Psychopharmacology: 2019 Medication Management Trends Social Workers Should Know

1. Psychopharmacology: 2019 Medication Management Trends Social Workers Should Know Joe Wegmann, PD, LCSW Joe@ThePharmaTherapist.com 504.587.9798 www.pharmatherapist.com Are you receiving our free monthly e-newsletter?

2. On Tap… • Review the mental disorders for which psychotropic medications are frequently prescribed • Discuss the major psychotropic medication classes, their clinical indications and the latest trends regarding their use • Examine the benefits, risks and side effects of contemporary psychotropics

3. My Approach For All Clients I Treat Help them develop pragmatic skills • Understand how to solve problems and the importance of cause • The process of motivation Help them overcome an imposter mentality • Everyone I see has some sort of a self-esteem or image problem which is at the core of why they came to see me – but they don’t realize it and don’t know what it is • There’s a difference between efficacy and self-worth Help them develop a sense of personal autonomy • Need for approval • Unsolicited feedback Improving in these areas can help clients better overcome unnecessary mood, anxiety and concentration problems that plague them and have them turning to medications for relief I can help clients better deal with emotional and psychological pain, but if someone is determined to suffer, I can’t do much about that

4. Unipolar Depression

5. Etiology • Depression is very confusing and there is no general consensus as to what’s going on or even what’s wrong with the brain • Where, in the brain, would we biopsy a depressed person? What specific area? Nobody knows • It’s cyclical – short-term duration for some, extended for others • Depression is likely a number of different illnesses – in the future, different nomenclature for different types of depression • The more intimate the relationship with the depression, and the greater the gains, the more difficult it will be to give up • Assess motivation to get better and… • Consider context – don’t depend on checklists, just let the client tell their story • For treatment purposes, focus more on potential causes

6. Possible Causes • Inflammatory • Reactive • Biological • Medical • Medication induced • Hormonal • Substance abuse • Chronic pain • Low self-esteem; poor self-image

7. Classes of Antidepressants • First came the Opiates • Cyclics: Elavil; Pamelor; Anafranil; Desyrel (trazodone) • SSRIs: Prozac Family • SNRIs: Effexor; Cymbalta; Pristiq; Fetzima • Atypicals: Wellbutrin; Remeron • Work primarily through “reuptake inhibition” or do they? • Approved: MDD; OCD; GAD; PTSD; SAD; Chronic Pain (Cymbalta) • None of the above are magic bullets and yet are routinely perceived as an easy way to feel better

8. Antidepressant Selection – Particularly For The First-Timer • How the depression presents. Accompanying anxiety and insomnia (high distress factor); Melancholia, hypersomnia, vegetative (low drive factor) • Prior history. Use biomarkers to the client’s advantage • Co-occurring disorders. SSRIs are effective for almost the entire anxiety spectrum. Effexor for pain; Wellbutrin for ADHD • Side effects. Most side effects are transient and will abate quickly. Two exceptions: weight gain and sexual problems. • Duration. Guideline for an initial trial: 4-6 weeks; some users may respond in 8-10 weeks • Dosing. Begin with 1/2 of the minimum recommended effective dose (e.g. Prozac 10mg) then if tolerated, increase to 20mg after a week - then another bump in 3 weeks, if warranted

9. Hottest New Players

10. Ketamine Infusion Therapy • Ketamine is classified as a preoperative general anesthetic for both human and animal use • No serotonin, norepinephrine or dopamine effects but instead is an NMDA receptor antagonist, similar to dextromethorphan and methadone • If you remember the days of the “rave” phenomenon, ketamine was a popular psychedelic going by the moniker “special K” • Touted as possessing rather fast-acting antidepressant properties, with many clinicians, predominately psychiatrists, offering ketamine infusion therapy as a alternative for treatment-resistant depression, particularly for those with suicidal tendencies • Because ketamine is not FDA approved for depression and is therefore considered an off-label procedure, free market forces enter the picture. Upfront fees can run up to $500 per infusion. • Side effects: Possible acute hypertensive crisis; free-floating, hallucinatory sensations • So is it possible that dissociation is either a predictor or even possibly responsible for its antidepressant effect? What then? Will the goal be to induce a psychedelic experience to maximize ketamine’s benefits?

11. Spravato (esketamine) • On March 5, 2019, the FDA approved Spravato (esketamine) nasal spray as additive treatment with antidepressants for treatment-resistant depression • Overall response rates after a month of treatment were much higher for esketamine plus an antidepressant, when compared to placebo plus an antidepressant. Also in a long-term maintenance trial, the midpoint time to relapse in stable responders to the esketamine-antidepressant combination was a whopping 635 days • Providers of this agent must sign up with the REMS (Risk Evaluation and Mitigation Strategy) system, and the Drug Enforcement Administration (DEA) performs an inspection of a provider’s office. A provider is mandated to supervise a patient while the intranasal dose is self-administered, and the supervision must be ongoing for at least 2 hours afterward to monitor for side effects • Esketamine is the first, really new and original antidepressant to reach the U.S. market in over 30 years • $600 for each 56mg dose and nearly $900 for each 84mg dose • Side effects: Bitter aftertaste; elevated BP; dissociation • There is an URGENT need for something new for those suffering from depression – particularly treatment-resistant depression • What’s next? How about opioids for depression?

12. Side Effects SSRIs and SNRIs • Increased anxiety or an “activated” feeling • Sedation • Insomnia • Sexual Dysfunction • Weight gain (Avg: 4 pounds over six months) Wellbutrin • Prominent for anxiety and insomnia • Little, if any weight gain • No sexual side effects Remeron • Weight gain can be a monster

13. Issues And Controversies • Serotonin levels are elevated rapidly by these drugs in days…not weeks – the reuptake inhibition theory for improving depressive symptoms is all but dead • Alternative explanation for how antidepressants work: “Antidepressants stimulate your nerve cells to grow and branch out, sort of like what fertilizer does for your lawn” • Neuroprotective benefits • Up to 60 percent of antidepressant users don’t achieve symptom remission, benefiting only partially • Conclusion: Antidepressants on average have modest/small efficacy, although they do outperform placebo • “Pick one from the list” approach – little thought given to how each patient’s many variables are often not addressed prior to selection

14. Bipolar Disorder

15. Overview • Runaway norepinephrine and neurons gone wild • Bipolar depressive symptoms far more prevalent than manic symptoms • Except for lithium, most treatments for bipolar symptoms were not developed as “anti-polar” therapies (anticonvulsants; atypical antipsychotics) • Major limitation to novel drug discovery: No consensus on neuropathology

16. Bipolar Mania • There is increased emphasis on energy and activity in diagnosing mania, not simply mood • Mania is characterized by: • Distractibility • Insomnia • Grandiosity • Flight of ideas • Appetite for risk • Speech (pressured) • Thoughtlessness (risk-taking)

17. Bipolar Depression: Does It Differ From Unipolar Depression? • Yes, but only a little • Bipolar depressive episodes occur earlier in life and more frequently • Involves more psychomotor slowing • Both unipolar and bipolar depression appear essentially the same on functional brain imaging • When seeing a depressed patient for the first time, obtain personal AND family history of potential mania; a positive family history of mania is suggestive of bipolarity

18. Mood Stabilizers • Lithium • Anticonvulsants: Depakote, Equetro • Most second generation antipsychotics are FDA approved for mania • Seroquel, Seroquel XR, Symbyax and Latuda are FDA-approved for bipolar depression • Traditional antidepressants offer very little for bipolar depression

19. Recommended Lithium Monitoring Initiation of treatment Every 3 to 7 days for first several weeks Routine Every 1 to 3 months in stable patient Lithium • Fight/Flight Deactivator • Onset of action 5-14 days, it’s slow • Full stabilization up to 3 months • Requires blood level monitoring • There in NO evidence that lithium raises suicide risk; there is strong evidence that it lowers it

20. Side Effects of Lithium

21. Depakote • First-line agent for mania, not as effective as lithium • Agent of choice for “rapid cyclers” • Lithium ineffective for rapid cycling • Treats rage reactions and extreme mood instability • Side effects: Fatigue, nausea, weight gain, teratogenic birth defects, PCOS

22. Lamictal • Primarily for bipolar depression • Works best at reducing the risk of future bipolar depressive episodes – in other words, maintenance treatment for bipolar depression • No weight gain; no blood work • Stevens-Johnson syndrome

23. Case Example Sally called me regarding her 25-year-old son. Michael (the son), had been prescribed the following: Celexa, Lexapro, Effexor, Pristiq, Cymbalta, and recently, Trintellix. When Michael failed to respond to any one of these antidepressants, it was discontinued and another was prescribed. These were prescribed by a general practice physician over the last couple of years. She stated that Michael showed sparks of improvement vis-à-vis these medications — which eventually slowed and has now ceased. He has quit graduate school and exhibits depression. Her question for me: “Joe, what would you suggest as a next step, really, how should I proceed?”

24. Anxiety

25. Generalized Anxiety • Chronic low-level anxiety • Resolved worries are quickly replaced with new ones, consuming excessive amounts of time • These are people who: worry all the time; worry about what they worry about; worry if they’re not worrying • We’re all often very competent at handling real, identifiable problems…because • An unambiguous problem invites an unambiguous solution, so… • A clear plan of action settles the anxious mind • Worriers have trouble distinguishing what is a problem from what might be a problem • Medication will numb symptoms only

26. Obsessive-Compulsive Disorder • We all have eccentricities, oddities, habits • OCD is quite the con artist • A disorder of excessive carefulness accompanied by an exaggeration of possible danger • Persistent thoughts and compulsions accompanied by shame and guilt • Often incapacitating • Having treated it for years, it’s amazing how many different manifestations present to my office • OCD is no longer DSM-classified as an anxiety disorder • Medication management?

27. Antianxiety Agents

28. Benzodiazepines: After 60 Years, Are They Still Viable? • Benzos are still widely used, but sparsely studied, primarily as a result of their age • Benzos are very addictive right? This is a common concern among patients, therapists and prescribers alike • The vast majority of those abusing benzos are also abusing other substances like opioids at the same time, as a way to enhance the opioid “high” • The number of people actually abusing benzos alone is rather small • All benzos enhance the actions of the neurotransmitter GABA – which has direct anti-anxiety effects • Quick rule of thumb: The faster they work, the quicker they wear off; the slower they work, the longer they last

29. Benzos For Specific Anxiety Disorders Panic Disorder: The best choices here are Xanax or clonazepam wafers because of rapid onset. I’ve found that for many people, just knowing they have these agents on hand and readily available on a moment’s notice, can go a long way to minimize attacks Social Anxiety Disorder: For someone with SAD, taking a benzo 30-60 minutes before an anxiety-triggering event can be beneficial. (Delivering a talk; relaxing on a date; making new acquaintances) Insomnia: Not an anxiety disorder, but in some instances where the insomnia is related to an acute, time-limited stressor (tight work deadline; coping with a sudden loss) benzos are the best choice. • Valium is often ideal because of its rapid onset and long-acting effects

30. Side Effects of theBenzodiazepines • Side effects are generally minimal • Little, next-day lethargy or grogginess • Enhanced disinhibition with alcohol or opioids for sure

31. The Psychotic Spectrum:Schizophrenia

32. Second Generation Agents • Reduced risk of tardive dyskinesia; overall better tolerability • Clozaril is the prototypical agent • Risperdal • Zyprexa • Seroquel • Vraylar • Fanapt • Geodon • Abilify • Rexulti • Invega • Saphris • Latuda

33. Clozaril (clozapine) • Not a first-line treatment of choice • FDA approval for treatment of recurrent suicidal behavior in schizophrenics • Can cause neutropenia (increased risk of opportunistic infection) • ANC count monitoring necessary weekly for 6 months, every 2 weeks for 6 months, then monthly • Significant weight gain and sedating • Linked to increased risk of Type II diabetes • Potential for increasing triglycerides and cholesterol • Constipation

34. ADHD • ADHD is definitively…a neurodevelopmental disorder with onset in mid-childhood through early adolescence…period • Those with ADHD have racecar brains with bicycle brakes • CDC: Nearly 20 % of high school age boys in the U.S. and 11% of school-age children have received a diagnosis of ADHD; 53% rise in diagnosis in those 4-17 this past decade alone • Some diagnosticians are hastily viewing any complaints of inattention as ADHD – so the diagnosis is poorly established • Parents pressure doctors for pills, instead of challenging and questioning this diagnosis • Once started on pills as a child, the now high school student or college student “can’t be without them” • Huge secondary market for stimulants • 30 percent of college students take “diverted” stimulants

35. Adult ADHD • If you have a never-before-diagnosed adult claiming ADHD, probably 95 percent of them have something else • People may be feigning symptoms in order to obtain a prescription, but many others are going online searching for a confirmation of ADHD • Symptoms must be present before age 12; there is no such thing as new-onset ADHD beyond this age, so the individual either wasn’t diagnosed or was diagnosed and decided to fight their way through symptoms • Adults who really have it report significant impairment – difficulty driving, job firings, lost relationships, poor credit rating upon questioning • If someone has gone say 30-40 years with ADHD, there’s going to be a paper trail of impairment, right?

36. Doing It Right • Before doing an adult ADHD assessment, keep in mind that most symptoms are nonspecific and can be present in many other psychiatric disorders – or even present in people without any disorder at all • Note: Positive answers to questions asked can’t confirm the diagnosis, but they can provide clues that may prompt a suspicion of ADHD • When an adult patient comes to my office with ADHD-like complaints, the 1st thing I do is assess their motivation

37. Medication

38. How Stimulant Medications Work; Types Of Stimulants • The most widely prescribed class of medications for ADHD symptoms is the Psychostimulants • Psychostimulants activate the chemicals dopamine and norepinephrine in the frontal and “wake up” the brain • Norepinephrine improves attention and focus; dopamine improves and lengthens attention span, lessens distractibility and helps decrease impulsivity and excessive movement • Two types of stimulants are routinely prescribed in the U.S. • The Ritalin (methlyphenidate) products (MPH) • The Dexedrine (amphetamine) products (AMP) • The delivery systems: Pills; Pump; Pellets; Patch; Pro-drug

39. The 5 Ps (Psychostimulants) The Pills: Ritalin; Focalin; Adderall The Pump: Concerta The Pellets: Ritalin LA; Focalin XR; Adderall XR The Patch: Daytrana The Pro-Drug Vyvanse

40. The Newest Mydayis (amphetamine) • Most of new long-acting versions of Adderall offer little advantages over the original Adderall XR – outside of an easier-to-swallow delivery • Mydayis is an exception • 16-hour duration offering a unique advantage for patients whose day is longer than the 12 hours of coverage provided by other extended-release formulations Aptensio XR (methylphenidate) • Onset is 2-3 times faster than Concerta with a similar duration Jornay PM ( methylphenidate) • To be taken at night, starts working upon awakening 8-10 hours later Aptensio XR and Jornay PM were developed to ease the early morning process when kids are getting ready for schoolas they are quick to act

41. Psychostimulant Side Effects • Appetite suppression in the beginning, but not persistent • Insomnia can occur, but usually not a significant issue (sleep improves due to less bedtime rumination) or because of decreased blood levels of the drug • Irritability, particularly with amphetamines • Dry mouth

42. The Highest Aim For Psychotropics Is… To improve functioning – not feelings.

43. Resources Adapted from : Wegmann, J. (2015). Psychopharmacology: Straight Talk on Mental Health Medications. 3rd Edition. Eau Claire, WI: Premier Publishing & Media

44. Thanks for Attending! Joe Wegmann, PD, LCSW