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Psychopharmacology: Monitoring for intended and unintended effects of medication.

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Title: Psychopharmacology: Monitoring for intended and unintended effects of medication.


1
PsychopharmacologyMonitoring for intended and
unintended effects of medication.
2
Source information
  • Most slides for this presentation are obtained
    from the National Institute of Mental Health
    which can be accessed on the web at
  • www.nimh.nih.gov

3
Welcome
  • My goal today is to talk in general terms about
    different classes of medications that you would
    see prescribed for children with mental health
    issues.
  • I will try to highlight what you, as a
    caregiver, would be monitoring for, in order to
    support treatment.

4
  • I will also throw in some interesting facts about
    current thinking in the science of mental health
    and illness.
  • I also hope to answer questions.

5
Time line
  • This workshop is from 9 15 1145 AM
  • Break at 1030 AM for 15 minutes. Alert me if I
    carry on.

6
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7
The synapse, where it all happens
8
This is a constructed slide of MRIs of healthy
children and teens over a 15 year span of time.
It shows from age 5 to the age of 20 how much
pruning occurs. Red is more grey matter in the 5
year old versus blue which represents less grey
matter in the 20 year old.
9
Composite MRI scan data showing areas of gray
matter loss over 5 years, comparing 12 normal
teens (left) and 12 teens with childhood onset
schizophrenia. Red and yellow denotes areas of
greater loss. Front of brain is at left.Image
Details 33 KB / jpg (Highest Resolution)
10
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11
Treatment with medications
  • Some medications treat the underlying cause of
    the illness.
  • Some medications treat symptom clusters of the
    illness.
  • Some medications really just try to make the
    client more available for the real treatment
    such as your interactions with the client.

12
Medications work differently for different people
  • Some people are more likely to have side effects.
  • Doses can be smaller or large depending on the
    medication and the person.

13
Some factors that affect how medications work
  • Type of disorder
  • Age, sex, cultural background and size
  • Physical illness
  • Smoker, drinker
  • Liver and kidney function
  • Genetics
  • Other medications taken (including herbals)
  • Diet

14
Considerations for all medications
  • Consent
  • Does the client want to take medication?
  • What is the parents perspective?
  • Do they want their child on medications?
  • Do they feel that the prescriber knows their
    child well enough to make recommendations.
  • AKA trust.

15
When starting medications things to attend to.
  • How to initiate the drug
  • How to terminate the drug
  • Cautions to clients
  • Contraindications to the use of this drug
  • Instructions
  • Drug interactions

16
If a client is on medication
  • Monitoring the medication after starting the
    medication
  • Frequency of follow-up
  • Is it approved for use in children?

17
Medications to treat psychotic disorders can be
called many different names.
  • Antipsychotic medication
  • Neuroleptic medication
  • Atypicals
  • First generation
  • Second generation
  • .

18
Antipsychotic medications
  • What to watch for early in treatment complaints
    of rigidity, muscle complaints, tremors,
    stiffness.
  • Movement problems (EPS) Extrapyrimadal Symptoms
  • Stiffness
  • Dystonia usually involves neck and shoulder
    muscles
  • Restlessness (Akasthesia)

19
Neuroleptic Malignant Syndrome
  • This can be a very serious adverse reaction to
    antipsychotic medications
  • Sudden onset of flu like symptoms early on in
    treatment
  • Characterized by a high fever and muscle problems.

20
Side effects of many antipsychotics
  • Drowsiness
  • Dizziness
  • Blurred vision
  • Rapid heart beat
  • Sensitivity to sun (can be severe)
  • Skin rash
  • Menstrual changes
  • Weight gain, metabolic changes

21
The good news is you have the heart of a
teenager. The bad news is nowadays most
teenagers have the heart of an old man.
22
Metabolic changes
  • Glucose metabolism
  • Lipid metabolism
  • Monitoring of blood sugar and fat levels in
    blood annually .

23
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24
Antidepressant medications
  • SSRIs
  • Common initial side effects go away after a
    couple of weeks.
  • If severe may need to slow the increase of the
    dose.

25
Types of antidepressants
  • SSRI serotonin reuptake inhibitor
  • fluoxetine Prozac
  • sertraline Zoloft
  • citalopram Celexa
  • Lexapro, Paxil.
  • Dual receptor types
  • Venalafaxine, Effexor
  • Cymbalta
  • Older drugs tricyclics (amines) imipramine,
    desipramine, amitryptylline,

26
Side effects of SSRI
  • Headache (usually transient)
  • Nausea (also transient)
  • Sleeplessness or drowsiness. Dose adjustment may
    be needed or adjustment of the time of day the
    medication is given.
  • Agitation feeling jittery.
  • Sexual side effects, decrease libido or drive.

27
older antidepressants orTricyclics
  • Dry mouth
  • Constipation
  • Bladder problems
  • Blurred Vision
  • Drowsiness
  • (exception strattera is used to treat ADHD and
    is chemicaly similar to a tricyclic)

28
Older Antidepressants
  • The tricyclics imipramine, amitriptyline,
    clomipramine, desipramine.
  • Concerns re cardiac reactions
  • chest pain, shortness of breath, heart racing,
    dizziness.

29
Antidepressants- what we want to know
  • These medications take several weeks to work.
  • A bad reaction would be a sudden change in
    personality or behavior. Off the charts, out of
    the norm. Euphoria, happiness a sudden change
    could mean mania.
  • If its just a continuation of behaviors it may
    just means we havent reached an effective dose
    or the right medication.

30
Stimulants
  • Early on in treatment there are some side effects
    that will most likely disappear over time
  • Fatigue
  • Anorexia , decreased appetite
  • Stomach ache
  • Headache
  • Sleep problems

31
Stimulants
  • Stimulants can cause some mood changes and may
    require dose adjustment.
  • Irritability or dysphoria can be a side effect of
    the medication.
  • If severe, a dose adjustment may be required.

32
Stimulants
  • Some children can develop tics on these
    medications.
  • Tics can be motor or vocal.
  • The tics will most likely go away if the
    medication is stopped.

33
Stimulants
  • The initial history needs to include a review of
    heart problems in the child and the family.
  • There have been rare sudden death events for
    children taking stimulants.

34
Stimulants
  • Notify the prescriber if the following symptoms
    are present in the child and are new
  • Acting subdued or withdrawn
  • Depressed or worsening depression
  • Thoughts of self harm
  • Extreme worry
  • Agitation
  • Trouble sleeping that does not go away
  • Aggression that is increased
  • Frenzied or abnormal excitement
  • Sudden change in behavior that seems odd or
    unusual

35
Stimulant dose is too high?
  • May cause dysphoria, depression, irritability
  • Moodiness when dose wears off
  • The child may seem to be too flat
  • Insomnia that is worse
  • Significant weight loss

36
Stimulants -what we want to know
  • Is the child more focused and attending.
  • Is the child experiencing side effects.
  • Is the child getting the medication regularly.

37
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38
Mood stabilizers
  • This can be a confusing term.
  • Many categories of medications can help stabilize
    mood but usually when we are talking about mood
    stabilizers we mean lithium and anticonvulsants
    (anti-seizure medications).

39
  • For example
  • If someone has bipolar disorder sometimes an
    antipsychotic medication may be used to
    stabilize mood like risperidone.

40
Mood medications
  • Essentially two categories
  • Lithium
  • And
  • Anticonvulsants

41
Lithium
  • Lithium is a salt.
  • So anything that upsets a fluid and salt balance
    in the body can increase risks.
  • Lithium has a narrow therapeutic range.
  • To low it might not work
  • To high toxic
  • This is one major reason why we order blood work.

42
Lithium side effects
  • Thirst
  • Frequent urination
  • Fast slow or irregular heart rate
  • Vision changes
  • Rash
  • Hair loss
  • Swelling
  • Serious
  • Blackouts, seizures, loss of coordination,
    slurred speech

43
Signs of lithium toxicity
  • If you see these symptoms - hold the dose, until
    you consult with a practitioner.
  • Consult with provider immediately or take the
    child to the emergency room.
  • looks drunk ataxia unsteady gait, slurring of
    words, confusion, lethargy or tremors

44
Anticonvulsants
  • In general
  • When these medications are started they cause
    some cognitive slowing and tiredness.
  • Usually this will abate as time goes by and it
    may take a few weeks. If severe consult with the
    provider.

45
Anticonvulsants
  • valproate
  • Depakote,divalproex
  • Tegretol, carbamazepine
  • Trileptal, oxycarbamazepine
  • Lamictal, lamotrigine
  • Topomax, topiramate
  • Neurontin, gabapentin

46
Anticonvulsants
  • Several of the anticonvulsants have a serious
    rash that can be associated with the start of
    treatment. Any rash in the first few weeks of
    treatment is a concern and should be evaluated.
    Do not administer additional medication until it
    is evaluated by a provider.

47
Side effects of Depakote/ divalproex
  • Change in weight
  • Nausea
  • Stomach pain
  • Vomiting
  • Loss of appetite
  • Menstrual cycle changesbirth defects

48
Anticonvulsants
  • With some of the anticonvulsants, early in
    treatment , there is a concern about liver
    problems or pancreatitis.
  • Both liver problems and pancreatitis could
    present with nausea and vomiting and diarrhea.
    If severe it may be an emergency.

49
Mood stabilizers what we want to know
  • The provider should hopefully identify the target
    symptoms for treatment at the outset of
    treatment.
  • We would look for those symptoms to decrease.
  • Might be episodes or duration of episodes of
    aggression, decrease lability of mood, improved
    sleep wake patterns, less risk taking

50
A word about genetics
  • It is not nature versus nature
  • It is not genes versus environment
  • It is
  • Genetics and the Environment
  • It is
  • Vulnerability

51
Etiology of mental illness
  • Prenatal environment
  • Attachment
  • Temperament
  • Parenting
  • Exposure
  • All of these factors interact with a persons
  • Genetics and vulnerabilities
  • phenotype and can lead to illness

52
DSMV
  • It is coming out in the spring 2013 (maybe).

53
CAM
  • Complementary Alternative Medicine
  • Exercise, folate, and omega-3 fatty acids can be
    recommended to most patients with MDD for their
    general health benefits, and St John's wort and
    S-adenosyl-L-methionine (SAM-e) may be
    appropriate to treat depression in some patients
    )Freeman MP - J Clin Psychiatry - 01-JAN-2009)

54
Nutrients essential for mental health and their
food sources Nutrient Food sources Essential
fatty acids (omega-3 fatty acids such as
linolenic acid) Fish (tuna, salmon, and mackerel)
fish oil, flax seeds, flax oil, canola oil,
walnut oil, dark green leafy vegetables Vitamin
B6 Beans, nuts, legumes Eggs, meats, fish Whole
grains and fortified breads and cereals Vitamin
C (All fruits and vegetables contain some amount
of vitamin C.) Green and red peppers, citrus
fruits and juices, strawberries, tomatoes,
broccoli, turnip greens and other leafy
greens, sweet and white potatoes, cantaloupe,
papaya, mango, watermelon, Brussels sprouts,
cauliflower, cabbage, winter squash, raspberries,
blueberries, cranberries, and pineapples
55
Folate Beans and legumes Citrus fruits and
juices Wheat bran and other whole grains Dark
green leafy vegetables Poultry, pork,
shellfish Liver Calcium Milk, yogurt,
buttermilk, cheese Calcium-fortified orange
juice Green leafy vegetables (broccoli, collards,
kale, mustard greens, turnip greens, and bok choy
or Chinese cabbage) Canned salmon and sardines
canned with their soft bones Shellfish Almonds,
Brazil nuts Dried beans
56
Vitamin D Fish, fish oils, oysters Fortified
foods such as cow milk, soy milk, and rice
milk, and some cereals Tryptophan Turkey,
chicken, fish Milk, cheese Eggs Soy, tofu Sesame
seeds Pumpkin seeds Tree nuts, peanuts, peanut
butter Zinc Beef, pork, lamb, oysters, dark
meat of poultry Peanuts, peanut butter, nuts, and
legumes (beans) Fortified cereals
57
Omega III fatty acids
  • Fish oil
  • The role of omega-3 fatty acids in mood
    disorders. - Stahl LA - Curr Opin Investig Drugs
    - 01-JAN-2008 9(1) 57-64 (MEDLINE is the
    source for the citation and abstract of this
    record )

58
AbstractResearch has established that
docosahexaenoic acid (DHA), a long-chain omega-3
polyunsaturated fatty acid (PUFA), plays a
fundamental role in brain structure and function.
Epidemiological and cross-sectional studies have
also identified a role for long-chain omega-3
PUFA, which includes DHA, eicosapentaenoic acid,
and docosapentaenoic acid, in the etiology of
depression. In the past ten years, there have
been 12 intervention studies conducted using
various preparations of longchain omega-3 PUFA in
unipolar and bipolar depression. The majority of
these studies administered long-chain omega-3
PUFA as an adjunct therapy. The studies have been
conducted over 4 to 16 weeks of intervention and
have often included small cohorts. In four out of
the seven studies conducted in depressed
individuals and in two out of the five studies in
bipolar patients, individuals have reported a
positive outcome following supplementation with
ethyl-eicosapentaenoic acid or fish oil
containing long-chain omega-3 PUFA. In the three
trials that researched the influence of DHA-rich
preparations, no significant effects were
reported. The mechanisms that have been invoked
to account for the benefits of long-chain omega-3
PUFA in depression include reductions in
prostaglandins derived from arachidonic acid,
which lead to decreased brain-derived
neurotrophic factor levels and/or alterations in
blood flow to the brain.
59
Omega-3 fatty acids are found primarily in fish,
yet many pregnant women avoid fish because of
concerns about potential mercury and
polychlorinated biphenyl contamination. It is
important for prenatal care providers to assess
women's diets for omega-3 fatty acid intake and
ensure that pregnant women are consuming between
200 and 300 mg daily from safe food
sources. Purified fish, algal oil supplements,
and DHA-enriched eggs are alternative sources for
pregnant women who do not eat fish.
60
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61
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62
Getting a high resolution wiring diagram of our
brains is a landmark in human neuroanatomy, said
NIMH Director Thomas R. Insel, M.D. This new
technology may reveal individual differences in
brain connections that could aid diagnosis and
treatment of brain disorders. Knowledge gained
from the study helped shape design specifications
for the most powerful brain scanner of its kind,
which was installed at MGHs Martinos Center last
fall. The new Connectom diffusion magnetic
resonance imaging (MRI) scanner can visualize the
networks of crisscrossing fibers by which
different parts of the brain to adapt through
evolution, suggest the researchers. communicate
with each other in 10-fold higher detail than
conventional scanners, said Wedeen. This
one-of-a-kind instrument is bringing into sharper
focus an astonishingly simple architecture that
makes sense in light of how the brain grows, he
explained. The wiring of the mature brain
appears to mirror three primal pathways
established in embryonic development. As the
brain gets wired up in early development, its
connections form along perpendicular pathways,
running horizontally, vertically and
transversely. This grid structure appears to
guide connectivity like lane markers on a
highway, which would limit options for growing
nerve fibers to change direction during
development. If they can turn in just four
directions left, right, up or down, this may
enforce a more efficient, orderly way for the
fibers to find their proper connections and for
the structure
63
  • Detail from DSI scan shows fabric-like 3D grid
    structure of connections in monkey brain.
  • Source Van Wedeen, M.D., Martinos Center and
    Dept. of Radiology, Massachusetts General
    Hospital and Harvard University Medical Scho
  • From NIMH

64
Resources
  • There is a very helpful publication put out by
    the National Institute of Mental Health
  • Mental Health Medications which can be
    downloaded from their web site for free.

65
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