9/17/2015 DIAGNOSTIC PUZZLES MENTAL ILLNESS MEDICAL COMORBIDITES - PDF document

9/17/2015 DIAGNOSTIC PUZZLES  MENTAL ILLNESS  MEDICAL COMORBIDITES  SUBSTANCE ABUSE  SPECIAL POPULATIONS  IMPROVING COMPLIANCE  CASE STUDIES L EARNING O BJECTIVES  Learner will be able to identify substance abuse and state 3 medications safe to use for depression, anxiety and insomnia in persons with a substance abuse history.  Learner will be able to differentiate between depression and dementia in the elderly and use of medications in this population  Learner will be able to state 3 strategies for improving treatment compliance M EDICAL C OMORBIDITIES  Many medical problems mimic or exacerbate psychiatric symptoms  Many medications can have side effects of depression  Medications metabolized by Cytochrome P pathways can interact with most psychotropic medications, and drug interactions should always be checked before making any medication changes.  There is a high incidence of depression and/or anxiety with many chronic illnesses; heart disease, diabetes, chronic pain 1

9/17/2015 A SSOCIATION OF C OMORBIDITIES Current Depression and Lifetime Diagnosis of Depression and Anxiety by Asthma, Diabetes, and CVD Status Status Current Depression (%) Lifetime Diagnosis of Lifetime Diagnosis of Anxiety Depression (%) (%) Asthma 16.5 27.1 20.2 No asthma 7.6 14 10 CVD 16.8 23.7 17.9 No CVD 7.9 14.9 10.6 Diabetes 14.5 22.4 15.3 No diabetes 8.2 15.2 11 D EPRESSION , S UBSTANCE A BUSE & S UICIDE  Over 60 percent of all people who die by suicide suffer from major depression. If one includes alcoholics who are depressed, this figure rises to over 75 percent. Depression affects nearly 10 percent of Americans ages 18 and over in a given year, or more than 24 million people. More Americans suffer from depression than coronary heart disease (17 million), cancer (12 million) and HIV/AIDS (1 million). According to reports published in the Journal of the American Medical Association :  Roughly 50 percent of individuals with severe mental disorders are affected by substance abuse.  37 percent of alcohol abusers and 53 percent of drug abusers also have at least one serious mental illness.  Of all people diagnosed as mentally ill, 29 percent abuse either alcohol or drugs. S UICIDE R ISKS  Alcohol and Suicide: Ninety-six percent of alcoholics who die by suicide continue their substance abuse up to the end of their lives. Alcoholism is a factor in about 30 percent of all completed suicides. Approximately 7 percent of those with alcohol dependence will die by suicide.  Firearms and Suicide : Although most gun owners reportedly keep a firearm in their home for "protection" or "self defense," 83 percent of gun-related deaths in these homes are the result of a suicide, often by someone other than the gun owner. Firearms are used in more suicides than homicides. Death by firearms is the fastest growing method of suicide. Firearms account for 50 percent of all suicides.  Medical Illness and Suicide : Patients who desire an early death during a serious or terminal illness are usually suffering from a treatable depressive condition. People with AIDS have a suicide risk up to 20 times that of the general population. Studies indicate that the best way to prevent suicide is through the early recognition and treatment of depression and other psychiatric illnesses. 2

9/17/2015 O REGON S UICIDE R ATES  Compared to the national average, Oregon suicide rates have been higher for the past three decades.  The most recently available national data shows Oregon age-adjusted suicide rate of 17.1 per 100,000 in 2010 was 41 percent higher than the national average  Oregon ranked 9th place among all US states in suicide incidence.  Between 2003 and 2010, Oregon suicide rates were significantly higher than the national average among all age groups except ages 10-17 and women ages 18-24. A DDRESSING S UBSTANCE AND A LCOHOL U SE P RIOR TO T REATMENT  Substance abuse is defi n ed as a pattern of harmful use of any substance for mood-altering purposes.  Mental illness refers to disorders generally characterized by dysregulation of mood, thought, or behavior ( as recognized by the Diagnostic and Statistical Manual, 5th edition, of the American Psychiatric Association (DSM-5 ).  Dealing with either can be difficult, but it is often more difficult to deal with both. Each disorder has its own unique symptoms that can impair one’s ability to function and often interact with each other. I DENTIFYING S UBSTANCE A BUSE CAGE Questions   1. Have you ever felt you should cut down on your drinking?  2. Have people annoyed you by criticizing your drinking?  3. Have you ever felt bad or guilty about your drinking?  4. Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)?  CAGE Questions Adapted to Include Drug Use (CAGE-AID)  1. Have you ever felt you ought to cut down on your drinking or drug use?  2. Have people annoyed you by criticizing your drinking or drug use?  3. Have you felt bad or guilty about your drinking or drug use?  4. Have you ever had a drink or used drugs first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)? 3

9/17/2015 W HY DO SOME DRUG USERS BECOME ADDICTED , WHILE OTHERS DON ’ T ? Risk factors that increase your vulnerability include:  Family history of addiction  Abuse, neglect, or other traumatic experiences in childhood  Mental disorders such as depression and anxiety  Early use of drugs  Method of administration—smoking or injecting a drug may increase its addictive potential W HEN CAN YOU GIVE A NARCOTIC TO SOMEONE WITH A HISTORY OF SUBSTANCE ABUSE ?  ADHD?  Anxiety?  Insomnia?  Chronic pain? D EPRESSION IN PRIMARY CARE 4

9/17/2015 T YPES OF T REATMENT  ANTIDEPRESSANT MEDICATIONS  PSYCHOTHERAPY  LIGHT THERAPY, ECT, ALTERNATIVE THERAPIES SSRI’ S FIRST LINE T REATMENT FOR DEPRESSION AND ANXIETY  Fluoxetine (Prozac)  Fluvoxamine (Luvox)  Sertraline (Zoloft)  Paroxetine (Paxil)  Escitalopram (Lexapro)  Citalopram (Celexa) A TYPICAL ANTIDEPRESSANT GENERIC AND BRAND NAMES  Bupropion (Wellbutrin)  Duloxetine (Cymbalta)  Venlafaxine (Effexor)  Mirtazapine (Remeron)  Trazodone (Desyrel) 5

9/17/2015 T RICYCLIC A NTIDEPRESSANTS GENERIC AND BRAND NAMES  Amitriptyline (Elavil)  Clomipramine (Anafranil)  Desipramine (Norpramin)  Doxepin (Sinequan)  Imipramine (Tofranil)  Nortriptyline (Pamelor, Aventyl)  Protriptyline (Vivactil)  Trimipramine (Surmontil ) MAOI GENERIC AND BRAND NAMES  Phenelzine (Nardil)  Tranylcypromine (Parnate)  Isocarboxazid (Marplan)  Selegiline (Emsam) A LTERNATIVE T REATMENTS  Herbal remedies; St. Johns Wort, Ginko, Kava to name a few. These may interfer with other medications.  Supplements; Vitamins, especially B12, Omega 3 Fatty acids  Music, pet therapy, massage, dance and acupuncture. 6

9/17/2015 D EPRESSION T REATMENT -R ISKS  Antidepressants can increase suicidal thoughts and behaviors in children, teens, and young adults. (Black Box Warning)  Be especially observant within the first few months of treatment or after a change in dose.  Over 36,000 people in the United States die by suicide every year, Suicide is the fourth leading cause of death for adults between the ages of 18 and 65 years in the United States. Currently, suicide is the 10th leading cause of death in the United States (2009). I NSOMNIA  Insomnia is one of the leading symptoms accompanying a variety of somatic and mental health problems. Approximately one-third of Americans experience difficulty sleeping, and in primary care patients the number may be as high as 2/3 of the patients seen. T REATMENTS  Medications  Alternative/Natural Sleep Remedies  Sleep Hygiene  Behavioral Techniques 7

9/17/2015 S LEEP T IPS  1. Establish a Regular Routine:  2. Get an Adequate Amount of Sleep Every Night  3. Go to Bed When You Are Sleepy:  4. Develop Sleep Rituals Before Going to Bed:  5. Avoid Stress and Worries at Bedtime:  6. Use Your Bed for Sleeping and Sex Only:  7. Avoid Heavy Meals Late in the Evening:  8. Reduce Your Intake of Caffeine and Nicotine:  9. Avoid Alcohol 4-6 Hours Before Bedtime:  10. Exercise regularly:  11. Don't nap for more than 30 minutes or after 3 p.m:  12. Keep it Dark and Cool:  13. Use Sleeping Aids Conservatively: . S EDATIVES /H YPNOTICS  Flurazepam-Dalmane  Temazepam-Restoril  Triazolam-Halcion  Zolpidem-Ambien  Zaleplon-Sonata  Lunesta  Rozerem (non-narcotic) safe in the elderly S EDATING ANTIDEPRESSANTS  Tricyclics-Amitriptyline, Nortriptyline (not FDA approved)  Silenor-(Doxepin) 3mg & 6mg FDA approved for insomnia adults, and geriatrics  Trazodone-Deseryl-(off label)  Mirtazepine-Remeron (off-label) 8

9/17/2015 O THERS …  Antipsychotics-Quetiapine  Antihistamines-hydroxyzine, diphenhydramine  Antianxiety-lorazepam, diazepam, alprazolam, clonazepam, ect… A LTERNATIVE T HERAPIES  L-Trytophan  Melatonin  Valerian root  Herbal Teas- chamomile A NXIETY Benzodiazepines; use or not use?  Benzodiazepines are effective in the treatment of anxiety, especially in panic disorder but have high risk of tolerance, dependence and abuse 9