1. Psychopharmacology: What you need to know before you graduate Carla Cobb, Pharm.D., BCPP June 2007

2. Or Clinical Pearls from the faculty! Or Clinical Pearls from the faculty! The answers to the questions are not all encompassing but cover some major important points The answers to the questions are not all encompassing but cover some major important points The questions are designed to prompt discussion with residents The questions are designed to prompt discussion with residents

3. Objectives At the end of this discussion the participant should be able to: At the end of this discussion the participant should be able to: Avoid some of the serious adverse effects of psychiatric medications Avoid some of the serious adverse effects of psychiatric medications Appropriately treat patients who fail to respond to first choice medications Appropriately treat patients who fail to respond to first choice medications Appropriately monitor patients for response to and adverse effects of psychiatric medications Appropriately monitor patients for response to and adverse effects of psychiatric medications

4. Depression Diagnosis What do you need to do before starting an antidepressant? What do you need to do before starting an antidepressant? Screen for bipolar disorder (among many other items) Screen for bipolar disorder (among many other items)

5. How Do You Choose a Drug? Pick a couple from each category and get comfortable using them Pick a couple from each category and get comfortable using them Identify mental health professionals in your area and develop a working relationship with them Identify mental health professionals in your area and develop a working relationship with them

6. Rating Scales What is the role of rating scales in screening for and monitoring psychiatric illness? What is the role of rating scales in screening for and monitoring psychiatric illness? Not a substitute for the clinical interview Not a substitute for the clinical interview One of many tools available to help with diagnosis, symptom management, treatment goals One of many tools available to help with diagnosis, symptom management, treatment goals Examples: PHQ and MDQ

7. Non-response What are the most common causes of patient failure to respond to medication? What are the most common causes of patient failure to respond to medication? Not taking the medication Not taking the medication Dose too low Dose too low Misdiagnosis Misdiagnosis Lack of adjunctive services Lack of adjunctive services Not waiting long enough Not waiting long enough

8. STAR*D Trial After a failure of an SSRI antidepressant, what is the next step? After a failure of an SSRI antidepressant, what is the next step? NIMH study, no industry funding NIMH study, no industry funding All comparators had equal results All comparators had equal results Messages: Messages: Goal should be remission Goal should be remission Remission may take ≥ 7 weeks Remission may take ≥ 7 weeks Don’t settle for less, don’t give up Don’t settle for less, don’t give up It doesn’t matter so much what you try - most people will get better even if it takes multiple trials It doesn’t matter so much what you try - most people will get better even if it takes multiple trials

9. Star*D Trial Steps Step 2 Step 2 Switch to Zoloft, Wellbutrin, Effexor, cognitive therapy (CBT) OR Switch to Zoloft, Wellbutrin, Effexor, cognitive therapy (CBT) OR Augment with Wellbutrin, BuSpar, CBT Augment with Wellbutrin, BuSpar, CBT Step 3 Step 3 Switch to Remeron or nortriptyline OR Switch to Remeron or nortriptyline OR Augment with lithium or thyroid hormone Augment with lithium or thyroid hormone Step 4 Step 4 Switch to MAOI or combination of Remeron and Effexor Switch to MAOI or combination of Remeron and Effexor

10. Bupropion (Wellbutrin) What is the most serious adverse effect with Wellbutrin? What is the most serious adverse effect with Wellbutrin? How can it be prevented? How can it be prevented? Seizures Seizures Contraindicated with history of seizures, eating disorder Contraindicated with history of seizures, eating disorder Use with caution if head injured Use with caution if head injured Divide dose of regular or SR Divide dose of regular or SR

11. Insomnia What are the options for treating insomnia? What are the options for treating insomnia? Poorly studied, big problem Poorly studied, big problem Benzos, Ambien-like drugs best studied; only for short-term use Benzos, Ambien-like drugs best studied; only for short-term use Use trazodone with caution Use trazodone with caution Little data to support its use Little data to support its use Lots of next day sedation, dizziness, potential for arrythmias Lots of next day sedation, dizziness, potential for arrythmias

12. Lay Terminology What does “mood swing” mean to a patient? What does “mood swing” mean to a patient? Irritability, labile mood, self-diagnosis of “bipolar disorder” Irritability, labile mood, self-diagnosis of “bipolar disorder” To you? To you? Clarify the diagnosis of bipolar disorder in patients that come to you with that dx Clarify the diagnosis of bipolar disorder in patients that come to you with that dx What does “panic” mean to a patient? To you? What does “panic” mean to a patient? To you? Same general idea! Same general idea!

13. Lithium What clinically significant drug interactions exist with lithium? What clinically significant drug interactions exist with lithium? Watch out for concomitant use of diuretics (esp. HCTZ) and regularly scheduled doses of NSAIDS Watch out for concomitant use of diuretics (esp. HCTZ) and regularly scheduled doses of NSAIDS They can increase levels of lithium and cause toxicity They can increase levels of lithium and cause toxicity

14. Lamictal What is the most serious adverse reaction with Lamictal? What is the most serious adverse reaction with Lamictal? How can it be prevented? How can it be prevented? Potentially fatal rash Potentially fatal rash Start low and go slow (see Epocrates for dosing) Start low and go slow (see Epocrates for dosing) Special dosing if patient is also on valproic acid/Depakote Special dosing if patient is also on valproic acid/Depakote Warn patients to report immediately Warn patients to report immediately

15. Drug Plasma Concentrations Which psych meds need drug level monitoring done? Which psych meds need drug level monitoring done? When should you test? When should you test? Lithium, Depakote, Tegretol Lithium, Depakote, Tegretol If using TCAs, clozapine If using TCAs, clozapine Measure trough level, usually 12 hours after the last dose Measure trough level, usually 12 hours after the last dose After the patient has been on the current dose regularly for about a week After the patient has been on the current dose regularly for about a week If toxicity is suspected If toxicity is suspected

16. PTSD What can you use for PTSD- associated nightmares? What can you use for PTSD- associated nightmares? Prazocin 1 mg nightly for 3 nights gradually increasing up to a max of 15 mg nightly (see article for more details) Prazocin 1 mg nightly for 3 nights gradually increasing up to a max of 15 mg nightly (see article for more details) Raskind MA. Biological Psychiatry 2007;61:928-34

17. CATIE Trial When is it OK to use older typical antipsychotics (e.g. perphenazine) vs atypicals? When is it OK to use older typical antipsychotics (e.g. perphenazine) vs atypicals? Studies have compared older and newer antipsychotics for people with long-standing schizophrenia Studies have compared older and newer antipsychotics for people with long-standing schizophrenia Less data with typicals for bipolar disorder and new onset schizophrenia (atypicals may be better) Less data with typicals for bipolar disorder and new onset schizophrenia (atypicals may be better)

18. TD and AIMS What is it? What is it? Tardive dyskinesia - irreversible movement disorder caused by antipsychotics; may be reversible if caught and managed early Tardive dyskinesia - irreversible movement disorder caused by antipsychotics; may be reversible if caught and managed early How can you monitor patients for it? How can you monitor patients for it? Screen for TD with the AIMS scale (abnormal involuntary movement scale) Screen for TD with the AIMS scale (abnormal involuntary movement scale) How often? How often? Every 6 months Every 6 months Some use if for all patients taking an antipsychotic, new or old Some use if for all patients taking an antipsychotic, new or old

19. Metabolic Syndrome Which psych meds can cause it? Which psych meds can cause it? Atypical antipsychotics; mainly Zyprexa, Seroquel, Risperdal Atypical antipsychotics; mainly Zyprexa, Seroquel, Risperdal How should you monitor for it? How should you monitor for it? Baseline and routine weight, lipids, glucose Baseline and routine weight, lipids, glucose What can you do about it? What can you do about it? Switch to Geodon or Abilify and/or treat the problem Switch to Geodon or Abilify and/or treat the problem

20. Controlled Substances What do you need to document to keep out of trouble? What do you need to document to keep out of trouble? 4As 4As Analgesia (effectiveness) Analgesia (effectiveness) Adverse effects Adverse effects ADLs (improvement in function) ADLs (improvement in function) Aberrant behavior (sign of misuse) Aberrant behavior (sign of misuse)

21. Urine Tox Screens Will a patient on Adderall (or other prescription amphetamines) test positive for methamphetamine? Will a patient on Adderall (or other prescription amphetamines) test positive for methamphetamine? NO! NO!

22. Alcohol Withdrawal Options? Options? Benzos needed to prevent withdrawal seizures in moderate to severe withdrawal Benzos needed to prevent withdrawal seizures in moderate to severe withdrawal For mild to moderate withdrawal in outpatients: For mild to moderate withdrawal in outpatients: Tegretol (carbamazepine) 600-800 mg daily, taper down to 200 mg on day 5 was as good (better on some measures) as lorazepam 6-8 mg taper J Gen Int Med 2002;17:349-55 Tegretol (carbamazepine) 600-800 mg daily, taper down to 200 mg on day 5 was as good (better on some measures) as lorazepam 6-8 mg taper J Gen Int Med 2002;17:349-55

23. TIMA/TMAP What is this? What is this? Texas Implementation of Medication Algorithms Texas Implementation of Medication Algorithms Psychiatric treatment algorithms Psychiatric treatment algorithms Where can you find it? Where can you find it? On the web On the web How is it used? How is it used? Useful for helping determine the next step in treatment Useful for helping determine the next step in treatment http://www.dshs.state.tx.us/mhprograms/TIMA.shtm

24. Lab Monitoring What lab tests should routinely be done for psych meds? What lab tests should routinely be done for psych meds? Baseline and Q6-12 months ( *more often during first few months) Baseline and Q6-12 months ( *more often during first few months) CBC* – lithium, Depakote, Tegretol CBC* – lithium, Depakote, Tegretol Metabolic – atypicals, lithium, Depakote Metabolic – atypicals, lithium, Depakote Liver - Depakote, Tegretol* Liver - Depakote, Tegretol* Renal, thyroid – lithium* Renal, thyroid – lithium* Electrolyes – lithium, Tegretol, Trileptal Electrolyes – lithium, Tegretol, Trileptal

25. Pharmacologic Debridement Don’t be afraid to stop drugs instead of continually adding them! Don’t be afraid to stop drugs instead of continually adding them!

26. Me Too Drugs What does this mean? What does this mean? Drugs that are introduced that have little to no advantage over older, generic medication but make more money for the company Drugs that are introduced that have little to no advantage over older, generic medication but make more money for the company Examples? Examples? Omeprazole/esomeprazole (Prilosec/Nexium) Omeprazole/esomeprazole (Prilosec/Nexium) Citalopram/escitalopram (Celexa/Lexapro) Citalopram/escitalopram (Celexa/Lexapro) Risperidone/9-OH-risperidone (Risperdal/Invega) Risperidone/9-OH-risperidone (Risperdal/Invega) What should you do? What should you do? Avoid using them, review the data Avoid using them, review the data

27. NAMI What is NAMI? What is NAMI? National Alliance on Mental Illness, in many communities across the country National Alliance on Mental Illness, in many communities across the country What services do they offer? What services do they offer? Educational information and meetings, support groups for patients and family members, advocacy Educational information and meetings, support groups for patients and family members, advocacy Who should be referred? Who should be referred? All patients that are willing to go All patients that are willing to go www.nami.orgwww.nami.org to locate a group www.nami.org

28. Patient Education Websites http://www.dshs.state.tx.us/mhprograms/TI MA.shtm http://www.dshs.state.tx.us/mhprograms/TI MA.shtm http://www.dshs.state.tx.us/mhprograms/TI MA.shtm http://www.dshs.state.tx.us/mhprograms/TI MA.shtm http://www.aafp.org/online/en/home.html http://www.aafp.org/online/en/home.html http://www.aafp.org/online/en/home.html http://www.nimh.nih.gov/ http://www.nimh.nih.gov/ http://www.nimh.nih.gov/ All of these have tons of great handouts and patient information All of these have tons of great handouts and patient information You can print and give them out or refer patients to the website You can print and give them out or refer patients to the website Check them out to see which ones you like the best Check them out to see which ones you like the best

29. How do you avoid drug company influence? Don’t allow reps in your office Don’t allow reps in your office Don’t use samples Don’t use samples Don’t eat the food or accept freebies Don’t eat the food or accept freebies Use industry drug information resources if you have specific questions Use industry drug information resources if you have specific questions Be skeptical and independently confirm anything you’re told Be skeptical and independently confirm anything you’re told Read the literature, ask trusted colleagues, pharmacists Read the literature, ask trusted colleagues, pharmacists