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Common mental health medicines

Chris Johnson , Antidepressant Specialist Pharmacist NHSGGC – Dec 2013. Common mental health medicines. Outline. Non-medicalised Non-pharmacological Drugs (Pharmacological) Antidepressants Anxiolytics and hypnotics. Non- medicalised. Addressing causes of stress

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Common mental health medicines

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  1. Chris Johnson, Antidepressant Specialist Pharmacist NHSGGC – Dec 2013 Common mental health medicines

  2. Outline Non-medicalised • Non-pharmacological Drugs (Pharmacological) • Antidepressants • Anxiolytics and hypnotics

  3. Non-medicalised • Addressing causes of stress • Money worries, relationship issues, etc • Exercise – 20-30min walks • Good sleep hygiene • Bedtime routine • ↓/avoid caffeine • Irn-Bru, coke, Red Bull, tea, coffee • ↓/avoid alcohol • Make time to unwind • Meditation, prayer, quiet time • Make time for yourself

  4. Antidepressants - Uses • Depression (Moderate to severe) • Anxiety disorders • General anxiety disorder (GAD) • Panic disorder • Post Traumatic Stress Disorder (PTSD) • Nerve pain • Neuropathic pain – Diabetes, slipped discs • Insomnia

  5. Different antidepressants • Selective serotoinin re-uptake inhibitors (SSRIs) • Citalopram, fluoxetine, sertraline, etc • Tricyclic antidepressants • Amitriptyline, lofepramine, clomipramine, etc • Others • Mirtazapine, venlafaxine, trazodone • Monoamine oxidase inhibitors • Phenelzine, etc • General theory on how antidepressants work

  6. Time to effect – Therapeutic doses SSRIs • Depression (initial doses) • 20’s plenty – citalopram, fluoxetine, paroxetine • 50’s enough – sertraline • Anxiety disorders • Start lower and increase according to response

  7. Time to effect – Therapeutic doses • TCAs • Depression – 100-150mg • Anxiety – depends on the drug • Mirtazapine – Depression 30-45mg • Venlafaxine • Depression 75mg to 150mg • Anxiety – start 75mg

  8. SSRIs - 20’s Plenty & 50’s Enough! Adli M, et al. Is dose escalation of antidepressants a rational strategy after a medium-dose treatment has failed? A systematic review. Eur Arch Psychiatry Clin Neurosci 2005;255:287-400.

  9. As an example all antidepressants demonstrate a similar profileBenkert O, M. Muller M, Szegedi A, Hum Psychopharmacol Clin Exp 2002; 17: S23–S26.

  10. Time to effect • Depression (Moderate to severe) • 2-4 weeks some effect • Response • 1/3 full response • 1/3 partial response • 1/3 no response • Anxiety (Moderate to severe) • Up to 6 weeks

  11. Papakostas GI J Clin Psychiatry 2007;68(supp 10):11

  12. Side effects When starting • SSRIs • Nausea 82% reducing to 32% • Restlessness, agitation – settles within 10 days • Rare suicidal thoughts • Venlafaxine • 45% nausea • TCAs and mirtazapine • Drowsiness

  13. Side effects – sexual dysfunction • 3-8% report this SE • 34-75% report on direct questioning Tolerance to side effect • 10% disappears • 11% partially disappears

  14. Side effects • Insomnia/sedation (hypersomnia) • SSRIs • 22% insomnia • 38% hypersomnia • TCAs, • Mirtazapine (low dose 15mg)

  15. Side effects • Falls • Especially elderly • Bigger doses more risk TCAs – Mirtazapine - SSRIs • Cognitive dysfunction – TCAs • Affects thought processes

  16. Weight changes Depression • ↓/↑ weight • ↓ appetite • ↓ motivation On treatment • Reduced symptoms • ↑motivation • Drug effects • ↑ carbohydrate craving

  17. How long’s a course Depression • 1st episode – 6 months • 2nd episode – 12 months • 3rd or more – 2 years (or longer) Anxiety • 1st episode – 9-12 months • Other episodes – individual basis

  18. Anxiolytics and hypnotics - Use • Muscle spasms (short term) • Epilepsy • Anxiety (short term 2-4 weeks max) • Insomnia (short term 2-4 weeks max)

  19. Anxiolytics and hypnotics • Benzodiazepines • Hypnotics – nitrazepam, temazepam, diazepam • Anxiety – diazepam, lorazepam, chlordiazepoxide • Z-hypnotics • Zopiclone, zolpadem • How they work • Others • Promethazine – sedating antihistamine • Propranolol – beta-blocker

  20. But for insomnia!!

  21. Side effects B&Zs Benzos and z-hypnotics – same problems • Day time sedation • Falls – hip fractures • Cognitive dysfunction (affects thoughts processes) • Confusion • ?Dementia

  22. Side effects – B&Zs • Disinhibition (like alcohol) • Risk if thoughts of suicide • Paradoxical effects • Increase anxiety and insomnia • Increase depressive symptoms

  23. Side effects others • Propranolol • Slow heart rate • Fatigue • Cold hand and/or feet • Avoid in asthma • Promethazine • Next day sedation

  24. Other drugs • St Johns Wort (Hypericum) - Depression • Interacts with lots of medicines • Similar effect to paroxetine BMJ 2005;330:503. • Not necessarily better tolerated!! • Omega-3 fatty acids • Treatment resistant depression add-in????? • Valerian – insomnia • Similar to oxazepam (n=70)

  25. Stopping Antidepressants/Benzos Speed of reduction depends on • Which drug? • Some more withdrawals than others • How long you have been taking them? Generally • Slow and managed (minimises withdrawals) • With follow up

  26. Support Services • Libraries – Health reading section • Glasgow SPCMH http://glasgowspcmh.org.uk/home.php • Glasgow Help. http://glasgowhelp.com/home.php • Moodgym (CBT) http://moodgym.anu.edu.au/welcome • NHS Choices http://www.nhs.uk/Pages/HomePage.aspx

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