Pharm psych med for social workers

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june 23 meeting with social workers group

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  • Note: title is prescribed, not illicit medications. Intended as overview about so-called psychiatric medicines.
  • Some terminology: In order to simplify information for easier understanding, I will organize medications by intended benefit and then into molecular similars. Molecular shapes can predict receptor binding and also unintended targets. The binding dynamics anticipate resulting. pharmacodynamics .(the effects of the drug in the body) The risks can include toxicity due to incomplete pharmacokinetics,(breakdown and excretion) adverse effects due to binding to unintended target sites, and excessive reaction due to inappropriate dose. Cognitive functioning can be improved or impaired. When medicine affects coping and mood, it can be life-saving.
  • This list describes some mental health conditions that can be alleviated with medicines. Insomnia is included because it affects all of these conditions by increasing stress and reduces ability to focus and think. Everyone has mental health, just as everyone has health. A mental health disorder is harder to accept because it is not visible and measurable. Society has a phobia around mental health issues When I say everyone plays an essential role, what I mean is each person with mental health problems affects the other people around them. The patient we see is involved with other people at work, at home, neighborhood and within family networks. If the client is not functioning as expected, the other people around him or her must notice and make adjustments.
  • Other modes to deal with stress, anxiety, and depression. Supportive relationships, learning new coping strategies: new ways of thinking, and relaxation for eg, Phototherapy for seasonal affective disorder Formal medical treatment includes institutional stays, electroshocktherapy. Self medicating with borrowed, shared, or purchased medications. Can be non-rx, prescription, alcohol, or other substances. People will often choose what is the safest, most efficacious and accessible to their circumstances. The patient’s choices and vision of the situation may not be the same as other people’s. Choices can be limited due to lack of insight, poor access to professional care, financial realities, or stigma and influence of other people. Some treatments will be truly helpful, others will not. I am sure social workers and counselors see many situations that limit clients choices. Any examples? I will be narrowing my talk to prescription only medication that is legally prescribed to one individual.
  • Indication: Allowed use where a benefit is expected Risk factor: situation that increases probability of problem arising Mechanism of action: nuts and bolts, where does active ingredients work and how Adverse effects: action of medication which is not intended and may or may not be desired Pharmacokinetics: How the human body deals with the introduction of a natural or unnatural substance Pharmacodynamics: How the drugenters the site where it acts and how it changes processes in the body Thymoleptics: antidepressants Neuroleptics: antipsychotics Pharmaceutical Discoveries: branding, advertising, lobbying, research, health professional education, patents, proof of safety and efficacy, comparison to placebo or existing classic therapy, publishing, testing in vitro, animal, in vivo select group, in actual expected population ( controlled efficacy), release to public (actual efficacy), population dangers arising after wide span release, due to unexpected or expected usage. Generics: only need to prove bioequivalence in simulated biosystem. The cost is much less because all of the above is done already. Competition between generic companies keep costs realistic for profit and sales. Me too’s: Unfortunately, research follows profit. Drug companies keep university and research centers busy developing their own products for their target population. Each company develops and vigorously promotes their own products. Drug companies also each lobby the government and target groups of ill people to pressure coverage of products.
  • Neurons can be at resting membrane potential, partial depole or hyperpolarized. Neurotransmitters can be excitatory or inhibitory, setting the stage for neuron reactivity Serotonin:calmness, attention, appetite or satiety, Serotonin is also important in many other function in gastrointestinal tract and in platelets. Norepinephrine: wakefulness and alertness, concentration Dopamine: learning, mood, reward, interest and attention Gaba: inhibitory for eg : benzodiazepine are gaba enhancers.
  • TCA's: Norepinephrine reuptake inhibitors, many anticholinergic side effects, also act on alpha adrenergic receptors, histamine and cholinergic receptors. Have known therapeutic serum levels. Serious problem in overdose causing cardiac collapse. Not appropriate for elderly. Require lab followups. Laundry list of anticholinergic effects: urinary retention, wt gain, dizziness, drying of mouth and eyes, orthostatic hypotension, sedation, falls and blurred vision, increased risk of seizures TCA's now used for bladder incontinence, insomnia, nerve pain and migraine prophylaxis. SSRI's much cleaner and safer. Prozac has most side effects. : anorexia initially, tremor insomnia,, restlessness, wt gain later, sweating, yawning, dizziness, diarrhea Serotonin syndrome include flushing, fever, shivering, sweating, confusion, inco-ordinattion and hypotension Onset of side effects is immediate, time to onset of benefit is slow. Prozac take 6 to 8 weeks to work and stays in body fat and brain for a long time. This eliminates the chance for withdrawal but increases chance pt will stop too soon thinking he or she is cured. Other straight up ssri's are paroxetine: sleepiness, sertraline:alertness fluvoxamine (poor efficacy) Sertraline is a good starter drug.(most serotonergic)gi distress,diarrhea, insomnia, serotonin affects rem sleep, may need hypnotic
  • Neuroleptics are often helpful with racing thoughts. Pt must be seen within 2 weeks and only given small amounts of medication until depression lifts. It is important to instill hope. The patient needs to know they will recover to normal self, not a different personality. Initial side effects disappear after a few days to a week, but may re-occur when dose is increased. Start low and go slow. Use the airplane analogy. Pt may want to start on a weekend and see how medicine affects function and driving. If depression recurs the treatment must be extended to one year. If recurs again, treatment may be life long. Initially, for sleep and anxiety, some sedative such as lorazepam may be given for stress, insomnia and panic. Depression and anxiety go hand in hand. Depression helps with focus and attention and filters out needless worry, indecision and shameful guilt Sudden withdrawal of antidepressants can cause symptoms in next few days, warn clients to ease off medication with guidance of the prescriber.
  • Older neuroleptics; Found chlorpromazine stopped psychosis Others were created, low potency and high potency. Both have numerous side effects due to blockade of inintended targets. Caused much damage to schizophrenics over decades. The old drugs only worked on the positive symptoms: disorganized speech, hallucinations and other perception disturbances, paranoia, delusions. Did not help with thinking, motivation, socializing or emotional expression. The new drugs do. And because they are safer, have replaced in large part the old school drugs. The new drugs are also being used for other functions such as agitation, slowing racing thoughts, helping sleep, reducing hostility, and as adjunct to antidepressants. They can also be used for bipolar disease. They still have their own set of side effects. People will often stop medication just to see if they still need it, to alleviate side effects, they forget or don't believe they are helping, lack insight to schizophrenia in general Psychosis can be induced by cocaine, amphetamines, ketamine, ecstasy, inhalants and lsd. Conditions that can cause psychosis are cns infection, neoplasms, fluid disturbance, hepatic disease, renal disease thyroid overactivity, hypoglycemia,hypoxia, electrolyte disturbance.
  • Affects 1 % of all people. Onset late teen to mid 30's life expectancy is short. Co-morbidity is common. Poor health maintenance. 50% attempt suicide. Risk factors is male unemployed young, and depressed. Starts with prodrome, then psychosis. Over time positive symptoms decrease and negative symptoms increase. Often depression. Often accompanied by substance usage.Nicotine 60-90%, alcohole 30-50%,canabis15-20%,speed or coke5-10% (meth?) Genetic diesase with environmental risk factors. Proposed etiology. There are 4 dopamine pathways 1. mesolimbic- starts in ventral tegmental area of mid brain and extends to limbic area Positve symptoms 2. mesocortical: starts midbrain goes to limbic area Negative symptoms 3. nigrostriatal- substansia nigra to basal ganglia Epse and td 4. tuberoinfundibular: hypothalamus to anterior pituitary Prolactin over production-amenorrhea, milk production, gynecomastia
  • Second generation antipsychotics: “pines” Ssri’s: “tines” Benzo”s: “pam” Brand name as easier to remember, but generic names are easier to identify and understand. Additive effects, possible enzymatic effects can be troublesome. Serotonin syndrome and withdrawal risks. These people are parents, commuter and workers, they need to know how the medicine will affect their ability to function. They need the understanding and commitment from the members of the household in order to succeed and trust in the treatment and to reinforce trust in the treatment. Detox entry, which medications do they need going into treatment? How will they get the medication if they have sold, lost or stashed their prescriptions? The rules around medication replacement are for public safety reasons, and can be difficult to sidestep when meds need to be replaced for successful rehab. The pharmacist needs a prescription, needs to get the cost covered by other agencies and insurance companies. If it is a drug falling under the narcotic or controlled substances laws, need the physician to be involved to re-write for immediate release of the substance. Physicians or not easy to contact and may not be willing, especially if they are not in the loop about rehab, or not familiar with the patient. Addictive medications are often overused and it is not easy to control. The physician must legally authorize any early fills and it is easy for patients to manipulate caregivers regarding these medications. The patient is not really being helped if they are being enabled in a prescription drug addiction. This is also true about “sleeping pills” Samples are free to the consumer, but become unavailable once the pt is established. Physicians are not available to supply enough for the expected duration of treatment and the sample drugs are new and usually not covered by formularies of insurance and third party payers. Often, samples are me-too’s. The drug reps stock the physicians office in order for the physician to become familiar with the product. By this marketing strategy, that med will often become the doctors trusted and easily accessible drug of choice. Samples leave no record outside the doctors files regarding which medication the doctor supplied them, why it was given, or how much was given. Samples have no labeling regarding the source, so unless the patient is able to tell caregivers, the prescribing source of the medication is untraceable. Psychiatrist prescribe based on what they see in front of them that day. They prescribe to control symptoms and are not as shy of precautions. Pharmacists will see some very unusual combinations and dosages from psychiatrists. It is important for caring supports in the family and social network to see the benefits and not be cowed by the side effects of psych meds as they will often influence the patient in adherence and treatment choices. Some side effects may be unavoidable. In the same way cancer pts receive meds to offset and make tolerable the side effects of other medications, mental health patients might benefit from similar “tweaking” of therapy. Many patients are now coming to community pharmacies in order for caregivers to track adherence to treatment.
  • There is a deluge of information on all aspects of psychiatry and treatments on the internet. Mount carmel clinic has a subscription to up to date online as well. This is not an exact science. We can only give clients the best information available and offer suggestions
  • Pharm psych med for social workers

    1. 1. Mount Carmel: Medication for all Generations Commonly Prescribed Medicine that Promotes Mental Health
    2. 2. “Psychiatric Medication” <ul><li>Medication groups
    3. 3. Indications, Benefits and Risks
    4. 4. Realistic expectations
    5. 5. How use and misuse of medication can affect our clientele </li></ul>
    6. 6. Agenda <ul><li>Depression, Bipolar Disease, Anxiety, Insomnia, OCD, ADDH, Social Phobia, Drugs Used to Treat Addiction Withdrawal, Schizophrenia etc.
    7. 7. Every person is individual
    8. 8. Each person plays an essential role in our community </li></ul>
    9. 9. Stigma of Mental Health Issues <ul><li>Medication is only one piece, it is not the answer
    10. 10. Each person uses the treatment modality he or she finds the most helpful </li></ul>
    11. 11. Vocabulary <ul><li>Indication, Risk Factors, Mechanism of Action, Adverse Effects, Pharmacokinetics, Pharmacodynamics, Thymoleptics, Neuroleptics.
    12. 12. Synapse, Neural Plate, Neural Signalling Pathways, Action Potential, Inhibitory and Excitatory Nerve Pathways
    13. 13. Pharmaceutical Companies, Generics and Me Too’s </li></ul>
    14. 14. Neuronal Synapse
    15. 15. Neural Communication <ul><li>Combination of electrical firing (depole) and chemical signaling
    16. 16. Intensity of neurotransmitter release and binding to post-synaptic sites opens voltage gated sodium channels
    17. 17. Resting membrane potential is affected and an action potential can result (electric signal) that travels down the axon
    18. 18. Neurotransmitter is released from sites and
    19. 19. re-uptake occurs </li></ul>
    20. 21. Antidepressants <ul><li>Older types: tricyclics, ssri’s
    21. 22. Mixed type and evolved ssri's etc
    22. 23. What does a depressed person look like:
    23. 24. What can they expect to feel on these medications? </li></ul>
    24. 25. <ul><li>Buproprion
    25. 26. Venlafaxine
    26. 27. Mirtazepine
    27. 28. Trazodone (ssri)
    28. 29. Research suggests too many clients are maintained on too small dose and have incomplete relief and still have the side effects. Once treatment is satisfactory, pt should stay on 6 months. </li></ul>Anitidepressants
    29. 30. Antipsychotics <ul><li>Older types: first generation
    30. 31. Risperidone, olanzapine, melt in your mouth etc.
    31. 32. Effects of stress and low dose antipsychotics on prodromal symptoms (PIER)
    32. 33. What does prodrome (premonitory symptoms) look like?
    33. 34. What can they expect to feel like on these meds? </li></ul>
    34. 35. Schizophrenia <ul><li>Avolition(lack of initiative, motivation)
    35. 36. Flat affect (withdrawal, poor hygiene)
    36. 37. Perception disturbance (hallucination)
    37. 38. Delusions
    38. 39. Disorganized or catatonic behaviour
    39. 40. Impaired social and occupational function
    40. 41. Disorganized speech
    41. 42. Decreased processes in thought or speech (slowed cognition) </li></ul>
    42. 43. Benzodiazepines <ul><li>Old types, history of barbitals and valium
    43. 44. Safer benzodiazepines and buspar
    44. 45. How can anxiety mar your life and stifle your participation in society?
    45. 46. panic disorder, ocd
    46. 47. How will they feel on this med?
    47. 48. Why is this family dangerous?
    48. 49. Sleep aids and sleep architechture </li></ul>
    49. 50. Mood Stabilizers <ul><li>Good old lithium and carbamazepine
    50. 51. The irritation and joy of serum levels
    51. 52. New indications for antipsychotics
    52. 53. Why don’t they want treatment?
    53. 54. Types of bipolar
    54. 55. What can the patient expect to happen after starting these medications? </li></ul>
    55. 56. Mood Stabilizers <ul><li>Lithium
    56. 57. Valproic acid
    57. 58. Carbamazapine
    58. 59. Olanzapine
    59. 60. Omega 3 fatty acid
    60. 61. lamotrigine </li></ul>
    61. 62. Bipolar Disorder <ul><li>Monoamine theory excess norepinephrine and dopamine alternates with low levels along with low serotonin
    62. 63. Permissive theory excess norepinephrine and serotonin with low levels
    63. 64. G-protein that regulates appetite,wakefulness and mood. Controls sodium and potassium cation channels
    64. 65. G-protein is hyperactive intracellular 2 nd messenger regulator
    65. 66. Lithium and epival down regulate protein kinase c activity </li></ul>
    66. 67. Bipolar Disorder <ul><li>Presents in adulthood, usually after years without diagnosis (genetic)
    67. 68. Time between cycles usually lengthen over time (maintain euthymia)
    68. 69. Important to avoid episodes which cause brain changes and resistance to medications
    69. 70. Treated with lithium, antiepileptics (carbamazepine and valproic acid), atypical antipsychotics and antidepressants </li></ul>
    70. 71. In Closing “Pearls” <ul><li>Brief description of “drug families” and nomenclature
    71. 72. Drug interactions galore
    72. 73. Pharmacy Perspective, Family issues, Pts going into detox, instilling hope and mastery
    73. 74. Legal and Ethical Issues for Pharmacists: the rules around addictive meds or drugs of abuse
    74. 75. The crazy expense of new meds and how samples defeat the purpose sometimes
    75. 76. How psychiatrists prescribe vs family doctors
    76. 77. How do families, co-workers, and friends react to “treatment”
    77. 78. Daily observed treatment, how the pharmacist is dispensing rounds in the community </li></ul>
    78. 79. Adherence & Patience
    79. 80. Where to Get More Information <ul><li>Online and anecdotal data can be confusing or just wrong.
    80. 81. “Up to date online”
    81. 82. Ask the patient what they understand about their medication. In what ways does it assist his or her functioning? In what ways does it diminish functioning/ </li></ul>

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