Sophia F. Dziegielewski, Ph.D., LCSW
Upon completion of this seminar the professional will be expected to demonstrate knowledge and:
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. Dziegielewski, S.F. Dziegielewski, S.F. Dziegielewski, S.F. (2010). Social work practice and psychopharmacology: A person and environment approach. New York: Springer Publishing.
Dziegielewski, S.FDziegielewski, S.FDziegielewski, S.FDziegielewski, S.F. (2010). DSM-IV-TR™ in action (2ndEdition). New York: Wiley Publishers. First edition published in 2001).
Dziegielewski, S.F. Dziegielewski, S.F. Dziegielewski, S.F. Dziegielewski, S.F. (2006). Psychopharmacology handbook: For the non-medically trained. New York: Norton Publishers.
Dziegielewski, S.F. Dziegielewski, S.F. Dziegielewski, S.F. Dziegielewski, S.F. (2005). Substance Addictions: Assessment and intervention. Chicago, IL: Lyceum Publications.
Speaker Contact Information: Speaker Contact Information: Speaker Contact Information: Speaker Contact Information: Sophia F. Dziegielewski, Ph.D., Sophia F. Dziegielewski, Ph.D., Sophia F. Dziegielewski, Ph.D., Sophia F. Dziegielewski, Ph.D., LCSWLCSWLCSWLCSW [email protected]
[email protected]@uc.edu
[email protected] or or or or [email protected]@[email protected]@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 6 out of 10 are mental health and two others are pain related6 out of 10 are mental health and two others are pain related 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
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
Atomoxetine (marketed as Strattera)
From January 2005-2008, six reported post-market 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)
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.
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 Complete a comprehensive safety plan with Complete a comprehensive safety plan with Complete a comprehensive safety plan with
clear documentation. clear documentation. clear documentation. clear documentation.
No HarmNo HarmNo HarmNo Harm----No Risk Agreements as Standard of No Risk Agreements as Standard of No Risk Agreements as Standard of No Risk Agreements as Standard of
Practice Practice Practice 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
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
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
LL-LL--Methylfolate/B12/B6/B2 is a vitamin -Methylfolate/B12/B6/B2 is a vitamin Methylfolate/B12/B6/B2 is a vitamin Methylfolate/B12/B6/B2 is a vitamin
combination. It provides nutritional combination. It provides nutritional combination. It provides nutritional combination. It provides nutritional supplementation for certain nutritional supplementation for certain nutritional supplementation for certain nutritional supplementation for certain nutritional requirements.
requirements.requirements. requirements.
Sold under multiple names. Sold under multiple names. Sold under multiple names. Sold under multiple names.
FDA approved Deplin for augmentation FDA approved Deplin for augmentation FDA approved Deplin for augmentation FDA approved Deplin for augmentation For use with clients that have low plasma For use with clients that have low plasma For use with clients that have low plasma For use with clients that have low plasma
and/or low blood cell folate and/or low blood cell folateand/or low blood cell folate 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:
Tricyclics:
Tricyclics:
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.
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 complicate heart problems, sweating,
dryness of the mouth, headache, increased appetite for sweets, weight gain, unpleasant taste, difficulty urinating, change in sexual desire and ability, decrease, muscle twitches, fatigue, and weakness.
Can interact with: thyroid hormones,
anti-hypertensive medications, oral contraceptives, blood coagulants, sleeping medications, anti-psychotics, diuretics, antihistamines, aspirin, bicarbonate of soda, vitamin C, alcohol and tobacco.
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)*
Dizziness, rapid heart rate.
Interaction potential with certain foods
(watch out for monosodium glutamate, MSG).
Can interact with OTC cold and allergy
preparations, antihistamines,
amphetamines, insulin, narcotics, anti-Parkinson medications.
Reactions may not appear for several hours
and can include: rapid heart rate, high blood pressure, seizures, stroke and/or coma.
Prozac (Fluoxetine) Zoloft (Sertraline)
Paxil (Paroxetine) - Do not use with MAO
inhibitors- stronger birth defect warning for 2006 (congenital malformations) not recommended in 1st
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:
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
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 Symbyak Symbyak Symbyak (olanzapine and (olanzapine and (olanzapine and (olanzapine and
fluoxetine HCl) fluoxetine HCl) fluoxetine HCl) 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
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
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.”