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PIPC® Psychiatry In Primary Care
Medications
Robert K. Schneider, MD
Departments of Psychiatry, Internal Medicine
and Family Practice
The Medical College of Virginia at
the Virginia Commonwealth University
Richmond, Virginia
PIPC® Goals
• Effectively recognize, diagnose and
treat mental illness in primary care
• Bring the psychiatry skills and
knowledge base of the primary care
physician on par with other medical
specialty knowledge bases
Outline
• PIPC 1
– Introduction
– PIPC Interview
®
– MAPS-O
– Mood Disorders
– Suicide
®
Outline
• PIPC 2
– Anxiety Disorders
• PIPC 3
– Neurotransmitters
– The 3 Phases and the 5Rs
– Medications
– Cases and Discussion
NEUROTRANSMITTERS
Neurotransmitter Receptor Hypothesis
of Antidepressant Action
Decreased state due to upregulation of receptors
6-2
Stahl S M, Essential
Psychopharmacology (2000)
Neurotransmitter Receptor Hypothesis
of Antidepressant Action
Antidepressant blocks the
reuptake pump, causing more
NT to be in the synapse
6-5
6-6
Increase in NT causes receptors
to down-regulate
Stahl S M, Essential
Psychopharmacology (2000)
amount of
NT
receptor
sensitivity
clinical effect
antidepressant introduced
6-1
Stahl S M, Essential
Psychopharmacology (2000)
The 3 Phases and 5 Rs
• Acute
• Response
• Continuation
• Remission
• Maintenance
• Relapse
• Recovery
• Recurrence
EPISODE OF DEPRESSION
RECOVERY OR
REMISSION
NORMAL MOOD
DEPRESSION
TIME
6 - 24 months
5-1
Stahl S M, Essential
Psychopharmacology (2000)
NORMAL
MOOD
REMISSION
100%
RECOVERY
DEPRESSION
acute
continuation maintenance
6 - 12 weeks 4-9 months 1 or more years
TIME
5-3
Stahl S M, Essential
Psychopharmacology (2000)
NORMAL
MOOD
RELAPSE RECURRENCE
DEPRESSION
acute
continuation maintenance
6 - 12 weeks 4-9 months 1 or more years
TIME
5-4
Stahl S M, Essential
Psychopharmacology (2000)
Acute Phase Treatment
• Focus is response and full remission
• establish target symptoms
• patient preference, “collaborative approach”
• Psychotherapy especially helpful in chronic
depression or depression exacerbated by recent
stressors
• Acute phase is over ONLY after a remission is
achieved
NORMAL MOOD
RESPONSE
RESPONSE
DEPRESSION
5-2
Stahl S M, Essential
Psychopharmacology (2000)
Changing the Medication
• “Pseudoresistance”
– Verifying Compliance (“like an antibiotic”)
– “Too little, too late”
– Inadequate duration
– Correct diagnosis (undetected comorbid diagnosis)
• Worsening Condition
– severity escalating
– new symptoms developing (destructive impulses)
• Partial Remission vs. Full Remission
Continuation Phase Treatment
• Focus is to prevent relapse
• Period of time following full remission during
which discontinuation of treatment will result
in relapse
• Don’t stop before 6-9 months of therapy
• Don’t decrease the dosage
• Full Dosage, for the Full Period of Time
NORMAL
MOOD
RELAPSE RECURRENCE
DEPRESSION
acute
continuation maintenance
6 - 12 weeks 4-9 months 1 or more years
TIME
5-4
Stahl S M, Essential
Psychopharmacology (2000)
Maintenance Phase Treatment
• Focus is to prevent recurrence
• Recurrence can only occur after the
recovery from a previous episode
• Therefore only recurrent major
depression is considered
• Maintain Full Dosage
Termination vs. Maintenance
•
•
•
•
Degree of Functional Impairment
Additional non-affective mental disorder
Chronic medical disorder
Prior history of depressive episode
1 episode: 50-80%
2 or more episodes: 80-90%
• Persistence of dysthymic symptoms
NORMAL
MOOD
RELAPSE RECURRENCE
DEPRESSION
acute
continuation maintenance
6 - 12 weeks 4-9 months 1 or more years
TIME
5-4
Stahl S M, Essential
Psychopharmacology (2000)
MEDICATIONS
General Considerations
• Three Neurotransmitters
– Serotonin
– Norepinephrine
– Dopamine
• Three major sites of action
– Reuptake pump
– Post-synaptic receptor
– MAO enzyme inhibition
Common Classes
• TCAD
– NE and 5HT Reuptake inhibition
• SSRI
– 5HT Reuptake inhibition
• “Less Selective” Reuptake inhibition
– DA and NE (buproprion)
– 5HT and NE (venlafaxime)
• Post synaptic receptor blockade
– Trazodone, nafazodone
Norepinephrine and Serotonin
Reuptake Inhibitors: TCAD
• Classic Tricyclic Antidepressants
–amitriptyline (Elavil)
–clomipramine (Anafranil)
–desipramine (Norpramin)
–imipramine (Tofranil)
–nortriptyline (Pamelor)
Norepinephrine and Serotonin
Reuptake Inhibitors: Effects
• Primarily blocks reuptake of norepinephrine,
serotonin and weakly dopamine
• Effective in severe depression and anxiety
disorders
• Sedating properties, reduces pain and
stimulates appetite
• Nortriptyline level is a meaningful
measurement
Norepinephrine and Serotonin
Reuptake Inhibitors
• Side Effects
– urinary retention, constipation, blurred vision,
dry mouth, weight gain, sexual dysfunction
– orthostatic hypotension, delayed cardiac
conduction
• Cautions
– the elderly
– cardiac patients
Selective Serotonin Reuptake
Inhibitors
• Classic SSRIs
–sertraline (Zoloft)
–fluoxetine (Prozac)
–paroxetine (Paxil)
–citralopam (Celexa)
Selective Serotonin Reuptake
Inhibitors: Effects
• Selectively blocks the serotonin reuptake
pump
• Mild to moderate depression (max doses
in severe)
• Safer in overdose
• Indicated for anxiety disorders
Selective Serotonin Reuptake
Inhibitors: Side Effects
• Side Effects
– nausea, headache
– jitteriness and insomnia (especially early)
– sexual dysfunction
– “Discontinuation Syndrome”
• Cautions
– very few
– notable exception: Serotonin Syndrome
Less Selective Reuptake
Inhibitors
• Serotonin, Norepinephrine and mild
Dopamine Reuptake Inhibitor
–venlafaxine (Effexor)
• Dopamine, Norepinephrine and mild
Serotonin Reuptake Inhibitor
–bupropion (Wellbutrin)
Serotonin, Norepinephrine &
Mild Dopamine Reuptake Inhibitor
• venlafaxine (Effexor)
– Effects
• blocks reuptake of serotonin, norepinephrine and
dopamine (mildly)
• antidepressant effects and anxiolytic properties
– Side Effects
• nausea, somnolence, dry mouth, constipation,
nervousness, dizziness
• risk of increased blood pressure
Dopamine, Norepinephrine & Weak
Serotonin Reuptake Inhibitor
• bupropion (Wellbutrin)
– Effects
• moderate dopamine reuptake inhibition,
norepinephrine reuptake inhibitor (bupropion metabolite),
and weak serotonin reuptake inhibition
• antidepressant, antismoking, NOT ANXIOLYTIC
– Side Effects
• agitation, tremor, insomnia, headache, constipation
• increased risk of seizures at doses above 450mg/day
• minimal sexual dysfunction, cardiac complications,
or weight gain
– Cautions
• history of seizures or previous head trauma
Postsynaptic Serotonin Inhibition
• Serotonin
(postsynaptic 5HT-2 inhibition)
– trazodone (Desyrel)
– nafazodone (Serzone)
Postsynaptic Serotonin Inhibition
• trazodone (Desyrel)
– Effects
• sedating, good hypnotic
• Post synaptic receptor blockade, weak SSRI
– Side Effects
• difficult to get to high enough doses for depression
• sedation, dry mouth, orthostasis, priapism (very rare)
• nafazodone (Serzone)
– Effects
• effective antidepressant
• good anxiolytic, effective in the anxious depressed
• Post synaptic blockade, moderate SSRI
– Side Effects
• sedation (much less than trazodone), nausea, visual
disturbances, lightheadedness
CASES