks high
Restrictedaccess inUS
Opiate Withdrawal
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Opiate Withdrawal
Mechanism
Symptoms
Management Methadone
Suboxone
Clonidine Benzos
Cocaine
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Cocaine
History Pharmacology/neurobiology
Pychopharmacology
Intoxication Initial symptoms
High dose effects
Overdose Psychiatric manifestations
Management
I t i ti
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Intoxication
Inhalation (7 s onset, 1-5 min peak, 20min duration, 40-60 min half-life)
IV (15 s onset, 3-5 min peak, 20-30 minduration, 40-60 min half-life)
Nasal (3 min onset, 15 min peak, 45-90min duration, 60-90 min half-life)
Oral (10 min onset, 60 min peak, 60 minduration, 60-90 min half-life)
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Smoke > IV > IM sniff >
Withd l
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Withdrawal
Classic physical withdrawal symptoms donot occur
Symptoms often seen after binge periodsinclude: Intense unpleasant feelings ofmarked anergia, dysphoria, irritability,impulsivity and depression - generally requiringseveral days of rest and recuperation
Management
Hallucinogens
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Hallucinogens
Lsd,mescaline,psilocybin,MDMA(ecstasy)
agonistsat5 htsynapseswithin rewardsystem
Tolerance toeuphoriceffectsmaybe dueto
lossof
serotonergicneurons
Other Substances
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Other Substances
GHB- agonist atGHBand GABA-Areceptors
Cannabis- hits endogenous cannabanoidreceptors to trigger dopamine release in n.accumbens
PCPand ketamine: antagonists at NMDAAmphetamines
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Insomnia
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Insomnia___________________________ Insomnia includes difficulty falling asleep, difficulty
staying asleep, and early morning awakening
Insomnia is not defined by the number of hours of
sleep, but rather, by an individuals ability to sleep
long enough to feel healthy and alert during the day.
The normal requirement for sleep ranges between 4
and 10 hours
Insomnia is a symptom, not a disorder by itself
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W k S t
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Wake System
___________________________
Sl S t
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Sleep System
___________________________
119
Sl W k C l
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Sleep Wake Cycle
___________________________
120
Changes in sleep with age
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Changes in sleep with age___________________________
Stages of sleep
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g p______________________
1. NREM Sleep
A. Stage 1
B. Stage 2C. Stage 3
D. Stage 4
2. REM Sleep
Sleep Stages
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Sleep Stages___________________________
REM Sleep
~20% of night
NREM Sleep
~80% of night
Wake
2/3 of life
Causes of insomnia
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Causes of insomnia
Drugs
Psychiatric disorders
Medical disorders
Poor sleep habits Shift work
Other sleep disorders
Circadian rhythm disorders
Restless legs syndrome Periodic limb movement disorder
Sleep apnea
M di ti d i i
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Medications and insomnia
___________________________Type of medication Example
Blood pressure drugs - blockers, - blockers
Decongestants Phenylephine, Pseudoephedrine
Other substances Alcohol, Nicotine, Caffeine
Management of insomnia
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Management of insomnia
___________________________
Good history
Review medications
Treat underlying Medical Condition
Treat underlying Psychiatric Condition
Improve sleep hygiene
Non-Benzo receptor agonists
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Non-Benzo receptor agonists
Zolpidem
Zolpidem CR
Zeleplon
Eszopiclone
Benzodiazepine receptor
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agonists
LorazepamClonezepam
DiazepamFlurazepamQuazepamAlprazolam
TriazolamEstazolam
Benzodiazepines
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Benzodiazepines
MechanismUse
AbuseSide effectsToxicity
Other classes of medications
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Other classes of medications
AntidepressantsTrazadone
Mirtazapine
Doxepin
Amitryptyline
Antipsychotics
Olanzapine
Quitiepine
Melatonin Receptor Agonists
Melatonin
Ramelteon
MiscellaneousValerian
Diphenhydramine
Cyclobenzaprine
Hydroxyzine
Alcohol
Barbiturates
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Barbiturates
____________________________Drug Duration of action Half-life
Phenobarbital Long 24 140 hrs.
Butabarbital Intermediate 34 42 hrs.
Amobarbital Short-intermediate 8 42 hrs.
Pentobarbital Short-intermediate 15 48 hrs.
Secobarbital Short-intermediate 19 34 hrs.
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Female Patients
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PMS
PMDD
Medications in Pregnancy Baby blues
Post Partum Depression
Menopause
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PMDD
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Prevalence- 3-5%
5 or more symptoms:
depression anxiety
Lability, irritability
loss of interest difficulty concentrating
lethargy appetite changes
sleep disturbance feeling out of
control
breast pain headaches
Treatment- fluoxetine (Sarafem)
Pregnancy
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Risk of not treating Depression: Risk of antidepressant
Treatment guidelines in pregnancy
SSRis and pregnancy Mao and pregnancy
TCA and pregnancy
Mood stabilizers in pregnancyAntipsychotics' in pregnancy
Ant-anxiety medications in pregnancy
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Postpartum Depression
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Postpartum Depression
Diagnostic criteria are similar to MDD
Symptomatology: at least 2 weeks
Impaired functioning in important areas
Presence of prominent anxiety symptoms Intrusive thoughts
Feelings of guilt and inadequacy about
mothering Prevalence of PPD is about 13%
Postpartum Psychosis
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p y
Occur in 1-2 women per1000 following delivery ofa child
Constant across culturesOnset within 2 weeks
Marked cognitive
disturbance & Unusualpsychotic symptoms .
Most postpartumpsychosis meet criteriafor mood disordersparticularly bipolar
disordersRisk of PPP
bipolar disordersdepressed type/manictupe
Primiparous women
Postpartum psychosis
Treatment
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Treatment
Aggressively treated with in hospitalsetting
Do not wait while the general medical
workup is underway
Antipsychotics which are more potent andless sedating agents are preferable
Mood stabilizers should be startedimmediately along with antipsychotics
Atypical antipsychotics
Recommendations for treatment of
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during pregnancy
Have them enroll in pregnancy registry
Reduce incidence of neural tube defectsby-Folic acid 4mg/d,monotherapy if
possible, lowest possible dose
Alpha feto protein screen
Ultrasound at 16-20 WKS
Treat depending on severity
Breast feeding
Pharmacological Rx
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P a aco og ca
SSRI
Considered first line Rx forPPD
Sertraline and paroxetineare least detectable innursing infants
Flouxetine may predisposeto accumulation
One report on celexashowed uneasy sleep ininfant
TCAs
Reasonable option fortreatment
Nortriptyline is the leastdetected in breast milkand nursing infants
Doxepin notrecommended
TCAs are not the primarychoice because ofanticholinergic side effectsand toxicity in overdose
Peri/ Menopause
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Fluctuations of estrogen can dysregulateneurotransmitter
projections to hypothal -> vasomotor
symptoms. Depression in 10%
H/o depression increases risk of
depression during menopause (4-9x). If hot flashes, depression 5x more likely
Hormonal Rx
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Hormonal Rx
Data is limited
Sublingual estrogen Rx,
Large doses of progesterone insuppository and oral micronized formsmay be effective but studies have alsoshown that administration of long acting
progesterone 48 hrs after deliveryincreased risk of ppd
Menopause
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The menopause syndrome Irritability, headaches, depression, anxiety, problems of
memory and concentration, loss of libido
Vasomotor symptoms Irregular menstruation accompanied by hot flashes
Hot flashes are felt as rising sensation of heat in the chest, neckand face
Rise in peripheral blood flow and heart rate
Mood Disturbances in Menopause Hormonal changes
Could be secondary to hot flash induced sleep problems
Psychosocial and cultural factors
Treatment
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Symptoms diary
Analysis of TSH
Vitamin supplements & Spironolactone
25mg 50mg daily NSAIDS
Caffeine avoidance
Oral Contraceptives SSRI, TCAs
Treatment
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Alternative therapy
Phytoestrogens
Ginseng
Dong quai
Black cohostChaste tree berry
Vallerian root
Exercise therapyRelaxation therapy
Harmone
EstrogenProgestins
Androgens
Selective estrogen
receptor modulatorsAnitdepressant
moderate or severesymptoms of
depressionConcurrentaugmentation withestrogen may beindicated
Suicide & Clinical Practice
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In any given year:
40,000 psychiatrists in USA
30,000 suicides
10,000 psychiatric care
1500 inpatient 8500 outpatient
Therefore, hypothetically:
Every 4 years one suicide psychiatrists career, 4-8 suicides.
World Data
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Why people kill themselves?
Suicide is a major public health concern worldwide
15-24 year and > 65 years
4 males:1 females
1 million suicide deaths this year
16/100,000 suicide rate 1 suicide every 40 seconds
US- 8th leading cause of death in the US
12/100,000 suicide rate
Translates to 30,000 deaths per year by suicide
81 suicides per day
15 - 24 year olds, suicide is 3rd leading cause of death (afteraccidents and homicides
Risk Factors for Suicide
SADPERSONS Scale
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SADPERSONS Scale
Sex (Male)Age (very young or very old)
Depression
Previous attempt
Ethanol abuse
Rational thinking loss (psychosis)
Social supports lacking
Organized plan No spouse
Sickness (chronic illness)
Suicidal Behavior/ Gestures
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151
Summary
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y
Cocaine Intoxication Dopamine reuptake inhibition
Psychiatric and medical complications
Cocaine Withdrawal Depression with suicidal ideations
Management Supportive stable environment
Etiology
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Biochemical FactorsGenetics and Family variables
Psychiatric diagnosis
Personality traits and disorders
Psychosocial and environmental
factorsChronic medical illness
NeurobiologyPersonality Disorders/Traits
Psychiatric IllnessCo-morbidity
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Severe Medical Illness
Access to Weapons
Life Stressors
Family History
Impulsiveness
Hopelessness
Psychodynamics
Substance Abuse
Suicidal Behavior
Suicide
Psychiatric Illness and SuicideContd
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Contd.
MDD
Bipolar Disorder
Schizophrenia
Alcohol Dependence Borderline PD
Antisocial PD
15% commit suicide
10 - 15%
10%
2% 4 - 9%
5%
Suicide Attempters
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Female Younger
Depression, Alcoholism, Personality D/O
Impulsive Low lethality (overdose)
High availability of help
Suicide Completers
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Male, Older
Depression, Alcoholism, Schizophrenia
Careful planning
High lethality (firearms)
Low availability of help, socially isolated 30% have history of suicide attempts
Approximately 1 in 6 completers leave asuicide note
50% of people who commit suicide have beenseen by a primary care MD
with older suicide victims, this rises to 70%
Outpatient Management
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Sole focus on treatment = safety Be alert to sudden changes in behavior
Consistently involve significant others
Consider day-treatment or other isolation-
reducing activities Document, document, document
National suicidal prevention lifeline1-800-273-talk
Crisis management
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Record-keeping
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Keeping good records is a must.
Never alter a record.
Include discussions with managed-care company
Think out loud about whether to appeal. Get records of past treatment, especially
hospitalizations.
Maintain records per legal requirements (nature
and duration).
Cytochrome P-450
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Liver enzymes metabolize mostmedications
Interactions occur when added other
medication with same pathway. Inducers
Inhibitors
Enzymatic activity affected by genetics
Children
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Many medications not sufficiently studiedin children
Atypical symptoms
Collateral information Careful monitoring required for SSRIs
Black box warning
Risk of Suicide on antidepressantsApproved medications for kids
Elderly
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Start low, go slow
Ultimately require same dose
Decreased metabolism can be dangerous
Often have other medical problems, druginteractions
Depression in elderly
Black box warning Suicide risk assessment
Invasive Treatments
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ECTVNS
TMS
DBS
Future modalities
Electroconvulsive Therapy(ECT)
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History of ECT
How doe sit work
Indications of ECT
Modern ECT
Risks of ECT
SE of ECT
TMS
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How TMS works
Unique experimental design issues
Capabilities and established results Comparison to other techniques
Therapeutic applications
Potential future work
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VNS
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What is VNS
Mechanism of action
Pros Cons
Cost
Indications
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DBS
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History
Interventions
Mechanism
Indications
Advantages and disadvantages
SE
Future Medications
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h k
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Thank You