Louis B. Cady, MD – CEO & Founder – Cady Wellness Institute  Adjunct Professor – University of Southern Indiana Adjunct Cl...
Dangers with Psychiatry/psychotropics <ul><li>Failure to diagnose </li></ul><ul><ul><li>(E.g “head case” and then they die...
Depression & Anxiety & a malpractice suit in 1 Easy Lesson <ul><li>DEPRESSION SIG: E- CAPS! </li></ul><ul><li>Sleep </li><...
Comorbidity of Depression and Anxiety % Patients  Disabled 3+ Days 33.7% 19.45% 16.9% 3.1% Disability Wittchen,  Depress A...
Kids and Adults – Differences in HYPERACTIVE domain <ul><li>AS A CHILD: </li></ul><ul><li>Squirming, fidgeting </li></ul><...
Horrigan J, et al. Presented at 47 th  Annual AACAP Meeting: October 24-29, 2000.  New York, NY.
Persistence of ADHD Into Adulthood <ul><li>ADHD is a heterogeneous disorder associated with considerable disability and co...
Diagnostic Pearls - Cady <ul><li>How ’s work? </li></ul><ul><ul><li>How has your employment history been? </li></ul></ul><...
Failure to adequately treat <ul><li>“ Begin with end in mind.” (Covey) </li></ul><ul><li>Start LOW – (rule of thumb – ½ wh...
THE FACTS <ul><li>SSRI’s treat  depression   AND/OR  anxiety </li></ul><ul><li>Patients may INITIALLY need something else ...
AVOID Alprazolam (Xanax ®) <ul><li>Addicting (and rapidly so) </li></ul><ul><li>Can have seizures if rapidly withdrawn (st...
Sleepers – my preferences <ul><li>Sleepers: </li></ul><ul><ul><li>Rozerem (brand) (a melatonin analog) – 8 (up to 16* mg) ...
Why treatment failures occur: too much or too little… The REAL mechanism of action of SSRI’s  Animation © NEI, Inc. (Neuro...
<ul><li>Drug, drug... who's got the drug? </li></ul>
Depression/anxiety Rx: <ul><li>TCA </li></ul><ul><li>Venlafaxine </li></ul><ul><li>Duloxetine </li></ul><ul><li>Mirtazapin...
Side Effects & Drug Interactions:  The Doc Cady  “Can ’ t s” of the TCA’s <ul><li>Pee </li></ul><ul><li>Poop </li></ul><ul...
Drug-drug interactions: chum for legal  “sharks”
“ Strattera  [coupled with Prozac or Paxil]   has been great for our admissions. ” -Dr. William Beute, MD Pine Rest Campus...
Cytochrome p-450 2D6 inhibition measured as % increase in  “Desipramine AUC” – in vivo data Preskhorn, Alderman, et al.  P...
Some  drugs metabolized through cytochrome P-450 IID6 system <ul><li>ADHD </li></ul><ul><ul><li>Amphetamines </li></ul></u...
The “not so selective” SSRI’s; how to “Do yourself a favor.” drug SSRI? 2 nd  order effects Side effects possible Escitalo...
New Agents, New Mechanisms (agent) (MOA) Differentiating points Venlafaxine (“IR” and XR) SSRI, NRI Nausea, GI side effect...
Duloxetine Versus Escitalopram and Placebo: An 8-month, Double-Blind Trial in Patients With Major Depressive Disorder Pigo...
Comparison of Escitalopram and Duloxetine:  8-Month Trial HAMD 17  (MMRM) *p<0.05 Pigott et al.,  Curr Med Res Opin , 2007...
Comparison of Escitalopram and Duloxetine: 8-Month Trial Significantly Different Adverse Events (p<0.05 Duloxetine vs Esci...
<ul><li>Remission rates for both escitalopram and duloxetine continued to improve over time </li></ul><ul><li>Significantl...
Two New Agents You Need to Know <ul><li>Extended release Trazodone </li></ul><ul><ul><li>NOT “son of Trazodone” </li></ul>...
XR Trazodone steady state dosing study <ul><li>(Levels done after 7 days steady state) </li></ul><ul><li>300 mg XR Traz AU...
XR Trazodone Food Effect Study <ul><li>PI says “take at night”  </li></ul><ul><li>CMax increase by 86% (!!!) under fed con...
Vilazodone – a  SPARI  (per Stephen Stahl, MD, Ph.D.) –  Serotonin Partial Agonist Reuptake Inhibitor <ul><li>Highly serot...
ADHD Rx for frontline medicine <ul><li>Desiderata – get control, and keep it consistent for predictable period of time </l...
Practicing beyond your ability (and knowledge) – the second generation antipsychotics <ul><li>Definitions: </li></ul><ul><...
Know who you’re playing with <ul><li>SGA’s and WEIGHT GAIN (Cady experience) </li></ul><ul><ul><li>olanzapine/risperidone ...
Cady recommendation for SGA’s in primary care <ul><li>As little as possible. </li></ul><ul><li>Do NOT use as primary mood ...
“ There are things known and there are things unknown, and in between are the doors.” - Jim Morrison
&quot;If I hadn't believed it, I wouldn't have seen it.&quot; - Yogi Berra Personal collection  Louis B. Cady, M.D.
Thanks for coming! Sunset at CWI –by  Louis B. Cady, M.D.
Contact information: Louis B. Cady, M.D. www.cadywellness.com   www.indianaTMS-cadywellness.com   Office: 812-429-0772 E-m...
Upcoming SlideShare
Loading in …5
×

Pedal to the metal allopathic psychiatry for generalists cady

1,405 views

Published on

Published in: Health & Medicine
  • Be the first to comment

  • Be the first to like this

Pedal to the metal allopathic psychiatry for generalists cady

  1. 1. Louis B. Cady, MD – CEO & Founder – Cady Wellness Institute Adjunct Professor – University of Southern Indiana Adjunct Clinical Lecturer – Indiana University School of Medicine Department of Psychiatry Child, Adolescent, Adult & Forensic Psychiatry – Evansville, Indiana Pedal to the Metal Allopathic Psychiatry – or, “How to Practice Like a Board Certified Psychiatrist Without Being One” This presentation is © Louis B. Cady M.D. and may not be reproduced or used without permission. World Link Medical is authorized to reprint/duplicate it for 2012 syllabi. (c) 2012 Louis B. Cady, M.D. - all rights reserved
  2. 2. Dangers with Psychiatry/psychotropics <ul><li>Failure to diagnose </li></ul><ul><ul><li>(E.g “head case” and then they die of a medical problem) </li></ul></ul><ul><li>Failure to adequately treat </li></ul><ul><li>Failure to prescribe accurately (Rx-rx interaction) </li></ul><ul><li>Giving people side effects </li></ul><ul><li>Using the wrong drug </li></ul><ul><li>Ignorance about best options because “I always did it that way.” </li></ul><ul><li>Getting people addicted </li></ul><ul><li>Practicing beyond your ability and expertise </li></ul><ul><li>Violating black box warnings </li></ul>
  3. 3. Depression & Anxiety & a malpractice suit in 1 Easy Lesson <ul><li>DEPRESSION SIG: E- CAPS! </li></ul><ul><li>Sleep </li></ul><ul><li>Sadness </li></ul><ul><li>Interest loss </li></ul><ul><li>Guilt </li></ul><ul><li>*Energy </li></ul><ul><li>Concentration </li></ul><ul><li>Appetite </li></ul><ul><li>Psychomotor Sx </li></ul><ul><li>Suicidal thinking </li></ul><ul><li>Gen. ANXIETY D.O. </li></ul><ul><li>Somatic Sx ( “ energy ”,etc.) </li></ul><ul><li>WORRY </li></ul><ul><li>Irritability </li></ul><ul><li>Concentration </li></ul><ul><li>Keyed up </li></ul><ul><li>Insomnia ( “sleep”) </li></ul><ul><li>Restlessness </li></ul>SWICKIR is Quicker: Worry + 3 = GAD (Baughman) 5of 9 with 1 of 2 x 2 weeks *ACCURATE MEDICAL diagnosis “mood disorder due to a general medical condition” AND r/o bipolar disorder BEWARE BEWARE – “too much” energy
  4. 4. Comorbidity of Depression and Anxiety % Patients Disabled 3+ Days 33.7% 19.45% 16.9% 3.1% Disability Wittchen, Depress Anxiety , 2002 Percent of Patients With ≥ 1 Disability Day in Past Month GAD + MDD MDD/no GAD GAD/no MDD no GAD/no MDD
  5. 5. Kids and Adults – Differences in HYPERACTIVE domain <ul><li>AS A CHILD: </li></ul><ul><li>Squirming, fidgeting </li></ul><ul><li>Cannot stay seated </li></ul><ul><li>Cannot wait turn </li></ul><ul><li>Runs/climbs excessively </li></ul><ul><li>Cannot play quietly </li></ul><ul><li>On the go/driven by motor </li></ul><ul><li>Talks excessively </li></ul><ul><li>Blurts out answers </li></ul><ul><li>Intrudes, interrupts others </li></ul><ul><li>AS AN ADULT: </li></ul><ul><li>Work inefficiencies </li></ul><ul><li>Can ’t sit through meetings </li></ul><ul><li>Cannot wait in line </li></ul><ul><li>Drives too fast </li></ul><ul><li>Self-selects very active job </li></ul><ul><li>Cannot tolerate frustration </li></ul><ul><li>Talks excessively </li></ul><ul><li>Makes inappropriate comments </li></ul><ul><li>Interrupts others </li></ul>Sources: DSM-IV (TR). APA 2000:85-93) Weiss MD, Weiss JR. J Clin Psychiatry 2004;65(Suppl 3):27-37.
  6. 6. Horrigan J, et al. Presented at 47 th Annual AACAP Meeting: October 24-29, 2000. New York, NY.
  7. 7. Persistence of ADHD Into Adulthood <ul><li>ADHD is a heterogeneous disorder associated with considerable disability and comorbidity that, in many cases, persists into adulthood 1 </li></ul><ul><ul><li>Some studies have found persistence as high as 36.3% 2 </li></ul></ul><ul><li>Mood, anxiety, and substance use disorders are the most common comorbid disorders in adults with ADHD 3 </li></ul><ul><li>Current prevalence of ADHD persistent into adulthood 4.4% 4 </li></ul><ul><li>Much of the treatment of adult ADHD can be based on experience in treating children/adolescents 5 </li></ul><ul><li>Barkley et al. J Abnorm Psychol . 2002;111:279-289. </li></ul><ul><li>Kessler RC et al. Biol Psychiatry 2005 June;57(11):1442-51. [retrospective review of 3,197 14-44 yo respondents in NCS-R] </li></ul><ul><li>Biederman et al. Am J Psychiatry . 1993;150:1792-1798. 4. Kessler et al. Am J Psychiatry. 2006;163(4):716-23 . 5. Dodson WW. J Clin Psychol . 2005;61:589-606. </li></ul>
  8. 8. Diagnostic Pearls - Cady <ul><li>How ’s work? </li></ul><ul><ul><li>How has your employment history been? </li></ul></ul><ul><li>How ’s your mood? Your marriage (relationship)? </li></ul><ul><li>How was school for you? </li></ul><ul><li>Are people nervous driving with you? </li></ul><ul><li>Are there periods of time when you have too much energy for no particular reason ? </li></ul><ul><li>Do you ever have to have a beer at the end of the day to relax? </li></ul><ul><ul><li>[gently lead in to other substances, especially stimulants that may have a CALMING effect] </li></ul></ul><ul><ul><li>“ Have you ever taken any of your child’s ADD Rx?” [or other stimulants, energy drinks, diet pills, or cocaine] </li></ul></ul>
  9. 9. Failure to adequately treat <ul><li>“ Begin with end in mind.” (Covey) </li></ul><ul><li>Start LOW – (rule of thumb – ½ what the drug rep and package insert says!) </li></ul><ul><li>Go up to the maximum tolerated dosage, with finesse. </li></ul><ul><ul><li>Tell them about “Goldilocks” </li></ul></ul><ul><li>If it doesn’t work, add something complimentary (that makes sense). </li></ul>
  10. 10. THE FACTS <ul><li>SSRI’s treat depression AND/OR anxiety </li></ul><ul><li>Patients may INITIALLY need something else for daytime anxiety or sleep. </li></ul><ul><li>BZD’s of choice: </li></ul><ul><ul><li>clonazepam 1 mg tablets – ½ to 1 twice daily to three times daily </li></ul></ul><ul><ul><li>Diazepam – 5 mg =- ½ - 1 ½ twice daily to three times daily </li></ul></ul><ul><ul><ul><li>(first pass and second pass effects) </li></ul></ul></ul><ul><li>ANTIANXIETY RX (non BZD) – Buspirone, per package insert. Push to 20 mg THREE TIMES DAILY or to the point of maximum tolerability for 4 – 6 weeks AT THAT DOSE. </li></ul><ul><ul><li>Start with 5 mg. Can use WITH SSRI’s </li></ul></ul>
  11. 11. AVOID Alprazolam (Xanax ®) <ul><li>Addicting (and rapidly so) </li></ul><ul><li>Can have seizures if rapidly withdrawn (structurally similar to carbamazepine) </li></ul><ul><li>MD’s shot over it. </li></ul><ul><li>NOT an “anti-anxiety” medication </li></ul><ul><li>NOT a sleeper. </li></ul><ul><li>Even if they need a BZD for anxiety, it doesn’t have to be Xanax. </li></ul>
  12. 12. Sleepers – my preferences <ul><li>Sleepers: </li></ul><ul><ul><li>Rozerem (brand) (a melatonin analog) – 8 (up to 16* mg) at bedtime. VASTLY under-rated. May need to take 2 weeks before adequate effect. (* off-label dose) </li></ul></ul><ul><ul><ul><li>Dual acting agent – homeostatic and circadian effects. 70x as potent as melatonin. </li></ul></ul></ul><ul><ul><li>Trazodone (50 – 150mg ½ - 2 hrs. before HS. (Note, off label “unapproved.” Warn on priapism). </li></ul></ul><ul><ul><li>Lunesta (brand) – 2 – 3 mg. Try samples. Have mouthwash on hand. (Probably most predictable agent) </li></ul></ul><ul><ul><li>Ambien 12.5 mg CR (brand) – legitimately lasts longer than zolpidem. Probably not as effective as Lunesta. </li></ul></ul><ul><ul><li>Zolpidem – generic. People get hooked on it. </li></ul></ul><ul><li>Paradigm: SYMPTOMATIC treatment – after depression is stabilized, fade out the sleeper </li></ul>
  13. 13. Why treatment failures occur: too much or too little… The REAL mechanism of action of SSRI’s Animation © NEI, Inc. (Neuroscience Institute) and is used specifically with permission from Stephen Stahl, MD, Ph.D. Pictures removed for publicly posted slide deck
  14. 14. <ul><li>Drug, drug... who's got the drug? </li></ul>
  15. 15. Depression/anxiety Rx: <ul><li>TCA </li></ul><ul><li>Venlafaxine </li></ul><ul><li>Duloxetine </li></ul><ul><li>Mirtazapine (alpha 2) </li></ul><ul><li>desmethylvenlafaxine </li></ul>SSRI's & others….
  16. 16. Side Effects & Drug Interactions: The Doc Cady “Can ’ t s” of the TCA’s <ul><li>Pee </li></ul><ul><li>Poop </li></ul><ul><li>Spit </li></ul><ul><li>Spurt </li></ul><ul><li>Focus </li></ul><ul><li>Think </li></ul><ul><li>Stand up </li></ul><ul><li>Stay awake </li></ul><ul><li>Stay thin </li></ul><ul><li>ANTICHOLINERGIC/ ANTIMUSCARINIC EFFECTS </li></ul><ul><li>Alpha-adrenergic blockade </li></ul><ul><li>&quot;Antihistamine&quot; effects </li></ul>& paroxetine
  17. 17. Drug-drug interactions: chum for legal “sharks”
  18. 18. “ Strattera [coupled with Prozac or Paxil] has been great for our admissions. ” -Dr. William Beute, MD Pine Rest Campus Clinic Grand Rapids, MI April 21, 2004 [quoted with permission]
  19. 19. Cytochrome p-450 2D6 inhibition measured as % increase in “Desipramine AUC” – in vivo data Preskhorn, Alderman, et al. Pharmacokinetics of desipramine Co-administered with sertraline or fluoxetine. J. Clin Psychopharmacol 1994;14:90-98; Escitalopram package insert - note – different source of data, but same method Critically important when combining with other Rx metabolized through 2D6 pathways
  20. 20. Some drugs metabolized through cytochrome P-450 IID6 system <ul><li>ADHD </li></ul><ul><ul><li>Amphetamines </li></ul></ul><ul><ul><li>STRATTERA </li></ul></ul><ul><li>Analgesics </li></ul><ul><ul><li>Acetaminophen </li></ul></ul><ul><ul><li>Aspirin </li></ul></ul><ul><li>Antacids </li></ul><ul><li>Antiarrhythmics </li></ul><ul><ul><li>Procainamide, </li></ul></ul><ul><ul><li>Quinidine </li></ul></ul><ul><ul><li>Encainide </li></ul></ul><ul><ul><li>Flecainide </li></ul></ul><ul><li>Anticonvulsant </li></ul><ul><ul><li>carbamazepine </li></ul></ul><ul><li>ANTI-PAIN </li></ul><ul><ul><li>CODEINE! </li></ul></ul><ul><li>Bronchodilators </li></ul><ul><ul><li>Theophylline </li></ul></ul><ul><li>Cardiac </li></ul><ul><ul><li>Digoxin; digitalis </li></ul></ul><ul><li>Cough </li></ul><ul><ul><li>Dextromethorphan </li></ul></ul><ul><li>Diuretics </li></ul><ul><ul><li>Chlorthalidone </li></ul></ul><ul><ul><li>Furosemide </li></ul></ul><ul><ul><li>HCTZ </li></ul></ul><ul><ul><li>Triamterine </li></ul></ul><ul><li>Antibiotics </li></ul><ul><ul><li>TMP & SMX </li></ul></ul><ul><ul><li>Ampicillin </li></ul></ul><ul><ul><li>Erythromycin </li></ul></ul><ul><ul><li>Penicillin </li></ul></ul><ul><ul><li>Tetracycline </li></ul></ul><ul><li>Antidepressants </li></ul><ul><ul><li>TCA ’ s & “ 2P ’ s ” </li></ul></ul><ul><li>Antihistamines </li></ul><ul><li>Antihypertensives </li></ul><ul><li>Antipsychotics </li></ul><ul><ul><li>Clozaril </li></ul></ul><ul><ul><li>Risperdal </li></ul></ul><ul><ul><li>Zyprexa </li></ul></ul>
  21. 21. The “not so selective” SSRI’s; how to “Do yourself a favor.” drug SSRI? 2 nd order effects Side effects possible Escitalopram (generic 3/2012) Yes NOTHING (excess serotonin side effects only) Sertraline Yes Dopamine (1/3 as potent as amphetamine) Agitation, nervousness; improved [ ] Citalopram Yes AntiH1 Sedation (note- FDA lowered max dose to 40mg) Paxil Yes Ach NOT “NRI” Doped up, TCA effects, neurocognitive problems, withdrawal. Sexual, Prostate sxs Fluoxetine Yes 5HT2C Agitation, appetite suppression
  22. 22. New Agents, New Mechanisms (agent) (MOA) Differentiating points Venlafaxine (“IR” and XR) SSRI, NRI Nausea, GI side effects, sxl dysfunction Duloxetine SSRI, NRI Same. Better tolerated. For pain w/ dep. Desvenlafaxine SSRI, NRI Better tolerated Trazodone XR with Contramid® 5HT2a/c BLOCKER, mild SSRI Vilazodone SPA, SSRI ONLY SPA. Weaker SSRI. Targets 5HT1A. Less sexual side effects. Bupropion (“XL” – not “SR”) “ NDRI” Possibility of anxiety & “wound up.” Improved concentration. Push to 450 mg. Seizures.
  23. 23. Duloxetine Versus Escitalopram and Placebo: An 8-month, Double-Blind Trial in Patients With Major Depressive Disorder Pigott et al., Curr Med Res Opin , 2007
  24. 24. Comparison of Escitalopram and Duloxetine: 8-Month Trial HAMD 17 (MMRM) *p<0.05 Pigott et al., Curr Med Res Opin , 2007 Total Score * Anxiety/ Somatization Sleep Maier Retardation Subscales
  25. 25. Comparison of Escitalopram and Duloxetine: 8-Month Trial Significantly Different Adverse Events (p<0.05 Duloxetine vs Escitalopram) Percent of Patients Pigott et al., Curr Med Res Opin , 2007
  26. 26. <ul><li>Remission rates for both escitalopram and duloxetine continued to improve over time </li></ul><ul><li>Significantly more escitalopram-treated patients continued treatment compared to duloxetine-treated patients </li></ul><ul><li>Escitalopram showed significant improvement vs duloxetine on the HAMD 17 sleep subscale </li></ul><ul><li>Compared to escitalopram, duloxetine significantly increased pulse and systolic blood pressure </li></ul>Comparison of Escitalopram and Duloxetine: 8-Month Trial Conclusions Pigott et al., Curr Med Res Opin , 2007
  27. 27. Two New Agents You Need to Know <ul><li>Extended release Trazodone </li></ul><ul><ul><li>NOT “son of Trazodone” </li></ul></ul><ul><ul><li>Possibility of legitimate antidepressant effect with anti-anxiety effect WITHOUT doping patient up. </li></ul></ul><ul><ul><li>A “SARI” – serotonin antagonist reuptake inhibitor </li></ul></ul><ul><li>Vilazodone – the only SPARI [not in PI, not “FDA approved” description] available. </li></ul><ul><li>How to appreciate: </li></ul><ul><ul><li>5HT1A is receptor for antidepressant effect of serotonin </li></ul></ul><ul><ul><li>5HT2A and 5HT2 C: anxiety, sleep disruption, sexual side effects. </li></ul></ul><ul><ul><li>ANYTHING which works preferentially on 5HT1A is GOOD! </li></ul></ul>
  28. 28. XR Trazodone steady state dosing study <ul><li>(Levels done after 7 days steady state) </li></ul><ul><li>300 mg XR Traz AUC comparable to 100 mg IR Traz tid </li></ul><ul><li>Cmax 42% lower than IR Trazodone </li></ul><ul><ul><li>Translation – it doesn’t dope the patient up. </li></ul></ul>Kramer, WG et al. Once-daily Trazodone: Overview of Pharmacokinetic Properties. Poster – ACCP 38 th Annual Meeting, San Antonio, TX 2005
  29. 29. XR Trazodone Food Effect Study <ul><li>PI says “take at night” </li></ul><ul><li>CMax increase by 86% (!!!) under fed conditions. Peak is at 7 hours post dose (with feeding). </li></ul><ul><li>Note – this may lead the enlightened prescriber to vary the time of dosing. </li></ul>Kramer, WG et al. Once-daily Trazodone: Overview of Pharmacokinetic Properties. Poster – ACCP 38 th Annual Meeting, San Antonio, TX 2005
  30. 30. Vilazodone – a SPARI (per Stephen Stahl, MD, Ph.D.) – Serotonin Partial Agonist Reuptake Inhibitor <ul><li>Highly serotonergic. START LOW (5 mg). </li></ul><ul><li>Because of 5HT1A agonism, LESS “SSRI” effect is required. </li></ul>
  31. 31. ADHD Rx for frontline medicine <ul><li>Desiderata – get control, and keep it consistent for predictable period of time </li></ul><ul><li>Recommendations (for children and adult): </li></ul><ul><ul><li>Focalin XR (Dexmethylphenidate XR) 5,10,15,20,30 and 40 mg capsules) </li></ul></ul><ul><ul><ul><li>Rationale: MPH based. FAST. 8 – 10 hours. Can dose twice daily (off-label), a.m. >pm. (can also start with ½ capsule) </li></ul></ul></ul><ul><ul><li>Vyvanse – (lisdexamfetamine [sic]) – 20,30,40,50,60,70 mg [= 7.5 – 30 mg] amphetamine equivalents. Lasts 12 – 14 hours. (Can dissolve in water – per PI!). </li></ul></ul><ul><ul><li>Kapvay/Intuniv – FDA approved in kids. </li></ul></ul><ul><ul><ul><li>Kapvay easier to use, better tolerated. </li></ul></ul></ul><ul><ul><ul><li>Intuniv more potent, but more side effects (sedation) </li></ul></ul></ul>
  32. 32. Practicing beyond your ability (and knowledge) – the second generation antipsychotics <ul><li>Definitions: </li></ul><ul><ul><li>Mood stabilizer – something that stabilizes mood (Lithium, carbamazepine, VPA) </li></ul></ul><ul><ul><li>Antipsychotic – something you give someone who is PSYCHOTIC to get them UNPSYCHOTIC. </li></ul></ul><ul><ul><li>Antidepressant – something for depression. </li></ul></ul><ul><ul><li>“ 2 nd generation antipsychotic (“SGA’s”) = S2/D2 blockers.” </li></ul></ul><ul><ul><ul><li>Can “stabilize mood” as well as function as antipsychotics </li></ul></ul></ul><ul><ul><ul><li>Now some FDA approved for either add-on use or single agents for “bipolar depression” (e.g., quietapine XR) </li></ul></ul></ul>
  33. 33. Know who you’re playing with <ul><li>SGA’s and WEIGHT GAIN (Cady experience) </li></ul><ul><ul><li>olanzapine/risperidone > quietapine> aripiprazole/arsenapine> lurasidone/ziprasidone </li></ul></ul><ul><ul><ul><li>(Zyprexa/Risperdal>Seroquel> Abilify/Saphris> Latuda/Geodon) </li></ul></ul></ul><ul><li>EXPENSIVE: $400 – $600 /per month </li></ul><ul><li>All will work for mania. NONE are pure “mood stabilizers.” Some make you fat. </li></ul><ul><li>Some will work for depression but dope you up. </li></ul><ul><li>Much less risky than 1 st generation for tardive dyskinesia. </li></ul><ul><li>Axiom: refine your psychopharmacology before going to look for an SGA. </li></ul><ul><li>If you have to use one (for bipolar or psychosis, Lurasidone is probably most benign – 40 – 80 mg twice daily) </li></ul>
  34. 34. Cady recommendation for SGA’s in primary care <ul><li>As little as possible. </li></ul><ul><li>Do NOT use as primary mood stabilizers for bipolar disorder. Use lithium and/or VPA. (And check levels and appropriate labs). Lamotrigine also a real option. </li></ul><ul><li>Can use if single, or better yet, DOUBLE mood stabilizers don’t work. </li></ul><ul><li>Abilify (only “dopaminergic” SGA) probably best for antidepressant augmentation. </li></ul><ul><ul><li>2 – 4 or 5 mg is optimum dose for this. (Start with ½ of a 2 mg and go up) </li></ul></ul><ul><ul><li>Onset is FAST when it happens. </li></ul></ul><ul><li>Olanzapine is most dependable for rapid onset and control of manic episode, or agitation, or EXTREME PANIC & anxiety (off label).. Lurasidone may be best tolerated. </li></ul>
  35. 35. “ There are things known and there are things unknown, and in between are the doors.” - Jim Morrison
  36. 36. &quot;If I hadn't believed it, I wouldn't have seen it.&quot; - Yogi Berra Personal collection Louis B. Cady, M.D.
  37. 37. Thanks for coming! Sunset at CWI –by Louis B. Cady, M.D.
  38. 38. Contact information: Louis B. Cady, M.D. www.cadywellness.com www.indianaTMS-cadywellness.com Office: 812-429-0772 E-mail: [email_address] 4727 Rosebud Lane – Suite F Interstate Office Park Newburgh, IN 47630 (USA)

×