Managing Mood and Anxiety Disorders in Primary Care 2021 - John Tierney, MD, MA Adjunct Professor UT Health San Antonio Medical School
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Managing Mood and Anxiety Disorders in Primary Care
2021
John Tierney, MD, MA
Adjunct Professor UT Health San Antonio Medical School
Disclosure • Dr. Tierney has disclosed that neither he nor members of his immediate family have a relevant financial relationship with an ineligible company.
Screening
Objectives Differentiating
Treating
Antidepressants • SSRI
• Citalopram
• SNRI
• Duloxetine
• NDRI
• Bupropion XL
• Glutamate Modulator
• Esketamine
Anxiolytic • SSRI
• Citalopram
• Benzodiazepines
• Lorazepam
• Clonazepam
NonPharmacologic
EBPT
• (Evidence‐Based PsychoTherapy)
• Cognitive Behavioral Psychotherapy
Psychiatry Neuroscience 2021
Eric Kandel, MD Psychiatrist • 2000 Nobel Prize Physiology or Medicine • Memory Occurs at the Synapse!
The Neuron! • 10,000 connections each • Billions of Neurons • More connections per cc than stars in the Milky Way Galaxy !!! Eagleman, D., Incognito, The Secret Lives of the Brain 2007
Cytokine Storm (IL‐6)
(Brain Fog?)Dexamethasone Suppression Test • COVID Killer? • Interleukin Antagonist? • Antidepressant?
Cytokines Sing the Blues: (Inflammation and Depression) • 2005 • Raison, Capuron and Miller • Psychiatry, Emory School of Medicine
Stressed Dendrites (Ketamine Rescue) • IL‐6 • Cytokine Storm • Decreased BDNF • Hippocampal Volume Loss • Ketamine!!!
Interleukin‐6 (IL‐6)
Managing Mood & Anxiety Disorders
Can’t make you an expert,
Today, but ….William Osler, MD Johns Hopkins (1893) “Listen to your patient, he is telling you the Diagnosis.”
Antidepressants • SSRI
• Citalopram
• SNRI
• Duloxetine
• NDRI
• Bupropion XL
• Glutamate Modulator
• EsKetamineScreening Depression: PHQ‐9 Questionnaire For Depression Scoring QIDS‐SR16 Quick Inventory of Depressive Symptomatology (16‐ item)(Self‐Report)
QIDS‐SR‐16 John Rush, MD UT Southwestern
QIDS‐SR‐16 NEJM April 2021 Psilocybin Study
The Texas Algorithms STAR*D†: Ongoing, randomized, controlled trial designed to determine best “next step” treatment options2 *TMAP=Texas Medication Algorithm Project. †STAR*D=Sequenced Treatment Alternatives to Relieve Depression. 1. Trivedi MH, et al. Arch Gen Psychiatry. 2004;61:669‐680. 2. Rush AJ, et al. Am J Psychiatry. 2003;160:237.
TMAP Major Depression Algorithm
• Developed by Texans • Science in the System • Stage 2 Today
• “There is no such thing as
consensus science. If it’s
consensus, it isn’t science. If
it’s science, it isn’t consensus.
Period.”
• Michael Crichton, MD
HarvardCitalopram (SSRI) • TMAP Control • 10‐40 mg • Major Depression • OCD • Baseline EKG
Duloxetine (SNRI) • 20‐120 mg • Major Depression • Generalized Anxiety • Diabetic Neuropathy • Fibromyalgia • Musculoskeletal pain
Bupropion XL Norepi/Dopamine(NDRI) • 150‐450 mg • Major Depression • ADHD • Seasonal Affective • Smoking Cessation • Tx Obesity w/ Naltrexone • Generic often inferior
Esketamine 56‐84 mg Intranasally Treatment Major Depression Acutely Suicidal Pts w/ Major Depression
Glutamate‐ based Therapy
Anxiolytics • SSRI
• Citalopram
• Benzodiazepines
• Lorazepam
• ClonazepamBenzodiazepines
(Danish National Registry; 235,465 patients; 1996‐2015)
Benzodiazepines, Z‐drugs, and other Anxiolytics do not increase
subsequent risk of Dementia
No association between Benzodiazepines and Subsequent Dementia!!
Odds of developing Dementia were higher in group with lowest exposure
to Benzodiazepines and Z‐Drugs!
Some results were compatible with a PROTECTIVE EFFECT … !!!
Am J Psychiatry 177:6, June 2020• 0.5‐ 6 mg
• Anxiety
• Alcohol Withdrawal
• Insomnia, short‐term
• Status Epilepticus
• Delirium Tremens
Lorazepam
• Chemo‐related N/V
• Pre‐op sedation
• Conjugative Metab
• PO/IM/IV
• Neuroleptic Malignant Syndrome• 0.5‐ 20 mg
• Anxiety
• Panic Disorder
• Sleep Walking
• Sleep Terrors
• REM Sleep Behavior
• Restless Legs (RLS)
Clonazepam • Confusional Arousals
• Tourette Syndrome
• Burning Mouth Syndrome
• Seizure DisorderScreening Anxiety: Generalized Anxiety Disorder 7‐item (GAD‐7)
GAD‐7
Mood Stabilizer Lithium
• (The Classic Mood Stabilizer)Screening Bipolar Disorder: Brief Bipolar Disorder Symptom Scale
TMAP Brief Bipolar Disorder Symptom Scale
TMAP Brief Bipolar Disorder Symptom Scale
MDD vs BDD
Identify Identify Declare
Identify Manic Identify Hypomanic Declare Unipolar
Episode (aka BD 1) episode (aka BD 2) MDD
• Mania by definition is • This is tough; more to • You will get this wrong;
psychotic, follow Don’t feel bad
incapacitating, and/or • 1st episode BDD is as
so severe that likely to be Depression
hospitalization is as Mania; misdiagnosis
required is INEVITABLE
Thase, ME. Primary Psychiatry. 2006;13(11):59‐67Risks for Bipolar Spectrum Conditions
BDD is not particularly responsive to antidepressants
Patients with BDD tend to have earlier onset of their depressions
Strong family h/o mania especially in 3, 1st‐degree relatives or 3 consecutive family
members
Hx of agitated depressions
Hx of psychotic depressions or catatonia
Thase, ME. Primary Psychiatry. 2006;13(11):59‐67Rule of 3’s: Hypomania
Proficiency in three languages for United States born citizens
3‐generation family history for affective illness
3 first‐degree relatives with affective illness
More than 3 major depressive episodes
Eminence in 3 fields in the family
3 failed antidepressants
3 simultaneous jobs
3 failed marriages
Thase, ME. Primary Psychiatry. 2006;13(11):59‐67Lithium:
(Classic Mood Stabilizer)
Acute and
300‐1200 mg
Maintenance
qd
of Bipolar I
Schizoaffective
DisorderLithium:
(Side Effects Exaggerated)
Robert Post, MD;
Bipolar Collaborative Network Creatinine Creep
2018 PsychoPharmacology Update ‐15‐30 yrs before it is seen; ‐ Not assoc with ESRD;
‐ ESRD more common w/ anticonvulsants
Thyroid Dysfunction
‐ Readily treated
Lower dosing & Avoiding episodes of Toxicity
‐ Reduces risk of all these problemsPrevents manias and depressions
Reduces suicide rate
Lithium
Benefits
Reduces medical comorbidities
Associated with decreased incidence
of dementia
Robert Post, MD; Bipolar Collaborative Network; 2018 PsychoPharm Update McAllen TXNonPharmacologic
EBPT
• (Evidence‐Based PsychoTherapy)
• Cognitive Behavioral PsychotherapyFamily Practice is Psychiatry
A Short List of Treatments can do a lot of Good
Psychiatry
Conclusion Scales are necessary in EMRs; but over‐rated
You can’t predict suicide; Help them not to be
alone in their darkness.
Esketamine Clinics may significantly reduce
suicide. Find one near you.Audience Polling Question #1 According to the FBI, approximately how many homicides occurred in the United States in 2016? 1. 15000 2. 25000 3. 35000 4. 45000
Audience Polling Question #2 According to the CDC, approximately how many Americans died by suicide in 2016? 1. 15000 2. 25000 3. 35000 4. 45000
Audience Polling Question #3 Which one of the following medications primarily targets Norepinephrine and Dopamine? 1. Citalopram 2. Duloxetine 3. Bupropion 4. Trazodone
Audience Polling Question #4 Which one of the following Cytokines is commonly elevated in severe Major Depression? 1. Interleukin‐1 (IL‐1) 2. Interleukin‐6 (IL‐6) 3. Tumor Necrosis Factor (TNF) 4. Brain‐derived Neurotrophic Growth Factor (BDNF)
Audience Polling Question #5 Which one of the following US cities is home of the principal investigators for Psychiatric Treatment Algorithms? 1. DALLAS 2. BOSTON 3. LOS ANGELES 4. NEW YORK CITY
2020 44834 11th leading
(Bumped by Covid)
Suicide
Deaths: 2016 43,000 10th Leading
(1.1 million
attempts/yr)
2016 17,000 HomicidesScreening Suicidality: “Based on limited advancements in prediction and prevention, the 2014 US Preventive Services Task Force concluded that population‐ level suicide risk screening could not accurately be recommended.” JAMA Psychiatry 2019
Documentation: “The patient has a chronic risk of suicide; however, the patient’s acute risk is low b/c patient’s psychiatric symptoms have responded to intervention, along with improvement in CBT skills and support system.”
Documentation: “Family was included in the treatment plan and advised If worsening symptoms of suicidal, homicidal or violent ideation develop call 911 or the: National Suicide Prevention HotLine: 1.800.272.8255 The patient is not currently an imminent risk to harm self, objects or others.”
Patient Suicide:
“ … you'll get your R.I.O. when you get
to the ship. And if you don't...
...give me a call. I'll fly with you”
Viper to Maverick in Top Gun (1986)You can also read
