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

Hey, you! Are you Hey, you! Are you Bipolar, Depressed, Bipolar, Depressed,

Borderline, or What?Borderline, or What?

John L. Schaeffer, D.O.John L. Schaeffer, D.O.Child, Adolescent & Adult Child, Adolescent & Adult

PsychiatristPsychiatristKaiser Permanente PsychiatryKaiser Permanente Psychiatry

Roseville, CARoseville, CAOctober 17, 2009October 17, 2009

Disclosure of Relevant Financial Disclosure of Relevant Financial RelationshipsRelationships

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

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

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.

Aren’t these pretty leaves?Aren’t these pretty leaves?

“Kids: They dance before they learn there is anything that isn’t music.” William

Stafford

Primary Care at KaiserPrimary 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?”

• 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 KaiserPrimary Care at Kaiser

Permission to use cartoon per Dwayne Booth

Though I’m sure it must sometimes feel Though I’m sure it must sometimes feel more like this:more like this:

Representing Psychiatry, I am Representing Psychiatry, I am here to tell you: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?

• 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?

• 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.

Robbie Pearl calls it the “Wow factor!”

How to get there.

• Push the eConsult button

• Facility: Sacramento

• Specialty: Adult Psychiatry

• Problem/Reason: “Other”

• This pulls up the Phone Consult screen.

So let’s give you some psychiatric muscle for So let’s give you some psychiatric muscle for you patients with mental illnessyou patients with mental illness

Trying to diagnose psych patients can feel likeTrying to diagnose psych patients can feel like

Keep it simple.Keep it simple.

Just what the heck is Bipolar Disorder?

Multiple types/multiple episodes Multiple types/multiple episodes within typeswithin types

• Bipolar I Disorder

• Bipolar II Disorder

• Major Depressive Episode

• Manic Episode

• Mixed Episode

• Hypomanic Episode

• 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 The following specifiers for Bipolar I Disorder

can be used to describe the current Manic, can be used to describe the current Manic, Mixed, or Major Depressive Episode (or, if Mixed, or Major Depressive Episode (or, if criteria are not currently met for a Manic, Mixed, criteria are not currently met for a Manic, Mixed, or Major Depressive Episode, the recent Manic, or Major Depressive Episode, the recent Manic, Mixed, or Major Depressive Episode): Mixed, or Major Depressive Episode):

• Mild, Moderate, Severe Without Psychotic Mild, Moderate, Severe Without Psychotic Features, Severe With Psychotic Features, In Features, Severe With Psychotic Features, In Partial Remission, In Full Remission...Partial Remission, In Full Remission... With Catatonic Features... With Catatonic Features... With Postpartum Onset... With Postpartum Onset...

• The following specifiers apply only to the The following specifiers apply only to the current (or most recent) Majorcurrent (or most recent) Major

• 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:Apply all that to:

• 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).

• 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.

• 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).

• 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).

Anybody bored yet?

How’s the gyroscope?

So let’s get real.So let’s get real.

Let’s play:Let’s play:

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

Take a piece of paper and draw

three horizontal lines.

___________________________________

___________________________________

___________________________________

Write the words:

Manic, Normal, Depressed

_______________Manic______________

_______________Normal______________

______________Depressed____________

Add a line in the middle of your other lines.

_______________Manic______________

_______________Normal______________

______________Depressed____________

Write the words:

Hypomanic

Dysthymic

_______________Manic______________

Hypomanic

_______________Normal______________

Dysthymic

______________Depressed____________

Manic

Normal

Depressed

Hypomanic

Dysthymic

ManicMoney Ass to Everybody Nothing is Neutral Impulsive Cyclical

Normal

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

HypoHalf the mania Yearning for greatness but still in control People’s opinions still matter Organized enough to

work/function

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

Manic

Normal

Depressed

Hypomanic

Dysthymic

NormalNormal

Manic

Normal

Depressed

Hypomanic

Dysthymic

Major Depressive DisorderMajor Depressive Disorder

Manic

Normal

Depressed

Hypomanic

Dysthymic

Cyclothymic DisorderCyclothymic Disorder

Manic

Normal

Depressed

Hypomanic

Dysthymic

Bipolar IIBipolar II

Manic

Normal

Depressed

Hypomanic

Dysthymic

Bipolar IBipolar I

Manic

Normal

Depressed

Hypomanic

Dysthymic

Borderline Personality Disorder (each shift triggered by external forces)Borderline Personality Disorder (each shift triggered by external forces)

Some PearlsSome Pearls

Mood Interview Pearl #1Mood Interview Pearl #1

Origin

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

Age of Onset and Gender IssuesAge of Onset and Gender Issues

Depressed

Infancy-Toddler

Six years

Thirteen years

Female 2X > male

Bipolar

Two to Three yrs

Six years

13-25 years

Average = 20

Male = female

BPD

15 yrs

19 yrs

21-30 yrs

75% female

Ages at Onset for 579 Patients With Bipolar I Disorder in Subgroups Ages at Onset for 579 Patients With Bipolar I Disorder in Subgroups With Early Onset, Intermediate Onset, and Late Onset With Early Onset, Intermediate Onset, and Late Onset

Frank Bellivier, M.D., Ph.D., Frank Bellivier, M.D., Ph.D., Am J Psychiatry 160:999-1001, May 2003Am J Psychiatry 160:999-1001, May 2003

Effect of Age at Onset on the Course of Major Depressive Effect of Age at Onset on the Course of Major Depressive DisorderDisorder

Sidney Zisook, M.D., Am J Psychiatry 164:1539-1546, October 2007Sidney Zisook, M.D., Am J Psychiatry 164:1539-1546, October 2007

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.”

Borderline Personality Disorder in under age 18:


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?”

Time frame (DSM-IV-TR)Time frame (DSM-IV-TR)

Depression

Consecutive 2 week period

Bipolar

I: Consecutive 1 week period

II: Consecutive 4 day period

BPD

It’s a lifestyle, a “pattern” if instability

Duration/FrequencyDuration/Frequency

Depression

60 Percent of people who experience a single episode experience a second.

70 Percent who have had two episodes with have a third.

90 Percent who have had three episodes will have a fourth.

Bipolar I

Worsens over years with increased severity of symptoms

BPD

Chronic instability in early adulthood.

10 Percent successfully commit suicide.

Tends to improve in 30s and 40s. 10 year f/u studies show half of thos


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 DisorderTo qualify as a Mood Disorder

It has to change the way you function.

True depression is not a frustrationTrue 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 Borderline Personality Disorder is not a game people play.game people play.

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

The best goal is preventionThe best goal is prevention and to catch things early. 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.


Genetics

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

Family HistoryFamily History

Depression

Dysthymic disorder.

Major Depression.

Alcohol abuse.

Panic Disorder.

Social Phobia.

ADHD is seen more in children of adults with Major Depression.

Bipolar I

Any Mood Disorder (depression, bipolar)

But especially

Bipolar I and Bipolar II

Alcohol & Substance abuse.

Adoptions.

ADHD.

BPD

BPD. 5X greater risk if a 1st degree relative has BPD.

Mood Disorders.

Alcohol & Substance abuse.

Neglect/PTSD.

Antisocial Personality Disorder.

Lifetime PrevalenceLifetime Prevalence

Depression

10-25 Percent for women.

5-12 Percent for men.

(Unrelated to ethnicity, education, income, or marital status.)

Bipolar I

1-2 Percent of the General Population.

10-15 Percent of adolescents with recurrent Major Depressive Episodes will go on to develop Bipolar I Disorder.

Male = female.

BPD

2 Percent of General Population.

10 Percent of psych outpatients.

20 Percent of psych inpatients.

EtiologyEtiology

Depression

Genetic

Neurochemical

Fetal Development

Brain Traumas

Nutritional deficiencies

Exacerbated by stress

Bipolar I

Genetic

Exacerbated by stress and hormones

BPD

Psychophysiologic secondary to neglect, abuse, mistreatment, abandonment

People are not born with BPD. It is a learned behavior. It must be acquired.

Mood Interview Pearls 1- 4Mood Interview Pearls 1- 4

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?


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.”


Go ahead and feel your feelings.

Use how you feel to better understand your patients.

How do you feel when talking to the patient?How do you feel when talking to the patient?

What is “Staff Splitting?”What is “Staff Splitting?”

• “Finally someone understands me. My other doctor never listened to me….”

How do you feel when talking to the patient?How do you feel when talking to the patient?

Mood Interview Pearl #6.1Mood 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.”

Anger, Irritability, Temper, RageAnger, Irritability, Temper, Rage

Depression

Persistent anger.

A tendency to respond to events with angry outbursts or blaming others.

Exaggerated sense of frustration over minor matters.

Separate from “spoiled child” pattern of irritability when frustrated.

Bipolar I

Secondary to limit-setting or attempts to control their excessive behavior

Rage can last for extended periods of time (at other times may be explosive and over quickly).

Over aggressive and assaultive.

BPD

Intense episodic dysphoria, irritability, and anxiety lasting a few hours and only rarely more than a few days.

Eternal “victim” position.

Rationalizes destructive retaliation.

Mood Interview Pearls 1- 6.1Mood Interview Pearls 1- 6.1





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.

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

Let’s pump those psych muscles up Let’s pump those psych muscles up some moresome more

DRUGS!DRUGS!

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 The top 5 money makers were Lipitor ($5.9 billion retail cost), Nexium ($4.8b), Plavix ($3.8b), Advair retail cost), Nexium ($4.8b), Plavix ($3.8b), Advair ($3.6b), and Prevacid ($3.3b).($3.6b), and Prevacid ($3.3b).

AARP: "Though brand names make up only 22% of AARP: "Though brand names make up only 22% of the names on the list, they represent 62% of the the names on the list, they represent 62% of the $53.2 billion."$53.2 billion."

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

20. Oxycodone (pain)20. Oxycodone (pain)21. Singulair (asthma)21. Singulair (asthma)22. Ibuprofen (pain/inflammation)22. Ibuprofen (pain/inflammation)23. Plavix (blood clotting)23. Plavix (blood clotting)24. Prednisone oral 24. Prednisone oral (allergies/inflammation)(allergies/inflammation)25. Fluoxetine (depression)25. Fluoxetine (depression)26. Synthroid (hypothyroidism)26. Synthroid (hypothyroidism)27. Warfarin (blood clotting)27. Warfarin (blood clotting)28. Cephalexin (bacterial infection)28. Cephalexin (bacterial infection)29. Lorazepam (anxiety)29. Lorazepam (anxiety)30. Clonazepam (epilepsy/anxiety)30. Clonazepam (epilepsy/anxiety)31. Citalopram (depression)31. Citalopram (depression)32. Tramadol (pain)32. Tramadol (pain)33. Gabapentin (epilepsy/pain33. Gabapentin (epilepsy/pain34. Ciprofloxacin HCl (bacterial 34. Ciprofloxacin HCl (bacterial infection)infection)35. Propoxyphene-N (pain)35. Propoxyphene-N (pain)36. Lisinopril (hypertension)36. Lisinopril (hypertension)

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

10 of the top 50 are for anxiety or depression.10 of the top 50 are for anxiety or depression.That's about 19% of the total cost ($10.3b of $53.2b). That's about 19% of the total cost ($10.3b of $53.2b). Depression is big business in this country.Depression is big business in this country.

4 of the top 50 are for high cholesterol, about 18% 4 of the top 50 are for high cholesterol, about 18% ($9.4b of $53.2b).($9.4b of $53.2b).9 of the top 50 are for hypertension, about 9% ($4.9b of 9 of the top 50 are for hypertension, about 9% ($4.9b of $53.2).$53.2).That adds up to 27% of the total cost, a lot of money That adds up to 27% of the total cost, a lot of money for conditions that have been shown repeatedly to for conditions that have been shown repeatedly to respond to diet and exercise.respond to diet and exercise.

These are a lot of drugs for not a lot of health.These are a lot of drugs for not a lot of health.11 ________________11 US Ranks Last Among Other Industrialized Nations US Ranks Last Among Other Industrialized Nations On Preventable Deaths, ScienceDaily, Jan 2008On Preventable Deaths, ScienceDaily, Jan 2008

"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

Drug-Drug Interactions:Drug-Drug Interactions:Physical meds causing psychiatric Physical meds causing psychiatric

issues:issues:

From: Advances in Psychiatric Treatment (2005), vol. 11, 58–70, From: Advances in Psychiatric Treatment (2005), vol. 11, 58–70, Nora Turjanski & Geoffrey G. Lloyd.Nora Turjanski & Geoffrey G. Lloyd.

As a psychiatrist, As a psychiatrist, I often see:I often see:

Beta blockers cause depression. Atenolol is hydrophilic. Propranolol Beta blockers cause depression. Atenolol is hydrophilic. Propranolol and Metoprolol are lypophilic. and Metoprolol are lypophilic. Statin drugs cause agitation, insomnia, anxiety, and mood swings—Statin drugs cause agitation, insomnia, anxiety, and mood swings—except prevastatin which doesn’t cross the BBB.except prevastatin which doesn’t cross the BBB.Triptan drugs cause Serotonin Syndrome when used with SSRIs.Triptan drugs cause Serotonin Syndrome when used with SSRIs.

(typically myoclonus & fever, but can be life threatening).(typically myoclonus & fever, but can be life threatening).Benzos and opiates cause depression, confusion, problems with short-Benzos and opiates cause depression, confusion, problems with short-term memory and with concentration/attention, and rebound insomnia.term memory and with concentration/attention, and rebound insomnia.Topamax = Dopamax = StupimaxTopamax = Dopamax = StupimaxKeppra makes people crazy (agitated, hostile, anxious, apathetic, Keppra makes people crazy (agitated, hostile, anxious, apathetic, depressed, and emotionally labile. depressed, and emotionally labile. Depakote # 1 pt complaint? Hair falls out. Give zinc & selenium.Depakote # 1 pt complaint? Hair falls out. Give zinc & selenium.Antiepileptic meds also have FDA black box warning 0.5 % risk of Antiepileptic meds also have FDA black box warning 0.5 % risk of suicide (higher on multiple antiepileptic drugs).suicide (higher on multiple antiepileptic drugs).Paxil deforms babies before you know you’re pregnant—don’t give it to Paxil deforms babies before you know you’re pregnant—don’t give it to women of childbearing years.women of childbearing years.

Drug-Drug Interactions:Psychiatric meds causing physical issues:

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

Ready?Ready?

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

We’re not prescribing water.We’re not prescribing water.You have to expect action, You have to expect action,

interaction, reaction.interaction, reaction.We’re doctors.We’re doctors.We practice.We practice.

The important thing is to do the The important thing is to do the best we can with what we have, best we can with what we have, and then forgive ourselves for and then forgive ourselves for

the rest.the rest.

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.

Let’s pump those psych Let’s pump those psych muscles up even more!muscles up even more!

PsychiatryPsychiatry

The Meds:The Meds:

What are you supposed to be able to do at the What are you supposed to be able to do at the end of this talk?end of this talk?

List psych meds and List psych meds and interactions with meds interactions with meds commonly seen in Primary Care.commonly seen in Primary Care.

Common Antidepressant Common Antidepressant MedicationsMedications

• 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)

Mood StabilizersMood Stabilizers

• Lithium Carbonate• Depakote

(Valproic Acid)• Tegretol

(carbamazapine)• Trileptal

(oxcarbazapine)

• Lamictal (lamotrigine)• Neurontin

(gabapentin)• Topamax (topiramate)• Neuroleptics &

Benzodiazepines

Atypical NeurolepticsAtypical Neuroleptics

• 1989 Clozaril (clozapine)

• 1993 Risperdal (risperidone)

• 1996 Zyprexa (olanzapine)

• 1997 Seroquel (quetiapine)

• 2001 Geodon (ziprasidone)

• 2002 Abilify (aripiprazole)

• 2007 Invega (paliperidone)

Seriously, how much do you really need Seriously, how much do you really need (or want) to know?(or want) to know?

AntidepressantsAntidepressants

Three neurotransmitters:Three neurotransmitters:

SerotoninSerotoninNorepinephrineNorepinephrine

DopamineDopamine

SSRIsSSRIs Selective Serotonin Reuptake Inhibitors Selective Serotonin Reuptake Inhibitors

Prozac (fluoxetine)Prozac (fluoxetine)Zoloft (sertraline)Zoloft (sertraline)Paxil (paroxetine)Paxil (paroxetine)

Celexa (citalopram)Celexa (citalopram)Lexapro (escitalopram)Lexapro (escitalopram)

Luvox (fluvoxamine)Luvox (fluvoxamine)

SNRIsSNRIsSerotonin Norepinephrine Reuptake Serotonin Norepinephrine Reuptake

InhibitorsInhibitors

Effexor (venlafaxine)Effexor (venlafaxine)Cymbalta (duloxetine)Cymbalta (duloxetine)

TCAsTCAsTricyclic AntidepressantsTricyclic Antidepressants

Although some TCAs (e.g., desipramine, Although some TCAs (e.g., desipramine, maprotilene) block norepinephrine reuptake more maprotilene) block norepinephrine reuptake more potently than serotonin reuptake, the TCAs are not potently than serotonin reuptake, the TCAs are not

selective since they block many other receptors selective since they block many other receptors such as alpha 1, histamine 1, and muscarinic such as alpha 1, histamine 1, and muscarinic

cholinergic receptors.cholinergic receptors.

NRINRINorepinephrine Selective Reuptake InhibitorsNorepinephrine Selective Reuptake Inhibitors

Strattera (atomoxetine)Strattera (atomoxetine)

NDRINDRINorepinephrine Dopamine Reuptake InhibitorNorepinephrine Dopamine Reuptake Inhibitor

Wellbutrin (bupropion)Wellbutrin (bupropion)(the higher the dose the greater the dopamine (the higher the dose the greater the dopamine

to norepinephrine ratio)to norepinephrine ratio)

How’s it work?How’s it work?

Insert dry erase board demonstration here.

• 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 effectPick a med by its side effect

Pick a med by its side effectPick a med by its side effectHow much energy does the pt have/need?How much energy does the pt have/need?

EnergizingProzacZoloftEffexorCymbalta

SedatingRemeronCelexa

Morning Bedtime

More Energy NeutralLexapro

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 effectPick a med by its side effectHow much hunger does the pt have/need?How much hunger does the pt have/need?

Appetite suppression

ProzacWellbutrin

Fat BuildersRemeron (from 7.5 go 30 mg but not at 45 mg)

Morning Bedtime

Appetite (therefore weight ) Neutral

LexaproZoloft

CelexaEffexor

Cymbalta

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 effectPick a med by its side effectOversexed or undersexed?Oversexed or undersexed?

Prozac = 10-25 % reduction.

Wellbutrin = 30 % boost

Remeron Is used to treat

sexual side effects from other

AD

Morning Bedtime

Appetite (therefore weight ) Neutral

Lexapro = 15-30 % reductionZoloft = 40-60 % reductionLuvox = 25-40 % reductionCelexa = 1-5 % reduction

Effexor = neutralCymbalta = neutral

BusparIs used to tx sexual

side effects from SSRIs

The antidepressant pearls #1The 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 #2The 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.Start with the liver.http://www.thehealthylonglifeblog.com/wp-content/uploads/2008/09/liver-detox.jpghttp://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 Let’s pretend your liver is the US Customs ServiceUS Customs Service

Specifically, an agent named

Mr. Cyto Chrome, Badge #P-450:

Now there are travelers who want to come Now there are travelers who want to come to the United Statesto 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

Cyto the LiverCyto the Liver

Now Now CytoCyto just does his job. 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!”

But there are these secret agents with But there are these secret agents with higher paying jobs, and they try to influence higher paying jobs, and they try to influence

CytoCyto as to which yes he picks. as to which yes he picks.

These special agents can either make These special agents can either make CytoCyto strong strong

Or weakOr weak

SmartSmart

Or StupidOr Stupid

So what makes So what makes CytoCyto the the LiverLiver weak or strong? 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 P450Some Cytochrome P450Substrates (travelers)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

Cytochrome P450Cytochrome P450Inhibitors (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

InhibitorsInhibitors (Paxil, Prozac, Luvox, (Paxil, Prozac, Luvox, Celexa, Wellbutrin) Celexa, Wellbutrin) weakenweaken Cyto Cyto the Liver (Cytochrome P450) and the Liver (Cytochrome P450) and

Substrates (Theophylline, Warfarin, Substrates (Theophylline, Warfarin, propranolol, benzos, Depakote, propranolol, benzos, Depakote,

Methadone, Thorazine) INCREASE Methadone, Thorazine) INCREASE in plasma concentrations.in plasma concentrations.

Zoloft is the weakest of the inhibitors.Zoloft is the weakest of the inhibitors.

InducersInducers (Smoking, charbroiled foods, (Smoking, charbroiled foods, Tegretol, Phenobarb, Phenytoin, Tegretol, Phenobarb, Phenytoin,

Rifampin, Nevirapine, St. John’s Wort) Rifampin, Nevirapine, St. John’s Wort) strengthenstrengthen Cyto the Liver (Cytochrome Cyto the Liver (Cytochrome P450) and Substrates (Theophylline, P450) and Substrates (Theophylline,

Warfarin, propranolol, benzos, Warfarin, propranolol, benzos, Depakote, Methadone, Thorazine) Depakote, Methadone, Thorazine)

DECREASE in plasma concentrations.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)

So,So,a restrictor inhibits Mr. Cyto Chrome’s a restrictor inhibits Mr. Cyto Chrome’s action, and the traveler gets through action, and the traveler gets through

unrestricted, unrestricted, but a booster makes Mr. Cyto Chrome but a booster makes Mr. Cyto Chrome stronger, so the traveler is restricted.stronger, so the traveler is restricted.

Inhibit to set free.Inhibit to set free.Induce to restrict.Induce to restrict.

Mood Interview Pearls 1- 6.1Mood Interview Pearls 1- 6.1





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 #1The 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 #2The 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

Beta blockers cause depression. Atenolol is hydrophilic. Propranolol and Beta blockers cause depression. Atenolol is hydrophilic. Propranolol and Metoprolol are lypophilic. Metoprolol are lypophilic.

Statin drugs cause agitation, insomnia, anxiety, and mood swings—except Statin drugs cause agitation, insomnia, anxiety, and mood swings—except prevastatin which doesn’t cross the BBB.prevastatin which doesn’t cross the BBB.

Triptan drugs cause Serotonin Syndrome when used with SSRIs.Triptan drugs cause Serotonin Syndrome when used with SSRIs.(typically myoclonus & fever, but can be life threatening).(typically myoclonus & fever, but can be life threatening).

Benzos and opiates cause depression, confusion, problems with short-term Benzos and opiates cause depression, confusion, problems with short-term memory and with concentration/attention, and rebound insomnia.memory and with concentration/attention, and rebound insomnia.

Topamax = Dopamax = StupimaxTopamax = Dopamax = StupimaxKeppra makes people crazy (agitated, hostile, anxious, apathetic, Keppra makes people crazy (agitated, hostile, anxious, apathetic, depressed, and emotionally labile. depressed, and emotionally labile. Depakote # 1 pt complaint? Hair falls out. Give zinc & selenium.Depakote # 1 pt complaint? Hair falls out. Give zinc & selenium.Antiepileptic meds also have FDA black box warning 0.5 % risk of suicide Antiepileptic meds also have FDA black box warning 0.5 % risk of suicide

(higher on multiple antiepileptic drugs).(higher on multiple antiepileptic drugs).Paxil deforms babies before you know you’re pregnant—don’t give it to Paxil deforms babies before you know you’re pregnant—don’t give it to women of childbearing years.women of childbearing years.

Mr. Cyto Chrome, Badge #P-450Mr. Cyto Chrome, Badge #P-450Inhibit to set the substrate free.Inhibit to set the substrate free.Induce to restrict the substrate.Induce to restrict the substrate.

I have woven a parachute out of

everything broken.William

Stafford

Psychiatry salutes Primary CarePsychiatry salutes Primary CareThe Spine of Kaiser PermanenteThe Spine of Kaiser Permanente

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Thought for the dayThought 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

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

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