MOOD DISORDERS, ANXIETY AND ADHD

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MOOD DISORDERS, ANXIETY AND ADHD

• A BRIEF OVERVIEW OF DIAGNOSIS PHARMACOLOGICAL
  TREATMENT
• RHETT H. TOMPKINS, MA, PA-C

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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

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DEPRESSIVE SYMPTOMS.

• Suicidal thinking/helpless hopeless
• Irritable liable mood
• Symptoms occur daily

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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

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BIPOLAR AFFECTIVE DISORDER NOS

• Very rapid alteration between MANIC and
  depressive symptoms that DO NOT meetduration
  criteria for MDE.
• Recurrent Hypo manic Episodes without
  intercurrent depressive episodes
• Bipolar illness is present but indeterminate
  cause/criteria

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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

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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

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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

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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

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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

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

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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

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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

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IMPULSIVITY

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

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PSYCHOPHARMACOLOGY

• ANTIDEPRESSANTS
• PSYCHOSTIMILANTS
• MOOD STABILIZERS
• ATYPICAL ANTIPSYCHOTICS

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ANTIDEPRESANTS

• SSRIS
• Celexa/citalopram
• Lexapro/escitalopram
• Prozac/fluoxetine
• Zoloft/sertraline
• Paxil/paroxetine

• SSRI/SNRI
• Effexor/venlafexine
• Cymbalta/duloxetine
• ATYPICALS
• Wellbutrin/Buproprion

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SSRIS 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

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SSRIS 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

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SSRIs 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

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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

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SSRIS 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

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SSRIS 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

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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

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SSRI/ SNRIVENLAFEXINE cont.

• Anti-anxiety effect present at higher doses
  gt150mg QD
• No weight gain
• Rare sedation
• Dizziness, lightheaded, restless, disturbed sleep
  more common
• Sweating, headaches
• Side effects are usually transient at onset of
  treatment

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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

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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

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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)

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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

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PHARMACOLOGIC TREATMENT OF ATTENTION DISORDERS

• Adderal, LA, XR
• Concerta
• Ritalin/methylphenidate
• Dexedrine preparations

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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

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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

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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

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MOOD STABLILIZERS

• Depakote , divalproate
• Lithium , Lithobid
• Lamictal lamotrigine
• Trileptal oxcarbazepine

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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

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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

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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

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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

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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

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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

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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

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ATYPICAL ANTIPSYCHOTICS

• Risperidol
• Seroquel
• Zyprexa
• Abilify
• Geodon

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QUESTIONS?? 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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