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PSYCHOPHARMACOLOGY IN INDIVIDUALS WITH I/DD

Diana J. Antonacci, MD Professor and Residency Program

Director, Brody SOM at ECU NC START East Medical Director

antonaccid@ecu.edu

Medication Debate

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Medication Debate

• The focus should be on individuals with I/DD obtaining appropriate care - psychosocial, educational, pharmacologic, etc. – for their developmental, emotional, vocational, behavioral, medical, psychological and psychiatric needs

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Rational Psychopharmacology

• Begins with a good psychiatric evaluation!

• Components:

– History

– Mental Status Exam

– Diagnostic Impression

– Treatment Plan

History

• The history includes an individual’s problems, strengths, functioning, impairments and background

• Seeks to elaborate a description of current and past problems and symptoms

• Seeks to elaborate a description of current and past coping styles and strengths

Other information is obtained from:

• Interview of the individual, parents, guardians, caretakers, case manager

• Review of previous records, including previous psychiatric, psychological, educational, medical, speech and language evaluations

• Review of physical, medical and psychiatric health, illness and treatment, including current medications being taken

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Mental Status Exam: • Interview of the individual

• May involve completion of rating scales or other data sheets

• If it is an initial exam prior to treatment, helps establish a baseline to compare after treatment is started

• If part of ongoing treatment, helps monitor progress, response to and tolerance of treatment

Diagnostic Impression:

• Assists in defining the treatment plan

• May include “rule out” or provisional diagnosis if additional information is needed or the presentation is not clear

Treatment Plan :

• Is a continuous process that is updated on a regular basis and as needed

• Defines target problems that will be the focus of treatment

• Defines a plan to monitor the individual, short/long term

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Treatment Plan (continued):

• May include further medical evaluation when appropriate

• May include obtaining more information or seeking further workup to refine the diagnosis or update/refine the plan. Examples include, laboratory studies such as blood tests, CAT scans, MRIs or psychological, educational, speech and language evaluations

• Treatment Plan (continued):

– The physician provides feedback about the diagnosis and educates the individual and circle of support regarding the disorder, treatment and monitoring plan

– The assent and consent discussion focuses on the risk and benefits of the proposed and alternative treatments

– The assent and consent discussion also occurs whenever medications are changed and at important points during treatment

Treatment Plan (continued):

• Recommends interventions and treatment :

– Therapy (ies)

– Medication management

– Medical/Physical

– Educational

– Case management

– Others

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“You can tell if a man is clever by his answers. You can tell if a man is wise by his questions” Naguib Mahfouz

Newer Antidepressants Generic Name Brand Name/Type Usual dose range

Citalopram Celexa /SSRI 20 to 60 mg/d, single dose

Duloxetine Cymbalta/SNRI 40 to 120 mg/d, divided

Venlafaxine XR Effexor XR/SNRI 37.5 to 225 mg/d, single dose

Venlafaxine Effexor 37.5 to 225 mg/d, divided

Selegine Emsam patch/MAOI 6 to 12 mg/d, single dose

Escitalopram Lexapro/SSRI 10 to 30 mg/d, single dose

Fluvoxamine Luvox/SSRI 25 to 300 mg/d, divided

Paroxetine Paxil/SSRI 10 to 60 mg/d, single dose

Paroxetine CR Paxil CR 25 to 62.5 mg/d, single dose

Desvenlafaxine Pristiq/SNRI 50 to 400 mg/d, single dose

Fluoxetine Prozac/SSRI 20 to 80 mg/d, single dose

Mirtazapine Remeron/NaSSA 15 to 45 mg/d, single dose

Bupropion SR/XL Wellbutrin/aminoketone 150 to 450 mg/d, divided or daily

Bupropion HCL Wellbutrin 75 to 450 mg/d, divided

Older Antidepressants

Generic Name Brand Name Usual dose range

Clomipramine Anafranil/tricyclic 25 to 250 mg/d, divided

Doxepin Sinequan 75 to 300 mg/d, divided

Trazodone Desyrel 50 to 400 mg/d, divided

Amitriptyline Elavil 50 to 300 mg/d, divided

Nortriptyline Pamelor 25 to 150 mg/d, divided

Imipramine Tofranil 50 to 300 mg/d, divided

Desipramine Norpramin 50 to 300 mg/d, divided

Newest Antidepressant

Generic Name Brand Name Usual dose range

Vilazodone Vibrid/SSRI 10 to 40 mg/d

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Antidepressant Side Effects

• Tricyclic antidepressants (TCAs) – Common: Drowsiness, constipation, low

blood pressure, dry mouth, urinary retention, blurry vision, confusion

– Others: sun sensitivity, changes in white blood cells and platelets, sexual difficulties including delayed, inhibited or retrograde ejaculation in males, increased anxiety or insomnia, increased appetite, risk of overdose, increase risk for seizures

Antidepressant Side Effects

• Monoamine Oxidase Inhibitors (MAOIs)

– Common: must avoid foods high in tyramine (cheese, beans, wine, pickled foods, yeast products, coffee, chocolate, soy sauce, sour cream). Many medications must be avoided.

– Others: two week minimum between taking other antidepressants and an MAOI

Antidepressant Side Effects

• Selective Serotonin Reuptake Inhibitors (SSRIs)

– Common: sedation or activation, increased risk of seizures, stomach upset, delayed ejaculation in males, decreased orgasm, sweating, insomnia, anxiety, headache, diarrhea

• Bupropion

– Common: agitation, dry mouth, insomnia, headache/migraine, nausea/vomiting, constipation, tremor, increased risk of seizures

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Antidepressant Side Effects

• Serotonin and norepinephrine reuptake inhibitors (SNRIs) – Nausea (particularly with duloxetine), dry

mouth, dizziness, insomnia, sleepiness, constipation, increased blood pressure (with venlafaxine), excessive sweating, reduced sexual desire or difficulty reaching orgasm, erectile dysfunction, increased heart rate, heart palpitations, difficulty urinating, tremor, headache, agitation or anxiety, changes in appetite, blurred or double vision, muscle weakness

Indications and Uses:

• Major Depressive Disorder • Anxiety Disorders:

• Panic Disorder • Social Phobia • General Anxiety Disorder • Separation Anxiety Disorder • OCD • PTSD

• Bipolar Disorder, Depressed • Dysthymic Disorder

Symptoms Most Likely to Respond

• Appetite disturbance and weight loss

• Sleep disturbance

• Decreased energy

• Decreased libido

• Psychomotor agitation or retardation

• Diurnal mood variation

• Major depression/agitated depression

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Symptoms Less Likely to Respond

• Demoralization

• Low self-esteem

• Hopelessness

• Helplessness

• Dysthymic disorder

• Personality disorder

Antipsychotics

Older Antipsychotics

Generic Name Brand Name FDA Maximum Dosage

Haloperidol Haldol 60 mg

Thioridazine Mellaril 800 mg

Pimozide Orap 10 mg

Fluphenazine Prolixin 40 mg

Trifluoperazine Stelazine 80 mg

Chlorpromazine Thorazine 2000 mg

Perphenazine Trilafon 64 mg

Haloperidal Haldol Decanoate 300 mg/mo

Fluphenazine Prolixin Decanoate 75mg/every 2 weeks

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Newer Antipsychotics

Generic Name Brand Name Usual Dose Range

Aripiprazole Abilify 10 to 30 mg/d, single dose

Clozapine Clozaril 25mg to 900 mg/d, divided

Iloperidone Fanapt 2 to 24 mg/d, divided

Ziprasidone Geodon 80 to 200 mg/d, divided

Paliperidone Invega 6 to 12 mg/d, single dose

Risperidone Risperdal 1 to 8 mg/d, divided

Asenapine Saphris 10 to 20 mg/d, divided

Quetiapine Seroquel 50 to 800 mg/d, divided

Olanzapine Zyprexa 10 to 40 mg/d, single dose

Risperidone Risperdal Consta 50 mg/2 weeks

Antipsychotic Side Effects

Atypical Antipsychotics • Common: sedation, weight gain, orthostatic

hypotension (low blood pressure) , QTc interval changes (EKG changes), extrapyramidal side effects: – Akinesia (inability to initiate movement) – Akathisia (inability to remain motionless, feeling of

restlessness) – Acute dystonia (twisting and repetitive movements or

abnormal postures) – Drug induced parkinsonism (muscular rigidity,

bradykinesia, akinesia, resting tremor, postural instability – Tardive dyskinesia (involuntary asymmetrical movements

of the muscles – a long term chronic condition associated with long term use of antipsychotics)

Antipsychotic Side Effects

• Hyperprolactinemia - high levels of prolactin in the blood – can be asymptomatic and found in lab work or symptomatic (lactation, menstrual period disruption, erectile dysfunction, gynecomastia (enlarged breasts in men), loss of libido, osteoporosis

• Others: headache, anxiety, nausea, insomnia, akasthisia, dizziness with Abilify, agranulocytosis (lowered white cell count) and increased seizures with Clozapine, severe hyperglycemia, diabetic ketoacidosis and weight gain with Zyprexa, QTc changes with Geodon

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Antipsychotic Side Effects

Typical Antipsychotics:

• Common - anticholinergic side-effects (dry mouth, urinary hesitancy (and even retention), constipation and visual disturbance), postural hypotension, disturbances of sexual functions, nasal congestion, sedation, weight gain, hyperprolactinaemia, galactorrhoea, amenorrhoea and gynaecomastia, extrapyramidal side-effects (EPSE), tardive dyskinesia

Indications and Uses

• Antipsychotic medications are used to treat schizophrenia and other psychotic disorders and certain mood disorders

• These medications may improve psychotic symptoms such as hallucinations, delusions, impaired reality testing and disorganized thinking

• Antipsychotic medications are sometimes referred to as neuroleptics

• Some have been available since the 1950s

Indications and Uses

• Psychosis – Schizophrenia and Schizoaffective Disorder

– Major Depressive Disorder with Psychotic Features

– Bipolar Disorder with Psychotic Features

– Psychotic Disorder NOS

• Mood Disorders – Bipolar Disorder I, most recent episode manic

– Major Depression (augmentation)

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Indications and Uses

• Autistic Disorder – Irritability, aggression, SIB, tantrums,

rapidly changing moods

• Tourette’s Disorder

• OCD – Treatment resistance

– Failure of 2 SSRIs and CBT

• Drug induced psychosis

• Aggression and SIB (????????)

Symptoms Most Likely to Respond

• Combativeness

• Hyperactivity

• Tension

• Hostility

• Hallucinations

• Sleeplessness

• Poor hygiene and self-care

• Acute delusions

• Social isolation

Symptoms Less Likely to Respond

• Lack of insight

• Poor judgment

• Impaired memory

• Disorientation

• Chronic delusions

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Mood Stabilizers

Mood Stabilizers

Generic Name Brand Name FDA Maximum Dose

Divalproex/Valproic Acid Depakote/Depakene* 60 mg/kg/day

Lithium carbonate Eskalith/Lithobid 1800 mg/d

Lamotrigine Lamictal* 0.15 to 3.0 mg/kg/d

Gabapentin# Neurontin* 1800 mg/d

Carbamazepine Tegretol* 1200 mg/d

Topiramate# Topamax* 5-9 mg/kg/d

Oxcarbazapine Trileptal* 1800 mg/kg/d

*Anticonvulsants # Not FDA approved

Mood Stabilizer Side Effects Anticonvulsant mood stabilizers • Depakote: weight gain, drowsiness, low

energy, stomach upset, changes in liver function, and problems with platelet functioning. Uncommon side effects can include temporary hair loss, headaches, and confusion. Rare but serious – pancreatitis (abdominal pain, nausea and vomiting)

• Tegretol: nausea, vomiting, diarrhea, Stevens-Johnson syndrome, dizziness, blurred vision, drowsiness, and headache

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Mood Stabilizer Side Effects

Anticonvulsant mood stabilizers

• Lamotrigine: headaches, sleepiness, weight gain, Rare side effects can include dizziness, blurred vision, nausea and vomiting, liver function problems, hypersensitivity reaction, and Stevens-Johnson syndrome which causes dangerous sores on the mucous membranes of the mouth, nose, genitals, and eyelids. This may require hospitalization and may be life-threatening

Mood Stabilizer Side Effects

Anticonvulsant mood stabilizers • Topamax – constipation, decreased sweating,

diarrhea, dizziness, drowsiness, dry mouth, flu-like symptoms, headache, loss of appetite, nausea, nervousness, numbness or tingling of the skin, runny nose, sore throat, stomach pain or upset, taste changes, tiredness, trouble sleeping, weight loss

• Neurontin – clumsiness, constipation, diarrhea, dizziness, drowsiness, dry mouth, nausea, stomach upset, tiredness, vomiting, weight gain

Mood Stabilizer Side Effects Lithium carbonate • Common: Nausea, vomiting, diarrhea, trembling,

increased thirst and increased need to urinate, weight gain in the first few months of use, drowsiness, a metallic taste in the mouth, abnormalities in kidney function, abnormalities in thyroid function

• More serious side effects: blacking out, slurred speech, changes in heart rhythm or a heart block, and an increase in the number of white blood cells (not usually because of an infection)

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Signs of Lithium Toxicity

• Slurred speech

• Drowsiness

• Muscle weakness

• Coarse tremor

• Anorexia

• Vomiting/diarrhea

• Ataxia

• Confusion

Early Signs

Signs of Lithium Toxicity

• Impaired consciousness

• Somnolence

• Confusion

• Hypertonic muscles

• Increased DTR’s

• Hyperextension of arms and legs

• Seizures

• Coma progressing to death

Late Signs

Indications and Usage

• Bipolar Disorder

• Schizoaffective Disorder

• Pain (Neurontin)

• Migraine, Obesity (Topiramate)

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Anxiolytics

Anxiolytics Generic name Brand Name Duration Other Uses

Alprazolam Xanax Short acting

Buspirone Buspar Long acting Anxiety assoc with ASD

Chlordiazepoxide Librium Short acting Alcohol detox

Diazepam Valium Long acting Seizures, status epilepticus

Clonazepam Klonopin Short acting Seizures, mania

Lorazepam Ativan Short acting

Oxazepam Serax Long acting

Clorazepate Tranxene Long acting

Anxiolytic Side Effects

• Benzodiazepines – Addiction and abuse, drowsiness, dizziness, decreased

alertness and concentration – Lack of coordination, falls and injuries – Decreased libido and erection problems – Depression and disinhibition – Nausea and changes in appetite, blurred vision,

confusion, euphoria, depersonalization and nightmares – Paradoxical reactions, such as increased seizures in

epileptics, aggression, violence, impulsivity, irritability and suicidal behavior sometimes occur

• Buspirone – Common: dizziness, nausea, headache, nervousness,

lightheadedness, and excitement

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Indications and Usage

• Acute situational anxiety • Generalized anxiety disorder • Phobic disorder • Panic disorder • Drug withdrawal syndromes • Extrapyramidal side effects • Insomnia

Sleep

• Symptom associated with a psychiatric disorder (depression and other mood disorders, psychotic disorders, anxiety disorders)

• Medical problem (chronic pain, breathing problems, urinary problems, GERD, thyroid disease, dementia)

• Environmental problem (stress, change in schedule, staffing, peers)

Sleep

• Medication side effect (psychotropics, heart and blood pressure, allergy, stimulants, steroids, OTC too)

• Caffeine, nicotine, alcohol

• Poor sleep habits (schedule, bedtime activities, environment, daytime activity)

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Sleep

• Learned insomnia (try too hard, fall asleep when not trying)

• Eating too much late in the evening

• Sleep disorder (sleep apnea, restless leg syndrome)

Sleep Medications Generic name Brand Name Dose Usage

Temazepam Restoril 7.5 to 30 mg Use for less than a few or several

Triazolam Halcion 0.125 to 0.5 mg weeks at a time. Best if not used

Flurazepam Dalmane 15 to 30 mg every night

Zolpidem Ambien 5 to 15 mg Use for limited time and not

Zalepion Sonata 5 to 20 mg every night

Eszopiclone Lunesta 1 to 3 mg New, less habit forming

Rameleton Rozerem 4 to 16 mg

TREATING “BEHAVIOR”

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Adult Behavior Problem Assessment Scale

For each item, give yourself 0 to 5 points according to the following scale:

Frequently 5 points

Occasionally 3 points

Seldom 1 point

Never 0 points

1. Smoking 2. Drinking caffeine 3. Drinking alcohol 4. Nail biting 5. Not keeping up with household chores 6. Eating too much sugar, fat, or cholesterol 7. Not exercising 8. Fighting with significant other 9. Impatient with children 10. Not finishing projects started 11. Not keeping up yard 12. Not keeping up your car 13. Not mending your clothes

11. Not recycling paper and aluminum

12. Gossiping

13. Telling white lies

14. Not balancing the check book

15. Not paying bills on time

16. Not keeping up with tax receipts

17. Not getting rid of old clothes

21. Not keeping closets and drawers clean

22. Not keeping up with politics and world events

23. Not registering and/or voting

24. Not doing community service

25. Not wearing your seat belt

26. Not regularly flossing your teeth

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Add up your score . . .

59 or below Mild Behavior Disorder

60-69 Moderate Behavior Disorder

70 or more Severe Behavior Disorder

• Rational pharmacotherapy requires decisions as to when and when not to medicate

• Emotional responses to ordinary life situations should generally not be medicated

• Psychiatric illnesses should be treated in order to not prolong the patient’s illness and suffering

• Irrational use of medications may lead to simultaneous adverse reactions to multiple drugs

• All medications should be temporarily withheld if an unexplained adverse response occurs

• It is generally advisable to start only one medication at a time, and to observe the patient before others are added

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EXPECTATIONS AND RESULTS

• We should assess effectiveness of treatment

• Agree upon discrete treatment goals

• Assess target symptoms

• If the individual is not experiencing improvement, review:

• The accuracy and completeness of the biopsychosocial diagnosis

• The comprehensiveness of the treatment plan

• The consistency of implementation of treatment by the caregivers

What are the three most important things a START Coordinator should know about the role of medication in treatment?

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• May be one element of treatment for clearly defined and accurately diagnosed psychiatric disorders

• May be one element of treatment for psychiatric symptoms that may not clearly meet criteria for a specific syndrome

• Use for the treatment of “behaviors” is a slippery slope

What are the three most important things a START Coordinator should teach providers and families about medication treatment?

• Garbage in is garbage out – a mutual exchange of information is essential

• Not every problem can be solved with a pill. Sometimes pills can make things way worse

• If we don’t know where we are going, how will we know when we get there? A comprehensive treatment plan with clearly defined outcomes should drive treatment

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To be able to ask a question clearly is two-thirds of the way to getting it answered. - John Ruskin

• Has an accurate psychiatric diagnosis been made?

• Does the medication “match” the diagnosis? e.g., Antidepressants prescribed for depression; antipsychotics for schizophrenia and other psychosis; mood stabilizers for bipolar disorder; stimulants for ADHD, etc.

• If the medication doesn’t “match” the diagnosis is there sufficient documentation to support the use of the medication(s)?

• If more than 2 medications are being prescribed is the justification present?

• Do the potential benefits of taking the medication(s) outweigh the potential risks?

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One who asks a question is a fool for five minutes; one who does not ask a question remains a fool forever. - Chinese proverb