Module 8, Pharm

Off-label drugs for Insomnia:

*Antidepressants: Mirtazapine (Remeron), trazodone (Desyrel) are frequently used in treating insomnia in the elderly* due to reassuring safety profiles. Although tricyclic antidepressants (TCAs) cause sedation, due to significant side effects, particularly in the elderly, *TCAs are used infrequently.* (AVOID) *Antihistamines: Diphenhydramine (Benadryl) and hydroxyzine*. However, if the patient has depression, *antihistamines can worsen depression* and if they are *elderly they can cause anticholinergic side effects (so AVOID those patient populations).* *Antipsychotic: Quetiapine (Seroquel), a second generation antipsychotic causes sedation but it has multiple side effects and is costly. AVOID off-label use for insomnia. *

What's the best Off-label drug for insomnia tx of the elderly?

*Antidepressants: Mirtazapine (Remeron), trazodone (Desyrel)* are frequently used in treating insomnia in the elderly due to reassuring safety profiles. AVOID TCAs!

*Hydroxyzine (Atarax, Vistaril)* is also used for

*Anxiety!* There are *no abuse or addiction concerns* with this medication. It is a *strong antihistamine* and will cause side effects consistent with antihistamines but in patients with severe anxiety can offer some relief of anxiety.

Benzodiazepines, what are they used for?

*Benzodiazepines and SSRIs/SNRIs* are most commonly used to *treat anxiety*. Benzodiazepines are *also used for acute seizure activity*. Also *routine daily use may lead to physical dependence and is highly discouraged.*

Which meds are excellent for *quick relief of anxiety* so when they are used on an as needed basis (*PRN*)?

*Benzodiazepines* Be sure to ask how many they are taking per week and any pattern for use (ie. what are their triggers?). *Prescribe no more than 30 tablets with no refills.* *Patients that use these correctly are those that have only a few tablets on hand for extreme anxiety.*

MAOIs (depression tx): issues??

-MANY food and drug interactions -NEVER used as a first or second line drugs -ONLY for tx of refractory depression *Side effects: ^ intake of tyramine foods can lead to HTN crisis!! AVOID tyramine containing foods/OTC cold and allergy preparations*

What is the most effective tx for *generalized anxiety disorder (GAD)*?

A *combination of psychotherapy & SSRI/SNRI*. For *acute anxiety*, such as that experienced before flying on a plane, may be treated with a *short-term benzodiazepine or an antihistamine ie. hydroxyzine (Atarax, Librium)*

Insomnia, OTC meds to treat?

A common treatment is the use of OTC preparations containing *diphenhydramine (Benadryl)*. In this case, the side effect of drowsiness is intentionally solicited. Many people self-medicate with Tylenol PM (acetaminophen and diphenhydramine). Diphenhydramine may cause morning drowsiness, has anticholinergic effects, and is generally only effective for a few days. There may also be an *idiosyncratic reaction in children and may cause delirium in the elderly.*

Adolescents & Antidepressants

Adolescents-recheck WEEKLY for 4 weeks, then every other week for 1 month

Anti-epileptic drugs (AEDs)

Examples: *Tegretol, Valporic acid, Lamictal, Topamax, Trileptal, Equetro, Keppra, and Zonegram* Side Effects: Somnolence, nausea, headache, fatigue, GI distress, weight gain, dizziness, ataxia, altered cognition, parathesias, dipolpia RARE: decrease in WBC/Plts, life-threatening rashes, SJS, etc.

SSRIs and SNRIs

FIRST line for depression tx. Few side effects: most common are GI upset (take at night), sexual dysfunction, nervousness and HA.

First step in treatment of Insomnia:

First *perform a full assessment of sleep difficulty including what type of problem they are having*. There may be difficulty with s*leep onset (falling asleep)* or *maintenance (staying asleep)*. Ideally, sleep medications should be given for a short duration only. Any underlying problem causing insomnia should be evaluated and treated.

MAOIs

MAO (monamine oxidase) inhibitors are *not commonly prescribed in primary care*. They *interact with many other agents*. Clients on MAO inhibitors must *have a wash-out period from other antidepressants prior to starting the MAO.*

Depression During Pregnancy article Pregnant and not currently on medication for depression:

Pregnant and not currently on medication for depression: Psychotherapy may be beneficial in women who prefer to avoid antidepressant medication. For women who prefer taking medication, risks and benefits of treatment choices should be evaluated and discussed, including factors such as stage of gestation, symptoms, history of depression, and other conditions and circumstances (eg, a smoker, difficulty gaining weight).

Depression During Pregnancy article Pregnant women currently on medication for depression:

Pregnant women currently on medication for depression: Psychiatrically stable women who prefer to stay on medication may be able to do so after consultation between their psychiatrist and ob-gyn to *discuss risks and benefits*. Women who would like to discontinue medication may attempt medication tapering and discontinuation if they are not experiencing symptoms, depending on their psychiatric history. Women with a history of recurrent depression are at a high risk of relapse if medication is discontinued. Women with recurrent depression or who have symptoms despite their medication may benefit from psychotherapy to replace or augment medication. *Women with severe depression (with suicide attempts, functional incapacitation, or weight loss) should remain on medication*. If a patient refuses medication, alternative treatment and monitoring should be in place, preferably before discontinuation.

Depression and Treatment during Childbearing Years

PMDD (premenstrual dysphoric disorder) or PMS (premenstrual syndrome) may be treated with oral contraceptives or with antidepressants. *Prozac* has been marketed under the name *Serafem for PMDD*. Significant changes in estrogen levels during the postpartum period increase risk for a major depressive, psychotic or bipolar episode.

Risks of Not Taking Antidepressants-pregnant woman

Relapse of major depression Increased suicidality due to increasing depression Poor self-care Poor motivation for prenatal care Disruption of mother-infant bonding Low birth weight, developmental delay in children of women with untreated depression Post partum psychosis and harm to the infant Medical-legal risks of not using antidepressants

If the client has performance anxiety (stage fright), consider using...

a *beta-blocker* to relieve the catecholamine-mediated autonomic symptoms without sedation. *Propranolol (Inderal®) or atenolol (Tenormin®)* taken an hour before the event is typically effective in reducing symptoms and does not cause sedation.

Due to their rapid onset of action, ___________________ are often used for immediate relief from an acute anxiety attack until a safer anxiolytic agent can take effect and/or resolve insomnia.

*Benzodiazepines* For acute anxiety, the savvy prescriber will prescribe the *benzodiazepine with the fastest onset of action*. However, prescribing for acute anxiety must be for *the shortest time possible*, as *those benzodiazepines with the fastest onset of action are associated with the highest potential for abuse*. Most importantly, due to the abuse potential, *use caution if alcohol or illicit drug use is suspected*. Benzodiazepines are metabolized in the liver and *CP450* drug and food interactions must be considered.

TCAs: issues??

*CARDIOTOXIC side effects!!, AVOID in pts with cardiac DA* *Use with caution if pt is also on an SSRI--> elevate levels of TCA* *LETHAL IN OD!!!!*

Patients *with pain*/depression may achieve some pain relief with the use of...

*Cymbalta (SSRI) or a tricyclic*. *Cymbalta also may be helpful in treating stress urinary incontinence and has an indication for treatment of diabetic neuropathy*.

*Non-benzodiazepines*, Lunesta?

*Eszopiclone (Lunesta)* is the only drug recommended for *long-term use.* Used for insomnia.

*Non-benzodiazepines* FDA approved for Insomnia:

*Eszopiclone (Lunesta), zaleplon (Sonata), and zolpidem (Ambien , Ambien CR and Intermezzo)*. *Eszopiclone (Lunesta) is the only drug recommended for long-term use.* *All others* are to be used a *maximum of 35 days* Ambien has gender specific dosing - lower doses are recommended for women Ambien comes in a sublingual form (Edluar) and nasal spray (ZolpiMist).

Which meds to choose first for depression tx?

*FIRST LINE: SSRIs* Second line: TCAs Last choice: MAOIs (many food/drug interactions)

Antidepressants in Children

*Fluoxetine (Prozac)* is the most studied antidepressant for use with children and is the only antidepressant recommended for use in children 8 years and above. --> SSRIs 12 yrs+ *One key point is that when an adolescent is started on an SSRI you will need to have them follow-up one week after initiation, then every 2 weeks for a month and then less frequently based on response and any side effects. This does not mean that there must be face to face contact but there needs to be contact with the adolescent at these intervals.*

Drugs for PD

*GOAL is to reduce symptoms. They activate dopamine receptors and block cholinergic receptors.* *LEVODOPA (combined with carbidopa)* is the most effective tx for motor symptoms.

What is the BIGGEST problem with TCAs?

*LETHAL IN OD!!!!*

What's the "Gold Standard" for the treatment of bipolar disorder?

*Lithium* It is *important that the client not become sodium depleted* as this leads to lithium retention and leads to a toxic reaction. For this reason, *diuretics and anticholinergic drugs may cause drug-drug interactions in a client on lithium*. *Lithium levels must be monitored*. Lithium has a narrow therapeutic range and patients can easily develop toxicity. *Hypothyroidism is often caused by long-term use of lithium.*

Examples of benzos used for anxiety?

*Lorazepam (Ativan)* is commonly used for anxiety -- it has a *slower onset and a shorter half-life* *Alprazolam (Xanax)* works *quickly and has a moderate half-life*. *Diazepam (Valium)*, has a *fairly long half-life*. It is used effectively to help reduce spasm and decrease seizure activity.

Which are the *only sleep products* that are *not controlled substances* (aside from benadryl)?

*Lunesta (eszopiclone)* and *Rozerem (ramelteon)*

Chronic Insomnia (duration greater than 6 months):

*Lunesta (eszopiclone)* and *Rozerem (ramelteon)* In clinical studies, Lunesta (eszopiclone) seems to have a preferable safety profile to other sleep aids. The most commonly reported adverse effect was bitter taste. Rozerem (ramelteon) is a unique agent, a selective melatonin agonist. Other than diphenhydramine (Benadryl), these are the *only sleep products* that are *not controlled substances.*

Melatonin for Insomnia:

*Melatonin agonist: Ramelton (Rozerem)* *Melatonin herb*: OTC 3 or 6 mg. *No potential for addiction or tolerance and is inexpensive*. It should *NOT be taken with remelton (Rozerem) (onset of action is delayed with this herb).*

What may be a good option for patients with *weight loss, anxiety, agitation, and insomnia*?

*Remeron* may be a good option for patients with *weight loss, anxiety, agitation, and insomnia.*

Someone feeling *sluggish, tired and depressed*? What to prescribe?

*SNRI* is best choice!

Algorithm for the *tx of adults with anxiety disorders*:

*Screen* for *anxiety disorders*> *Screen* for medical, *psychiatric, and substance comorbidities*/*Start an SSRI or SNRI* and *refer to mental health provider for therapy*.>>Lack of Remission or Poor Response?>Refer to *psychiatric provider.*

Medications for ADHD

*Stimulants-promote release of epi and norepi (stabilizes mood)---side effect: wt loss and insomnia* DO NOT GIVE BEFORE BED. 2nd line: non-stimulants Behavioral therapy-least effective in tx Assoc risk factors for untreated ADHD- drug abuse, alcoholism, accidents caused by impulsivity, job loss, academic failure, depression and anxiety

ADHD Article-Concerns of Parents

*Thoughts by parents that these ADHD meds CREATE drug users because of use of these stimulants early on*-->*NOT TRUE*

If a patient suffers from mild depression and has difficulty with sleeping...

*Trazodone (Antidepressant, SSRI)* is often given before bed due to its sedative effects. This medication produces a moderate blockade of 5HT reuptake. *Overdose is less of a risk with this drug* than with TCAs.

SNRI examples

*Venlafaxine (Effexor) was the first SNRI marketed in the U.S. Desvenlafaxine SR (Pristiq), duloxetine (Cymbalta) are other SNRIs currently on the market.*

What's the WORST that can happen if I choose to prescribe an antidepressant?

*You can activate a LATENT case of Bipolar Disorder (or their mania)!* *Proper screening* is vital in treatment.

Atypical Antidepressants

*bupropion (Wellbutrin) and triazolopyridine (Trazodone)* *Bupropion* is a unique agent that has been used as an aid for *smoking cessation called Zyban*. It should *not be given to anyone who has a history of seizure risk*. The benefit of this antidepressant is that there is *less sexual dysfunction* reported and also may be associated with *mild weight loss*. *Trazodone (triazolopyridine) tends to be very sedating and is helpful in mildly depressed clients with insomnia*

For moderate to severe depression the evidence supports...

*combination of medication and counseling as the most effective approach to treatment.*

Goal for depression treatment?

*complete remission of symptoms* Evidence suggests that often complete remission is not achieved with the first antidepressant treatment. Once a patient is in remission the *antidepressant treatment should be continued for six to twelve months in order to promote complete recovery.*

Buspirone (BuSpar®) is indicated for...?

*long-term treatment of panic attacks*. *Buspirone (Buspar) is only used for anxiety with panic attacks*, is not habituating, and does not have the side effect profile or abuse potential of the benzodiazepines, since it is not a CNS depressant. The MOA for buspirone is largely unknown; it is known that buspirone (Buspar) has a *high affinity for serotonin receptors and a lesser affinity for dopamine receptors*. Efficacy, however, is mixed and often the SSRIs that are indicated for anxiety offer better coverage for generalized anxiety disorder (GAD).

Individuals with *depression and anxiety* may benefit from

*paxil or lexapro*

What is MOST important in regards to Benzodiazepine prescribing?

*prescribe benzodiazepines cautiously and for as short a time as possible*

Key points for PD drugs

-"wearing off" and abrupt loss of effect ("on-off" phenomenon) lead to an acute loss of response to LEVODOPA. -Side effects: *Nausea, dyskinesias, hypotension, and psychosis.* -*1st generation antipsychotics* block dopamine receptors and thereby can *negate the effects of LEVODOPA* -*BECAUSE AMINO ACIDS COMPETE WITH LEVODOPA FOR ABSORPTION FROM THE INTESTINE AND FOR TRANSPORT ACROSS THE BBB, HIGH PROTEIN MEALS CAN REDUCE THERAPEUTIC EFFECTS*

Anxiolytics and Pregnancy: overall "take home" message is essential

-- that the prescribing provider must correctly diagnose and treat these conditions, in order to best support the patient. Often collaboration, consultation, and referral to a psychiatric mental health professional is needed, as well as a multi-disciplinary approach.

SSRIs and SNRIs--when to take?

-high risk for nausea and/or sedation have the patient *take it at bedtime (ie. paxil and celexa)*. -may cause insomnia such as *fluoxetine (Prozac®), then the patient should take this in the a.m*. NOTE: These side effects typically disappear after 2 weeks.

If the patient reports severe anxiety and that nothing helps except except benzodiazepines, then...?

...refer to a *PMHNP or psychiatrist*. For a patient who has *chronically used* benzodiazepines, *abrupt discontinuation can cause seizures*; therefore, discontinuation should be gradually tapered over many weeks.

Algorithm for Depression Treatment:

1. *Careful evaluation*. Co-morbid conditions need to be identified and addressed. Also note, it is extremely important to evaluate and document suicidality. 2. *Start SSRI #1* and *refer to mental health provider* for therapy 3. *Switch options/Augmentation Options* 4. Switch options: *SSRI #2, NDRI, SNRI* Augmentation options: *+NDRI, +5HT1A* 5. *Lack of Remission or Poor Response?* >>Refer to *psychiatric provider*.

Key points for antidepressant prescribing:

1. *FORM AN ALLIANCE WITH THE PT* 2. Mild depression-psychotherapy Mod-Severe-combo of psychotherapy + meds 3. Start low and go slow 4. Adolescents-recheck WEEKLY for 4 weeks, then every other week for 1 month (remember suicide risk) 5. Start with SSRIs, SNRI, or NDRI (think about their symptoms when choosing) 6. Educate on sexual dysfunction issue

What are the 4 classes of Antidepressants?

1. SSRIs 2.NDRIs 3. TCAs 4. MAOIs

Tx for GAD:

1. SSRIs and SNRIs 2. Benzos (for short term use only and in acute situations) -->careful of abuse/misuse! Also, benzos +narcotics, can be a deadly combo 3. Beta blockers for performance anxiety (musical, play, test anxiety, etc.)

Neurotransmitters and their role.

1. Serotonin: mood, intestinal movements, appetite, sleep, memory and learning 2. Dopamine: movement, cognition, pleasure, and motivation *has a role in Parkinson's DA* 3. Norepi and Epi: motivation, intellect, executive function *Tyrosine precursor to norepi (high protein foods)*

How long to keep on antidepressants for 1st and 2nd episodes of depression?

1st episode: for 6-12 mos after complete remission of symptoms 2nd episode: cont for 2 YEARS after complete remission of symptoms *In general, effects are expected in 4-8 weeks*

Due to their rapid onset of action, this benzo is often the *MOST addictive*?

Alprazolam (Xanax)

Anti-Depressant Drugs: MOA

Anti-depressant medications block the reuptake of norepinephrine, serotonin and some dopamine from the pre-synaptic neuron, thereby increasing the amount of neurotransmitter in the synapse. There are several different receptors for serotonin and norepinephrine. Different anti-depressants block specific combinations of these receptors in an attempt to refine the effects of the neurotransmitters.

Adolescents and antidepressants

Be aware of SUICIDE risk in first few weeks of treatment with medications.

SSRIs and SNRIs--drug of choice for?

Because of their low abuse potential, lack of lethality with overdose, and effectiveness, they are generally the drugs of choice for *depression and/or chronic anxiety*.

Which *drugs for anxiety tx* are *schedule IV* and *have a low potential for abuse when used SHORT-TERM*?

Benzodiazepines. Benzos have few drug-to-drug interactions, BUT be aware that severe side effects CAN still occur if used with other CNS depressants.

Antidepressant Use During Pregnancy: Depression During Pregnancy article, overview:

Both depression symptoms and the use of antidepressant medications during pregnancy have been associated with negative consequences for the newborn. Identifying depression in pregnant women can be difficult because its symptoms mimic those associated with pregnancy, such as changes in mood, energy level, appetite, and cognition. Regardless of circumstances, a woman with suicidal or psychotic symptoms should immediately see a psychiatrist for treatment.

MAOIs (depression tx): MOA

Breaks down and degrades the neurotransmitters (PAC MAN)--MAOIs blocks this from happening-->more serotonin, more dopamine, more epi/norepi Also used in tx of PD

Cocaine effects...

Can deplete a person's neurotransmitters, can end up with more depression after use. These drugs block dopamine transporters causing an intensity of effect on the body.

*Benzodiazepine* FDA approved for Insomnia:

Estazol*am* (ProSom), fluraze*pam* (Dalmane), temaze*pam* (Restoril). All are indicated for *short term use, ten days maximum. These are habit forming.*

Antidepressants in the Elderly

Due to polypharmacy and pharmacokinetic changes in the elderly *caution is advised in starting an antidepressant*. The *SSRIs and SNRIs* are the drugs of choice. the dose is started at one-third to one-half of the usual starting adult dosage. *TCAs are contraindicated as well as MAOIs.* *Mirtazapine (Remeron)* an atypical antidepressant is often given at bedtime to *elderly patients with insomnia and weight loss* as it stimulates appetite, is sedating and exerts an antidepressant effect.

SSRIs and SNRIs--side effects?

During the first two to three weeks of therapy increased suicidal ideation may be seen until the antidepressant effect of the SSRI reaches full effect. Sedation or insomnia may be present depending on the SSRI selected. Sexual dysfunction is one side effect of that may occur in addition to psychomotor retardation or agitation.

General Considerations in Choosing Anti-Depressant Therapy

Guided by other concurrent conditions or attributes of the depression. Clients who manifest tiredness as part of their depression may do better with drugs that are *activating* such as *Prozac or an SNRI*. Individuals with *depression and anxiety* may benefit from *paxil or lexapro*. Patients *with pain* may achieve some pain relief with the use of *cymbalta or a tricyclic*. *Cymbalta also may be helpful in treating stress urinary incontinence and has an indication for treatment of diabetic neuropathy*. *Remeron* may be a good option for patients with *weight loss, anxiety, agitation, and insomnia.*

What's another use for TCAs?

IBS!

TCAs (2nd line tx of depression): MOA

Inhibit presynaptic norepi and serotonin uptakes. Induces anticholinergic and antihistamergic effects *CARDIOTOXIC side effects!!, AVOID in pts with cardiac DA* *Lethal in OD*

Assessing the anxious patient:

It is important to assess anxious or depressed patients for suicidal or homicidal ideation. Sometimes new providers are shy about asking, fearing they may put the idea in someone's head. You just have to ask: "Do you have any thoughts of hurting yourself or someone else?" Anxiety often occurs with other mental health conditions such as depression, ADHD, OCD and PTSD. Patients presenting with anxiety should be evaluated for contributing medical conditions such as hyperthyroidism or tachycardia.

SSRIs and SNRIs--how long for initial/full effect?

It will take *two to three weeks to see an initial effect and up to six weeks to achieve a full effect*, therefore if a patient complains they are not getting any better after a two week trial, it is important that they are told that it may take six weeks to achieve the maximum benefit from the medication.

Sexual Dysfunction and Antidepressants

Keep this in mind, esp during pt teaching. *Wellbutrin (buproprion)*--fewest side effects r/t sexual dysfunction, it is a NDRI *Contraindicated in pts with seizure disorders*

Fluoxetine (Prozac), sertraline (Zoloft) paroxetine (Paxil) and citalopram (Celexa) are all SSRIs that come in generic form.

Many can be found on the $4 drug list offered by Wal-Mart, Target, Certain Grocery Pharmacies etc. for a month's supply.

Selective Serotonin Reuptake Inhibitors (SSRIs) treat?

Many types of *anxiety disorders/depression.* Post-traumatic stress disorder (PTSD), obsessive compulsive disorders (OCD) and panic attacks are some conditions that are commonly treated with SSRIs. *Social anxiety disorder* is also treated with SSRIs, particularly *paroxetine (Paxil)*.

Herbal Remedies: Insomnia tx:

Melatonin, kava and valerian. Although sleep disorders infrequently occur due to melatonin deficiencies, data indicates that melatonin may be helpful for sleep latency if used for several days.

Bipolar Disorder

Mood fluctuations, be sure to FULLY screen before prescribing. *Meds: Mood stabilizers- Lithium & Anticonvulsant agents* ---Lithium need levels, very NARROW therapeutic range. PUSH COMPLIANCE!

Serotonin Syndrome

OD of serotonin. Keep in mind for a DD if your pt is on a serotonin drug! Can occur due to combo of drugs: -SSRIs and MAOIs -Drug and herbal interactions -SSRIs & St. John's Wort

Discontinuation Syndrome

Occurs when abruptly STOPPING antidepressants. --flu-like symptoms, fatigue/lethargy, myalgia, decreased concentration, N/V, impaired memory, psychosis (MAOIs), and brain zaps (SSRIs/SNRIs). *TAPER medications appropriately when discontinuing, mainly the short half-life meds cause issues here*

MAIN issue with SSRIs???

One of the main issues is the *CP450 enzyme metabolism.* Scientists continue to find more cytochrome sites in which various medications and foods act as inhibitors or inducers of other medications.

Parkinson's DA

PD: It is a result is an imbalance between Dopamine and Acetylcholine *Remember with elders, always assess for PD, dementia or delirium, alzheimer's, depression, etc*

SNRIs: MOA?

SNRIs BOOST *serotonin and norepinephrine* throughout the brain and boost dopamine in the prefrontal cortex. *Venlafaxine (Effexor) was the first SNRI marketed in the U.S., Desvenlafaxine SR (Pristiq), duloxetine (Cymbalta) are other SNRIs currently on the market.*

Best drugs for antidepressant treatment?

SSRIs, NDRIs, or SRNIs!

In the central nervous system (CNS), benzodiazepines cause:

Sedation Decreased anxiety Muscle relaxation Anti-convulsant action

Bipolar Disorder Therapy

Should be referred to a psychiatrist for treatment. *If misdiagnosed as depression only, and an antidepressant is prescribed, this can cause hypomania or mania in a bipolar patient* Typically the patient presents with depression because when they are experiencing mania they feel great so beware of the patient who presents with depression and obtain a thorough history.

Sedative/Hypnotic Drugs: Let's talk Insomnia...

Sleep deprivation over long periods of time can increase risk for hypertension, lowered immunity, slowed cognitive processing, anxiety and mood disorders. *A pharmaceutical challenge is to simultaneously promote sleep and avoid dependency on medications for those who are following recommendations for sleep hygiene practices*. *It is essential to rule out other causes of sleeplessness such as pain, obstructive sleep apnea and restless leg syndrome before treating insomnia*. Insomnia can also suggest particular psychiatric disorders such as major depressive disorder, bipolar disorder, PTSD, generalized anxiety disorder, psychotic disorders, ADHD, alcoholism and drug abuse.

Zolpidem (Ambien , Ambien CR and Intermezzo)...what about women?

Zolpidem has gender specific dosing - *lower doses are recommended for women* Zolpidem comes in a sublingual form (Edluar) and nasal spray (ZolpiMist).

What is the primary differences amongst the benzodiazepines?

THEIR ONSET OF ACTION. *prescribe benzodiazepines cautiously and for as short a time as possible*

Insomnia, OTC Benadryl, what's important to know?

There may also be an *idiosyncratic reaction in children and may cause delirium in the elderly.*

BBW for children and adolescents (antidepressants)

^ suicidal behaviors in first few weeks of tx

TCAs, where's there a benefit?

Tricyclics may be beneficial to *patients who have trouble sleeping*. They have also been found to *decrease pain in many patients with chronic pain including neuropathic pain* *Patients having trouble sleeping secondary to pain often benefit from the use of a tricyclic antidepressant.*

Pts on MAOIs should avoid???

Tyramine containing foods (pickled, aged, smoked, marinated, fermented cheeses, tofu, soybeans, soy sauce, yoghurt, sour cream, etc) AND avoid most OTC cold and allergy preparations

Venlafaxine (Effexor XR), a Serotonin-Norepinephrine Reuptake Inhibitor (SNRI), has been used in the treatment of ....

Venlafaxine (Effexor XR), a Serotonin-Norepinephrine Reuptake Inhibitor (SNRI), has been used in the treatment of *hot flashes in those patients who may not be candidates for hormone therapy*. This medication has been shown to *decrease the frequency and severity of hot flashes with minimal side effects. *

Medications for Psychosis

Will not be treating ALONE, but will have pts on these meds that you need to be aware of. 1. *1st generation antipsychotics-high risk of extrapyramidal symptoms such as: EPS symptoms: akasthisia, akinesia, dystonia, pseudo-parkinson's and tardive dyskinesia* 2. *2nd generation antipsychotics-less risk of EPS*, but MAJOR PROBLEM WITH *WEIGHT GAIN, METAB SYNDROME, AND EVENTUALLY TYPE II DM*. Monitor Lipids, weight gain, etc.

Depression During Pregnancy article Women thinking about getting pregnant:

Women thinking about getting pregnant: For women on medication with mild or no symptoms for six months or longer, it *may be appropriate to taper and discontinue medication before becoming pregnant*. *Medication discontinuation may not be appropriate in women with a history of severe, recurrent depression (or who have psychosis, bipolar disorder, other psychiatric illness requiring medication, or a history of suicide attempts)*.Women with suicidal or acute psychotic symptoms should be referred to a psychiatrist for aggressive treatment.

Other medications used for bipolar disorder are mood stabilization such as...

anticonvulsants (AEDs) and atypical antipsychotics. Common AEDs for mood stabilization are valproic acid (Depakote), lamotrigene (Lamictal) and topiramate (Topamax).

For *long-term anxiety treated in a primary care setting*...

consider an SSRI or SNRI indicated for anxiety. Because the patient will often present with *severe anxiety and is hoping for quick relief, consider a 2-week course of an intermediate acting benzodiazepine PRN Q 8 hrs to provide relief until an SSRI/SNRI can take effect*.

Clients who manifest tiredness as part of their depression may do better with

drugs that are *activating* such as *prozac or an SNRI*.

For mild depression...

often counseling may resolve the depressive episode.

If the choice is made to start benzodiazepines, consider....?

the *half-life of the drug* and the *indication for its use*. *Diazepam (Valium), has a fairly long half-life*. It is used effectively to help reduce spasm and decrease seizure activity. *Alprazolam (Xanax) works quickly and has a moderate half-life*. Alprazolam's quick onset leads to rapid relief of symptoms. Again, due to their rapid onset of action, these are often the *most addictive*. However, patients may come to expect almost immediate relief of their anxiety and be reluctant to switch to another agent. *Lorazepam is commonly used for anxiety -- it has a slower onset and a shorter half-life.*