Download Is it ADHD, Bipolar I, or RAD? - Kaiser Permanente Sacramento

Hey, you! Are you
Bipolar, Depressed,
Borderline, or What?
John L. Schaeffer, D.O.
Child, Adolescent & Adult
Psychiatrist
Kaiser Permanente Psychiatry
Roseville, CA
October 17, 2009
Disclosure of Relevant Financial
Relationships
Dr. Schaeffer has disclosed that he has no
relevant relationships with commercial or
industry organizations.
The CME Department has reviewed disclosure
information for the planners and developers
for this program and they do not have
relationships that present a relevant conflict
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?
“Kids: They dance before they learn there is
anything that isn’t music.”
William Stafford
Primary 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 Kaiser
Permission to use cartoon per Dwayne Booth
Though I’m sure it must sometimes feel
more like this:
Representing Psychiatry, I am
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
you patients with mental illness
Trying to diagnose psych patients can feel like
Keep it simple.
Just what the heck is Bipolar Disorder?
Multiple types/multiple episodes
within 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:
• Specifiers
• The following specifiers for Bipolar I Disorder
can be used to describe the current Manic,
Mixed, or Major Depressive Episode (or, if
criteria are not currently met for a Manic, Mixed,
or Major Depressive Episode, the recent Manic,
Mixed, or Major Depressive Episode):
•
Mild, Moderate, Severe Without Psychotic
Features, Severe With Psychotic Features, In
Partial Remission, In Full Remission...
With Catatonic Features...
With Postpartum Onset...
•
The following specifiers apply only to the
current (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?
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.
Let’s play:
“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
Hypomanic
Normal
Dysthymic
Depressed
Money
Half the mania
Ass to Everybody
Manic
Nothing is Neutral
Yearning for greatness but still in control
Impulsive
Hypo
People’s opinions still matter
Cyclical
Organized enough to work/function
Normal
Determined to see Negative “Yes, butt….” Serious
Time is 2 yrs
Dysthymic
Haggard “Yesterday….” Interested but little joy
Depressed
Demented cognition Everything is affected Personal hygiene Regressed
Suicidal
Melancholic Ill Cynical
Septic Energy vacuum Death/morbid thoughts
Normal
Manic
Hypomanic
Normal
Dysthymic
Depressed
Major Depressive Disorder
Manic
Hypomanic
Normal
Dysthymic
Depressed
Cyclothymic Disorder
Manic
Hypomanic
Normal
Dysthymic
Depressed
Bipolar II
Manic
Hypomanic
Normal
Dysthymic
Depressed
Bipolar I
Manic
Hypomanic
Normal
Dysthymic
Depressed
Bipolar I
Manic
Hypomanic
Normal
Dysthymic
Depressed
Borderline Personality Disorder (each shift triggered by external forces)
Manic
Hypomanic
Normal
Dysthymic
Depressed
Some Pearls
Mood Interview Pearl #1
Origin
“When were you first aware of these
feelings? At what age?”
Age 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
With Early Onset, Intermediate Onset, and Late Onset
Frank Bellivier, M.D., Ph.D., Am J Psychiatry 160:999-1001, May 2003
Effect of Age at Onset on the Course of Major Depressive Disorder
Sidney Zisook, M.D., Am J Psychiatry 164:1539-1546, October 2007
Borderline Personality Disorder in under age 18:
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.”
Mood Interview Pearl #2
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)
Depression
Consecutive 2 week
period
Bipolar
BPD
I: Consecutive 1 week It’s a lifestyle, a
period
“pattern” if instability
II: Consecutive 4 day
period
Duration/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
Mood Interview Pearl #3
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 Disorder
It has to change the way you function.
True depression is not a frustration
It is an agony, a misery, a despair.
True Bipolar is not a fun little rollercoaster ride.
It is a sadistic master ripping you apart.
Borderline Personality Disorder is not a
game people play.
It’s a vast, lonely emptiness expecting total annihilation in the next breath.
The best goal is prevention
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.
Mood Interview Pearl #4
Genetics
“Who else in your biological family has the
same thing or something like it?”
Family History
Depression
Bipolar I
BPD
Dysthymic disorder.
Major Depression.
Alcohol abuse.
Panic Disorder.
Social Phobia.
ADHD is seen more in
children of adults with
Major Depression.
Any Mood Disorder
(depression, bipolar)
But especially
Bipolar I and Bipolar II
Alcohol & Substance
abuse.
Adoptions.
ADHD.
BPD. 5X greater risk
if a 1st degree relative
has BPD.
Mood Disorders.
Alcohol & Substance
abuse.
Neglect/PTSD.
Antisocial Personality
Disorder.
Lifetime 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.
Etiology
Depression
Bipolar I
Genetic
Genetic
Neurochemical
Exacerbated by stress
and hormones
Fetal Development
Brain Traumas
Nutritional deficiencies
Exacerbated by stress
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- 4
1.
2.
3.
4.
Origin—When did it begin?
Duration—How long does it last?
Severity—How much does it limit you?
Genetics—Who gave it to you?
Mood Interview Pearl #5
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.”
Mood Interview Pearl #6
Go ahead and feel your feelings.
Use how you feel to better understand your patients.
How do you feel when talking to the patient?
Annoyed?
Angry?
Hurt?
Hopeless?
How do you feel when talking to the patient?
Annoyed?
Maybe the pt
wants Attention.
Angry?
Maybe the pt
wants Power.
Hurt?
Maybe the pt
wants Revenge.
Hopeless?
Maybe the pt
wants Pity.
How do you feel when talking to the patient?
Attention seeking
could cue you in
to Borderline.
Power seeking could
cue you in to Bipolar if
it’s grandiosity and
Borderline if it’s “staff
splitting.”
Revenge seeking
could cue you in
to Borderline.
Pity could cue you
in to Depression if
it’s low self esteem
or Borderline if it’s
RESCUE.
What is “Staff Splitting?”
• “Finally someone understands me. My other
doctor never listened to me….”
How do you feel when talking to the patient?
Annoyed?
Angry?
Hurt?
Hopeless?
How do you feel when talking to the patient?
Annoyed?
Maybe the pt
wants Attention.
Angry?
Maybe the pt
wants Power.
Hurt?
Maybe the pt
wants Revenge.
Hopeless?
Maybe the pt
wants Pity.
How do you feel when talking to the patient?
Attention seeking
could cue you in
to Borderline.
Power seeking could
cue you in to Bipolar if
it’s grandiosity and
Borderline if it’s “staff
splitting.”
Revenge seeking
could cue you in
to Borderline.
Pity could cue you in to
Depression if it’s low
self esteem or
Borderline/Manipulation
if it’s RESCUE.
Mood 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, Rage
Depression
Bipolar I
BPD
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.
Secondary to limitsetting 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.
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- 6.1
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?
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 some more
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
retail cost), Nexium ($4.8b), Plavix ($3.8b), Advair
($3.6b), and Prevacid ($3.3b).
AARP: "Though brand names make up only 22% of
the names on the list, they represent 62% of the
$53.2 billion."
1. Hydrocodone (pain)
2. Lisinopril (hypertension)
3. Simvastatin (high cholesterol)
4. Levothyroxine (hypothyroidism)
5. Amoxicillin (bacterial infection)
6. Azithromycin (bacterial infection)
7. Lipitor (high cholesterol)
8. Hydrochlorothiazide (edema/hypertension)
9. Alprazolam (anxiety/depression)
10. Atenolol (hypertension)
11. Metformin (type 2 diabetes)
12. Metoprolol Succinate (hypertension)
13. Furosemide oral (edema/hypertension)
14. Metoprolol tartrate (hypertension)
15. Sertraline (depression)
16. Omeprazole (ulcers/reflux)
17. Zolpidem tartrate (insomnia)
18. Nexium (ulcers/reflux)
19. Lexapro (depression)
20. Oxycodone (pain)
21. Singulair (asthma)
22. Ibuprofen (pain/inflammation)
23. Plavix (blood clotting)
24. Prednisone oral
(allergies/inflammation)
25. Fluoxetine (depression)
26. Synthroid (hypothyroidism)
27. Warfarin (blood clotting)
28. Cephalexin (bacterial infection)
29. Lorazepam (anxiety)
30. Clonazepam (epilepsy/anxiety)
31. Citalopram (depression)
32. Tramadol (pain)
33. Gabapentin (epilepsy/pain
34. Ciprofloxacin HCl (bacterial
infection)
35. Propoxyphene-N (pain)
36. Lisinopril (hypertension)
37. Triamterene (edema/hypertension)
38. Amoxicillin (bacterial infection)
39. Cyclobenzaprine (muscle injury/spasm)
40. Prevacid (ulcers/reflux)
41. Advair (asthma)
42. Effexor XR (depression)
43. Trazodone HCl (depression)
44. Fexofenadine (allergy)
45. Fluticasone nasal (allergy)
46. Diovan (hypertension)
47. Paroxetine (depression/anxiety)
48. Lovastatin (high cholesterol)
49. Crestor (high cholesterol)
50. Trimethoprim (bacterial infection)
10 of the top 50 are for anxiety or depression.
That's about 19% of the total cost ($10.3b of
$53.2b). Depression is big business in this country.
4 of the top 50 are for high cholesterol, about 18%
($9.4b of $53.2b).
9 of the top 50 are for hypertension, about 9% ($4.9b of
$53.2).
That adds up to 27% of the total cost, a lot of money
for conditions that have been shown repeatedly to
respond to diet and exercise.
These are a lot of drugs for not a lot of health.1
________
1 US Ranks Last Among Other Industrialized Nations
On 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 diseaseawareness 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:
Physical meds causing psychiatric
issues:
From: Advances in Psychiatric Treatment (2005), vol. 11, 58–70,
Nora Turjanski & Geoffrey G. Lloyd.
As a psychiatrist,
I often see:
Beta blockers cause depression. Atenolol is hydrophilic. Propranolol
and Metoprolol are lypophilic.
Statin drugs cause agitation, insomnia, anxiety, and mood swings—
except prevastatin which doesn’t cross the BBB.
Triptan drugs cause Serotonin Syndrome when used with SSRIs.
(typically myoclonus & fever, but can be life threatening).
Benzos and opiates cause depression, confusion, problems with shortterm memory and with concentration/attention, and rebound insomnia.
Topamax = Dopamax = Stupimax
Keppra makes people crazy (agitated, hostile, anxious, apathetic,
depressed, and emotionally labile.
Depakote # 1 pt complaint? Hair falls out. Give zinc & selenium.
Antiepileptic meds also have FDA black box warning 0.5 % risk of suicide
(higher on multiple antiepileptic drugs).
Paxil deforms babies before you know you’re pregnant—don’t give it to
women of childbearing years.
Drug-Drug Interactions:
Psychiatric meds causing physical issues:
Here is a list of the Adverse
Reactions culled from the FDA
Individual Safety Reports where
Psychiatric Drugs were identified
as the Primary Suspect Drug:
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.
You have to expect action,
interaction, reaction.
We’re doctors.
We practice.
The important thing is to do the
best we can with what we have,
and then forgive ourselves for
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
muscles up even more!
Psychiatry
The Meds:
What are you supposed to be able to do at the
end of this talk?
List psych meds and
interactions with meds
commonly seen in Primary Care.
Common Antidepressant
Medications
•
•
•
•
•
•
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 Stabilizers
• Lithium Carbonate
• Depakote
(Valproic Acid)
• Tegretol
(carbamazapine)
• Trileptal
(oxcarbazapine)
• Lamictal (lamotrigine)
• Neurontin
(gabapentin)
• Topamax (topiramate)
• Neuroleptics &
Benzodiazepines
Atypical 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
(or want) to know?
Antidepressants
Three neurotransmitters:
Serotonin
Norepinephrine
Dopamine
SSRIs
Selective Serotonin Reuptake Inhibitors
Prozac (fluoxetine)
Zoloft (sertraline)
Paxil (paroxetine)
Celexa (citalopram)
Lexapro (escitalopram)
Luvox (fluvoxamine)
SNRIs
Serotonin Norepinephrine Reuptake
Inhibitors
Effexor (venlafaxine)
Cymbalta (duloxetine)
TCAs
Tricyclic Antidepressants
Although some TCAs (e.g., desipramine,
maprotilene) block norepinephrine reuptake more
potently than serotonin reuptake, the TCAs are not
selective since they block many other receptors
such as alpha 1, histamine 1, and muscarinic
cholinergic receptors.
NRI
Norepinephrine Selective Reuptake Inhibitors
Strattera (atomoxetine)
NDRI
Norepinephrine Dopamine Reuptake Inhibitor
Wellbutrin (bupropion)
(the higher the dose the greater the dopamine
to norepinephrine ratio)
How’s it work?
Insert dry erase board demonstration here.
Pick a med by its side effect
• 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 effect
How much energy does the pt have/need?
Morning
Bedtime
More Energy Neutral
Lexapro
Sedating
Remeron
Celexa
Energizing
Prozac
Zoloft
Effexor
Cymbalta
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 effect
How much hunger does the pt have/need?
Morning
Appetite
suppression
Prozac
Wellbutrin
Bedtime
Appetite (therefore
weight ) Neutral
Lexapro
Zoloft
Celexa
Effexor
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
Fat Builders
Remeron (from
7.5 go 30 mg but
not at 45 mg)
Pick a med by its side effect
Oversexed or undersexed?
Morning
Prozac = 10-25 %
reduction.
Bedtime
Appetite (therefore weight )
Neutral
Lexapro = 15-30 % reduction
Zoloft = 40-60 % reduction
Luvox = 25-40 % reduction
Celexa = 1-5 % reduction
Effexor = neutral
Cymbalta = neutral
Wellbutrin = 30 %
boost
Buspar
Is used to tx sexual
side effects from
SSRIs
Remeron
Is used to treat
sexual side
effects from other
AD
The 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 #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.
Now the interactions with meds commonly
seen in primary care.
Start with the liver.
http://www.thehealthylonglifeblog.com/wp-content/uploads/2008/09/liver-detox.jpg
Cytochrome P450 for Dummies:
Let’s first anthropomorphize the Liver
Let’s pretend your liver is the
US Customs Service
Specifically, an agent named
Mr. Cyto Chrome, Badge #P-450:
Now there are travelers who want to come
to 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 Liver
Now Cyto 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
higher paying jobs, and they try to influence
Cyto as to which yes he picks.
These special agents can either make Cyto strong
Or weak
Smart
Or Stupid
So what makes Cyto the Liver 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 P450
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 P450
Inhibitors (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
Inhibitors (Paxil, Prozac, Luvox,
Celexa, Wellbutrin) weaken Cyto
the Liver (Cytochrome P450) and
Substrates (Theophylline, Warfarin,
propranolol, benzos, Depakote,
Methadone, Thorazine) INCREASE
in plasma concentrations.
Zoloft is the weakest of the inhibitors.
Inducers (Smoking, charbroiled foods,
Tegretol, Phenobarb, Phenytoin,
Rifampin, Nevirapine, St. John’s Wort)
strengthen Cyto the Liver (Cytochrome
P450) and Substrates (Theophylline,
Warfarin, propranolol, benzos,
Depakote, Methadone, Thorazine)
DECREASE in plasma concentrations.
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,
a restrictor inhibits Mr. Cyto Chrome’s
action, and the traveler gets through
unrestricted,
but a booster makes Mr. Cyto Chrome
stronger, so the traveler is restricted.
Inhibit to set free.
Induce to restrict.
Mood Interview Pearls 1- 6.1
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?
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 #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 #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
Metoprolol are lypophilic.
Statin drugs cause agitation, insomnia, anxiety, and mood swings—except
prevastatin which doesn’t cross the BBB.
Triptan drugs cause Serotonin Syndrome when used with SSRIs.
(typically myoclonus & fever, but can be life threatening).
Benzos and opiates cause depression, confusion, problems with short-term
memory and with concentration/attention, and rebound insomnia.
Topamax = Dopamax = Stupimax
Keppra makes people crazy (agitated, hostile, anxious, apathetic,
depressed, and emotionally labile.
Depakote # 1 pt complaint? Hair falls out. Give zinc & selenium.
Antiepileptic meds also have FDA black box warning 0.5 % risk of suicide
(higher on multiple antiepileptic drugs).
Paxil deforms babies before you know you’re pregnant—don’t give it to
women of childbearing years.
Mr. Cyto Chrome, Badge #P-450
Inhibit to set the substrate free.
Induce to restrict the substrate.
I have woven a parachute out of
everything broken.
William Stafford
Psychiatry salutes Primary Care
The Spine of Kaiser Permanente
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Thought 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
www.flickr.com/photos/pattpoom/3205572737/