Transcript Serotonin

Getting the Most of
Antidepressants
RVU
05-03-2014
Larry O. Sanders, MD
Diplomate of the American Board of Psychiatry and Neurology
Goals
Screening the Primary Care population for
Mental Disease.
First Line and Second Line Treatment of MDD.
Evidence that more than Major Depression is
Involved.
When to Refer to Mental Health.
In US, Major Depression is a
Common Medical Illness
Why Treat Depression?
Disability
Morbidity- Depression makes existing somatic
conditions worse. (Inflammatory Factors)
Mortality- Psychiatric patients die up to 20
years earlier than average. Most Common
reason is Cardiovascular Disease!
Second is Suicide.
Inflammatory Factors, 1
Major Depression Increases
Inflammatory Factors,
Worsening the Prognosis of
Somatic Illness
Inflammatory Factors, 2
Somatic Illnesses
Increase
Inflammatory Factors,
Worsening the Prognosis of
Major Depression
Depression and Atherosclerotic Disease.
• Major Depression carries 4X Risk of developing a
Myocardial Infarction! Anda 1993, Barefot, et. Al. 1996, Pratt 1996
• MIs comorbid with MDD are 5X More likely to be
Fatal. Anda 1993
• 16.5% Mortality Risk @ 6 months following Acute
MI if also Depression vs 3% if not Depressed.
Frasure-Smith 1993
• Major Depression carries same Risk Factor for
developing an MI, as Cigarette Smoking!
Major Depression
5 Symptoms, 2 Weeks, >50% each day
(pneumonic “Sige Caps”)
Mood*
Sleep
Interest*
Guilt or Hopelessness
Energy
Concentration
Appetite
Psychomotor
Suicidal/Homocidal Ideation
* Depressed
Mood or
Anhedonia
must be
present
Nature vs Nurture
• MDD is strongly genetic, with well over 100
genes involved.
• However, the largest risk for developing
MDD as an adult is losing a parent before
age 12.
• Many Environmental, Psychological and
Sociological factors can effect it.
10
Medical Disease can appear as
Major Depressive Disorder
• Many Medical Diseases can appear as
MDD. R/O:
–Hypothyroidism
–Anemia, both Microcytic and Macrocytic
–Any inflammatory Disease
–Hyperparathyroidism (even slightly elevated Ca++
may be important)
–Various Vitamin deficiencies, including: D, B12,
B6, Folate, etc.
• Vitamin D deficiency seems more common since the
11
use of high SPF Sunscreens.
Other (Free) Scales
• PHQ 2 Screener
•
( Very brief. I don’t encourage its’ use).
• Zung Depression Rating Scale
• QIDS-SR
•
Quick Inventory Depressive
Symptomatology (Self Report)
• CUDOS
•
Clinically Useful Depression Outcome Scale
Treat to Remission!
Sub-Syndromal Depression = Relapse
One or more
Symptoms
7 months until
Relapse!
No Symptoms
Months Well
Judd
1998
Symptoms and Circuits
Advocated by
Stephen M. Stahl, MD
Circuit
When a Brain Circuit,
when overstimulated or
under-stimulated, it will
produce certain
symptoms.
(adapted from Steven Stahl, MD)
Each Symptom,
regardless of
the disease,
comes from the Same
Circuit Malfunction!
(adapted from Steven Stahl, MD)
Symptoms & Circuits
By Knowing Which Symptom is related
to which Circuit,
and by Knowing How Each Medication
Effects Each Circuit
You can Logically Deduce Which
Medication Will Best Treat Most Mental
Conditions.
(adapted from Steven Stahl, MD)
3 Major Circuits
Contributing to
Mental Illness
Circuits
Serotonin
Circuits
Serotonin
Norepinephrine
Circuits
Serotonin
Norepinephrine
Dopamine
Symptoms
Associated with these
Circuits
Symptoms associated
with Serotonin
• Serotonin helps us “Cope”.
• If Serotonin is too Low: Irritable, Anxious,
Easily Overwhelmed, Hopeless, Suicidal,
“poor sense of Well-being”
• If Serotonin is too High:
Serotonin
Syndrome; Agitation, Fasciulations,
Hyperthermia, Vital Sign Disturbance, leading
to stupor, come then death. [Although
pharmacists warn of this, neither I nor any
Psychiatric Colleagues have ever seen this
Symptoms associated
with Norepinephrine
• Norepinephrine is like “Adrenaline”.
• If Norepinephrine too Low: Anergy,
Immediate Memory Impaired,
Psychomotor Retardation.
• If Norepinephrine too High:
Irritable,
Agitation, Insomnia. (Similar Symptoms
to Low Serotonin).
Symptoms associated
with Dopamine
• Dopamine provides Interests/Desire,
mentally. (Dopamine has other physical
functions as well).
• If Dopamine too Low: Apathy,
Dementia, Muscle
• If Dopamine too High: Hedonism,
Psychosis, Mania
Symptoms & Circuits
Serotonin
Mood*
Emotion
Cognitive Function
Norepinephrine
Dopamine
Symptoms & Circuits
Serotonin
Suicidal/Homicidal
Frustration, “Sense of Well Being”
Obsession, Sleep, Guilt or Hopelessness
Mood*
Emotion
Cognitive Function
Norepinephrine
Dopamine
Symptoms & Circuits
Serotonin
Suicidal/Homicidal
Frustration, “Sense of Well Being”
Obsession, Sleep, Guilt or Hopelessness
Mood*
Emotion
Cognitive Function
Energy
Alertness
Psychomotor
Working Memory
Norepinephrine
Dopamine
Symptoms & Circuits
Serotonin
Suicidal/Homicidal
Frustration, “Sense of Well Being”
Obsession, Sleep, Guilt or Hopelessness
Mood*
Emotion
Cognitive Function
Energy
Alertness
Psychomotor
Working Memory
Norepinephrine
Desire
Interest*
Dopamine
Symptoms & Circuits
Serotonin
Suicidal/Homicidal
Frustration, “Sense of Well Being”
Obsession, Sleep, Guilt or Hopelessness
Irritability
Anxiety
Mood*
Emotion
Cognitive Function
Energy
Alertness
Psychomotor
Working Memory
Norepinephrine
Desire
Interest*
Dopamine
Symptoms & Circuits
Serotonin
Suicidal/Homicidal
Frustration, “Sense of Well Being”
Obsession, Sleep, Guilt or Hopelessness
Irritability
Anxiety
Mood*
Emotion
Cognitive Function
Energy
Alertness
Concentration
Psychomotor
Motivation
Working Memory
Norepinephrine
Desire
Interest*
Dopamine
Symptoms & Circuits
Serotonin
Suicidal/Homicidal
Frustration, “Sense of Well Being”
Obsession, Sleep, Guilt or Hopelessness
Appetite
Mood*
Aggression
Emotion
Sex
Energy
Cognitive Function
Alertness
Desire
Concentration
Psychomotor
Interest*
Motivation
Working Memory
Irritability
Anxiety
Norepinephrine
Dopamine
Slaby and Tancradi 2002, Stahl 2004
Symptoms, Circuits &
Medications
5HT1a
5HT1a
Classes of Antidepressants
• SSRIs
• SNRIs, NaSSI
• SDRIs
• NDRIs (mechanism of Wellbutrin not fully understood)
• DRIs, DAgs
• NRIs – (not very effective).
• (MOAIs, not covered here, are powerful
Antidepressants; but carry HTN risk with
certain foods and/or meds and Serotonin
Syndrome with SRIs.)
Suicidality vs Suicide
• An ironic fact about Antidepressant use
is that Suicidality risk (thoughts, not
death) increases transiently, BUT
SUICIDE (DEATH) risk DECREASES in
patients less than 24 y.o.! (expound)
Medications
Effecting Primarily
Serotonin
SSRIs
•
•
•
•
“Multi Action” – ssri, 5HT1a, 1b, 3, & 7.
•
Vortioxetine (Brintellix).
“Dual Action” - SSRI & 5HT1a.
•
Vilazadone (Viibryd).
“Single Action” – SSRI.
•
•
Escitalpram (Lexapro).
Fluoxetine (Prozac). SSRI + bits of others.
“Half Action” - Racemic mixture, half active.
•
Cilatopram (Celexa).
Symptoms, Circuits & Medications-Trade Names
SSRI
“Multi Action”- Brintellix 5-20mg
“Dual Action” - Viibryd 10-40mg
“Single Action”- Lexapro 10-20mg
Prozac 20mg
“Half Action” - Celexa 40mg
Larry O. Sanders,
MD
c 2002, 2014
Serotonin
Suicidal/Homicidal
Frustration, “Sense of Well Being”
Obsession, Sleep, Guilt or Hopelessness
Appetite
Mood*
Aggression
Emotion
Sex
Energy
Cognitive Function
Alertness
Desire
Concentration
Psychomotor
Interest*
Motivation
Working Memory
Irritability
Anxiety
Norepinephrine
Dopamine
Medications effecting
Both Serotonin and
Norepinephrine
SNRIs
• Levomilnacipram (Fetzima) 1:2 S:N
• Duloxetine (Cymbalta) 9:1 S:N
• Desvenlafaxine (Pristiq) 15:1 S:N
• Venlafaxine(Effexor) 30:1 S:N
•
At low dose is SSRI. At high dose SNRI.
Strong W/D issues!
• {Paroxetine (Paxil) 20-40mg}
•
Weight gain, Fatigue, Strong W/D issues!
Symptoms, Circuits & Medications-Trade Names
SSRI
Fetzima 40-120mg
Cymbalta 60mg
Pristiq 50-100mg
Effexor 75-375mg
(Paxil) 20mg
“Multi Action”- Brintellix 5-20mg
“Dual Action” - Viibryd 10-40mg
“Single Action”- Lexapro 10-20mg
Prozac 20mg
“Half Action” - Celexa 40mg
Larry O. Sanders,
MD
c 2002, 2014
Serotonin
Suicidal/Homicidal
Frustration, “Sense of Well Being”
Obsession, Sleep, Guilt or Hopelessness
SNRI
Appetite
Mood*
Aggression
Emotion
Sex
Energy
Cognitive Function
Alertness
Desire
Concentration
Psychomotor
Interest*
Motivation
Working Memory
Irritability
Anxiety
Norepinephrine
Dopamine
NaSSA
Indirectly elevates
Norepinephrine (Noradrenaline)
and Serotonin
• Mirtazapine (Remeron)
• Sedating, increases appetite and
weight gain.
Symptoms, Circuits & Medications-Trade Names
SSRI
Fetzima 40-120mg
Cymbalta 60mg
Pristiq 50-100mg
Effexor 75-375mg
(Paxil) 20mg
Remeron 30-45mg
(Indirect ^ S & N)
“Multi Action”- Brintellix 5-20mg
“Dual Action” - Viibryd 10-40mg
“Single Action”- Lexapro 10-20mg
Prozac 20mg
“Half Action” - Celexa 40mg
Larry O. Sanders,
MD
c 2002, 2014
Serotonin
Suicidal/Homicidal
Frustration, “Sense of Well Being”
Obsession, Sleep, Guilt or Hopelessness
SNRI
Appetite
Mood*
Aggression
Emotion
Sex
Energy
Cognitive Function
Alertness
Desire
Concentration
Psychomotor
Interest*
Motivation
Working Memory
Norepinephrine
Irritability
Anxiety
Dopamine
Medications Effecting
Norepinephrine
and
Dopamine
NDRI
• Bupropion (Wellbutrin) 300-450mg
• IR. Not Well Tolerated.
• SR. Lasts 12 hours.
• XL. Lasts 24 hours.
Amphetamines
• Terminal Releasers
and
• Reuptake Inhibitors
of Norepinephrine and Dopamine
Symptoms, Circuits & Medications-Trade Names
SSRI
Fetzima 40-120mg
Cymbalta 60mg
Pristiq 50-100mg
Effexor 75-375mg
(Paxil) 20mg
Remeron 30-45mg
(Indirect ^ S & N)
Larry O. Sanders,
MD
c 2002, 2014
Serotonin
Suicidal/Homicidal
Frustration, “Sense of Well Being”
Obsession, Sleep, Guilt or Hopelessness
SNRI
Appetite
Mood*
Aggression
Emotion
Sex
Energy
Cognitive Function
Alertness
Desire
Concentration
Psychomotor
Interest*
Motivation
Working Memory
Norepinephrine
NRI
“Multi Action”- Brintellix 5-20mg
“Dual Action” - Viibryd 10-40mg
“Single Action”- Lexapro 10-20mg
Prozac 20mg
“Half Action” - Celexa 40mg
Irritability
Anxiety
NDRI
Wellbutrin 300-450mg
Amphetamines 10-30mg
b.i.d.
Dopamine
Medication Effecting
Serotonin
and
Dopamine
SDRIs
• Sertraline (Zoloft)
• Usual Dose range 50-200 mg/d
• One of the best tolerated, most
effective AD.
Symptoms, Circuits & Medications-Trade Names
SSRI
Fetzima 40-120mg
Cymbalta 60mg
Pristiq 50-100mg
Effexor 75-375mg
(Paxil) 20mg
Remeron 30-45mg
(Indirect ^ S & N)
Larry O. Sanders,
MD
c 2002, 2014
Serotonin
Suicidal/Homicidal
Frustration, “Sense of Well Being”
Obsession, Sleep, Guilt or Hopelessness
SNRI
SDRI
Appetite
Mood*
Aggression
Emotion
Sex
Energy
Cognitive Function
Alertness
Desire
Concentration
Psychomotor
Interest*
Motivation
Working Memory
Norepinephrine
NRI
“Multi Action”- Brintellix 5-20mg
“Dual Action” - Viibryd 10-40mg
“Single Action”- Lexapro 10-20mg
Prozac 20mg
“Half Action” - Celexa 40mg
Zoloft
50-200mg
Irritability
Anxiety
NDRI
Wellbutrin 300-450mg
Amphetamines 10-30mg
b.i.d.
Dopamine
Medications Effecting
Primarily
Dopamine
DRI & DAgs
• Methylphenidate (Ritalin)
• Dopamine Agonists:
• Pramipexole (Mirapex).
• Evidence based treatment. Avg
dose 0.95 mg.
• Ropinirole (Requip).
Symptoms, Circuits & Medications-Trade Names
SSRI
Fetzima 40-120mg
Cymbalta 60mg
Pristiq 50-100mg
Effexor 75-375mg
(Paxil) 20mg
Remeron 30-45mg
(Indirect ^ S & N)
Larry O. Sanders,
MD
c 2002, 2014
Serotonin
Suicidal/Homicidal
Frustration, “Sense of Well Being”
Obsession, Sleep, Guilt or Hopelessness
SNRI
SDRI
Appetite
Mood*
Aggression
Emotion
Sex
Energy
Cognitive Function
Alertness
Desire
Concentration
Psychomotor
Interest*
Motivation
Working Memory
Norepinephrine
NRI
“Multi Action”- Brintellix 5-20mg
“Dual Action” - Viibryd 10-40mg
“Single Action”- Lexapro 10-20mg
Prozac 20mg
“Half Action” - Celexa 40mg
Zoloft
50-200mg
Irritability
Anxiety
NDRI
Wellbutrin 300-450mg
Amphetamines 10-30mg
b.i.d.
Dopamine
Ritalin 10-40mg bid
DRI
Mirapex 0.25-1.5 mg
DAg
HS
Medications Effecting
Primarily
Norepinephrine
NRIs
• Desiparamine
• Atomoxetine (Strattera)
• (Atomoxetine is a failed
antidepressant approved for use
in AD/HD. No NRI, other than
the TCA Desipramine, has beat
placebo).
Symptoms, Circuits & Medications-Trade Names
SSRI
Fetzima 40-120mg
Cymbalta 60mg
Pristiq 50-100mg
Effexor 75-375mg
(Paxil) 20mg
Larry O. Sanders,
MD
c 2002, 2014
Serotonin
Suicidal/Homicidal
Frustration, “Sense of Well Being”
Obsession, Sleep, Guilt or Hopelessness
SNRI
Remeron 30-45mg
(Indirect ^ S & N)
Desipramine
Strattera
SDRI
Appetite
Mood*
Aggression
Emotion
Sex
Energy
Cognitive Function
Alertness
Desire
Concentration
Psychomotor
Interest*
Motivation
Working Memory
Norepinephrine
NRI
“Multi Action”- Brintellix 5-20mg
“Dual Action” - Viibryd 10-40mg
“Single Action”- Lexapro 10-20mg
Prozac 20mg
“Half Action” - Celexa 40mg
Zoloft
50-200mg
Irritability
Anxiety
NDRI
Wellbutrin 300-450mg
Amphetamines 10-30mg
b.i.d.
Dopamine
Ritalin 10-40mg bid
DRI
Mirapex 0.25-1.5 mg
DAg
HS
Symptoms, Circuits & Medications-Trade Names
SSRI
Fetzima 40-120mg
Cymbalta 60mg
Pristiq 50-100mg
Effexor 75-375mg
(Paxil) 20mg
Larry O. Sanders,
MD
c 2002, 2014
Serotonin
Suicidal/Homicidal
Frustration, “Sense of Well Being”
Obsession, Sleep, Guilt or Hopelessness
SNRI
Remeron 30-45mg
(Indirect ^ S & N)
Desipramine
Strattera
SDRI
Appetite
Mood*
Aggression
Emotion
Sex
Energy
Cognitive Function
Alertness
Desire
Concentration
Psychomotor
Interest*
Motivation
Working Memory
Norepinephrine
NRI
“Multi Action”- Brintellix 5-20mg
“Dual Action” - Viibryd 10-40mg
“Single Action”- Lexapro 10-20mg
Prozac 20mg
“Half Action” - Celexa 40mg
Zoloft
50-200mg
Irritability
Anxiety
NDRI
Wellbutrin 300-450mg
Amphetamines 10-30mg
b.i.d.
Dopamine
Ritalin 10-40mg bid
DRI
Mirapex 0.25-1.5 mg
DAg
HS
Symptoms, Circuits & Medications-Trade Names
SSRI
Fetzima 40-120mg
Cymbalta 60mg
Pristiq 50-100mg
Effexor 75-375mg
(Paxil) 20mg
Larry O. Sanders,
MD
c 2002, 2014
Serotonin
Suicidal/Homicidal
Frustration, “Sense of Well Being”
Obsession, Sleep, Guilt or Hopelessness
SNRI
Remeron 30-45mg
(Indirect ^ S & N)
Desipramine
Strattera
SDRI
Appetite
Mood*
Aggression
Emotion
Sex
Energy
Cognitive Function
Alertness
Desire
Concentration
Psychomotor
Interest*
Motivation
Working Memory
Norepinephrine
NRI
“Multi Action”- Brintellix 5-20mg
“Dual Action” - Viibryd 10-40mg
“Single Action”- Lexapro 10-20mg
Prozac 20mg
“Half Action” - Celexa 40mg
Zoloft
50-200mg
Irritability
Anxiety
NDRI
Wellbutrin 300-450mg
Amphetamines 10-30mg
b.i.d.
Dopamine
Ritalin 10-40mg bid
DRI
Mirapex 0.25-1.5 mg
DAg
HS
Symptoms, Circuits & Medications-Trade Names
SSRI
Fetzima 40-120mg
Cymbalta 60mg
Pristiq 50-100mg
Effexor 75-375mg
(Paxil) 20mg
Larry O. Sanders,
MD
c 2002, 2014
Serotonin
Suicidal/Homicidal
Frustration, “Sense of Well Being”
Obsession, Sleep, Guilt or Hopelessness
SNRI
Remeron 30-45mg
(Indirect ^ S & N)
Desipramine
Strattera
SDRI
Appetite
Mood*
Aggression
Emotion
Sex
Energy
Cognitive Function
Alertness
Desire
Concentration
Psychomotor
Interest*
Motivation
Working Memory
Norepinephrine
NRI
“Multi Action”- Brintellix 5-20mg
“Dual Action” - Viibryd 10-40mg
“Single Action”- Lexapro 10-20mg
Prozac 20mg
“Half Action” - Celexa 40mg
Zoloft
50-200mg
Irritability
Anxiety
NDRI
Wellbutrin 300-450mg
Amphetamines 10-30mg
b.i.d.
Dopamine
Ritalin 10-40mg bid
DRI
Mirapex 0.25-1.5 mg
DAg
HS
Symptoms, Circuits & Medications-Trade Names
SSRI
Fetzima 40-120mg
Cymbalta 60mg
Pristiq 50-100mg
Effexor 75-375mg
(Paxil) 20mg
Larry O. Sanders,
MD
c 2002, 2014
Serotonin
Suicidal/Homicidal
Frustration, “Sense of Well Being”
Obsession, Sleep, Guilt or Hopelessness
SNRI
Remeron 30-45mg
(Indirect ^ S & N)
Desipramine
Strattera
SDRI
Appetite
Mood*
Aggression
Emotion
Sex
Energy
Cognitive Function
Alertness
Desire
Concentration
Psychomotor
Interest*
Motivation
Working Memory
Norepinephrine
NRI
“Multi Action”- Brintellix 5-20mg
“Dual Action” - Viibryd 10-40mg
“Single Action”- Lexapro 10-20mg
Prozac 20mg
“Half Action” - Celexa 40mg
Zoloft
50-200mg
Irritability
Anxiety
NDRI
Wellbutrin 300-450mg
Amphetamines 10-30mg
b.i.d.
Dopamine
Ritalin 10-40mg bid
DRI
Mirapex 0.25-1.5 mg
DAg
HS
Symptoms, Circuits & Medications-Trade Names
SSRI
Fetzima 40-120mg
Cymbalta 60mg
Pristiq 50-100mg
Effexor 75-375mg
(Paxil) 20mg
Larry O. Sanders,
MD
c 2002, 2014
Serotonin
Suicidal/Homicidal
Frustration, “Sense of Well Being”
Obsession, Sleep, Guilt or Hopelessness
SNRI
Remeron 30-45mg
(Indirect ^ S & N)
Desipramine
Strattera
SDRI
Appetite
Mood*
Aggression
Emotion
Sex
Energy
Cognitive Function
Alertness
Desire
Concentration
Psychomotor
Interest*
Motivation
Working Memory
Norepinephrine
NRI
“Multi Action”- Brintellix 5-20mg
“Dual Action” - Viibryd 10-40mg
“Single Action”- Lexapro 10-20mg
Prozac 20mg
“Half Action” - Celexa 40mg
Zoloft
50-200mg
Irritability
Anxiety
NDRI
Wellbutrin 300-450mg
Amphetamines 10-30mg
b.i.d.
Dopamine
Ritalin 10-40mg bid
DRI
Mirapex 0.25-1.5 mg
DAg
HS
Symptoms, Circuits & Medications-Trade Names
SSRI
Fetzima 40-120mg
Cymbalta 60mg
Pristiq 50-100mg
Effexor 75-375mg
(Paxil) 20mg
Larry O. Sanders,
MD
c 2002, 2014
Serotonin
Suicidal/Homicidal
Frustration, “Sense of Well Being”
Obsession, Sleep, Guilt or Hopelessness
SNRI
Remeron 30-45mg
(Indirect ^ S & N)
Desipramine
Strattera
SDRI
Appetite
Mood*
Aggression
Emotion
Sex
Energy
Cognitive Function
Alertness
Desire
Concentration
Psychomotor
Interest*
Motivation
Working Memory
Norepinephrine
NRI
“Multi Action”- Brintellix 5-20mg
“Dual Action” - Viibryd 10-40mg
“Single Action”- Lexapro 10-20mg
Prozac 20mg
“Half Action” - Celexa 40mg
Zoloft
50-200mg
Irritability
Anxiety
NDRI
Wellbutrin 300-450mg
Amphetamines 10-30mg
b.i.d.
Dopamine
Ritalin 10-40mg bid
DRI
Mirapex 0.25-1.5 mg
DAg
HS
Compliance
“No Involvement, No Commitment”
• Month 1 40% of Patients are off meds.
• Month 2 60% of Patients are off meds.
• S/E-Weight Gain, Sexual Dysfunction,
Emotional Blunting, Cognitive
Dysfunction.
• Don’t Realize the Condition is Genetic.
• Confusion with Treatment vs Cure.
When 1st Line Fails in
MDD
• Refer to Venn Diagram to
• Increase Dose,
• Change Meds or
• Augment.
• 5HT1a - Abilify, Seroquel, Viibryd.
• Lithium.
Don’t Underdose!
If dose 50-200, PCP often give 50mg,
maybe 75 mg.
“You haven’t reached maximum dose until
you have reached effect or intolerable side
effects.”
Just When I Learned All of Life’s
Answers,
They Changed the Questions!
The Most Common Causes of
Treatment Failure
• Non-Compliance.
• Comorbid Anxiety.
• Bipolar Depression.
• Most experts believe that 20-30% of all
Depressed Patients have a Bipolar Disorder
• Comorid Substance Abuse
• Depression with Psychosis (47% risk of
manifesting BP1 or BP11 with in 10 years).
When is more than
MDD Involved?
• Anxiety
• Psychosis
• Mania
• Substance Abuse
Anxiety
•
•
•
•
•
Anxiety Disorders are present in 20% PC Pts.
Depression and Anxiety are HIGHLY Co-Morbid.
If Depression present, 60% Chance of having
Significant Anxiety Disorder AND vice versa.
Untreated Anxiety consumes
•
•
6x more of your time &
6x more resources.
Most Antidepressants Treat Anxiety Disorders, but it
is Really Important to Know How to Select Proper
Medication.
Types of Anxiety Disorders
• Generalized Anxiety Disorder (GAD)
• Social Phobia (aka Social Anxiety)
• Panic Disorder
• Post-traumatic Stress Disorder (PTSD)
-
Chronic Worry.
- Fear
Social Judgement.
- Sudden, Intense Fear with Physical
Symptoms.
-
symptoms delayed by > 1 month after trauma. Can be years. For
every 1 soldier killed in action in Afganistan, 25 will die by suicide.
• Acute Stress Disorder
• Obsessive-Compulsive Disorder (OCD)
- within 1 month of trauma.
- Germs, Order, Counting, that they have Harmed to Others.
Anxiety Rating
Scales
• GAD 7 - Rates GAD
• Zung Anxiety
• CUXOS
• YBOCS - for OCD
Treatment of Anxiety
Disorders
• Antidepressants
• Serotonin Agents treat all.
• NE helps GAD, but may make Panic
Worse.
• BZs
• Gabapentin
Be Certain It’s NOT
Bipolar Depression!
Experts agree that 30-40% of
ALL Depressive Disorders
have a component of
Bipolar Disorder
Bipolar Mood States
Bipolar I
Bipolar II
(146 pts, 12.8 yrs)
(86 pts, 13.4 yrs)
1% 2%
% of Weeks
6%
9%
32%
53%
50%
50%
46%
46%
46%
46%
Adapted from Judd 2002
Judd 2003
MDQ
Scoring
False Positives and
False Negatives with
MDQ
Treating Bipolar
Disorder
• Treating Bipolar Disorder is often a
Complex Challenge, much more difficult
than treating Depression or Anxiety.
• “Every Bipolar is an “n of 1.”
• Must treat Current State and
• Prevent both Mania and Depression.
If Psychotic
Depression
• Treat BOTH Psychosis and Mood.
• Psychotic Depression is a High Risk for
having an underlying Bipolar Disorder
Non-Medical
Treatments
• Individual Psychotherapies
• CBT, Supportive, Psychodynamic.
• Exercise
• Family Therapy
• Group Therapy
When to Refer
• Anytime you are uncomfortable.
• When Gravely Disabled, Imminently Suicidal or
Homocidal (SEND TO ER!!!)
• Mania is present
• Psychosis present
• Anxiety doesn’t respond rapidly (Suicide Risk)
• When Substance Abuse present
• Therapy Needed or Helpful.
Epitaph of the Hypochondriac
(or the Psych Patient)