1. Brief Overview of Common Psychotropic Medications --and--
The Role of the Complex Care Clinician in Supporting Psychiatric Medications
Marc Avery, MD, Psychiatrist
University of Washington School of Medicine

2. Objectives
Participants in this training will:
1. Be familiar with the classes of common psychiatric medications.
2. Learn of some important basic concepts about how psychiatric medications are used effectively.
3. Understand the role of
The complex care clinician
In supporting psych meds.

3. Psychiatric Medications – only a few classes:
Antidepressants
Antianxiety
Anti-Psychotics
Mood Stabilizers
MAT
Sure, there are ADHD meds and a bunch of other spurious meds, but these are less common.

4. Deliver Coordinated Services
Antidepressants
How do they work?
How effective are they?
What can patients expect?
Can work as soon as 48 hours, but usually takes 1 -6 weeks.
The PHQ is a great tool for judging improvement.
Do they have side effects?
Startup side effects (nausea, sweating, sedation).
Ongoing side effects (sweating, sexual dysfunction)
Dangerous side effects (suicidality, mania, serious allergy)
How does a prescriber choose an antidepressant?
All just as likely to work.
Different people respond differently, but you can’t tell ahead of time.
Often need to try 2 or 3 different ones to find the best match.
It does appear that medications can stop working over time.. but….
Typically use side effects to guide
Engage Clients in their whole health
Actively engage each client/patient in his/her Care Planning:
Collaborate with the client/patient/family to develop a whole health service plan including services from agencies outside the partnership
Deliver Coordinated Services
Develop Shared Care Plans across primary care, mental health and substance use :
Develop and use processes for the collecting and updating shared goals among client/patient and providers
Develop and use processes for communicating and supporting client’s shared goals among providers

5. Antianxiety Sleeping Medications SSRI antidepressants
Treatment of choice
Benzodiazepines
Are habit forming.
Must take them often
Sleeping Medications
Many are also benzodiazepines, and don’t work long term very well.
Not habit forming meds don’t work as well.
Sleep counseling is the treatment of choice.

6. PTSD Prazosin for nightmares
Prazosin is a blood pressure medication – so some patients can experience LOW blood pressure when taking it.

7. Abilify (aripiprazole), Clozaril (clozapine), Geodon (ziprasidone), Latuda (lurasidone)
Risperdal (risperidone), Saphris (asenapine), Seroquel (quetiapine), Zyprexa (olanzapine)
Antipsychotics
There are about a dozen of them. They also all “work” about the same, but often with VERY different side effect profiles. Onset of action is much faster than antidepressants.
Many have:
Metabolic side effects: diabetes, weight gain, increased cholesterol.
Neurologic side effects: akathesia, tremor, dyskinesia.
Generally treat the symptoms of psychosis: hallucination, delusion, ideas of reference, etc.
Less good at the “negative” symptoms of psychosis
Also treat mania, ‘resistant depression’, anxiety, but high side effects.

8. Mood Stabilizers So what is bipolar disorder?
What is a ‘mood stabilizer’?
Medication Choices – the big 4: 
LITHIUM – need labs.
Depakote (Valproate) – need labs.
Lamictal – need to take reliably
Antipsychotics – side effects
“Mood stabilization” takes more time to treat than depression or psychosis
Often using meds that are more difficult to use.

9. MAT
Opiates
Suboxone – (Buprenorphine/Naloxone) needs waivered. – needs induction.
Buprenorphine (Subutex)
Both the above need ‘induction treatment’
Methadone – treatment program.
Naltrexone – Long Acting Injectable (Vivitrol) every four months.
Alcohol: Antabuse –Acamprosate –Naltrexone – 
Smoking: Chantix – Bupropion - Gum/Patches

10. What is the role of care manager, care coordinator, BH clinician in supporting effective medication treatment?
You can do as at least as much with the
patient as they (or their family) might
do for themselves.
Inquire about what they heard or learned when they met with their prescriber.
Help patients formulate (and write down) medication questions for their prescriber.
Ask about side effects and how they have adjusted to them.
Educate patients about what to expect from medication.
Celebrate any benefits!
Look up medications on the internet (WebMD is my fave).
Look up medication interactions (the AARP drug interaction checker is my fave).

11. What if patients
don’t want to
take psychiatric
medication?

12. Medication Reconciliation – What and why?
What is?
Prescribed
Dispensed
Purchased
Mixed, traded, stolen, tossed, flushed
Taken
Prescriptions, OTCs, herbs, remedies.
Why bother?
Medication Errors are COMMON!!!
Sharing of information
Patient Education

13. MEDICATION ADHERENCE The sobering facts:
75% of all patients are non-adherent in some way.
30% of Rx’s never filled at all
50% of Rx’s filled not taken correctly
Non-adherence following hospitalization for schizophrenia approach 50% during the first year post discharge
10% of all hospitalizations are due to non-adherence
Est. cause of 125,000 deaths annually  

14. Predictors of Poor Adherence
Homelessness, other social factors
Adjustment to daily routine
Lack of family involvement 
Confusion
Depression (doubles risk of non-adherence)
Psychosis
Cognitive impairment
Poor insight and denial
Lack of perceived efficacy
Side Effects
Complexity (QID dosing alone reduces adherence from 80% to 50%)
Duration
Stigma
Fear of dependency
 Cost / loss of benefits / availability
 Clinician–patient relationship issues
Inadequate follow-up
The Take Home: Side effects and lack of efficacy
are high on the list!
Mitchell, Selmes Adv Psych Tr (2007) 13: Lars Osterberg, M.D., and Terrence Blaschke, M.D., N Engl J Med 2005; 353: August 4, 2005,

15. MEDICATION ADHERENCE Tips for improving medication adherence
Tips for improving medication adherence
ACTUALLY TALK ABOUT IT!
Work out how they GET their medication
Help patients get organized – pill boxes, medisets, medication lists
Keep meds in a familiar place
Pull in family
Peers! Peers! Peers!
Associate with another daily task.

16. AARP drug interaction checker AIMS Center COMMONLY
If you’re like me: you’ll forget most of this information after a while – so where to get info when you need it?
Resources:
WebMD
GoodRx
AARP drug interaction checker
AIMS Center COMMONLY
PRESCRIBED PSYCHOTROPIC
MEDICATIONS HANDOUT
Aims.uw.edu
Above provided courtesy of the AIMS Center, University of Washington – sharing is permissible with appropriate reference.