PIPC

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PIPC Psychiatry In Primary CareMedications

• Robert K. Schneider, MD
• Departments of Psychiatry, Internal Medicine
• and Family Practice
• The Medical College of Virginia at
• the Virginia Commonwealth University
• Richmond, Virginia

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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

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Outline

• PIPC 1
• Introduction
• PIPC Interview
• MAPS-O
• Mood Disorders
• Suicide

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Outline

• PIPC 2
• Anxiety Disorders
• PIPC 3
• Neurotransmitters
• The 3 Phases and the 5Rs
• Medications
• Cases and Discussion

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NEUROTRANSMITTERS
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Neurotransmitter Receptor Hypothesis of
Antidepressant Action
Decreased state due to up-regulation of receptors
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Neurotransmitter Receptor Hypothesis of
Antidepressant Action
Antidepressant blocks the reuptake pump, causing
more NT to be in the synapse
Increase in NT causes receptors to down-regulate
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The 3 Phases and 5 Rs

• Acute
• Continuation
• Maintenance

• Response
• Remission
• Relapse
• Recovery
• Recurrence

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EPISODE OF DEPRESSION
TIME
6 - 24 months
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acute 6 - 12 weeks
continuation 4-9 months
maintenance 1 or more years
TIME
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acute 6 - 12 weeks
continuation 4-9 months
maintenance 1 or more years
TIME
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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

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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

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Continuation Phase Treatment

• Focus is to prevent relapse
• Period of time following full remission during
  which discontinuation of treatment will result in
  relapse
• Dont stop before 6-9 months of therapy
• Dont decrease the dosage
• Full Dosage, for the Full Period of Time

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acute 6 - 12 weeks
continuation 4-9 months
maintenance 1 or more years
TIME
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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

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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

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acute 6 - 12 weeks
continuation 4-9 months
maintenance 1 or more years
TIME
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MEDICATIONS
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General Considerations

• Three Neurotransmitters
• Serotonin
• Norepinephrine
• Dopamine
• Three major sites of action
• Reuptake pump
• Post-synaptic receptor
• MAO enzyme inhibition

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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

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Norepinephrine and Serotonin Reuptake Inhibitors
TCAD

• Classic Tricyclic Antidepressants
• amitriptyline (Elavil)
• clomipramine (Anafranil)
• desipramine (Norpramin)
• imipramine (Tofranil)
• nortriptyline (Pamelor)

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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

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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

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Selective Serotonin Reuptake Inhibitors

• Classic SSRIs
• sertraline (Zoloft)
• fluoxetine (Prozac)
• paroxetine (Paxil)
• citralopam (Celexa)

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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

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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

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Less Selective Reuptake Inhibitors

• Serotonin, Norepinephrine and mild Dopamine
  Reuptake Inhibitor
• venlafaxine (Effexor)
• Dopamine, Norepinephrine and mild Serotonin
  Reuptake Inhibitor
• bupropion (Wellbutrin)

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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

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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

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Postsynaptic Serotonin Inhibition

• Serotonin (postsynaptic 5HT-2 inhibition)
• trazodone (Desyrel)
• nafazodone (Serzone)

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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

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CASES