9/19/2011
Disclosure

I have no actual or potential conflicts of interest in
relation to this presentation.
Increase Your Comfort Level with Psychiatric
Medications and Learn How to Effectively
Counsel your Patients
Kelly N. Gable, Pharm.D., BCPP
SIUE School of Pharmacy
September 24, 2011
Pharmacist Learning Objectives




Discuss abnormalities of the mental status exam that may
warrant treatment with a psychiatric medication.
Review clinical pearls and counseling points for
antipsychotics, antidepressants, mood stabilizers, sedativehypnotics, and anxiolytics.
Identify barriers to effective medication education within
the psychiatric patient population.
Describe techniques to enhance communication and
patient interviewing skills.
Assessment Question #1
During a routine clinic appointment, a patient presents to
you with very eccentric attire, talking extremely fast, and
frequent. They begin to tell you about their ability to
communicate with the deceased and aspirations to become
a physician, senator, and preacher. They describe “not
sleeping for days.” This patient is displaying symptoms that
best represent:
1.
2.
3.
4.
Schizophrenia
Mania
Depression
Anxiety
Assessment Question #2
Assessment Question #3
You dispense a prescription for asenapine (Saphris®) to a
patient taking it for the first time. It is important to counsel
the patient on which of the following?
While working at the local independent pharmacy, you
receive a phone call from the town physician. He is
requesting a recommendation for a non-addictive sleep aid
for his patient that is depressed. The patient has a history
of alcohol dependence and he would like to prescribe
something that is not a controlled substance. It would be
appropriate for you to suggest:
1.
2.
3.
4.
This medication must be placed under the tongue to dissolve
sublingually
It is necessary to take this medication with at least a 350
calorie meal
This medication commonly makes people feel restless, let
your prescriber know if you start to feel anxious
You will need to get your blood drawn weekly for the first 6
months of treatment
1.
2.
3.
4.
Zolpidem
Bupropion
Temazepam
Trazodone
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Assessment Question #4
Abnormalities of Mental Status
It is important to recognize that an individual with a severe
and persistent mental illness is faced with many barriers
that may prevent successful treatment. A barrier to
treatment adherence that you (the pharmacist) can directly
impact daily would be:

1.
2.
3.
4.
Co-occurring alcohol dependence
Negative stigma associated with mental illnesses
Paranoia and auditory hallucinations
Homelessness and poverty
Abnormalities of Mental Status
Appearance:
 Poor grooming, mismatched dress, hygiene, unshaven,
poor dentition
Behavior:
 Difficult to engage, psychomotor slowed, poor eye
contact, stooped posture, poor impulse control, abnormal
movements (tremor, tics)
Speech:
 Poverty of speech, neologisms, difficulty with word finding,
clanging

Sara J. is a 45 year old female wearing mismatched
clothes, malodorous, presenting to the pharmacy counter
window. She is demanding to speak to the pharmacist. “I
can’t take this Zyprexa anymore….I’ve gained too much
weight!”
As you observe her walking up & down the store aisle,
she is talking to herself.
Abnormalities of Mental Status
Mood:





Affect: how one displays
their mood to you
Depressed
Dysphoric
Euthymic
Elevated
Euphoric
◦ Restricted
◦ Flat
◦ Is it appropriate?
Euphoria
Euthymia
Depression
What is Depression?
Abnormalities of Mental Status
Thought Process:
 The expression of one’s thoughts
 Are they goal-oriented or illogical?
Sleep
changes
Suicidal
Appetite
changes
Depression
+/Anhedonia






Hopeless
Circumstantial
Tangential
Flight of ideas
Loose associations
Concrete thinking
Thought blocking
Poor
energy
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Abnormalities of Mental Status
What is Schizophrenia?
Thought Content:
 Inner beliefs
 Abnormalities:





Positive
Symptoms
Delusions
Suicidality
Thought insertion/broadcasting
Hypersexuality
False perceptions: hallucinations
Negative
Symptoms
Cognitive
Symptoms
What is Mania/Bipolar Disorder?
↓ Need
for Sleep
Pressured
Speech
Flight of
Ideas
• Flat affect, asocial, amotivation,
anhedonia
• Impaired attention & memory, poor
executive functioning
2nd-Generation Antipsychotics (SGAs)

Grandiose,
Irritable,
or
Euphoric
• Hallucinations, delusions,
disorganization









Clozapine (Clozaril®)- 1990
Risperidone (Risperdal®)- 1994
Olanzapine (Zyprexa®)- 1996
Quetiapine (Seroquel®)- 1997
Ziprasidone (Geodon®)- 2001
Aripiprazole (Abilify®)- 2002
Paliperidone (Invega®)- 2006
Asenapine (Saphris™)- 2009
Iloperidone (Fanapt™)- 2009
Lurasidone (Latuda ™)- 2011
Stahl SM, Essential Psychopharmacology:
Neuroscientific Basis and Practical Applications 2nd Edition. 2000
Antipsychotic Clinical Pearls

Clozapine: 300 – 450 mg/day



Benefits: decreases violence & aggression, treats refractory psychosis,
reduces suicidal ideation, improves tardive dyskinesia (least likely to
cause EPS)
Adverse Effects: agranulocytosis (0.5 – 2% incidence), seizure risk,
excessive sedation, weight gain, hyperlipidemia, hyperglycemia,
tachycardia / myocarditis, cardio/respiratory depression
Antipsychotic Clinical Pearls

Risperidone vs. Paliperidone

Risperidone: 4 – 6 mg/day (can be BID)





Smokers may require higher doses (CYP1A2 substrate)
Benefits: multiple dosages forms (tablets, ODT- Zydis, short acting
& long-acting IM)

IM administration with benzodiazepines = severe hypotension

Adverse Effects: weight gain, hyperlipidemia, hyperglycemia

Paliperidone: 3 – 9 mg/day

Olanzapine: 10 – 30 mg/day



Dosage Forms: tablet, solution, ODT, long-acting IM (q 2 weeks)
T ½: 21 hrs
$
Dosage Forms: OROS capsule, long-acting IM (q 4 weeks)
T ½: 24 hrs
$$$$
Adverse Effects: orthostatis, weight gain, EPS, ↑ prolactin
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Antipsychotic Clinical Pearls:
‘the new kids on the block’
Antipsychotic Clinical Pearls

Quetiapine: 300 – 800 mg/day




Ziprasidone: 80 – 160 mg/day (given BID)





Commonly under-dosed (25 or 50 mg q HS)
Dosage Forms: IR tabs; ER tabs (break to become IR)
Adverse Effects: sedation, weight gain, hypertriglyceridemia,
hyperglycemia
Bioavailability ↑ 2-fold when given with food
Dosage Forms: capsules, short-acting IM (max: 2 x 20 mg doses in
24 hr)
IM administration with benzodiazepines = severe hypotension
Adverse Effects: insomnia, nausea, headache, QTc prolongation
Aripiprazole: 10 – 30 mg/day



D2 partial agonist/antagonist
Dosage forms: tabs, solution, ODT, short-acting injection
Adverse Effects: insomnia, anxiety, akathisia, HA, nausea
Antipsychotic:
Long-Acting Injections (LAIs)

Iloperidone: 1 mg BID




Asenapine: 5 mg BID (sublingual tablet)



Lurasidone: 40 – 80 mg/day




Clinical Pearls
Haloperidol
50 mg/mL
100 mg/mL
Q 2 – 4 weeks
Yes ~ 4
weeks
Room temp
Sesame oil vehicle
More painful injection
Fluphenazine
25 mg/mL
Q 3 weeks
No
Room temp
Sesame oil vehicle
More painful injection
Risperidone
12.5, 25, 37.5,
50 mg
Q 2 weeks
Yes- 3
weeks
Refrigerator
Hydrophilic
microspheres
Paliperidone
117, 156, 234
mg
Q 4 weeks
(must load with 234
mg; then 156 mg 1
week later)
No
Room temp
Prefilled syringes
Loading dose $$$
Q 2 – 4 weeks
No
210, 300, 405
mg
Aripiprazole
Room temp
Post Injection Delirium
Syndrome (must be
monitored x 3 hrs post
injection)











Reduce psychosis, agitation
Improved negative & cognitive symptoms
Reduce manic symptoms
Improved QOL (occupational, social)
Minimize/prevent relapse
Highlight common adverse effects:

Pseudoparkinsonism (resting tremor)
Akathisia (internal restlessness)
Weight gain, glucose dysregulation
Discuss more rare adverse effects:


Tardive dyskinesia
Hyperprolactinemia
Community Pharmacy

Prescription:

Thought organizer
Mood stabilizer
Avoid statements such as:

Focus on the benefits:

Coming soon…
Use patient-friendly terminology

Hypothesized to possibly improve cognition (5-HT1 partial agonist)
Administer with 350 cal meal for full absorption
Adverse effects: insomnia, akathisia/restlessness, elevated prolactin, minimal
weight gain and cholesterol changes are minimal

Antipsychotic Counseling Points

Do NOT swallow tablet (bioavailablity <2% if swallowed; 35% sublingually)
NO eating or drinking 10 min post dose
Antipsychotic Counseling Points
Antipsychotic Strengths Administration Oral
Storage
Overlap
Olanzapine
Increase to target of 12 – 24 mg/day
Similar binding profile (D2/5-HT) to risperidone
Adverse Effects: orthostasis, dizziness, sedation, HA, wt gain, nausea


Abilify 30 mg q day #30
Not covered by insurance / needs prior authorization
What do you do?
“You need to take this medication to avoid from going crazy!”
“This is an antipsychotic, people take it if they are hearing
voices.”
“You will likely gain weight with this medication.”
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Community Pharmacy
Antipsychotic FDA-Indications
Schizophrenia
Questions to ask?
 How long has this person been taking Abilify?
 Is this a new prescription?
 What is it being used to treat?
 What happens if the patient misses several doses of their
antipsychotic?
 Are the antipsychotics interchangeable?
Bipolar
Disorder,
acute mania
Bipolar
Disorder,
maintenance
therapy
Bipolar
Disorder,
Depression
Clozapine*
X
Risperidone
X
(≥ 13 y.o.)
X
(≥ 10 y.o.)
X (Risperdal
Consta)
Olanzapine
X
(≥ 13 y.o.)
X
(≥ 13 y.o.)
X
X (Symbyax)
Quetiapine
X
(≥ 10 y.o.)
X
(≥ 13 y.o.)
X
(≥ 10 y.o.)
X
Ziprasidone
X
X
X (ADJUNCT)
Aripiprazole
X
(≥ 13 y.o.)
X
(≥ 10 y.o.)
X
(≥ 10 y.o.)
Paliperidone
X
Asenapine
X
Iloperidone
X
Lurasidone
X
Irritability
Associated
with Autism
Major
Depressive
Disorder
(ADJUNCT)
Agitation
associated with
schizophrenia
or bipolar
mania
X
(≥5 y.o.)
X (IM)
X
X (IM)
X
(≥6 y.o.)
X
X (IM)
X
*Treatment resistant & recurrent suicidal behavior associated with schizophrenia
Antidepressants
Selective Serotonin Re-Uptake
Inhibitors (SSRIs)
SSRI Clinical Pearls
Tri-cyclic
Antidepressants (TCAs)

Fluoxetine: 20 – 80 mg/day


Fluoxetine (Prozac®, Prozac Weekly®,
Sarafem®, Symbyax®)
Desipramine (Norpramin®)
Paroxetine (Paxil®/
Nortriptyline (Pamelor®)

Sertraline: 50 – 200 mg/day

CR®)

Amitriptyline (Elavil®)

Fluvoxamine (Luvox®/ CR®)
Imipramine (Tofranil®)

Citalopram (Celexa®)
Clomipramine (Anafranil®)
Escitalopram (Lexapro®)
Doxapin (Sinequan®)
Short t ½
Constipation, dry mouth, sedation more common
Fluvoxamine: 50 – 300 mg/day


Nausea & diarrhea common
Paroxetine: 10 – 50 mg/day
Sertraline (Zoloft®)

Long t ½ = good for non-adherent patient
Insomnia & activation common
Clinically used for OCD
Citalopram / Escitalopram: 20 – 40 mg/day / 10 – 20 mg/day

Newest SSRIs, fewer drug interactions
All SSRIs are equally efficacious; better tolerated than TCAs & MAOIs
TCA Clinical Pearls
Often used for: depression, neuropathic pain,
anxiety disorders, & enuresis
 Poorly tolerated!!:




Anticholinergic side effects (dry mouth, urinary
retention, blurred vision, constipation)
Sedation, weight gain, sexual dysfunction, seizure
risk
Cardiovascular complications
 Orthostatic hypotension, tachycardia, cardiac
conduction abnormalities

Other Antidepressants







Trazodone (Desyrel®,Oleptro™)
Bupropion (Wellbutrin IR, SR, XL®, Zyban®)
Venlafaxine (Effexor®, Effexor XR®)
Desvenlafaxine (Pristiq®)
Duloxetine (Cymbalta®)
Mirtazapine (Remeron®)
Vilazodone (Viibryd™)
Lethal in overdose
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9/19/2011
Antidepressant Clinical Pearls
Trazodone: 200 – 600 mg/day

25 – 100 mg/day = insomnia treatment
No abuse potential, safer in overdose


Bupropion: 150 – 300 mg/day

IR rarely used; SR BID dosing; XR q day dosing
Only dopamine enhancing antidepressant
Adverse effects: insomnia, weight loss, NO sexual dysfunction,
lowered seizure threshold
NOT used with epilepsy, eating disorders, alcoholism




SNRIs: may increase diastolic blood pressure

OTC/Herbal Antidepressants



St. John’s Wort: 300 mg TID
Efficacy: placebo < St. John’s Wort = TCA
Drug Interactions: CYP2C9, 3A4, 2D6, 1A2 inducer



Reports of ↓ serum concentrations of OC, theophylline,
warfarin, protease inhibitors
Serotonin syndrome risk
5-HTP
Efficacy very similar among all 3; commonly used for neuropathic
pain

Mirtazapine: 15 – 45 mg/day

Common use in geriatric depression due to sedation & weight gain
Anti-nausea effect


http://www.ssrireview.com/Natural_Serotonin_Boosters/Natural_Serotonin_Boosters.php
Antidepressant Counseling Points




Emphasize the benefits!
Importance of adherence → serotonin withdrawal
Drug interactions → serotonin syndrome
Common adverse effects:

HA, nausea, diarrhea
Sexual dysfunction

How do you counsel on sexual dysfunction?



Discontinuation Syndrome



Anxiety, agitation, irritability, sleep disturbances, dizziness,
nausea, paresthesias
 Usually occurs 1-3 days after d/c SSRI; lasts up to 2 wks
Worse with paroxetine & venlafaxine
Minimal with fluoxetine
Anorgasmia, delayed ejaculation, ↓ libido,
There are treatment options:




Dose reduction of antidepressant
Drug holiday or timing of dosing
Choose another antidepressant: bupropion, mirtazapine
For erectile dysfunction: sildenafil (Viagra ) PRN
http://thebrain.mcgill.ca/
Serotonin Syndrome: Does this really exist?
What do you recommend?







SSRIs + MAOIs?
SSRIs + dextromethorphan?
Phenelzine + meperidine?
TCAs + lithium?
SSRIs + St John’s Wort?
TCA + trazodone?
SSRIs + linezolid?
Mood Stabilizers






Lithium
Valproate (Depakote®)
Lamotrigine (Lamictal®)
Carbamazepine (Tegretol®)
Oxcarbazepine (Trileptal®)
Atypical Antipsychotics
Symptoms:

Confusion (mental status Δ), N/V/D, tremor, restlessness,
hyperreflexia, HTN, tachycardia, fever, diaphoresis,
myoclonus, rigidity
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Mood Stabilizer Clinical Pearls

Depakote: 1000 – 4000 mg/day



Lamotrigine: 100 – 200 mg/day
Better for bipolar depression (no anti-manic activity)
Dose escalation is slow due to SJS risk (initiate at 25 mg/day)



Carbamazepine: 400 – 1600 mg/day
Potent liver enzyme inducer

In The Hospital


Studies have shown efficacy for use in:

Better for rapid cycling bipolar disorder
Monitor for hepatotoxicity
Quicker control of manic symptoms
Adverse Effects: GI upset, sedation, weight gain, hair loss


Lithium Clinical Pearls




Most effective for bipolar disorder, type I (mania)
Less effective for rapid cycling / mixed mania
NO hepatic metabolism (~100% renal clearance)
0.6 – 1.2 mEq/L = therapeutic (>1.5 mEq/L = toxic)




Lithium Counseling Points
You are providing discharge counseling for a 25 year old
patient taking lithium 300 mg q day and citalopram
(Celexa®) 40 mg q day.
What are important counseling points?

Adverse effects:








You routinely see a patient in your clinic for diabetes
management. He also has hypertension and
hyperlipidemia. He suffers from chronic insomnia.
Current medications:





Nausea, diarrhea, fine hand tremor, polydipsia & polyuria,
“loss of creativity”
Increased risk for toxicity:

The Outpatient Clinic
Bipolar mania & depression
Bipolar relapse prevention
Unipolar depression augmentation
Suicidality prevention
Poor renal function, drug rxn (HCTZ, ACEI/ARBs, NSAIDs)
Sodium restricted diets (< 2 g/day)
Dehydration, heavy exercise, hot weather
Vomiting & severe diarrhea
Stress importance of regular blood monitoring &
outpatient follow-up
Contraception for females
The Outpatient Clinic

Is it appropriate to prescribe a patient a benzodiazepine +
zolpidem for insomnia?
Metformin 500 mg BID
Simvastatin 40 mg q HS
Lisinopril 20 mg q day
Zolpidem 10 mg q HS
Diazepam 10 mg q HS
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Benzodiazepines
Anxiolytics
Clonazepam (Klonopin®)
Alprazolam (Xanax®)
Lorazepam (Ativan®)
Diazepam (Valium®)
Clorazepate (Tranxene®)
Chlordiazepoxide (Librium®)
Oxazepam (Serax®)
The Outpatient Clinic
Clinical Pearls: Benzodiazepines

Metabolism:






Lorazepam, oxazepam, & temazepam

Short t½ (5 – 14 hrs): oxazepam
Intermediate t½ (10 – 20 hrs): alprazolam, lorazepam
Clonazepam t ½ ~40 hrs
Long t½ (100 hrs): diazepam, clorazepate, chlordiazepoxide



DEA Schedule IV
All have a relatively fast onset of 15-20 minutes
Ambien® & Lunesta® have longer half lives & are better
indicated for maintaining full night of sleep
Sonata® best for patients having trouble falling asleep
Structurally unrelated to BZDs






Highly lipophilic: diazepam, alprazolam
Clinical Pearls: Non-benzodiazepines


Antihistamines (diphenhydramine, hydroxyzine)
Natural products (melatonin, valerian)
Chloral hydrate
Antidepressants (trazodone)
Melatonin receptor agonist (ramelteon- Rozerem®)
Zolpidem (Ambien®)
Zaleplon (Sonata®)
Eszopiclone (Lunesta®)
Onset of Action:




Pharmacokinetics:
Which benzodiazepine is most appropriate for the
treatment of insomnia vs anxiety?
Other Sedative-Hypnotics
Bypass major hepatic metabolism:



Sedative-Hypnotics
Temazepam (Restoril®)
Triazolam (Halcion®)
Quazepam (Doral®)
Estazolam (ProSom®)
Flurazepam (Dalmane®)
Primarily have sedative properties (NOT anxiolytic, muscle relaxant,
or anticonvulsant)
Sedative-Hypnotic Counseling Points

Timing of dosing






Length of treatment

Common side effects: dizziness, headache, nausea, psychosis (at
higher doses)


Trazodone ~30 – 60 min before bed
Temazepam ~ 60 min before bed
Quetiapine IR ~15 – 30 min before bed
Quetiapine XR ~ 2 – 3 hrs before bed
Zolpidem ~ 15 – 30 min before bed
6 weeks, 6 months, or long-term?
Transient insomnia (from acute stress), short-term, and
chronic insomnia
Sleep hygiene
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Barriers in Medication Education


Barriers in Medication Education

Stigmatized perception of mental illness
Public perceptions of mental illnesses:








71%- due to emotional weakness
65%- caused by bad parenting
45%- victim’s fault; can will it away
43%- incurable
35%- consequence of sinful behavior
10%- has a biological basis; involves the brain



Poverty-related factors
Complex dosing regimens
Internet resources
Poor disease insight
Co-occurring substance use
Active symptoms:
Psychosis (paranoia)
Amotivation (negative symptoms; depression)
Cognitive dysfunctions (memory deficits)





No consensus on treatment recommendations among
prescribers
Pharmacist attitude & behavior (poor communication)
Stahl SM, Essential Psychopharmacology:
neuroscientific basis and practical applications, 2000.
Assessing Adherence & Building Rapport

Important questions to ask:





Tell me how your medications are helpful to you?
Do you think you need all of the medications you are taking?
How do your medications make you feel?
How often do you forget to take your medications?
When you feel better, do you sometimes stop taking your
medication?
Improving Patient Communication


Let the patient discuss their concerns first
Listen to patient’s beliefs and attitudes




Withhold the urge to contradict or “correct” patient beliefs
The patient’s subjective beliefs rather than objective medical
reality ultimately influence behavior
Be sensitive to cultural beliefs
Patients are more likely to be adherent when they experience
the clinician as competent, supportive, optimistic, and
encouraging
Improving Patient Communication


Psychoeducation
Motivational Interviewing (MI)


Directive, person-centered counseling style for eliciting behavior
change; helping patients to explore & resolve ambivalence
Work within the stages of change




Precontemplation:“there is no problem”
Contemplation:“there may be a problem, I have mixed feelings about it.”
Determination / preparation:“there is a problem & I want to change.”
Action → Maintenance
Core features of MI


Express Empathy

Develop Discrepancy

Avoid Argumentation

Roll with Resistance
Assessment Question #1
During a routine clinic appointment, a patient presents to
you with very eccentric attire, talking extremely fast, and
frequent. They begin to tell you about their ability to
communicate with the deceased and aspirations to become
a physician, senator, and preacher. They describe “not
sleeping for days.” This patient is displaying symptoms that
best represent:
1.
2.
3.
4.
Schizophrenia
Mania
Depression
Anxiety
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Assessment Question #2
Assessment Question #3
You dispense a prescription for asenapine (Saphris®) to a
patient taking it for the first time. It is important to counsel
the patient on which of the following?
While working at the local independent pharmacy, you
receive a phone call from the town physician. He is
requesting a recommendation for a non-addictive sleep aid
for his patient that is depressed. The patient has a history
of alcohol dependence and he would like to prescribe
something that is not a controlled substance. It would be
appropriate for you to suggest:
1.
2.
3.
4.
This medication must be placed under the tongue to dissolve
sublingually
It is necessary to take this medication with at least a 350
calorie meal
This medication commonly makes people feel restless, let
your prescriber know if you start to feel anxious
You will need to get your blood drawn weekly for the first 6
months of treatment
1.
2.
3.
4.
Zolpidem
Bupropion
Temazepam
Trazodone
Assessment Question #4
It is important to recognize that an individual with a severe
and persistent mental illness is faced with many barriers
that may prevent successful treatment. A barrier to
treatment adherence that you (the pharmacist) can directly
impact daily would be:
1.
2.
3.
4.
Co-occurring alcohol dependence
Negative stigma associated with mental illnesses
Paranoia and auditory hallucinations
Homelessness and poverty
Questions?
[email protected]
(314) 603-5223
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