What to Do If Traditional Medications Are Not Achieving Expected Results

Darlyne G. Nemeth, Ph.D., M.P., M.P.A.P.

Clinical, Medical, and NeuropsychologistThe Neuropsychology Center of Louisiana

www.louisiananeuropsych.com

The CW Austin Learning Disabilities Conference

Saturday, April 25, 2015

Antidepressant Medications

Generic Name+ Brand Name FDA Approval*

SSRI

Fluoxetine Prozac, Sarafem Approved for ages 8 and older

Sertraline Zoloft Approved for ages 6 and older

Paroxetine Paxil Not specifically approved for children and adolescents

Citalopram Celexa Not specifically approved for children and adolescents

Escitalopram Lexapro Approved for ages 12 and older

Fluvoxamine Luvox Approved for ages 8-17 for OCD

SNRI

Venlafaxine XR Effexor XR Not specifically approved for children and adolescents

Desvenlafaxine Pristiq Not specifically approved for children and adolescents

Duloxetine Cymbalta Not specifically approved for children and adolescents

NRI

Atomoxetine Strattera Approved for ages 6 and older for ADHD

NDRI

Bupropion SR/XL Wellbutrin SR/XL Not specifically approved for children and adolescents

Atypical

Mirtazapine Remeron Not specifically approved for children and adolescents

Trazodone Desyrel Not specifically approved for children and adolescents

* Stahl, S. M., & Grady, M. M. (2011). Stahl's essential psychopharmacology: The prescriber's guide (4th ed.). Cambridge, UK: Cambridge University Press.

+ Preston, O’Neal, and Talaga (2010), pp. 20-22.

Common Side Effects of Antidepressants

Medication Activation Sedation Nausea Sexual Dysfunction Weight Gain

SSRI

Fluoxetine +++ +/0 + ++ 3

Sertraline ++ +/0 ++ ++ 3

Paroxetine + ++ + ++ 3

Citalopram + +/0 + ++ 3

Escitalopram + +/0 + ++ 3

Fluvoxamine +/0 ++ ++ ++ 3

SNRI

Venlafaxine + + + ++ 3

Desvenlafaxine + + + ++ 3

Duloxetine + + ++ + 4

NRI

Atomoxetine + ++ +/0 0 0

NDRI

Bupropion ++ 0 + 0 0

Atypical

Mirtazapine +/0 ++ 0 ++ +++

Trazodone 0 +++ 0 0 0

KEY: +++: substantial side effects, ++: moderate side effects, +: mild side effects, +/0: possible side effects, 0: none

Interactions and Monitoring ParametersDrug Interactions with Drugs Commonly Used in Pediatrics Monitoring Parameters

Lithium

Increased lithium levels: Nonsteroidal anti-inflammatory agents Metronidazole (Flagyl)

Decreased lithium levels: Theophylline

Neurotoxicity*: Antipsychotics TCAs SSRIs Carbamazepine

Serum Plasma Levels:Acute mania:0.8-1.5 mEq/LMaintenance:0.6-1.2 mEq/LEKG, CBC, electrolytes,r enal function tests, thyroid function, weight

Divalproex (Depakote; DVP)

Erythromycin increases DVP levels.DVP increases levels of TCAs.DVP decreases levels of bupropion.Risk of serious rash is increased when DVP and Lamotrigine are taken together.Variable effect on levels of other anticonvulsants when taken with DVP.

Serum Plasma Levels:50-150 mcg/mlCBC, platelets, liver function, weight

Carbamazepine(Tegretol; CBZ)

Neurotoxicity*: Lithium

CBZ decreases levels/effectiveness of: TCAs Antipsychotics Oral contraceptives Doxycycline

Serum Plasma Levels:8-12 mcg/mlCBC, EKG, liver function, weight

*Although neurotoxicity can occur, it is infrequent and does not contraindicate combinations of lithium with the medications listed.

Preston, O’Neal, and Talaga, 2010, pp. 45-46

Obsessive-Compulsive Disorder Medications

Generic Name Brand Name

Citalopram Celexa

Clomipramine (FDA indications for children and adolescents) Anafranil

Fluvoxamine (FDA indication for ages 8-17 years) Luvox

Fluoxetine(FDA indication for ages 7-17 years) Prozac

Sertraline(FDA indication for ages 13-17 years) Zoloft

Schizophrenia Positive Schizophrenia Symptoms• Hallucinations • Delusions• Agitation • Floridly bizarre behavior

Negative Schizophrenia Symptoms• Anhedonia • Apathy• Blunted affect • Poverty of thought• Feelings of emptiness • Amotivational states

Disorganization Schizophrenia Symptoms• Behavioral disorganization• Distractibility• Thought disorder

Characterological Schizophrenia Symptoms• Social isolation or alienation• Marked feelings of inadequacy• Poorly developed social skills

Other psychotic disorder include the following:• Brief psychotic disorder: symptoms lasting less than one month, usually with an identifiable stressor• Delusional disorder: persistent nonbizarre delusions• Schizoaffective disorder: episodes of mania and/or depression in addition to the symptoms of schizophrenia• Shared psychotic disorder: symptoms developing as a result of intense relationship with someone who is already

psychotic

Preston, O’Neal, and Talaga, 2010, pp. 61-62

Side Effects of Antipsychotic Medications

Brand Name Generic Name Sedation Extrapyramidal Anticholinergic

Low Potency First GenerationThorazine Chlorpromazine ++++ ++ ++++Serentil Mesoridazine ++++ + +++++Mellaril Thioridazine ++++ + +++++High Potency First GenerationProlixin Fluphenazine + +++++ ++Haldol Haloperidol + +++++ +Loxitane Loxapine + +++ ++Moban Molindone + +++ +++Trilafon Perphenazine ++ +++ ++Orap Pimozide + +++++ +Navane Thiothixene + ++++ ++Stelazine Trifluoperazine + ++++ ++Second GenerationAbilify Aripiprazole + +/0 0Clozaril Clozapine ++++ 0 +++++Fanapt Iloperidone + + +/0Zyprexa Olanzapine ++ +/0 +Invega Paliperidone + + +/0Seroquel Quetiapine ++ +/0 ++Risperdal Risperidone + + +/0Geodon Ziprasidone + + +Key: +++: substantial side effects; ++: moderate side effects; +: mild side effects; +/0: possible side effects; 0: nonePreston, O’Neal, and Talaga, 2010, pp. 66-68

Attention-Deficit/Hyperactivity Disorder Medications

Immediate Release Stimulants(duration of effect is 3 to 6 hours)

Generic Name Brand Name

Methylphenidate

RitalinMetadataMethylinConcerta

Dexmethylphenidate FocalinDextroamphetamine Dexedrine

AmphetaminesAmphetamine mixed salts (Adderall)Methamphetamine (Desoxyn)

Sustained Release Stimulants(duration of effect is 6 to 12 hours)

Methylphenidate

Ritalin SRRitalin LAMetadata ERMetadata CDMethylin ERConcertaDaytrana (patch)

Dextroamphetamine Dexedrine spansulesLisdexamphetamine VyvanseAmphetamine Adderall XRPreston, O’Neal, and Talaga, 2010, p. 75

Stimulant Side Effects and Solutions

Side Effect Solutions

Initial insomnia Try earlier dosing, or co-administer clonidine or Trazodone given at bedtime

Reduced appetite (Generally only affects the patient when the drug is active; it has not been associated with significant problems obtaining adequate nutrition. Thus the side effect is generally not treated.)

If necessary, switch to Focalin, which may result in less of this effect.

Stomach ache Give medications with food.

Mild dysphoria Switch classes of stimulants, or add an antidepressant such as bupropion.

Lethargy, sedation, or impaired concentration (Generally indicates that the dose is too high.) Reduce dose

Headache Reduce dose, or change stimulants

Preston, O’Neal, and Talaga, 2010, pp.77-78

Consequences of Misdiagnosis

Consequences of Misdiagnosis and Subsequent Stimulant Treatment

Correct Diagnosis Consequences

Anxiety disorder Increased anxiety

Agitated depression Increased agitation

Preschizophrenia Psychosis

Bipolar disorder Increased manic symptomsPossible cycle acceleration

Situational stress Failure to address psychological issues

Preston, O’Neal, and Talaga, 2010, p. 79

Other Choices to Treat ADHD

Alpha-2 Adrenergic Agonists

Generic Brand

Clonidine Catapres/Kapvay

Guanfacine Tenex/Intuniv

Preston, O’Neal, and Talaga, 2010, p. 80

Antidepressants Used to Treat ADHD

Generic Brand

Bupropion Wellbutrin SR/LA

Atomoxetine Strattera

Preston, O’Neal, and Talaga, 2010, p. 81

Autism Spectrum Disorder & Asperger’s Disorder

Diagnostic Criteria for Autism Spectrum Disorder according to the DSM-IV-TR

Significant impairment in social interaction such as the following: Impairment in the use of nonverbal behaviors such as facial expression in social interaction Failure to develop peer relationships appropriate to age A lack of spontaneous seeking to share interests with others

Significant impairments in communication as shown by at least one of the following: Delayed or absent development of spoken language In individuals with adequate speech, impaired ability to converse with others Use of language in stereotyped or idiosyncratic ways Lack of make-believe play or imitative play appropriate to age

Stereotyped patterns of interests and activities, as shown by at least one of the following: Intense preoccupation with one or more stereotyped and restricted patterns of interest Rigid adherence to nonfunctional routines or rituals Stereotyped and repetitive motor mannerisms Intense preoccupations with parts of objects

Diagnostic Criteria for Asperger’s Disorder according to the DSM-IV-TR

Qualitative impairment in social interaction, as manifested by at least two of the following: Impairment in the use of nonverbal behaviors such as facial expression in social interaction Failure to develop peer relationships appropriate to age Lack of spontaneous seeking to share interests with other people Lack of social or emotional reciprocity

Stereotyped patterns of interest and activities as shown by at least one of the following: Intense preoccupation with one or more stereotyped and restricted patterns of interest Rigid adherence to nonfunctional routines or rituals Stereotyped and repetitive motor mannerisms

The disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning.

No clinically significant delay in language is seen.

New Medications & Uses

A. For Executive Dysfunction and Affective/Behavioral Dyscontrol1) Amantadine – 100 mg b.i.d. for older children, or, for young children, 50 mg per mL

with black cherry flavoring

2) Propranolol – 40 mg b.i.d. for older children, or, for young children, 20 mg b.i.d.

3) Nuedexta – 20 mg/10 mg for ages 18 and above who have had a neurological trauma.

B. For Bipolar Depression (ages 18 and above) 1) Latuda – Starting at 20 mg

C. For Bipolar Mania (age 10 and above) and/or Schizophrenia (age 12 and above)

1) Saphris – Starting at 5 mg sublingual

D. For ADHD (ages 6 to 12)1) Quillivant XR – Liquid

Genetic Testing

Private Insurance

Medicare, Medicare, Tricare

Psychotropic Medications

For access to Dr. John Preston’s Quick Reference to Psychotropic

Medications®, visit…

http://psyd-fx.com/quickreference2014.pdf

References

Nemeth, D.G., Franz, S., Kruger, E., & Schexnayder, M.M. (2011). The practice of medical psychology in an RxP state: New opportunities for comprehensive pediatric care. In G. Kapalka (Ed.) Pediatricians and pharmacologically trained psychologists: Practitioner’s guide to collaborative treatment, 49-66, New York, NY: Springer.

Preston, J., Neal, J. H., & Talaga, M. (2010). Child and adolescent clinical psychopharmacology made simple (2nd ed.). Oakland, CA: New Harbinger Publications.

Stahl, S. M., & Grady, M. M. (2011). Stahl's essential psychopharmacology: the prescriber's guide (4th ed.). Cambridge, UK: Cambridge University Press.