What Works, Healing the Mind and Spirits with Medication and traditional talk therapy.

Outline of medication workshop

October 27, 2006

 by John Swank, MS

Last Updated: 08/19/2009

Assumptions

·        Role of Medication in counseling. Does it cross the line legally?  I preface or end with “consult/inform your physician.”  I think of my role legally much like an interior decorator’s relationship to building the house. They may recommend a certain sink, kitchen faucet, bathtub or toilet, but it is the licensed plumber who installs it. Thus any and all comments are my best interpretation of the available evidence, as well as my own experience from clinical practice.

·        My interest in it…experience back to 1973 working with physicians in Neighborhood clinic in Springfield, Ohio, and working in physician office for about 5 years in Troy (1985>)

·       

Quote: “If all I have is a hammer, everything begins to look like a nail.”  Problem…each profession uses what it has easily available…

·        My understanding is that research indicates that counseling and medication gets fastest response.  Each alone not as good.  Also medication remits symptoms, but many will return if quit medication unless patient has learned new coping skills. Also some people too depressed to work in therapy or too angry or resistant.

·        I will be talking about 3 specific classes of  medications, using common descriptions

·        Antidepressants

·        Mood Stabilizers

·        ADHD medication (mostly psychostimulants)

·        However don’t get too focused on the class of a drug. Many patients become confused when given an antidepressant for pain, sleep, obsessions, irritability.

·        Note: Caution about FDA on label, off label.  Off label is not illegal, but it is certainly better that the patient has been explained that.

·        To use the word Patient or Client : Patient=from French; one who suffers, and one under medical care, while client is one dependent/subordinate to another

·        Gender reference: I usually switch to the plural “they” rather than “he/she”.  This may drive purists/English majors a bit crazy when I am referring to one person, but it is less dangerous to offend English majors than half the population.

·        Not everyone at the same place in knowledge (as scaling question as to where people are in terms of knowledge)

Antidepressants

Various Uses of Antidepressant Medications

f the antidepressants had been used for something else first, they wouldn’t be called antidepressants.  The antidepressant medications, especially the SSRI’s (defined later) are useful for many disorders including: (broad categories-obsessions, depression, stuck)

·        Alcohol and Substance Abuse (with underlying mood disorder)

·        Anger/irritability

·        Anorexia

·        Anxiety Disorders (social phobia, social anxiety, performance anxiety)

·        Attention Deficit Hyperactivity Disorder

·        Atypical Depressions (mood shifts based on situation)

·        Binge Eating Disorder

·        Bipolar Disorders when used with mood stabilizers.

·        Body Dysmorphic Disorder

·        Borderline Personality Disorder

·        Bulimia

·        Chronic Anger

·        Chronic Pain Syndromes

·        Diabetes

·        Dysthymia

·        Eating Disorders

·        Enuresis (bed wetting) in children

·        Gambling

·        Grief-prolonged

·        Heart Attacks, use after speeds recovery and use appears to reduces risk 

·        Hypochondriasis

·        Illness Induced Depressions

·        Inflammatory Bowel Disease (Crohn’s, ulcerative colitis)

·        Major Depression

·        Multiple Sclerosis

·        Obsessive Compulsive Disorder

·        Oppositional Defiant Disorder (rigidity)

·        Pain Management

·        Panic Disorders

·        Premenstual Dysphoric Disorder (PDD) or Premenstrual Syndrome (PMS)

·        Premature Ejaculation

·        Post Traumatic Stress Disorder

·        Seasonal Affective Disorder

·        Smoking Cessation

·        Trichotillomania (hair pulling)

Depressive Symptoms Indicating Possible Need for Medication

• Sleep disruption, usually early morning awakening, sometimes sleeping too much
• Morning times are worse, feel better as day wears on
• Loss of pleasure  (anhedonia) in most usual interests
• Weight gain or loss, recent, undesired and significant
• Depressed affect, irritability, and anger
• Decreased energy and motivation
• Grief reactions, intense
• Intense obsessional preoccupation
• Genetic history of depression (be more aggressive with depressive symptoms if the history is positive for severe depression, even if it appears to be an adjustment, crisis or loss.”
• Prevention of depression setting mood thermostat lower.
• Prevention of brain cell death, and possible restoration --Brain neurogenesis

Antidepressants are Designed to...

·         Return a person to a normal level of functioning (Remission) or improve the person’s mood (All drugs tested regarding improvement of depression, not remission)

·         Assist the person to experience norma feelings of enjoyment and pleasure (Help you feel the way you want to feel

·         Allow a greater sense of well being

·         Diminish unwanted thoughts (ruminations)

·         Help people “roll with the punches more”

·         Allow people to “let things roll off of their backs more”

·         A tool to help you do and be more the way you wish to be

Antidepressants--What They are Not

·        Are not uppers or stimulants (except for rare use of Ritalin as an antidepressant).

·        Are not addicting.  They have no street value since abused drugs are fast acting.  Antidepressants are slow acting and relatively easy to discontinue (Paxil may be exception.)

·        Do not “zonk you” (except as occasional unintended side effect).

·        Do not cause you to have pleasure.

·        Do not “make” you function better.

Use HANDOUT#1:  MAJOR ANTIDEPRESSANTS

Listing Generic/trade Side effect profiles

Classes/Types of Antidepressants

And neurochemical impact on

Serotonin, Norepinephrine, Dopamine

Dopamine, Norepinephrine, Serotonin

SSRI, Role of Serotonin

• Explain Selective Serotonin Reuptake Inhibitor
• draw picture of synapse. (or Take Adderall Chart) reuptake pump
• Analogy- protection like oil on duck in rain…
• Linkage between 3 things: A: depressed people more perceptive in experiments, more in touch with reality.  B. SSRI’s used in pain clinics, C: Obsessive people respond to SSRI’s.  Common linK is that when depressed—more gets through, when not depressed, less gets through to you.
• Earliest SSRI=Prozac…best known to your patients. Almost all people resist if suggest Prozac. 
• The progression has been more and more specific “pure serotonin” meds…
• Latest is Lexapro XR

The SSRI’s in the order of date of FDA approval and usual daily dosage ranges:

Fluoxetine (Prozac) 20-60 mg per day

Sertraline (Zoloft) 50-200 mg per day

Paroxetine (Paxil) 20-60 mg per day

Fluvoxamine (Luvox) 50-300 mg per day  (FDA approved for OCD)

Citalopram (Celexa) 20-60 mg per day

Escitalopram (Lexapro) 10-20 mg/day

The first prominent SSRI was Prozac, released in 1987. Within 3 years it was the mostly commonly prescribed drug for depression.

We are so used to the SSRI’s that we almost have forgotten what tremendous benefit that they offered:

·        Not likely to have fatal overdose (could have fatal overdose on one week’s worth of previous antidepressant medications.) Less than a 5% risk of overdose when used alone at high doses.

·        Fewer anticholinergic side effects

No dry mouth, constipation, dizziness, fainting

No heart rhythm disruption at higher dosages or overdosage

No need for tests to check blood levels or cardiac functions

·        No dietary restrictions such as with MAO’s

Greater compliance because fewer side effects

SSRI’s Side Effects

·        Activating-sometimes insomnia, restlessness and agitation (Prozac/Wellbutrin most likely)

·        Akathisia (extreme restlessness) a rare side effect

·        Sexual dysfunctions a problem (see separate section)

·        Insomnia (Prozac most likely)

·        Drowsiness (Paxil most likely)

·        REM sleep disruption

·        Nausea, gastrointestinal upset cause intolerance in 1/3 of those who try it

·        Sweating, insomnia, headache

·        Joint and muscle pain

·        Weight gain (Paxil most likely)

·        Development of rash

·        Serotonin Syndrome

·        Discontinuation syndrome-Paxil/Effexor are worse offenders, Prozac low incident

Increase suicidal thoughts, attempts?

Tricyclics

These are old drug type that affect norepinephrine and serotonin and effective as SSRI's in most people, but have strong side effects and should not be used at the first level of treatment. Common side effects of it are dry mouth, constipation, bladder problems, sexual dysfuntion, blurred vision, dizziness, drowsiness and increased heart rate.

Tricyclics may cause arrhythmias and EKG changes and are very lethal in overdose. So they should be used with extreme precaution and not at all for children, some are listed below

MAOI's

Monamine oxydase inhibitors are mostly and generally effective in major depression and used for those who do not respond to other antidepressants easily and used to treat panic disorder. Also should not take along with decongestants and certain foods that contain high levels of tyramine like cheeses, wines, and pickles etc. The interaction of tyramine with MAOIs may cause a sharp increase in BP that may lead to a stroke.

SNRI’s/NRI’s and dual Antidepressants

The SNRI’s (selective norepinephrine reuptake inhibitors) are what appear to be now on the leading edge of development, or at least the approval process with the FDA. The drug Strattera atomoxetine is an NRI which is being developed for ADHD, and is expected to be released in late 2002.  Older TCA’s such as Norpramin are also NRI’s, but the anticholinergic side effects make them unpleasant to use. 

·        Vestra (reboxetine) has not yet received FDA approval, although it is used in over 50 countries.  It appears to be more helpful than SSRI’s with overcoming psychomotor retardation and may help in social aspects of those severely depressed. 

• Cymbalta/duloxetine is a dual inhibitor of both NE and 5HT (serotonin).  It is an investigational drug by Eli Lilly.
• Effexor is a dual inhibitor, but Cymbalta appears to be a dual inhibitor at the initial dosage, while Effexor needs a higher dosage to get dual inhibition of NE and 5HT.
• REMERON (mirtazapine),  the newer antidepressant, impacts the NE as well as serotonin reuptake.

Handout Page 2 Choosing An Antidepressant

Specific Antidepressents and Use

• Mirtazapine (Remeron) : It is mainly used to stimulate appetite and improve sleep when depression is associated with sleeping disorders.
• bupropion (Wellbutrin) : Used for smoking cessation
• duloxetine (Cymbalta) : Newest antidepressant.
• nefazodone (Serzone)  : Discontinued- Liver function
• trazodone : Used mainly as a sleep agent

·        venlafaxine (Effexor) : Also used to treat generalized anxiety disorder and social anxiety disorder.

·        Remeron (mirtazepine) and Wellbutrin (bupropion) must not be used for people  at risk for suicide.

• Remeron: promotes sleep and creates weight gain. Helpful for those who don’t weigh enough, such as a ADHD child who is very thin taking stimulants which suppress appetite.

• Prozac: It is activating.  May cause nervousness in some, but that may be helpful in someone too sluggish.