Uncovering the Mysteries of

PsychiatryNancy Gerrard

June 8, 2014

Alternative treatments for depression

3 new medications

Drugs of abuse

Today’s review:

Young adult years have also been called the AGE of INSTABILITY EMERGING ADULTHOOD Children and adolescents increasingly take

antidepressants (1/13 on psych meds) Thin line between diagnosing depression

and teaching youth to view any emotional upset as pathological

NY Times, Iarovici, April 2014

OUR clientele

Patients I see at the University Health Center:

Anxiety Depression Bipolar disorder First episode psychosis Obsessive Compulsive Disorder Eating disorders ADHD Transgender clients

OUR Clientele

DepressionAlternative therapies

Depressed mood most of day Diminished interest in pleasurable activities

Decrease or increase in appetite Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue or loss of energy Feelings of worthlessness or excessive guilt

Depression

Diminished ability to think or concentrate

Recurrent thoughts of death, recurrent suicidal thoughts or attempts

These symptoms occur nearly every day and they cause clinically significant distress or impairment in social, occupational or other important areas of functioning.

Depression (cont)

GeneticsSituational (life events and environmental stress)

Personality or temperamentBiological/medical factorsDrug/alcohol induced

Depression – what causes it??

TherapyMedicationsCombination of therapy and medication

Hospitalization

Standard treatment for depression

Prozac Paxil Zoloft Celexa Lexapro Cymbalta Effexor Pristiq Wellbutrin

Medications for depression

SleepHealthy dietNo alcohol or drugsLimit caffeine useGet outside for natural light at least 20 minutes per dayExercise dailySocialize with positive people

Treatments for depression

Hastens the effects of antidepressant drugsRapid onset of antidepressant actionAntidepressant effects mediated through eyesUseful as a nonpharmacological intervention during pregnancy

Bright light therapy

Use a light box with full spectrum light – 10, 000 luxTime with patient’s circadian phase of melatonin secretion (7.5-9 hrs after evening melatonin secretionRare side effects such as: headache, eyestrain, nausea, and agitation

Bright light therapy

Approved for treatment resistant depression

Electromagnetic coil placed against scalp and delivers pulses

Session is between 30-50 minutes Treatments are 5x week for 4-6 weeks Occasional headache after treatment Some insurance coverage

Transcranial Magnetic Stimulation

Deep brain stimulation (same as what is used for Parkinsons)

Electroconvulsive therapy (ECT)

Sleep Deprivation (still being studied)

Alternative Treatments

L- methylfolate or Deplin A form of folate that can cross blood brain

barrier 70% of depressed persons have a genetic

factor that limits their ability to convert folic acid or folate in food to l-methylfolate.

L-methylfolate regulates neurotransmitter production

Used as an adjunct to antidepressant medications

Alternative Therapies

St John’s wort – antidepressant effects (mild to modest effects)

SAMe – possible benefit for depression

Omega 3 – possible benefit for depression

Melatonin- possible benefit for depression but can improve sleep

Alternative Therapies

PsychotherapyVisualization JournalingMeditationAcupuncture

Mind Body Therapies

New Medications

3 New Medications

Fetzima – antidepressant

Works on norepinephrine and serotonin

In same family as cymbalta, pristiq, effexor

New medications

Latuda – atypical antipsychotic

Using for mood stabilization, psychosis, adjunct for depression

Same family as Abilify, Geodon, Zyprexa, Seroquel

New medications

Brintellex – antidepressant

Works on serotonin but several different receptors involved. Less weight gain and less sexual side effects reported

New medications

Drugs of Abuse

Most frequently used drug by teens

½ of jr high students drink monthly

14% of teens intoxicated at least 1x in past yr.

8% of teens who drink, drink 5+ drinks

Alcohol

Underage drinking attracts many developing adolescents

Peer pressure Increased independenceEasy access Increased stress

Alcohol

Lowers attention/car accidents Decreases memory Tend to mix with other drugs – DANGER Intoxication associated with suicides and

suicide attempts Males tend to complete less yrs of

education if abusing alcohol Drinking increases risk of engage in unsafe

sexual practices, or victimization Brain is still developing in adolescents

Alcohol Dangers

Family history of alcoholism Genetics Environment Family problems Peers abusing alcohol Psychiatric problems Personality (risk takers)

Students at risk with alcohol

Dried flowers, leaves, stems, seeds from hemp plant Cannabis Sativa which contains THC

Most common illicit drug used in US Hand rolled in cigarettes or used in pipes or water pipes (bongs).

Can also be mixed in food or brewed as a tea

Marijuana

THC rapidly passes through lungs into blood which carries chemical to brain and other organs

Influences pleasure, memory, thinking, concentration, sensory, and time perception

Can affect brain development in young people – affects thinking and memory

Increases HR by 20-100% which can last 3 hrs.

Increased risk of heart attack

Marijuana effects on body

High doses of marijuana can cause a temporary psychotic reaction (hallucinations and paranoia)

Possible link between marijuana and later development of psychosis

Long term marijuana users trying to quit have irritability, sleeplessness, decreased appetite, anxiety, drug craving

Marijuana effects on body

In 1980, the concentration of THC in marijuana was 4%

In 2012, the concentration of THC in marijuana was around 15%

Potency of marijuana

Big problem on college campuses Stimulants cannot make you smarter!

Persons like to go after the “rush” or the “high” that stimulants can give

Also allow to stay awake all night to study

Statistics are hard to find for the amount of abuse

Stimulant abuse

Synthetic/Designer Drugs

Labeled as not for human consumptionCamouflaged under names such as stain remover, insect repellantActive ingredients are a moving targetGrown in popularity due to representation as legal and their limited detection by standard testsMay present with s/s that resemble psychiatric disorders such as schizophrenia, anxiety, depressionLongterm consequences relatively unknown

Synthetic/designer drugs

First used in US in July 2010Cheap ($20-50 per 50mg packet)Users predominantly young and maleOften coingested with marijuana, alcohol, opiods

Bath salts

Contain ingredients similar to ecstasy, methamphetamine, cocaineContains cathinone in khat plantIncrease in serotonin, dopamine, norepinephrine

Bath Salts

Purple wave Zoom Cloud Nine Lunar Wave White Lightening Scarface Vanilla Sky Bloom

Bath Salts Names

Cause a surge in dopamine Also surge in norepinephrine

Bath Salts

Desired effects:EuphoriaAlertnessIncreased sociabilityIncreased empathyIntensification of sensory experiencesSexual arousal

Bath Salts

Adverse effectsTachycardia HypertensionHyperthermia/sweatingMydriasisSeizures/spasmsRespiratory distressDeath

Bath Salts

Behavioral side effects

Panic attacksAgitationHallucinations/psychosis/paranoiaAggressionSelf mutilationInsomniaDepression

Bath Salts

May be inhaled, injected, snorted, swallowed , or inserted into rectum or vaginaEffects occur with doses of 2-5mgTypical dose is 5-20mgEffects occur 10-20 minutes after ingestionDesired effects last 2-4 hrs

Bath Salts

Addiction potential: strong urge to re-dose occurs 20-30” after ingestionMay be 10x more addictive than methamphetamine in rat studies

Bath Salts

What to look for:May mimic a psychiatric disorderDisorientation/agitationDilated pupils with nystagmusLockjaw and teethgrindingRapid, loud, incoherent speechEmotional, verbal, physical abuseNegative results on standard urine toxicology but developing new testing

Bath Salts

Treatment

Mainly supportiveSedatives (benzodiazepines)Monitor for respiratory depressionAntipsychoticsPhysical restraints may be necessaryLab work may show elevated liver enzymesInderal for BP, tachycardia, tremors, sweating

Bath Salts

Pure form of MDMA or Ecstacy Many more times potent than MDMA Popular Makes it feel as if “everything is right with

the world”, euphoria Usually taken as tablet or capsule Surge of serotonin – emotional closeness,

sexual arousal Negative: confusion, depression, sleep

problems, anxiety

Molly

Synthetic cannabinoids

Spice/K2

Designed to mimic THC (tetrahydrocanninol)Carry a higher risk of causing psychois1st appeared in US in 200877% of users are maleInhalation most common route of administration$10-20 per gram (usual dose is 0.3g)

Spice/K2

What to watch for:

AgitationAnxiety/DepressionElevated Blood Pressure/TachycardiaHallucinations/ParanoiaNauseaSeizuresSymptoms may last up to 6 hrs

Spice/K2

Commerical testing is available – formulations change so rapidly that testing quickly becomes obsoleteIV benzodiazepines usually treatKidney failure reported in several casesPossible 3x risk of psychosisDepression and suicidal ideation may continueDependence and withdrawal reported

Spice/K2

Derived from salvia divinroum, a member of the mint familyWorks on kappa opiodsSmoke or ingest salvia leavesLow addiction potentialMay have antidepressant effects

Salvia

Desired effects

Relaxation/better moodIntense psychedelic effectsHallucinationsFloating feeling, dream like experienceIncrease of sensual and aesthetic appreciationIncreased self confidence/insightSpiritual experience

Salvia

Adverse effectsRacing thoughtsSleeplessnessDizzinessAnxietyPsychosisAgitationSweating/chillsNausea/vomitting

Salvia

Website:

www. Erowid.org

Synthetic Drugs

National Institute of Health, www.nih.gov/ April 2014

Saddock & Saddock, Synopsis of Psychiatry, 9th edition, 2003

DSM-5, Diagnostic and Statistical Manual of Mental Disorders, American Psychiatric Association, 2013

MedicineNet.com, March 2014 NEI Psychopharmacology Congress, 2013 Iarovici, NY Times, April 2014

References

A student with a history of illicit substance abuse is considering trying bath salts as a cheap alternative high that won’t be detectable in standard drug tests. Recent studies indicate:

A. it is 10x more addictive B. 5x less addictive C. 10x less addictive

Quiz

In 2009, what percentage of 16-17 yr olds drove under the influence of drugs/alcohol

A. 1.2% B. 3.6% C. 6.3% D. 10.7%

Quiz

Which of the following statements about adderall (stimulant) is true?

A. It can make you smarterB. It can help a person focus, even if they don’t have ADHD

C. It causes your body to need less sleep

D. None of the above

Quiz

Alcohol and marijuana are the drugs most abused by teens. What comes next?

A. Ecstacy B. Cocaine C. Bath Salts D. Prescription drugs and cough medicine

E. Tobacco

Quiz

What are things dangerous about bath salts?

A. Cause paranoia, hallucinations, violent behavior

B. Made with cathinones C. May end up in emergency room after taking them

D. Contain unknown ingredients E. All of the above

Quiz