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MOOD DISORDERS, ANXIETY AND ADHD

MOOD DISORDERS, ANXIETY AND ADHD. A BRIEF OVERVIEW OF DIAGNOSIS & PHARMACOLOGICAL TREATMENT RHETT H. TOMPKINS, MA, PA-C. MAJOR DEPRESSION DSM CRITERIA. Depressed mood Anhedonia (loss of interest) Decreased energy/motivation Sleep disturbances/non-restorative sleep

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MOOD DISORDERS, ANXIETY AND ADHD

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  1. MOOD DISORDERS, ANXIETY AND ADHD A BRIEF OVERVIEW OF DIAGNOSIS & PHARMACOLOGICAL TREATMENT RHETT H. TOMPKINS, MA, PA-C

  2. MAJOR DEPRESSION DSM CRITERIA • Depressed mood • Anhedonia (loss of interest) • Decreased energy/motivation • Sleep disturbances/non-restorative sleep • Worthlessness guilt loss of confidence • Difficulties with attention & concentration • Slow comprehension

  3. DEPRESSIVE SYMPTOMS. • Suicidal thinking/helpless hopeless • Irritable liable mood • Symptoms occur daily

  4. ATYPICAL DEPRESSION • Meets all criteria for Depression PLUS • Mood reactivity • Hypersomnia • Appetite changes • Long standing pattern of interpersonal rejection sensitivity that results in significant social or occupational impairment

  5. BIPOLAR AFFECTIVE DISORDER NOS • Very rapid alteration between MANIC and depressive symptoms that DO NOT meet…duration criteria for MDE. • Recurrent Hypo manic Episodes without intercurrent depressive episodes • Bipolar illness is present but indeterminate cause/criteria

  6. ANXIETY DISORDERS • Symptoms are associated with FEAR & distress, dread of events places or thoughts • Causes some dysfunction because of the sense of fear, dread of loss of control • Subject is avoidant, behaves in ways incongruent with the situation • There are social consequences associated with the behavior & distress

  7. SOCIAL PHOBIA • Persistent fear of social or performance situations • Dreads they will embarrass themselves or show anxiety • In children, tantrums, crying, clinging to adults • Recognition of inappropriate fears

  8. OCD • Recurrent & persistent thoughts, impulses or images…..intrusive and inappropriate • Cause marked distress, dysfunction • Not consistent with current life stressors • A product of the individuals own mind/thoughts • Not able to remove thoughts, be distraced or reassured

  9. PTSD • Exposure to traumatic events • Recurrent distressing and intrusive thoughts or perceptions • Dreams/nightmares/terrors • Realization of event, as if it were occurring • Vigilance, exposure to stimulus which occurred during event

  10. GENERALIZED ANXIETY DISORDER • Excessive worry (apprehensive expectation) • 6 months or more with dysfunction • Unable to control worry/thoughts • Associated with; restlessness,fatigue, concentration, irritability, tension, sleep disturbance • Must cause changes in the ability to function

  11. DSM IV Classification Diagnostic Criteria for ADHD Six or more of the following symptoms for 6 months or longer

  12. INATTENTION • does not give close attention to details • makes careless mistakes • trouble staying focused on tasks/play • does not seem to listen when spoken to • does not follow through with instructions • difficulty completing work/projects

  13. INATTENTION • disorganized • avoids or hesitates to be involved in tasks requiring sustained mental effort • loses objects needed for duties/activities • distracted by external stimuli • forgets daily activities

  14. HYPERACTIVITY • Fidgets with hands or feet or squirms in seat • leaves seat in places where remaining seated is the norm • runs around or climbs in places where it is inappropriate • difficulty playing quietly or participating in leisure activities • “on the go” “driven by a motor” • speaks excessively

  15. IMPULSIVITY • blurts out answers before the questions are completed • has trouble waiting his/her turn • interrupts or butts into conversations or games with others

  16. PSYCHOPHARMACOLOGY ANTIDEPRESSANTS PSYCHOSTIMILANTS MOOD STABILIZERS ATYPICAL ANTIPSYCHOTICS

  17. ANTIDEPRESANTS • SSRI’S • Celexa/citalopram • Lexapro/escitalopram • Prozac/fluoxetine • Zoloft/sertraline • Paxil/paroxetine • SSRI/SNRI • Effexor/venlafexine • Cymbalta/duloxetine • ATYPICALS • Wellbutrin/Buproprion

  18. SSRI’S PROZAC • Fluoxetine, 1st of the 2nd generation • Available in 10-20mg caps in US • Dosage range 10-60mg QD • Two active metabolites, fluoxetine half life 4-6 days, norfluoxetine 7-9 days • 4 weeks between dose increases • Has a weekly dosing (Serafem) • FDA approval depression, OCD, Bulemia, AN, Panic,PMDD

  19. SSRI’S SERTRALINE • Sertraline, Zoloft® 2nd of 2nd generation • Available 25-50-100mg tabs. Elixir 20mg/ml • Half life 25 hours • Steady state 2-4 weeks • Better for anxiety, OCD symptoms • Sexual side effect common as well as sedation • FDA approval, depression, PTSD, panic, PMDD • Less activating than Prozac

  20. SSRI’s PAROXETINE • Paroxetine, Paxil® • Approved about the same time as Zoloft • Available 10-20-30-40mg tabs and CR 12.5-25-37.5mg tabs • Dose range 10-60mg QD • Half life 24 hours, steady state 2-4 weeks • Most active serotonin inhibitor, least well tolerated. • Effective for OCD and anxiety disorders

  21. PAROXETINE cont. • Sedation, cognitive impairment common at 40mg of higher. • Sexual dysfunction and weight gain • Anticholinergic effects, dry mouth, constipation • FDA approval major depression, OCD, panic, social anxiety DO, GAD, PTSD

  22. SSRI’S CITALOPRAM & ESCITALOPRAM • citalopram, Celexa® • escitalopram, Lexapro® ( D isomer of citalopram) • Available Celexa 20-40mg tabs Lexapro 10-20mg tabs • Half life 30 hour, steady state 1 week • Dosage range Celexa 20-60mg QD, Lexapro 10-30mg • Well tolerated SSRI, both effective to a moderate degree for anxiety symptoms

  23. SSRI’S CITALOPRAM & ESCITALOPRAM cont. • Specific 5Ht agonist useful with the elderly and bipolar patients who cannot tolerate high levels of activation • Better tolerated in pediatric population than sertraline through less effective for anxiety symptoms

  24. SSRI/ SNRIVENLAFEXINE • venlafexine, Effexor® • 1st available as IR, not well tolerated • Approval of XR resulted in better tolerance at higher doses better efficacy • Available in 37.5-75-150mg caps • Dose range 75-300 in XR form • Half life 5 hours steady state in 3 days, longer with XR preparation • Very effective with comorbid depression and anxiety , OCD, panic

  25. SSRI/ SNRIVENLAFEXINE cont. • Anti-anxiety effect present at higher doses >150mg QD • No weight gain • Rare sedation • Dizziness, lightheaded, restless, disturbed sleep more common • Sweating, headaches • Side effects are usually transient at onset of treatment

  26. SSRI/SNRI DULOXETINE • Duloxitine, Cymbalta® • Newest addition to SSRI/SNRI group • Available 30-40-60mg caps • Dose range 30-120mg QD • Marketed as effective for patients with somatic/pain issues • More efficacious SNRI mg for mg than venlafexine

  27. SSRI/SNRI DULOXETINE cont. • Very useful in the elderly with chronic pain, discomfort • Effective with FMS • As effective as venlafexine in anxiety, panic • Not as efficacious as venlafexine in OCD, by experience • Well tolerated, no sedation, weight gain • Dry mouth, headaches, restless, insomnia dose related

  28. ATYPICAL BUPROPRION • buproprion, Wellbutrin SR, XL® • SNRI & dopamine reuptake inhibitor • Available 100-150-200SR, 75-100-150IR, 100-150-300XL, tabs • Dosage range 75-450mg QD rarely exceeds 300mg QD • Half life 20 hours, steady state 2-4 weeks • Effective for depression with low mood , energy and motivation, (anhedonia)

  29. ATYPICAL BUPROPRION cont. • Effective at addressing cognitive symptoms associated with mood disorders. • Improves attention and concentration and mental energy. • Well tolerated no sedation, weight gain, no sexual dysfunction • Headaches, restless, rare agitation, insomnia

  30. PHARMACOLOGIC TREATMENT OF ATTENTION DISORDERS • Adderal, LA, XR • Concerta • Ritalin/methylphenidate • Dexedrine preparations

  31. DEXTROAMPHETAMINES • Adderal, AdderalXR ® ,Dextrostat, dexedrine spansules. • All formulations of dextroamphetamine salts • Norepinephrine and dopamine agonist • Dose ranges from 5-30mg QD, once to three times a day • Effect is not paradoxical • Direct stimulation of attention and concentration • In higher doses decreases hyperactivity

  32. METHELPHENIDATE methylphenidate (MPH), Ritalin, RitalinSR, Focalin, Concerta, Vyvanse® Dopamine/Norepinephrine reuptake inhibitor No paradoxical effect Dosage range 5-80mg QD, once a day or divided doses Direct effect on attention and lowers distractibility Actual mechanism in treatment of ADD/ADHD unknown

  33. PSYCHOSTIMULANTS • Side effects are all similar • Restless, agitation, insomnia, appetite suppression, headaches stomach complaints • Rebound effects, especially with short acting MPH in multiple dosing • Can worsen mood disorders • Overdosing can cause lethargy, “zombie effect” or depression

  34. MOOD STABLILIZERS • Depakote® , divalproate • Lithium , Lithobid® • Lamictal® lamotrigine • Trileptal® oxcarbazepine

  35. VALPROATE • valproic acid, divalproate, Depakote, Depakote EC, Depakote ER, Depakote Sprinkles, Depakene® • Available in 125-500mg caps sprinkles • Various release forms from 24 hours to IR • Steady state 5-7 days • ER forms well tolerated • Requires serum levels (valproic acid total) • FDA approval for mania, bipolar disorders

  36. VALPROATE • Effective for irritable liable mood, impulsive reactive presentations • Effective for ruminating, anxious patient • Well tolerated in pediatric and geriatric populations • Sedation common, some cognitive blunting in higher doses • If used with lamotrigine levels will double

  37. LAMOTRIGINE • Lamotrigine, Lamictal® • Available in 25,50,100, 200 mg tabs • Dosage ranges from 100-200mg QD for mood stabilization • Slow titration, increase by 25mg every 2 week to effective dose • Allergic reactions rare but can be life threatening; Steven-Johnsons Syndrome

  38. LAMOTRIGINE • Effective for bipolar patients with primarily a depressed presentation • Also effective for some BPD pts with an anxious ruminative presentation • Can be used as adjunctive therapy with valproate which doubles lamotrigine serum levels

  39. LITHIUM • Available in numerous forms, lithium carbonate, Lithium CR, Eskalith® • Half life depends on release type,up to 24 hours • Steady state in 3-5days dependent on type • Sedation, tremors, GI upsets • Long term thyroidosis, decreased renal function • Difficult drug with long term maintenance due to adverse reaction and side effects

  40. LITHIUM • Effective in controlling both manic and depressive phases of bipolar • Effective in “mixed states” • Works rapidly within 2-3 days • Cheap lithium carbonate is literally pennies a capsule • Oldest and most studied mood stabilizer • Not well tolerated in pediatric and geriatric population overall

  41. CARBAMAZAPINE • Carbamazapine, Tegretol® • Available in 100, 200,300mg tablet, chewable, elixir and sprinkles • Half life 18 to 55hours • Steady state (plateaus) 3-5 weeks • No FDA approval for bipolar or mood disorders • No proven efficacy, anecdotal and case support • Limited use

  42. ATYPICAL ANTIPSYCHOTICS • Risperidol • Seroquel • Zyprexa • Abilify • Geodon

  43. QUESTION’S?? COMMENTS?? QUERIES??? Rhett H Tompkins.MA.PA-C Psychiatric Recovery 2550 University Ave. West St.Paul, MN 55114 651-645-3115

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