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Hey, you! Are you Bipolar, Depressed, Borderline, or What?. John L. Schaeffer, D.O. Child, Adolescent & Adult Psychiatrist Kaiser Permanente Psychiatry Roseville, CA October 17, 2009. Disclosure of Relevant Financial Relationships.

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hey you are you bipolar depressed borderline or what

Hey, you! Are you Bipolar, Depressed, Borderline, or What?

John L. Schaeffer, D.O.

Child, Adolescent & Adult Psychiatrist

Kaiser Permanente Psychiatry

Roseville, CA

October 17, 2009

disclosure of relevant financial relationships
Disclosure of Relevant Financial Relationships

Dr. Schaeffer has disclosed that he has no relevant relationships with commercial or industry organizations.

The CME Department has reviewed disclosure information for the planners and developers for this program and they do not have relationships that present a relevant conflict of interest.

the assigned task
The assigned task:
  • At the end of this conference, participants should be able to:
    • Demonstrate interviewing techniques for differentiating bi-polar vs depression and other psychiatric diagnoses.
    • List psych meds and interactions with meds commonly seen in Primary Care.
slide5
“Kids: They dance before they learn there is anything that isn’t music.”William Stafford
primary care at kaiser
Primary Care at Kaiser

You are the Spinal Cord of this organization.

The psychiatry department exists to support you.

And 70 percent of what walks through your door is psychiatric.

So, “Why,” you ask “does psychiatry always dump patients back on us?”

slide7

Because there are only 20 psychiatrists (only four of which are subspecialty trained and actively working as child/adolescent psychiatrists) to support over 200 primary care doctors in the North Valley.

primary care at kaiser1
Primary Care at Kaiser

Permission to use cartoon per Dwayne Booth

representing psychiatry i am here to tell you
Representing Psychiatry, I am here to tell you:
  • Thank you for your dedication, your attention, your focus, your power to heal and to guide many thousands of human beings toward health and safety.
  • We really appreciate everything you do.
  • Without you, Kaiser would not exist, and many lives would crumble into chaos.
so if there are only 20 of us how can we support you
So if there are only 20 of us,how can we support you?
  • Phone Consults via eConsult
  • Monday – Friday 8:30 AM to 5:00 PM a psychiatrist is holding a cell phone waiting for your call. Immediate Access. For medication questions, call 916-973-4888.
  • For Crisis/Urgent appts, call the COD line directly at 916-973-7697 (suicidal, homicidal, psychotic, or need same/next day appt).
immediate access
Immediate Access?
  • You have a depressed patient in your office. You’ve tried Prozac and Celexa and both failed. Instead of telling pt to call psychiatry, pick up the phone and call right there with the patient in your room. A psychiatrist answers the phone. Discuss, address issues, come up with a tx plan, implement.
how to get there
How to get there.
  • Push the eConsult button
  • Facility: Sacramento
  • Specialty: Adult Psychiatry
  • Problem/Reason: “Other”
  • This pulls up the Phone Consult screen.
keep it simple
Keep it simple.

Just what the heck is Bipolar Disorder?

multiple types multiple episodes within types
Multiple types/multiple episodes within types
  • Bipolar I Disorder
  • Bipolar II Disorder
  • Major Depressive Episode
  • Manic Episode
  • Mixed Episode
  • Hypomanic Episode
slide20
C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic.
  • D. The disturbance in mood and the change in functioning are observable by others.
  • E. The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features.
  • F. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).
  • Note: Hypomanic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar II Disorder.
oh and there are specifiers too
Oh, and there are “specifiers” too:
  • Specifiers
  • The following specifiers for Bipolar I Disorder can be used to describe the current Manic, Mixed, or Major Depressive Episode (or, if criteria are not currently met for a Manic, Mixed, or Major Depressive Episode, the recent Manic, Mixed, or Major Depressive Episode):
  •          Mild, Moderate, Severe Without Psychotic Features, Severe With Psychotic Features, In Partial Remission, In Full Remission...          With Catatonic Features...          With Postpartum Onset...
  •          The following specifiers apply only to the current (or most recent) Major
slide22
Depressive Episode only if it is the most recent type of mood episode:
  •   Chronic...           With Melancholic Features...           With Atypical Features...
  • The following specifiers can be used to indicate the pattern of episodes:
  • Longitudinal Course Specifiers (With or Without Full Interepisode Recovery)...             With Seasonal Pattern (applies only to the pattern of Major Depressive Episodes)...             With Rapid Cycling...
so you ready
So you ready?

Apply all that to:

slide24
Diagnostic Criteria for a Manic Episode (DSM-IV-TR)
  • A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary).
  • During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
    • inflated self-esteem or grandiosity
    • decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
    • more talkative than usual or pressure to keep talking
    • flight of ideas or subjective experience that thoughts are racing
    • distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
    • increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
    • excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
  • The symptoms do not meet criteria for a Mixed Episode.
  • The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
  • The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).
slide25
Diagnostic Criteria for a Major Depressive Episode (DSM-IV-TR)
  • Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) or (2).
    • depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood.
    • markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)
    • significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.
    • Insomnia or Hypersomnia nearly every day
    • psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
    • fatigue or loss of energy nearly every day
    • feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
    • diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
    • recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
  • The symptoms do not meet criteria for a Mixed Episode.
  • The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).
  • The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.
slide26
Diagnostic Criteria for a Hypomanic Episode (DSM-IV-TR)
  • A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual non depressed mood.
  • During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:
    • inflated self-esteem or grandiosity
    • decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
    • more talkative than usual or pressure to keep talking
    • flight of ideas or subjective experience that thoughts are racing
    • distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
    • increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
    • excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., the person engages in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
  • The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic.
  • The disturbance in mood and the change in functioning are observable by others.
  • The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features.
  • The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).
slide27
Diagnostic Criteria for a Mixed Episode (DSM-IV-TR)
  • The criteria are met both for a Manic Episode and for a Major Depressive Episode (except for duration) nearly every day during at least a 1-week period.
  • The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.
  • The symptoms are not due to the direct physiological effects of a substance (e.g., a illicit drugs, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).
slide30
So let’s get real.

Let’s play:

“I can name that mood disorder in 5 lines.”

slide31
Take a piece of paper and draw

three horizontal lines.

slide32
___________________________________

___________________________________

___________________________________

slide33

Write the words:

Manic, Normal, Depressed

slide34
_______________Manic______________

_______________Normal______________

______________Depressed____________

slide36
_______________Manic______________

_______________Normal______________

______________Depressed____________

slide37

Write the words:

Hypomanic

Dysthymic

slide38
_______________Manic______________

Hypomanic

_______________Normal______________

Dysthymic

______________Depressed____________

slide39

Manic

Normal

Depressed

Hypomanic

Dysthymic

slide40

Manic

Money Ass to Everybody Nothing is Neutral Impulsive Cyclical

Normal

Depressed

Demented cognition Everything is affected Personal hygiene Regressed Suicidal Septic Energy vacuum Death/morbid thoughts

Hypo

Half the mania Yearning for greatness but still in control People’s opinions still matter Organized enough to work/function

Dysthymic

Determined to see Negative “Yes, butt….” Serious Time is 2 yrs Haggard “Yesterday….” Interested but little joy Melancholic Ill Cynical

slide41

Manic

Normal

Depressed

Normal

Hypomanic

Dysthymic

major depressive disorder

Manic

Normal

Depressed

Major Depressive Disorder

Hypomanic

Dysthymic

cyclothymic disorder

Manic

Normal

Depressed

Cyclothymic Disorder

Hypomanic

Dysthymic

bipolar ii

Manic

Normal

Depressed

Bipolar II

Hypomanic

Dysthymic

bipolar i

Manic

Normal

Depressed

Bipolar I

Hypomanic

Dysthymic

bipolar i1

Manic

Normal

Depressed

Bipolar I

Hypomanic

Dysthymic

borderline personality disorder each shift triggered by external forces

Manic

Normal

Depressed

Borderline Personality Disorder (each shift triggered by external forces)

Hypomanic

Dysthymic

mood interview pearl 1
Mood Interview Pearl #1

Origin

“When were you first aware of these feelings? At what age?”

slide51

Ages at Onset for 579 Patients With Bipolar I Disorder in Subgroups With Early Onset, Intermediate Onset, and Late Onset Frank Bellivier, M.D., Ph.D., Am J Psychiatry 160:999-1001, May 2003

slide52
Effect of Age at Onset on the Course of Major Depressive DisorderSidney Zisook, M.D., Am J Psychiatry 164:1539-1546, October 2007
slide53

Borderline Personality Disorder in under age 18:

Personality disorders generally should not be diagnosed in children and adolescents because personality development is not complete and symptomatic traits may not persist into adulthood. Therefore, the rule of thumb is that personality diagnosis should not be made until the person is at least 18 years of age. That being said, page 687 of the DSM-IV-TR:

“Personality Disorder categories may be applied to children and adolescents in those relatively unusual instances in which the individual’s particular maladaptive personality traits appear to be pervasive, persistent, and unlikely to be limited to a particular developmental stage or an episode of an Axis I disorder. It should be recognized that the traits of a Personality Disorder that appear in childhood will often not persist unchanged into adult life. To diagnose a Personality Disorder in an individual under age 18 years, the features must have been present for at least 1 year. The one exception to this is Antisocial Personality Disorder, which cannot be diagnosed in individuals under age 18 years.”

mood interview pearl 2
Mood Interview Pearl #2

Duration

“How long have you had this mood?”

“Does it come and go?”

“Does it ever last a week? Two weeks? Or is it a few hours and never more than a few days?”

mood interview pearl 3
Mood Interview Pearl #3

Severity

“Can you still function?”

“Do you control the mood, or does the mood control you?”

“Do you find yourself asking if you would rather be more dead than alive?”

to qualify as a mood disorder
To qualify as a Mood Disorder

It has to change the way you function.

true depression is not a frustration
True depression is not a frustration

It is an agony, a misery, a despair.

true bipolar is not a fun little rollercoaster ride
True Bipolar is not a fun little rollercoaster ride.

It is a sadistic master ripping you apart.

borderline personality disorder is not a game people play
Borderline Personality Disorder is not a game people play.

It’s a vast, lonely emptiness expecting total annihilation in the next breath.

the best goal is prevention and to catch things early
The best goal is prevention and to catch things early.
  • But that may be more of a Public Health issue than a front-line issue.
  • An adjustment disorder is just that, and adjustment to a serious change in your life. Most adjustment disorders do not go on to become major mental illness.
  • If you want to “prevent” depression, treat child abuse, neglect, poverty, and screen starting in 1st grade for those genetically susceptible.
mood interview pearl 4
Mood Interview Pearl #4

Genetics

“Who else in your biological family has the same thing or something like it?”

mood interview pearls 1 4
Mood Interview Pearls 1- 4
  • Origin—When did it begin?
  • Duration—How long does it last?
  • Severity—How much does it limit you?
  • Genetics—Who gave it to you?
mood interview pearl 5
Mood Interview Pearl #5

I can name that mood disorder in 5 lines.

To be “Bipolar,” you have to have two poles.

To be “Major” depressed, it has to last two weeks.

To be “Borderline,” it has to be a lifestyle where you don’t “act upon” but rather “react to.”

mood interview pearl 6
Mood Interview Pearl #6

Go ahead and feel your feelings.

Use how you feel to better understand your patients.

what is staff splitting
What is “Staff Splitting?”
  • “Finally someone understands me. My other doctor never listened to me….”
mood interview pearl 6 1
Mood Interview Pearl #6.1

Don’t confuse Pity with a true Empathic Moment.

11 year old kid with Asperger’s says “I just want you to give me a medication that will make me normal.”

15 year old polysubstance abusing kid on an ankle monitor says “I just want you to give me a med that makes me feel good because I can’t feel anything at all and haven’t since I was six years old.”

mood interview pearls 1 6 1
Mood Interview Pearls 1- 6.1

1. Origin—When did it begin?

2. Duration—How long does it last?

3. Severity—How much does it limit you?

4. Genetics—Who gave it to you?

5. I can name that mood disorder in 5 lines.

6. How do YOU feel?

6.1. Trust your feelings. To be effective, you have to be affected.

slide80
I embrace emerging experience.

I participate in discovery.

I am a butterfly.

I am not a butterfly collector.

I want the experience of the butterfly.

William Stafford

slide83

Wednesday, October 07, 2009

The 50 Most Prescribed Drugs in 2008

If you multiply the number of prescriptions written for these drugs by their retail cost, you come up with $53.2 billion.  According to AARP, which was the source for this list, more than 10% of our annual health care costs are attributed to prescription drugs.

The top 5 money makers were Lipitor ($5.9 billion retail cost), Nexium ($4.8b), Plavix ($3.8b), Advair ($3.6b), and Prevacid ($3.3b).AARP: "Though brand names make up only 22% of the names on the list, they represent 62% of the $53.2 billion."

slide84

1. Hydrocodone (pain)2. Lisinopril (hypertension)3. Simvastatin (high cholesterol)4. Levothyroxine (hypothyroidism)5. Amoxicillin (bacterial infection)6. Azithromycin (bacterial infection)7. Lipitor (high cholesterol)8. Hydrochlorothiazide (edema/hypertension)9. Alprazolam (anxiety/depression)10. Atenolol (hypertension)11. Metformin (type 2 diabetes)12. Metoprolol Succinate (hypertension)13. Furosemide oral (edema/hypertension)14. Metoprolol tartrate (hypertension)15. Sertraline (depression)16. Omeprazole (ulcers/reflux)17. Zolpidem tartrate (insomnia)18. Nexium (ulcers/reflux)19. Lexapro (depression)

slide85

20. Oxycodone (pain)21. Singulair (asthma)22. Ibuprofen (pain/inflammation)23. Plavix (blood clotting)24. Prednisone oral (allergies/inflammation)25. Fluoxetine (depression)

26. Synthroid (hypothyroidism)27. Warfarin (blood clotting)28. Cephalexin (bacterial infection)29. Lorazepam (anxiety)30. Clonazepam (epilepsy/anxiety)31. Citalopram (depression)32. Tramadol (pain)33. Gabapentin (epilepsy/pain34. Ciprofloxacin HCl (bacterial infection)35. Propoxyphene-N (pain)36. Lisinopril (hypertension)

slide86
37. Triamterene (edema/hypertension)38. Amoxicillin (bacterial infection)39. Cyclobenzaprine (muscle injury/spasm)40. Prevacid (ulcers/reflux)41. Advair (asthma)42. Effexor XR (depression)43. Trazodone HCl (depression)44. Fexofenadine (allergy)45. Fluticasone nasal (allergy)46. Diovan (hypertension)47. Paroxetine (depression/anxiety)48. Lovastatin (high cholesterol)49. Crestor (high cholesterol)50. Trimethoprim (bacterial infection)
slide87

10 of the top 50 are for anxiety or depression.That's about 19% of the total cost ($10.3b of $53.2b).  Depression is big business in this country.4 of the top 50 are for high cholesterol, about 18% ($9.4b of $53.2b).9 of the top 50 are for hypertension, about 9% ($4.9b of $53.2).That adds up to 27% of the total cost, a lot of money for conditions that have been shown repeatedly to respond to diet and exercise.These are a lot of drugs for not a lot of health.1

________

1 US Ranks Last Among Other Industrialized Nations On Preventable Deaths, ScienceDaily, Jan 2008

slide89

"Disease mongering is the selling of sickness that widens the boundaries of illness and grows the markets for those who sell and deliver treatments.

It is exemplified most explicitly by many pharmaceutical industry–funded disease-awareness campaigns—more often designed to sell drugs than to illuminate or to inform or educate about the prevention of illness or the maintenance of health.”

J. Douglas Bremner, M.D., author of Before You Take That Pill

from advances in psychiatric treatment 2005 vol 11 58 70 nora turjanski geoffrey g lloyd
From: Advances in Psychiatric Treatment (2005), vol. 11, 58–70, Nora Turjanski & Geoffrey G. Lloyd.
as a psychiatrist i often see
As a psychiatrist, I often see:

Beta blockers cause depression. Atenolol is hydrophilic. Propranolol and Metoprolol are lypophilic. Statin drugs cause agitation, insomnia, anxiety, and mood swings—except prevastatin which doesn’t cross the BBB.Triptan drugs cause Serotonin Syndrome when used with SSRIs. (typically myoclonus & fever, but can be life threatening).

Benzos and opiates cause depression, confusion, problems with short-term memory and with concentration/attention, and rebound insomnia.Topamax = Dopamax = StupimaxKeppra makes people crazy (agitated, hostile, anxious, apathetic, depressed, and emotionally labile.

Depakote # 1 pt complaint? Hair falls out. Give zinc & selenium.Antiepileptic meds also have FDA black box warning 0.5 % risk of suicide (higher on multiple antiepileptic drugs).

Paxil deforms babies before you know you’re pregnant—don’t give it to women of childbearing years.

slide99

Here is a list of the Adverse Reactions culled from the FDA Individual Safety Reports where Psychiatric Drugs were identified as the Primary Suspect Drug:

Ready?

slide100

Abasia, Abdominal Discomfort, Abdominal Distension, Abdominal Pain, Abdominal Pain Upper, Abnormal Behaviour, Abnormal Dreams, Abortion Induced, Abortion Spontaneous, Activities of Daily Living Impaired, Acute Myocardial Infarction, Affective Disorder, Aggression, Agitation, Agitation Neonatal, Agoraphobia, Akathisia, Akinesia, Alopecia, Amnesia, Anaemia, Anaemia Neonatal, Anaesthetic Complication Neonatal, Anger, Ankyloglossia Congenital, Anomaly of External Ear Congenital, Anorexia, Anxiety, Apathy, Aphasia, Apraxia, Arrhythmia, Arrhythmia Neonatal, Arthralgia, Asthenia, Ataxia, Atelectasis, Atelectasis Neonatal, Autism, Back Pain, Balance Disorder, Benign Congenital Hypotonia, Bipolar Disorder, Bipolar I Disorder, Bipolar II Disorder, Blepharophimosis Congenital, Blindness Congenital, Blood Glucose Increased, Blood Pressure Increased, Bradycardia, Bradycardia Foetal, Bradycardia Neonatal, Bradykinesia, Brain Death, Bruxism, Camptodactyly Congenital, Cardiac Arrest, Cardiac Arrest Neonatal, Cardiac Disorder, Cardiac Failure, Cardiac Failure Congestive, Cardiomegaly, Cardiomyopathy, Cardiomyopathy Neonatal, Cardio-Respiratory Arrest, Cardio-Respiratory Arrest Neonatal, Cataract Congenital, Catatonia, Cerebral Atrophy Congenital, Cerebral Haemorrhage, Cerebral Haemorrhage Foetal, Cerebral Haemorrhage Neonatal, Cerebrovascular Accident, Chest Pain, Chills, Chorea, Circulatory Collapse, Circulatory Failure Neonatal, Cognitive Disorder, Cogwheel Rigidity, Coma, Coma Neonatal, Completed Suicide, Complications of Maternal Exposure To Therapeutic Drugs, Condition Aggravated, Confusional State, Congenital, Congenital Absence of Bile Ducts, Congenital Absence of Cranial Vault, Congenital Acrochordon, Congenital Anaemia, Congenital Anomalies of Ear Ossicles, Congenital Anomaly, Congenital Anomaly of Inner Ear, Congenital Aortic Atresia, Congenital Aortic Stenosis, Congenital Aortic Valve Incompetence, Congenital Aplastic Anaemia, Congenital Arterial Malformation, Congenital Atrial Septal Defect, Congenital Bladder Anomaly, Congenital Bowing of Long Bones, Congenital Brain Damage, Congenital Cardiac Septal Defect, Congenital Cardiovascular Anomaly, Congenital Central Nervous System Anomaly, Congenital Cerebellar Agenesis, Congenital Cerebral Cyst, Congenital Cerebrovascular Anomaly, Congenital Choroid Plexus Cyst, Congenital Claw Toe, Congenital Cleft Hand, Congenital Coagulopathy, Congenital Corneal Anomaly, Congenital Coronary Artery Malformation, Congenital Cyst, Congenital Cystic Kidney Disease, Congenital Cystic Lung, Congenital Diaphragmatic Anomaly, Congenital Diaphragmatic Hernia, Congenital Ectopic Bladder, Congenital Elevation of Scapula, Congenital Eye Disorder, Congenital Eyelid Malformation, Congenital Facial Nerve Hypoplasia, Congenital Floppy Infant, Congenital Foot Malformation, Congenital Gastric Anomaly, Congenital Genital Malformation, Congenital Genital Malformation Male, Congenital Genitourinary Abnormality, Congenital Great Vessel Anomaly, Congenital Hair Disorder, Congenital Hand Malformation, Congenital Hearing Disorder, Congenital Heart Valve Disorder, Congenital Hepatobiliary Anomaly, Congenital Hip Deformity, Congenital Hydrocephalus, Congenital Hydronephrosis, Congenital Hyperextension of Spine, Congenital Hypertrichosis, Congenital Hypoparathyroidism, Congenital Hypothyroidism, Congenital Infection, Congenital Intestinal Malformation, Congenital Jaw Malformation, Congenital Joint Malformation, Congenital Labia Pudendi Adhesions, Congenital Limb Hyperextension, Congenital Lip Fistula, Congenital Macrocephaly, Congenital Megacolon, Congenital Megaureter, Congenital Mitral Valve Incompetence, Congenital Multiplex Arthrogryposis, Congenital Musculoskeletal Anomaly, Congenital Myopathy, Congenital Nail Disorder, Congenital Neurological Disorder, Congenital Nose Malformation, Congenital Nystagmus, Congenital Oesophageal Anomaly, Congenital Oral Malformation, Congenital Osteodystrophy, Congenital Pulmonary Artery Anomaly, Congenital Pulmonary Hypertension, Congenital Pulmonary Valve Atresia, Congenital Pulmonary Valve Disorder, Congenital Pyelocaliectasis, Congenital Pyloric Stenosis, Congenital Renal Cyst, Congenital Scoliosis, Congenital Spinal Cord Anomaly, Congenital Spinal Fusion, Congenital Teratoma, Congenital Thrombocyte Disorder, Congenital Thymus Absence, Congenital Tongue Anomaly, Congenital Torticollis, Congenital Tracheomalacia, Congenital Tricuspid Valve Atresia, Congenital Ureteric Anomaly, Congenital Urethral Anomaly, Congenital Varicella Infection, Congenital Ventricular Septal Defect, Congenital Vesicoureteric Reflux, Congenital Visual Acuity Reduced, Congenital Vitreous Anomaly, Constipation, Convulsion, Convulsion Neonatal, Coordination Abnormal, Crying, Cyanosis Neonatal, Cyclothymic Disorder, Dacryostenosis Congenital, Deafness Congenital, Death, Death Neonatal, Decreased Appetite, Delirium, Delusion, Delusional Disorder (Unspecified Type), Dementia, Depressed Level of Consciousness, Depressed Mood, Depression, Depression Suicidal, Diabetes Mellitus, Diabetes Mellitus Inadequate Control, Diabetes Mellitus Insulin-Dependent, Diabetes Mellitus Non-Insulin-Dependent, Diarrhoea, Diarrhoea Neonatal, Difficulty In Walking, Diplopia, Disorientation, Disturbance In Attention, Dizziness, Drug Dependence, Drug Exposure Before Pregnancy, Drug Exposure During Pregnancy, Drug Exposure Via Breast Milk, Drug Ineffective, Drug Toxicity, Drug Withdrawal Syndrome, Drug Withdrawal Syndrome Neonatal, Dry Mouth, Dysarthria, Dysgeusia, Dyskinesia, Dyskinesia Neonatal, Dyspepsia, Dysphagia, Dyspnoea, Dysstasia, Dysthymic Disorder, Dystonia, Dysuria, Eating Disorder, Emotional Disorder, Emotional Distress, Encephalopathy, Encephalopathy Neonatal, Epilepsy, Epilepsy Congenital, Erythema, Extrapyramidal Disorder, Fatigue, Fear, Feeding Disorder Neonatal, Feeling Abnormal, Feeling Jittery, Fever Neonatal, Foetal Anticonvulsant Syndrome, Foetal Arrhythmia, Foetal Cardiac Disorder, Foetal Disorder, Foetal Distress Syndrome, Foetal Growth Retardation, Foetal Heart Rate Abnormal, Foetal Heart Rate Deceleration, Foetal Heart Rate Decreased, Foetal Heart Rate Disorder, Foetal Heart Rate Increased, Foetal Malformation, Foetal Movements Decreased, Foetal Valproate Syndrome, Formication, Gait Disturbance, Gastrointestinal Disorder Congenital, General Physical Health Deterioration, Genu Varum Congenital, Grand Mal Convulsion, Haemangioma Congenital, Haemorrhage, Hallucination, Hallucination (Auditory), Hallucination (Olfactory), Hallucination (Tactile), Hallucination (Visual), Hallucinations (Mixed), Headache, Heart Disease Congenital, Heart Rate Increased, Hepatic Failure, Hepatitis, Hepatitis Neonatal, Hepatosplenomegaly Neonatal, Hernia Congenital, Homicidal Ideation, Homicide, Hostility, Hyperbilirubinaemia Neonatal, Hyperglycaemia, Hyperhidrosis, Hypersensitivity, Hypersomnia, Hypertension, Hypertension Neonatal, Hypertonia, Hypertonia Neonatal, Hypoaesthesia, Hypoglycaemia, Hypoglycaemia Neonatal, Hypokinesia Neonatal, Hypomania, Hyponatraemia, Hypotension, Hypothermia Neonatal, Hypotonia, Hypotonia Neonatal, Hypoventilation Neonatal, Impulsive Behaviour, Incoherent, Incontinence, Insomnia, Intentional Self-Injury, Intraventricular Haemorrhage Neonatal, Irritability, Jaundice Neonatal, Lens Abnormality, Lethargy, Leukopenia Neonatal, Limb Hypoplasia Congenital, Long QT Syndrome Congenital, Loss of Consciousness, Major Depression, Malaise, Mania, Maternal Condition Affecting Foetus, Maternal Distress During Labour, Maternal Drugs Affecting Foetus, Maternal Use of Illicit Drugs, Memory Impairment, Meningitis Neonatal, Mental Disorder, Mental Impairment, Metabolic Disorder, Migraine, Mood Altered, Mood Swings, Movement Disorder, Multiple Congenital Abnormalities, Multiple Sclerosis, Murder, Muscle Rigidity, Muscle Spasms, Muscle Twitching, Muscular Weakness, Musculoskeletal Stiffness, Myalgia, Myocardial Infarction, Myocardial Ischaemia, Myoclonic Epilepsy, Myoclonus, Nausea, Neck Pain, Necrotising Enterocolitis Neonatal, Neonatal Anoxia, Neonatal Apnoeic Attack, Neonatal Asphyxia, Neonatal Aspiration, Neonatal Candida Infection, Neonatal Cardiac Failure, Neonatal Cholestasis, Neonatal Complications of Substance Abuse, Neonatal Diabetes Mellitus, Neonatal Disorder, Neonatal Hepatomegaly, Neonatal Hyponatraemia, Neonatal Hypotension, Neonatal Hypoxia, Neonatal Infection, Neonatal Intestinal Obstruction, Neonatal Neuroblastoma, Neonatal Oversedation, Neonatal Pneumonia, Neonatal Respiratory Acidosis, Neonatal Respiratory Arrest, Neonatal Respiratory Depression, Neonatal Respiratory Distress Syndrome, Neonatal Respiratory Failure, Neonatal Tachycardia, Neonatal Tachypnoea, Nervous System Disorder, Nervousness, Neuroleptic Malignant Syndrome, Neutropenia, Neutropenia Neonatal, Night Sweats, Nightmare, Obesity, Obsessive-Compulsive Disorder, Oculogyration, Oedema Neonatal, Pain, Pain In Extremity, Palpitations, Pancreatitis, Panic Attack, Paraesthesia, Paranoia, Parkinsonian Gait, Parkinsonian Rest Tremor, Parkinsonism, Parkinson's Disease, Peripheral Oedema Neonatal, Personality Change, Petit Mal Epilepsy, Pilonidal Cyst Congenital, Pneumonia, Poisoning, Poor Weight Gain Neonatal, Pruritus, Psychomotor Hyperactivity, Psychotic Disorder, Pulmonary Artery Stenosis Congenital, Pulmonary Oedema Neonatal, Pulmonary Valve Stenosis Congenital, Pyrexia, Rash, Rash Neonatal, Renal Failure, Renal Failure Acute, Renal Failure Neonatal, Respiratory Arrest, Respiratory Disorder Neonatal, Respiratory Failure, Respiratory Tract Haemorrhage Neonatal, Restless Legs Syndrome, Restlessness, Retching, Retinal Anomaly Congenital, Schizophrenia, Screaming, Sedation, Self Esteem Decreased, Self Injurious Behaviour, Self Mutilation, Self-Injurious Ideation, Sensory Disturbance, Sepsis Neonatal, Serotonin Syndrome, Shock, Sleep Disorder, Social Avoidant Behaviour, Somnolence, Somnolence Neonatal, Speech Disorder, Stereotypic Movement Disorder, Stereotypy, Stevens-Johnson Syndrome, Stillbirth, Stomach Discomfort, Strabismus Congenital, Subarachnoid Haemorrhage Neonatal, Subdural Haemorrhage Neonatal, Sudden Death, Suicidal Ideation, Suicide Attempt, Syncope, Tachycardia, Tachycardia Foetal, Tardive Dyskinesia, Thinking Abnormal, Thrombocytopenia Neonatal, Tic, Tinnitus, Torticollis, Tourette's Disorder, Tremor, Tremor Neonatal, Trichotillomania, Urinary Tract Infection Neonatal, Urticaria, Vertigo, Vision Abnormal Neonatal, Vision Blurred, Visual Acuity Reduced, Visual Disturbance, Vomiting, Vomiting Neonatal, Weight Decrease Neonatal, Weight Decreased, Weight Increased

slide101
We’re not prescribing water.You have to expect action, interaction, reaction.We’re doctors.We practice.
slide102
The important thing is to do the best we can with what we have, and then forgive ourselves for the rest.
slide104

¹ MedWatch is the Food and Drug Administration's program for reporting any undesirable experience associated with the use of a medical product. These tables tally the listed adverse reactions by drug class, culled from the Individual Safety Reports submitted to the FDA's Adverse Event Reporting System (MedWatch) between 2004 and 2008 where a psychiatric drug was cited as the Primary Suspect Drug, deemed by the reporter to have been responsible for causing or inducing the listed adverse reaction in the patient.

what are you supposed to be able to do at the end of this talk
What are you supposed to be able to do at the end of this talk?
  • List psych meds and interactions with meds commonly seen in Primary Care.
common antidepressant medications
Prozac (fluoxetine)

Celexa (Citalopram)

Zoloft (Sertraline)

Paxil (Paroxetine)

Luvox (Fluvoxamine)

Lexapro (Escitalopram)

Effexor (venlafaxine)

Pristic (desvenlafaxine)

Cymbalta (Duloxetine)

Wellbutrin (Bupropion)

(Aplenzin is just Wellbutrin XL; 522 mg AM = 300 AM + 150 PM)

Remeron (Mirtazapine)

Common Antidepressant Medications
mood stabilizers
Lithium Carbonate

Depakote (Valproic Acid)

Tegretol (carbamazapine)

Trileptal (oxcarbazapine)

Lamictal (lamotrigine)

Neurontin (gabapentin)

Topamax (topiramate)

Neuroleptics & Benzodiazepines

Mood Stabilizers
atypical neuroleptics
Atypical Neuroleptics
  • 1989 Clozaril (clozapine)
  • 1993 Risperdal (risperidone)
  • 1996 Zyprexa (olanzapine)
  • 1997 Seroquel (quetiapine)
  • 2001 Geodon (ziprasidone)
  • 2002 Abilify (aripiprazole)
  • 2007 Invega (paliperidone)
antidepressants three neurotransmitters serotonin norepinephrine dopamine
AntidepressantsThree neurotransmitters:SerotoninNorepinephrineDopamine
slide114

SSRIs Selective Serotonin Reuptake Inhibitors Prozac (fluoxetine)Zoloft (sertraline)Paxil (paroxetine)Celexa (citalopram)Lexapro (escitalopram)Luvox (fluvoxamine)

slide116

TCAsTricyclic AntidepressantsAlthough some TCAs (e.g., desipramine, maprotilene) block norepinephrine reuptake more potently than serotonin reuptake, the TCAs are not selective since they block many other receptors such as alpha 1, histamine 1, and muscarinic cholinergic receptors.

slide118

NDRINorepinephrine Dopamine Reuptake InhibitorWellbutrin (bupropion)(the higher the dose the greater the dopamine to norepinephrine ratio)

how s it work
How’s it work?

Insert dry erase board demonstration here.

pick a med by its side effect
Pick a med by its side effect
  • If the pt’s lethargic, boost his/her energy.
  • If the pt’s agitated/hyper, calm him/her down.
  • If the pt’s fat, aim for skinny.
  • If the pt’s skinny, aim for fat.
  • If the pt’s oversexed, decrease libido.
  • If the pt has no libido, boost it up.
pick a med by its side effect how much energy does the pt have need
Pick a med by its side effectHow much energy does the pt have/need?

Morning

Bedtime

More Energy Neutral

Lexapro

Sedating

Remeron

Celexa

Energizing

Prozac

Zoloft

Effexor

Cymbalta

Luvox is sedating,

But it’s a BID med.

So start at HS and titrate to lower dose AM compared to PM

pick a med by its side effect how much hunger does the pt have need
Pick a med by its side effectHow much hunger does the pt have/need?

Morning

Bedtime

Appetite (therefore weight ) Neutral

Lexapro

Zoloft

Celexa

Effexor

Cymbalta

Fat Builders

Remeron (from 7.5 go 30 mg but not at 45 mg)

Appetite suppression

Prozac

Wellbutrin

Luvox is a fat builder.

But it’s a BID med.

So start at HS and titrate to lower dose AM compared to PM

pick a med by its side effect oversexed or undersexed
Pick a med by its side effectOversexed or undersexed?

Morning

Bedtime

Appetite (therefore weight ) Neutral

Lexapro = 15-30 % reduction

Zoloft = 40-60 % reduction

Luvox = 25-40 % reduction

Celexa = 1-5 % reduction

Effexor = neutral

Cymbalta = neutral

Remeron

Is used to treat sexual side effects from other AD

Prozac = 10-25 % reduction.

Wellbutrin = 30 % boost

Buspar

Is used to tx sexual side effects from SSRIs

the antidepressant pearls 1
The antidepressant pearls #1

Start with an SSRI

Newer and more expensive isn’t better

All the meds take 30 to 45 days to take effect

Try two solid SSRIs trials before going to an SNRI

Antidepressants tend to cause akathisia in the first month, so maybe a low dose benzo for 2 to 4 wks to get the SSRI on board.

the antidepressant pearls 2
The antidepressant pearls #2
  • Get them to below a two on 1-10 scale
  • Keep them there for a year
  • Meds only continue to work if you teach new skills
  • Use side effects to your advantage
  • Faking it is good (or “fake it till you make it”)
  • Push the five senses
  • Intent is 95 percent the success
psych med lists check
Psych med lists? Check.

Now the interactions with meds commonly seen in primary care.

start with the liver http www thehealthylonglifeblog com wp content uploads 2008 09 liver detox jpg
Start with the liver.http://www.thehealthylonglifeblog.com/wp-content/uploads/2008/09/liver-detox.jpg
cytochrome p450 for dummies
Cytochrome P450 for Dummies:

Let’s first anthropomorphize the Liver

let s pretend your liver is the us customs service
Let’s pretend your liver is the US Customs Service

Specifically, an agent named

Mr. Cyto Chrome, Badge #P-450:

now there are travelers who want to come to the united states
Now there are travelers who want to come to the United States

We’ll call these travelers “Substrates”

Maybe you sent them. Maybe I sent them. Maybe neurology sent them.

But they want in.

First they have to talk to Cyto the Liver

now cyto just does his job
Now Cyto just does his job.

So a Substrate comes up and says:

“Hey, can I come in to your great country?”

And Cyto the Liver is a nice guy. So he always says “Yes.”

But sometimes he says

“Yes, with limited access.”

And other times he says “Yes, and here’s a free million taxpayer dollars! Have a ball!”

slide133
But there are these secret agents with higher paying jobs, and they try to influence Cyto as to which yes he picks.
so what makes cyto the liver weak or strong
So what makes Cyto the Liver weak or strong?

Restrictor secret agents weaken (inhibit) Cyto, and the travelers (substrate) pass with diplomatic immunity (and a million of your hard earned tax dollars).

Booster secret agents strengthen (induce) Cyto, and he limits the traveler’s (substrate) access.

some cytochrome p450 substrates travelers
Warfarin

Valium

Propranolol

Theophylline

Caffeine

Zyprexa

Haldol

Clozaril

TCAs

Cymbalta

Opiates (Methadone, codeine)

Birth Control Pills

Benzos

Tegretol

Trazodone

Protease Inhibitors

Provigil

Depakote

Some Cytochrome P450Substrates (travelers)
cytochrome p450
Inhibitors (Restrictor)

Erythromycin

Grapefruit

Reglan

Ketoconazole

Luvox

Serzone

Paxil (Strongest)

Prozac (Strong)

Celexa/Zoloft (weak)

ASA

Inducers (Booster)

Phenobarbital

Phenytoin

Rifampin

St. John’s Wort

Tegretol

Smoking

Charbroiled foods

Cruciferous veggies

Cytochrome P450
slide141

Inhibitors (Paxil, Prozac, Luvox, Celexa, Wellbutrin) weaken Cyto the Liver (Cytochrome P450) and Substrates (Theophylline, Warfarin, propranolol, benzos, Depakote, Methadone, Thorazine) INCREASE in plasma concentrations.Zoloft is the weakest of the inhibitors.

slide142

Inducers (Smoking, charbroiled foods, Tegretol, Phenobarb, Phenytoin, Rifampin, Nevirapine, St. John’s Wort) strengthen Cyto the Liver (Cytochrome P450) and Substrates (Theophylline, Warfarin, propranolol, benzos, Depakote, Methadone, Thorazine) DECREASE in plasma concentrations.

so what
So what?

More Methadone in the blood = toxicity.

Less Methadone in the blood = pain.

Depakote + Prozac = higher VPA level.

Depakote + Klonopin = greater sedation.

Depakote + Tegretol = lower VPA level and higher Tegretol level.

Depakote + Lamictal = lower VPA and higher Lamictal (more Steven’s Johnson Syndrome)

Depakote + ASA = higher VPA level

Indomethacin + Lithium = increased Lithium levels

Lithium + NSAIDS = less Lithium clearance (and greater concentration)

Tegretol + BCP = pregnancy

Tegretol + anticoagulants = clots

Tegretol + Haldol = psychosis (or delirium or Tourette's)

Tegretol + Lamictal = increased Tegretol and decreased Lamictal

Tegretol + Tegretol = an autoinducer (decreases its own concentration)

Trazodone + Ritonivir = increased risk of seizure

Smoking + Clozaril (or Zyprexa or Haldol) = increased risk of psychosis

If a Clozaril pt stops smoking, increased levels of Clozaril (risk of sz, agranulocytosis)

SSRIs + Clozaril = increased Clozaril level (and risk of agranulocytosis and szs)

Thorazine + any inhibitor = increased QTc Prolongation

Luvox + caffeine = caffeine intoxication (flushed, palpitations, nervousness, GI upset)

slide144

So,a restrictor inhibits Mr. Cyto Chrome’s action, and the traveler gets through unrestricted, but a booster makes Mr. Cyto Chrome stronger, so the traveler is restricted.Inhibit to set free.Induce to restrict.

mood interview pearls 1 6 11
Mood Interview Pearls 1- 6.1

1. Origin—When did it begin?

2. Duration—How long does it last?

3. Severity—How much does it limit you?

4. Genetics—Who gave it to you?

5. I can name that mood disorder in 5 lines.

6. How do YOU feel?

6.1. Trust your feelings. To be effective, you have to be affected.

the antidepressant pearls 11
The antidepressant pearls #1

Start with an SSRI

Newer and more expensive isn’t better

All the meds take 30 to 45 days to take effect

Try two solid SSRIs trials before going to an SNRI

Antidepressants tend to cause akathisia in the first month, so maybe a low dose benzo for 2 to 4 wks to get the SSRI on board.

the antidepressant pearls 21
The antidepressant pearls #2

Get them to below a two on 1-10 scale

Keep them there for a year

Meds only continue to work if you teach new skills

Use side effects to your advantage

Faking it is good (or “fake it till you make it”)

Push the five senses

Intent is 95 percent the success

slide149

Beta blockers cause depression. Atenolol is hydrophilic. Propranolol and Metoprolol are lypophilic. Statin drugs cause agitation, insomnia, anxiety, and mood swings—except prevastatin which doesn’t cross the BBB.Triptan drugs cause Serotonin Syndrome when used with SSRIs. (typically myoclonus & fever, but can be life threatening).

Benzos and opiates cause depression, confusion, problems with short-term memory and with concentration/attention, and rebound insomnia.Topamax = Dopamax = StupimaxKeppra makes people crazy (agitated, hostile, anxious, apathetic, depressed, and emotionally labile.

Depakote # 1 pt complaint? Hair falls out. Give zinc & selenium.Antiepileptic meds also have FDA black box warning 0.5 % risk of suicide (higher on multiple antiepileptic drugs).

Paxil deforms babies before you know you’re pregnant—don’t give it to women of childbearing years.

slide150

Mr. Cyto Chrome, Badge #P-450

Inhibit to set the substrate free.Induce to restrict the substrate.

slide151
I have woven a parachute out of

everything broken.

William Stafford

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thought for the day
Thought for the day
  • Work like you don’t need the money.
  • Dance like no one is watching.
  • Love like you’ve never been hurt.

Satchel Paige