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Depression and Psychopharm. How Medications work and which to choose. Suicide (approximately 1 in 10 of those with depression). Antoine Wiertz (1806-1865). http://www.modjourn.brown.edu/mjp/Image/Wiertz/Wiertz.htm. Your client may need a medication consultation for anti-depressants if:.

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Depression and psychopharm

Depression and Psychopharm

How Medications work and which to choose


Suicide approximately 1 in 10 of those with depression
Suicide (approximately 1 in 10 of those with depression)

Antoine Wiertz (1806-1865)

http://www.modjourn.brown.edu/mjp/Image/Wiertz/Wiertz.htm


Your client may need a medication consultation for anti depressants if
Your client may need a medication consultation for anti-depressants if:

  • Not so much a characterological depression as a physiological depression

    • Sleep, sex, and/or appetite disturbance

    • Fatigue

    • Agitation or psychomotor retardation

    • Anhedonia

  • Dysthymia is really sucking the energy out of them

  • Grief/heartbreak becomes depression

  • Psychotherapy isn’t helping

  • Suicidality

  • Daily functioning is markedly impaired

  • Always assess for Hypomania and Mania


Anti depressants
Anti-depressants anti-depressants if:

Cymbalta

No prescription is required as we ship from outside the United States.


Antidepressants
Antidepressants: anti-depressants if:

Have only been around since the 1950’s

Fall into categories:

MAOIs

TCAs

SSRIs

Atypical: SNRI, NSRI, etc.


Maois antuberculosis
MAOIs (antuberculosis) anti-depressants if:

  • Powerful Antidepressants that also work with panic disorder and social phobia

  • The original Antidepressants

  • Inhibit enzymes that destroy serotonin, norepinephrine, and Dopamine


Problems with maois
Problems with MAOIs anti-depressants if:

  • Foods rich in tyramine are fatal

    • Avoid aged cheese; aged or cured meats (e.g., air-dried sausage); any potentially spoiled meat, poultry, or fish; broad (fava) bean pods; Marmite concentrated yeast extract; sauerkraut; soy sauce and soy bean condiments; and tap beer.

    • Listed in book


TCAs anti-depressants if:

  • Some work as anti OCD and Antipanic

  • Block reuptake pump for 5HT, NE, and to a lesser extent Dopamine. (level of blockage for each NT is dependent on the medication)

    BUT ALSO……


TCAs: anti-depressants if:

  • BLOCK

    • Muscarinic Cholinergic receptors

      • Dry mouth, blurred vision, urinary retention, constipation

    • H1 Histamine receptors

      • Sedation and weight gain

    • Alpha 1 adrenergic receptors

      • Hypotension and dizziness

    • Sodium channels in the heart and brain

      • Overdose will cause seizures, cardiac arrest, or arrhythmias


Selectivity and the ssris
Selectivity and the SSRIs anti-depressants if:

  • Depending on where the neuron goes and what receptors are blocked will change the effects of the drug

  • Currently we can’t control where the drug goes in the brain, but selectivity demonstrates better control over which receptors are blocked


Ssris
SSRIs anti-depressants if:

  • Block serotonin reuptake selectively-thus limited danger in overdose

  • Less side effects (only 5HT ones such as nausia, insomnia, headache, gastrointestinal, sweating, anxiety, restlessness

  • Initial anxiety and difficulty with sleep is common

  • AND…sexual side effects are a big problem

  • Additional difficulties into tx of fatigue and apathy should be monitored and treated with adjunct medication…For example Dopamine or NE meds….


The current hypothesis is people may have a ne deficiency and show symptoms of
The current hypothesis is: People may have a NE deficiency and show symptoms of

  • Poor attention

  • Poor concentration

  • Poor working memory

  • Poor speed of information processing

  • Psychomotor retardation

  • Fatigue

  • Apathy

  • Depressed mood


Or a 5ht deficiency and have symptoms of
Or a 5HT deficiency and have symptoms of and show symptoms of

  • Depressed mood

  • Anxiety

  • Phobias

  • Panic

  • OCD symptoms

  • Food cravings and Bulimia

  • How does this knowledge help you help your client?


Other antidepressants
Other antidepressants and show symptoms of

  • SNRIs block 5ht and NE reuptake

  • NRIs block NE reuptake (not available in US)

  • Atypical: Welbutrin (works on Dopamine and NE in complex way), Serzone (off the market), BuSpar, Remeron (no sexual, anxiety or nausia, but weight gain and sedation), Effexor (1:30), Milnacipran (1:3) (not in us), and cybalta

  • 1 + 1 = 3


Other notes
Other notes and show symptoms of

  • Trazodone: For sleep, reduces SSRI side effects of insomnia and agitation and enhances SSRI effect

    • Can cause priapism in men

    • Can cause nightmares

    • What diagnosis would caution the use of this medication

      Keep in mind that because SSRIs inhibit enzyme 2D6, they increase levels of TCAs in Plasma


Some bad mixtures
Some bad mixtures and show symptoms of

  • Luvox with atypical antidepressants, theophylline (for chronic asthma), and even caffeine can lead to seizures

  • Prozac and Luvox inhibit enzyme 3A4; Xanax, Halcion, and Propulsid (heartburn) are substrates of 3A4 and can become toxic causing cardiovascular trouble or sudden death


Other issues
Other Issues and show symptoms of

  • Drugs can increase (induce) enzymes in the liver too.

    • For example: Tegretol induces 3A4 and is broken down by 3A4. Thus doses must be monitored and increased to avoid breakthru symptoms

    • And if Tegretol is stopped, any other drug metabolized by 3A4 will increase their concentration in the plasma (217)


Did i cover these topics
Did I cover these topics? and show symptoms of

Luvox,- addresses ruminations and OCD symptoms

Welbutrin and other drugs for sexual side effects

Reboxitine

Stimulants

Providual, Lexapro, Paxil & Luvox (ACH)


Primary care patients with depression

Poor medication adherence is prevalent and show symptoms of

1 out of 3 did not take antidepressant as directed within the first 30 days

More than half (56%) did not adhere within four months!

Reasons for non-adherence

Side effects

Belief that meds were not necessary

Medication not working

Forgot to take meds.

Cost ($75 to $250/month)

Primary Care Patients with Depression


If clinicians closely monitor manage side effects
If clinicians closely monitor/manage side effects: and show symptoms of

  • It may enhance compliance with medication

  • Adequate dosing = better for patient

  • Patients may not prematurely abandon therapy


Sexual dysfunction during antidepressant treatment
Sexual Dysfunction During Antidepressant Treatment and show symptoms of

  • Is a huge problem and underreported in studies. Studies are less likely to address effects in women, which are different than in men

    • Diminished or absent libido

    • Arousal difficulties

    • Erectile dysfunction (in men)

    • Delayed orgasm

    • Anorgasmia

    • Or...undesirable sexual arousal and hypersexuality

    • Sexual partner may not understand


Potential consequences of sexual dysfunction
Potential Consequences of Sexual Dysfunction and show symptoms of

  • Psychological distress

  • Reduced quality of life

  • Self-esteem plummets

  • Sexual partner still doesn’t understand and relationships may dissolve with blame

  • Diminished motivation to get intimate with people

  • Non-compliant with medication


A major obstacle in effective treatment of depression (and other disorders) is medication non-adherenece.

  • What do you do about it? Follow through with your clients!

    • Tell them what you know

    • Help them formulate what they’d like to discuss with doctor

    • Call or ask them to call a doctor and make an appointment

    • Obtain a release to talk to client’s doctor

    • Call doctor to introduce self and collaborate treatment


So your client has a prescription for anti depressant medication
So your client has a prescription for anti-depressant medication

  • Ask client for name and dosage

  • Assess client’s attitude, feelings, and thoughts about prescription

  • What is client’s response to meds?

  • Discuss side effects, discuss research, discuss options…discuss…

  • Encourage them to keep in contact with physician


Race and anti depressants
Race and Anti-depressants medication

  • Comparative, two month, pilot study investigating efficacy of Zoloft (Sertraline) found individuals (n=20) with a Chinese heritage:

    • Responded at a lower dose than Caucasians

  • One study (Melfi et al. 2000) found that African-Americans/blacks were less likely than whites to receive an antidepressant when their depression was first diagnosed (27% versus 44%).

    • Of those who did receive antidepressant medications, African Americans were less likely to receive the newer selective serotonin reuptake inhibitor (SSRI) medications than were the white clients.

  • African-Americans may require lower doses of medication because of metabolic differences (most research has been done on white populations e.g., heart disease study)

http://www.depressionet.com.au/articles/251004efod.html


Latinos and mental health study s show
Latinos and Mental Health – Study’s show… medication

  • Fewer than 1 in 11 contact mental health specialists, while fewer than 1 in 5 contact general health care providers.

  • Among Latino immigrants with mental disorders, fewer than 1 in 20 use services from mental health specialists, while fewer than 1 in 10 use services from general health care providers (Mental Health, 2001).

  • One study found that 24 percent of African-American/Blacks, & Hispanics with depression and anxiety received appropriate care, compared to 34 percent of Whites.

  • Another study found that Latinos who visited a general medical doctor were less than half as likely as Whites to receive either a diagnosis of depression or antidepressant medicine.

  • Further…..


Physician patient communication and hispanic ethnicity
Physician-patient communication and Hispanic ethnicity medication

  • Physicians were more likely to state information to patients who started on new anti-depressants

  • Physicians were more likely to give information about anti-depressants to Whites than to Hispanics

  • 1 in 5 patients were asked how well their anti-depressants were working

  • 1 in 10 patients were asked if they were experiencing side effects

  • Hispanics were less likely than Whites to talk about their anti-depressants

  • Remember that research is rarely racially specific.

  • What does this implicate in working with Diverse Populations?

Sleath B, Rubin RH, Huston SA

Compr Psychiatry. 2003 May-Jun;44(3):198-204


Discuss/role-play how these client factors may affect how you communicate about depression and anti-depressants

  • Sex and Gender

  • Age

  • Race

    • Ethnicity

  • Nationality

  • Religion

  • Learning style

  • Socio-economic status

  • Personality and attitude about medication


Latinos and suicide
Latinos and Suicide you communicate about depression and anti-depressants

  • In 2001, Latinos had a suicide rate of 5 per 100,000 compared to nearly 12 per 100,000 for Whites.

    • However, in the 2003 Youth Risk Behavioral Surveillance System, Latino students (10.6 percent) were more likely than White students (6.9 percent) to have reported a suicide attempt.

    • Latino students were more likely to have made a suicide plan (17.6 percent) than White males (16.2 percent).

    • Latino female students (5.7 percent) were significantly more likely than White female students (2.4 percent) to attempt suicide and require medical attention.


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