Upon completion of this seminar the professional will be expected to demonstrate knowledge and: Sophia F. Dziegielewski, Ph.D., LCSW Identify important terms, myths and practices related to the treatment of depression Identify several methods for addressing treatment resistant depression Summarize the risks and benefits of using several commonly prescribed treatments for depression Identify ways to better empower clients taking prescribed medications for depression Dziegielewski, S.F. (2010). Social work practice and psychopharmacology: A person and environment approach. New York: Springer Publishing. Dziegielewski, S.F. (2010). DSM-IV-TR in action (2 nd Edition). New York: Wiley Publishers. First edition published in 2001). Dziegielewski, S.F. (2006). Psychopharmacology handbook: For the nonmedically trained. New York: Norton Publishers. Dziegielewski, S.F. (2005). Substance Addictions: Assessment and intervention. Chicago, IL: Lyceum Publications. Speaker Contact Information: Sophia F. Dziegielewski, Ph.D., LCSW dziegisf@uc.edu or siripro@aol.com Lexapro Zoloft Prednisone (reduces swelling and allergic reaction) Hydrocodone Cymbalta (Duloxetine) depression Xanax Wellbutrin Effexor Vicodin (narcotic hydrocodone and non-narcotic acetaminophen) Lipitor (statin, lowers blood cholesterol, 12.9 billion in sales, largest selling drug in the world). 6 out of 10 are mental health and two others are pain related Exercise Sleep Diet Medications are never enough Relapse is now referred to as Reinstatement Compliance vs. Adherence and Constance Withdrawal is often referred to as Discontinuance Syndrome Compliance: Use of blister packs to make sure medications are taken as prescribed in drug trials Drop-Out Rates: Always using behavioral reinforcement as drop-out rates are so high 1
Research and Process Groups Bipolar Disorders Schizophrenia Healthcare professionals and patients are encouraged to report adverse events or side effects related to the use of these products to the FDA's MedWatch Safety Information and Adverse Event Reporting Program: Complete and submit the report Online: www.fda.gov/medwatch/report.htm Download form or call 1-800-332-1088 to request a reporting form, then complete and return to the address on the pre-addressed form, or submit by fax to 1-800-FDA-0178 What are the implications of this? Many medications have stomach problems, N& V At least 30% of all individuals never refill a prescription because of concerns related to side-effects. Three most common side effects: Fatigue Nausea Insomnia The liver is the main organ for metabolizing, activating and/or deactivating drugs prior to excretion via the bile or the urine. Sometimes drug use can cause chemical injury to the cells. Damage can vary from elevation of liver enzymes to liver failure and transplantation or death. Jaundice Nausea and vomiting Abdominal pain Bleeding Mental confusion Kidney failure 2
Atomoxetine (marketed as Strattera) From January 2005-2008, six reported postmarket cases of serious liver injury and one death. Watch for jaundice or laboratory evidence of hepatotoxicity- discontinue at once. Neurochemical activity Dopamine Serotonin Norepinephrine Glutamate GABA (Gamma-aminobutyric acid) Glycine Step 1: Synthesis Step 2: Storage Step 3: Release Step 4: Receptor Binding Step 5: Termination (reuptake, enzymatic degradation and diffusion) 3
Can create transmitter synthesis (increase or decrease) Can create transmitter storage Can promote or inhibit transmitter release Can influence receptor binding Agonist versus Antagonist Can influence termination such as blocking reuptake Mood Episodes Manic, hypomanic, major depressive episode and mixed Mood Disorders: Bipolar I, Bipolar II, Cyclothymia Major Depressive Disorder, Dysthymia supplement depression related medications with a synthetic version of the hormone Cytomel (Liothronine) Can use stimulants such as Ritalin for treatment resistant depression Can use beta blockers such as Visken (Pindolol) for HBP to speed up the effects of the antidepressants 2004, the FDA ordered the strongest safety warning possible: Antidepressants increase the risk of suicidal thinking and behavior (suicidality) in children and adolescents with major depressive disorder (MDD) and other psychiatric disorders. Anyone considering the use of [Drug Name] or any other antidepressant in a child or adolescent must balance this risk with the clinical need. Warning was extended in 2006 to include young adults (aged 18-24) Be especially observant within the first few months of antidepressant treatment or whenever there is a change in dose. Antidepressants may increase suicidal thoughts or behaviors in some children, adolescents, and young adults. 4
Effexor (venlafaxine), Cymbalta (duloxetine), Lexapro (escitalopram), Celexa (citalopram), Zoloft (sertraline), Paxil (paroxetine), Prozac (fluoxetine), Wellbutrin (bupropion), Zyban (bupropion), TCAs (tricyclic antidepressants), most likely including newer one Symbyak MAOIs (monoamine oxidase inhibitors) Nardil (phenelzine) Atypical antidepressants Sinequan (doxepin) Anafranil (clomipramine), Asendin (amoxapine), Aventyl (nortriptyline), Celexa (citalopram hydrobromide), Cymbalta (duloxetine, Desyrel (trazodone HCl), Effexor (venlafaxine HCl), Elavil (amitriptyline), Etrafon (perphenazine/amitriptyline), fluvoxamine maleate, Lexapro (escitalopram hydrobromide), Limbitrol (chlordiazepoxide/amitriptyline), Ludiomil (maprotiline), Marplan (isocarboxazid), Nardil (phenelzine sulfate), Norpramin (desipramine HCl), Pamelor (nortriptyline) Parnate (tranylcypromine sulfate), Paxil (paroxetine HCl), Pexeva (paroxetine mesylate), Prozac (fluoxetine HCl) Remeron (mirtazapine), Sarafem (fluoxetine HCl), Serzone (nefazodone HCl), Sinequan (doxepin), Surmontil (trimipramine), Symbyax (olanzapine/fluoxetine), Tofranil (imipramine), Tofranil-PM (imipramine pamoate),triavil (perphenazine/amitriptyline), Vivactil (protriptyline), Wellbutrin (bupropion HCl), Zyban (bupropion HCl) Zoloft (sertraline HCl), Prestiq (Desvenlafaxine) Complete a comprehensive safety plan with clear documentation. No Harm-No Risk Agreements as Standard of Practice I will not harm myself or someone else, if I feel as though I could harm myself or someone else I will immediately go to the nearest emergency room at. Have family member acknowledge and document acknowledgement. If children at risk call CPS. REM sleep We all need it! Assess for sleep problems Can help with sleep- Chamomile tea, Melatonin, Valerian, Kava 100-400 milligrams of magnesium? Keep noise and light to a minimum Start and keep a routine Avoid large meals prior to sleep Don t drink caffeine 4-6 hrs before bedtime Stop working on tasks an hour before bedtime to clear mind Practice relaxation before bedtime If in pain, try Tylenol 5
Self-report Self-report measures Blood Levels Anything designed to be strong enough to change a feeling, thought or emotion can indeed change feelings thoughts or emotions. For antidepressants taking a medication for at least 12 months is recommended for best results. Quitting too soon individuals are more likely for depression to return. Treatment Resistant Depression (TRD) Five Treatments Cutting Edge (2008) 3 devices 1 medicine 1 medicinal food ECT most rapid onset of action, high relapse rates and cognitive side effects Vagus Nerve Stimulation (VNS) Transcranial Magnetic Nerve Stimulation (TMS) A type of treatment in which short bursts of electrical energy are directed into the brain via the vagus nerve, a large nerve in the neck. The energy comes from a battery, about the size of a silver dollar, which is surgically implanted under the skin, usually on the chest. Leads are threaded under the skin and attached to the vagus nerve in the same procedure. The physician programs the device to deliver small electrical stimulation bursts every few minutes. 6
Considered non-invasive and painless. TMS involves placing an electromagnetic coil against the patient's scalp. An electric current passes through this coil that creates a magnetic pulse, which causes small electrical currents in the brain. These currents stimulate nerve cells in the region of the brain involved in mood regulation and depression. The Atypical Antipsychotic Aripiprazole (generic) ABILIFY Approved based on positive results of two six week placebo controlled studies. L-methyfolate L-Methylfolate/B12/B6/B2 is a vitamin combination. It provides nutritional supplementation for certain nutritional requirements. Sold under multiple names. FDA approved Deplin for augmentation For use with clients that have low plasma and/or low blood cell folate Exposure to light that is brighter than indoor light but not as bright as direct sunlight. Do NOT use ultraviolent light, full-spectrum light, heat lamps or tanning beds. Use light for 30 minutes to 2 hours per day, usually first thing in the morning is best time. Response occurs in 2-4 days, for SAD up to 3 weeks Used for SAD, jet lag, and sleep disorders. Replaces lost sunlight exposure and resets circadian rhythms (biological clock). Most common side-effects: eyestrain, headaches, nausea, sweating, agitation of feeling weird, if sensitive eyes or skin avoid this. Tricyclics: They inhibit the uptake of the neurotransmitters: serotonin, norepinephrine and dopamine. Peak concentrations achieved in 2-8 hours but may extend to 10-12 hours. Can take 10-14 days to get a full therapeutic dose and six weeks for full effect. 7
Elavil (Amitryptline) Strong sedative Tofranil (Imipramine) Moderate sedative Pamerlor/Aventyl (Nortriptyline) Mild sedative 150-300mg a day 150-300mg a day 75-150mg a day Can dryness complicate of the mouth, heart problems, headache, sweating, 2013 increased S. Dziegielewski difficulty ability, weakness. appetite decrease, for urinating, sweets, muscle change weight twitches, in gain, sexual unpleasant fatigue, desire and taste, Can hypertensive blood psychotics, bicarbonate interact coagulants, diuretics, with: medications, thyroid sleeping antihistamines, hormones, oral medications, contraceptives, anti- tobacco. of soda, vitamin C, alcohol aspirin, and anti- These drugs work by blocking the enzyme monoamine oxidase. These medications work by prohibiting the breakdown of key chemicals in the brain, including norepinephrine. *MAO inhibitors have a high potential for interacting with other drugs. Many dietary restrictions: No foods with the chemical tyramine (e.g., cheese, beef or chicken liver, pickled herring, red wine, chocolate, coffee, raisins, pineapple and bananas.) Eating these foods that have a high amount of the amino acid tyramine. The body cannot break it down and the tyramine pushes the increased norepinephrine (sort of like adrenaline) in the blood stream, blood pressure increases with possible stroke and death. Marplan (Isocarboxazid) 30-50mg Nardil (Phenelzine) 45-90mg a day Eldepryl (Selegiline) 20-50mg Parnate (Tranylcypromine) 30-50mg Aurorix (Moclobemide)* *Currently not available in the United States 8
Dizziness, rapid heart rate. Interaction potential with certain foods (watch out for monosodium glutamate, MSG). Reactions may not appear for several hours and can include: rapid heart rate, high blood pressure, seizures, stroke and/or coma. Can interact with OTC cold and allergy preparations, antihistamines, amphetamines, insulin, narcotics, anti- Parkinson medications. Prozac (Fluoxetine) Zoloft (Sertraline) Paxil (Paroxetine) - Do not use with MAO inhibitors- stronger birth defect warning for 2006 (congenital malformations) not recommended in 1 st trimester. Luvox (Fluvoxamine) Celexa (Citalopram) Lexapro (S-citalopram) this medication is used for Depression, Dementia, Panic Disorder and GAD Listed by brand name first) Some examples: Prozac, Celexa and Zoloft Clients report strange and variable side-effects such as extremely tired, horrible hang-over, even with one glass of wine Always go slow and try a very little amount first to see if there is a reaction SSRIs alone put individual at small risk of stomach bleeding Aspirin and Ibuprofen can damage the damage the stomach lining Risk increases significantly when these drugs are mixed For pain consider acetaminohen Paxil appears to negate the effects of the cancer drug given primarily to women who have tumors that respond to estrogen Paxil inhibits the metabolism of the other drug preventing it from breaking down into a more active component Safer SSRIs that are less likely to interact are: Zoloft, Celexa, Lexapro 9
Effexor (Venlafaxine HCL) - 75mg a day in 2 or 3 equal doses-snri Wellbutrin (Buprorion) Watch high dose never exceed 450mg a day Remron (Mirtazpine) Reboxetine Cymbalta (Duloxetine) nerve pain in diabetes Prestiq (Desvenlafaxine)-SNRI Effexor and Effexor XL Effexor must not be used concomitantly in patients taking MAOIs or in patients who have taken MAOIs within the preceding 14 days due to the risk of serious, sometimes fatal, drug interactions with SNRI or SSRI treatment or with other serotonergic drugs. These interactions have been associated with symptoms that include tremor, myoclonus, diaphoresis, nausea, vomiting, flushing, dizziness, hyperthermia with features resembling neuroleptic malignant syndrome, seizures, rigidity, autonomic instability with possible rapid fluctuations of vital signs, and mental status changes that include extreme agitation progressing to delirium and coma. Based on the half-life of venlafaxine, at least 7 days should be allowed after stopping Effexor before starting an MAOI. Be careful of overdose (especially when used with alcohol) Should be prescribed in smallest quantity available Manufacturer Wyeth has but out over-dose information because of higher risk of death when compared to those on SSRIs and lower risk when compared to tricyclics Watch for tachycardia, changes in level of consciousness, seizures, vomiting and liver necrosis, serotonin syndrome and death. Wellbutrin affects dopamine levels if you have a history of seizures this magnifies risk of having seizures Without seizures if you increase normal daily dose you can also have increased risk of developing them (2x normal daily dose increases risk tenfold) Approved for: Depression, Generalized Anxiety Disorder, diabetic nerve pain, and fibromyalgia Works with Serotonin and norephinephrine Monitor when starting therapy closely for new or worsening depression symptoms, suicidal thoughts or behavior, or unusual changes in behavior. Cymbalta is not approved for use in patients under age 18. No increased risk has been shown for adults over age 24, and risk decreased for those over age 65. Do not take with MAO s or Mellaril (Thioridazine) 10
watch for new or worsening symptoms, unusual changes in behavior, thoughts of suicide, anxiety, agitation, panic attacks, difficulty sleeping, irritability, hostility, aggressiveness, impulsivity, restlessness, or extreme hyperactivity. restlessness, agitation, dizziness, dry mouth, difficulty sleeping, headache, nausea, vomiting, constipation, change in weight, tremor, confusion, rash, itching, seizures, sexual disinterest, possible weight gain, suicide potential, postural hypotension, possible fertility decrease. Do not use these medications with a MAO inhibitor. Symbyak (olanzapine and fluoxetine HCl) Uses the big three neurochemicals Approved for treatment of bipolar depression Combines active ingredients of Zyprexa and Prozac Should start to feel better in one week, keep getting better if on it longer No Mellaril No MAOs Not for use with Dementia Psychosis Not approved for use with children Beware of mixing SSRIs (e.g., Prozac, Paxil, Zoloft or Lexapro) with the family of migraine drugs known as Triptans (e.g., Imitex, Imigran [sumatriptan-injection], Zomig [zolmitriptan], Amerge, Narmig [naratriptan] and Maxalt [rizatriptan] Both drugs cause increase in serotonin levels can cause serotonin syndrome Symptoms include: diarrhea or nervousness to increased heart rate, seizures, rare cases death Traditional Chinese Medicine (TCM) uses herbs, acupuncture, acupressure (shiatsu, tsabu, jin shin, jujitsu), and physical exercise like t ai chi chian or qigong 11
Ayurveda uses pranayama (alternate nostril breathing), Abhyanga (rubbing skin with oil, usually sesame), Rasayana (herbs and mantras during meditation), Yoga, panchakarma (intense cleansing therapy including diaphoretics, diuretics, cathartics, and emetics), and Herbal remedies Hypnotherapy technique of focused attention; especially helpful for pain management, addictions, and phobias Biofeedback relaxation technique to enable people to gain control over autonomic responses, such as heart rate, blood pressure, and voluntary muscle contractions Relaxation Techniques autogenic training, progressive muscle relaxation, meditation lymphatic massage, neuromuscular (deep tissue) massage, rolfing (fascial manipulation) Reiki practitioners place their hands lightly on or just above the person with the goal of facilitating the person s own healing response Acupuncture use of needles placed along the meridians to relieve symptoms of many diseases Healing touch practitioner identifies imbalances and corrects a client s energy by passing his/her hands over the patient Millimeter wave therapy (MW) low-power millimeter wave irradiation used to treat skin diseases, aid in wound healing, relieve symptom related to cancer GI and cardiovascular diseases, and psychiatric illnesses Sound energy therapy music therapy, wind chime and tuning fork therapy; used to relieve pain and anxiety Chamomile Feverfew Ginger Kava Lavender SAMe St John s Wort Valerian 12
Methadone and antidepressants should never be mixed as each drug increases the sedative properties of the other The power of caffeine and alcohol. Anything Strong Enough to Create an Action, is CLEARLY Strong Enough to Create a Reaction. There are no quick fixes. When in doubt ask! 13