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Basic Psychopharmacology For Counselors And Psychotherapists Chapter 5 First Draft 

Basic Psychopharmacology For Counselors And Psychotherapists Chapter 5 First Draft


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Slide 1: Basic Psychopharmacology for Counselors and Psychotherapists - Chapter 5 CHAPTER FIVE: TREATMENT OF UNIPOLAR DEPRESSION Jeff Garrett Ph.D.
Slide 2: • Objective: To examine the medications and other treatment considerations for clients with depression.
Slide 3: - Depression is the most common presenting concern in all treatment settings. - Assessing the nature and type of depression is key to proper med-ication suggestions.
Slide 4: Topics to be addressed • - Biological versus environmental depression. - Causes of biological depression. - Counseling and psychotherapy. - Medications for depression. - Herbal and holistic substances. - Light therapy for seasonal affective disorders (SAD). - Importance of exercise. - Electroconvulsive therapy (ECT). - A step approach to treatment.
Slide 5: BIOLOGICAL VERSUS ENVIRONMENTAL DEPRESSION - Depression is probably the most frequently presented issue in any mental health setting. - Less than 20 percent of those who seek treatment take antidepressants.
Slide 6: Determining the nature of the depression. • - Biological or endogenous in nature; caused from within the person. Has a biological link – family history of depression. - Reactive or exogenous in nature; caused from forces outside of the body such as stress or grief. - Therapists often find that both internal and external factors play a role.
Slide 7: Determining the nature of the depression. - Therapists must also aware be that dysthymia, cyclothymia, and grief reactions have some bio-logical components. - Determine the role of other complicating factors such as substance use, psychotic features, physical diseases, and medications that may cause depression. - Physical disorders can cause or exacerbate depression. - Many medications and other substances can cause or worsen depression.
Slide 8: Treatment Options - Psychotherapy - Medication, including pharmaceuticals and herbal remedies - Light therapy for those with seasonally influenced depression. - Exercise - Electroconvulsive therapy (ECT) and other treatments
Slide 9: PSYCHOTHERAPY FOR DEPRESSION - Psychotherapy is effective. - Greatest gains in the first 16-20 sessions. - Evidence-based treatment e.g., CBT and Brief Solution focused Therapy.
Slide 10: PSYCHOTHERAPY FOR DEPRESSION - In cases of dysthymia (chronic-mild depression), psychotherapy alone may be attempted. If little response is noticed, an antidepressant may be added. - Psychotherapy and medication together are most efficacious.
Slide 11: PSYCHOTHERAPY FOR DEPRESSION - In cases of a grief reaction with sleep disturbances, medications to improve sleep may be used without an antidepressant. - Only when the grief is prolonged, severe, and accompanied by suicidal ideation, should antidepres-sants be considered.
Slide 13: Four main categories of antidepressants 1. Tricyclic antidepressants (TCA). 2. Selective serotonin reuptake inhibitors (SSRI). 3. Monoamine oxidase inhibitors (MAOI). 4. Heterocyclics or "others."
Slide 14: 1. Tricyclic antidepressants (TCA). - The oldest classifications of antidepressants - been around for more than forty years. - TCAs prevent the reuptake of neuro-transmitter substance back into the presynaptic cell. - Depression may be caused by depletions in the neurotransmitters serotonin (5-HT), norepinephrine (NE), dopamine (D) or all three.
Slide 15: 1. Tricyclic antidepressants (TCA). - Although effective, TCAs are not "clean" medications i.e., they affect many nontarget organs and systems in the body. - They have troublesome anticholinergic side effects that include sedation, weight gain, difficulty urinating, dizziness, dry mouth, sexual dysfunction, orthostatic hypotension, and blurred vision. - Typically not safe for children or the elderly. - TCAs pose a serious risk of overdose for clients with significant suicidal ideation.
Slide 16: Tricyclic Antidepressants (TCAs) Trade Name – Generic Name – Level of Sedation Anafranil – clomipramine. – Heavy. Ascendin – amoxapine. – Moderate-heavy. Elavil – amitriptyline. – Heavy. Ludiomil – maprotiline. – Moderate. Norpramin – desipramine. – Light. Pamelor, Aventyle – nortriptyline. – Moderate-heavy. Sinequan, Adapin – doxepin. – Heavy. Surmontil – trimipramine. – Heavy. Surmontil – trimipramine. – Moderate. Tofranil – imipramine. – Light-moderate. Vivactil – protriptyline. – Light.
Slide 17: Second Generation of TCAs (early 1980s) -Trade name Desyrel / Generic name trazodone. - Affects primarily serotonin but acts more as a 5-HT2 receptor antagonist. - Fewer side effects than older TCAs and is less of a suicidal risk, but the typical side effects of sedation and dry month remain. - Often used as a general sedating medication without the risk of addiction.
Slide 18: 2. Selective Serotonin Reuptake Inhibitors (SSRIs) (Late 1980s) - Block the reuptake of serotonin back into the presynaptic cell. - This blocking action allows more serotonin to exert its influence on the postsynaptic cell. SSRIs are "cleaner" - SSRIs interact with few other medications.
Slide 19: 2. Selective Serotonin Reuptake Inhibitors (SSRIs) (Late 1980s) - The side effects for SSRIs are considerably less severe than for older TCAs. - Typical side effects include headache, nausea, diarrhea, dry mouth, anorexia, weight gain, restlessness, insomnia, tremor, sweating, yawning, dizziness, inhibited sexual desire, and inhibited orgasm for some. - They are considered safer medications for children, seniors, and patients who may be at risk for a suicide overdose.
Slide 20: 2. Selective Serotonin Reuptake Inhibitors (SSRIs) (Late 1980s) - However, 2 to 3 percent of children and adolescents will demonstrate an increase in suicide thinking and behavior. - If serotonin levels inside the central nervous system become too elevated from SSRIs or other medications, some patients may experience serotonin syndrome. - Symptoms of serotonin syndrome may in-clude agitation, confusion, insomnia, flushing, fever, shivering, muscle rigidity, incoordination, diarrhea, and hypotension.
Slide 21: Selective Serotonin Reuptake Inhibitors (SSRIs) Trade Name - Generic Name - Level of Sedation Celexa - citalopram -Light Lexapro - escitalopram - None Luvox - fluvoxamine - Light Paxil, Paxil CR - paroxetine - Moderate-heavy Prozac, Sarafem - fluoxetine -None Prozac Weekly - fluoxetine - None Zoloft - sertraline - None
Slide 22: 3. Heterocyclic Antidepressants (recent) • - Have side effects similar to SSRIs, but they have less possibility of sexual dysfunction. - Venlafaxine (Effexor/Effexor XR), a serotonin-norepinephrine reuptake inhibitor (SNRI), - Usually well tolerated and has been shown to be helpful in general depression, generalized anxiety, and postpartum depression.
Slide 23: 3. Heterocyclic Antidepressants (recent) - Duloxetine (Cymbalta), released in 2004, is similar to venlafaxine as a result of its dual mechanism of action. Duloxetine has the advantage of allowing for stimulation of both serotonin and norepi-nephrine equally at all doses. - Mirtazepine (Remeron) is helpful in restoring normal sleep patterns. It has also been found to increase appetite, which may help depressed HIV or cancer patients who are having trouble with weight loss.
Slide 24: 3. Heterocyclic Antidepressants (recent) - Like mirtazepine, nefazodone (Serzone) may help restore sleep patterns and cause sedation for many. Unfortunately, the medication has an FDA "black-box" warning due to its increased risk of liver failure and must be used only with caution. - Bupropion (Wellbutrin) is well tolerated but is rather uplifting and agitating for some. While bupropion has not been associated with sexual dysfunction, it is not appropriate for patients with seizure or eating disorders, as it lowers the seizure threshold and reduces appetite.
Slide 25: Hetercyclic Antidepressants Trade Name – Generic Name – Level of Sedation. Cymbalta – duloxetine – None. Effexor – venlafaxine – None. Effexor XR – venlafaxine XR – None. Remeron, Remeron Soltab – mirtazepine – Heavy. Serzone (Trade brand no longer available)– nefazodone – Moderate. Wellbutrin – bupropion – None. Wellbutrin SR – burpropion SR - None Wellbutrin XR – burpropion XR - None
Slide 26: 4. Monoamine Oxidase Inhibitors (MAOIs). - MAOIs inhibit MAO or the enzyme that breaks down neurotransmitters and renders them ineffective. - MAOIs exert most of their influence in the presynaptic cell. - Side effects closely resemble those of TCAs, but MAOIs are usually well tolerated.
Slide 27: 4. Monoamine Oxidase Inhibitors (MAOIs). - Must adhere to strict dietary restrictions, as ingestion of any food containing tyramine may cause a hypertensive crisis. - MAOIs have fallen out of use in this country but are still widely used in Europe. - Used as a last-resort drug for clients who do not respond well to other medications.
Slide 28: Monoamine Oxidase Inhibitors (MAOIs). Trade Name – Generic Name – Level of Sedation. Marplan – isocarboxazid – Light. Nardil – phenelzine – Light. Parnate – tranylcypromine – Light.
Slide 29: Lithium - Another treatment option for unipolar depression as well as for bipolar depression. - Usually reserved for more difficult and treatment-resistant cases. - Lithium will be explored fur-ther in Chapter 6 for Bipolar Depression.
Slide 30: HERBAL AND HOLISTIC SUBSTANCES • St. John's wort - Research primarily conducted in Europe. - Most clinicians believe that few patients are helped by St. John's wort. - It may interfere or react to other medications clients may be taking. Ginkgo biloba - Is a tree of Chinese origin. - It is said to relieve mild depression and increase memory and concentration. - It has not been as effective as antidepressants in the treatment of moderate to severe depression. The hormone dehydroepiandrosterone (DHEA) - Is normally secreted by the adrenal gland and is a precursor to testosterone and estrogen. - It is said to reduce mild to moderate depression, cause weight loss, increase large muscle mass, and may increase sexual appetite. - These claims have yet to be fully proven. S-adenosyl-L-methionine (SAM-e) - Research conducted in Italy. It is available as a prescription in many European countries. - Believed to increase serotonin and dopamine. - Has been shown to be as effective as many prescription antidepressants for relieving depression. - Also be helpful in relieving joint pain and for cleansing the liver of other toxins.
Slide 31: LIGHT THERAPY FOR SEASONAL AFFECTIVE DISORDER (SAD) • - Used with clients living in colder, darker climates and suffering from seasonal depression. - The light source should produce at least 10,000 lux of full-spectrum light. - Clients need to be directly exposed to the light for 3060 minutes/day and sit approximately 10-12 inches from most light sources. - Several commercially produced lamps or boxes are available (cost be-tween $100 and $500).
Slide 32: IMPORTANCE OF EXERCISE • - Helps to release im-portant endorphins like phenylethylamine (PEA) which is associated with increased levels of endorphins and improvement in energy and mood. - Helps with weight loss. - Increases motivation.
Slide 33: ECTROCONVULSIVE THERAPY (ECT) • - ECT is used with some clients suffering from severe depression who do not respond to antidepressants. - Elec-trodes are placed on the scalp, usually on the nonspeech-dominant hemisphere to avoid later damage to verbal memories. - Electricity is then administered, resulting in a seizure. - Most patients receive three sessions per week for up to four weeks, or until improvement is noted. - Some clinicians believe that the risks associated with ECT are equivalent or even preferable to many medications used to treat depression. - Others believe that excessive use of ECT may cause brain damage and memory loss.
Slide 34: PROCEDURAL STEPS FOR PATIENT TREATMENT • A treatment protocol for deciding on the appropriate medications and how to use them.
Slide 35: PROCEDURAL STEPS FOR PATIENT TREATMENT Step 1. Most prescribing professionals start with the easier medications first. - These include the SSRIs such as fluoxetine (Prozac), citalopram (Celexa), sertraline (Zoloft), and so on. These medications have fewer side effects and interact with fewer other medications. - In many cases, the patient is started on a low dose and titrated up. - Research suggests that too many clients are maintained on a too small dose of antidepressants, which is no better than no dose at all. - If the patient has a satisfactory response and all symp-toms appear to remit, the therapist should continue with psychotherapy and not in-crease the medication.
Slide 36: PROCEDURAL STEPS FOR PATIENT TREATMENT Step 2. In some cases the client has only a partial response to SSRIs, even when the dose is increased. In such cases, ad-ditional medications aimed at the other neurotransmitters might need to be added or substituted. - Since SSRIs only affect the neurotransmitter serotonin, the clients depression may be related to norepinephrine and/or dopamine. - Antidepressants can be augmented or "boosted" by adding a low dose of lithium for one or two weeks, or by adding a stimulant like methylphenidate (Ritalin). - It is not unusual for such clients to be taking an SSRI like fluoxetine and also taking venlafaxine (Effexor) or bupropion (Wellbutrin). - Buspirone (Buspar), a nonbenzodiazepine anxiety medication with antidepressant qualities may also boost the antidepressant response.
Slide 37: PROCEDURAL STEPS FOR PATIENT TREATMENT Step 3. If the client appears to have psychotic features in addition to his or her depression, an appropriate neuroleptic or antipsychotic medication might need to be added to the regime. - In rare cases, the patient may also have racing thoughts that inter-fere with his or her ability to relax. - In these cases, neuroleptics may also be added to calm the thoughts and allow the patient to sleep better.
Slide 38: PROCEDURAL STEPS FOR PATIENT TREATMENT Step 4. If the therapist and the prescriber have tried several drugs with no re-sponse, they should … - Check with the patient to determine if he or she is using alcohol or other substances. - Taking the medication as directed. - Not taking the medication at all. - Taking an unreported dietary supplement.
Slide 39: PROCEDURAL STEPS FOR PATIENT TREATMENT Step 5. The therapist should keep in mind that certain medications are con-traindicated for certain types of patients. - For clients with poor appetite or eating dis-orders, do not use bupropion as it may decrease appetite. - For overweight clients, use mirtazepine (Remeron) and TCAs with caution, as they have been shown to cause an in-crease in weight and appetite. - Clients with a history of seizure should not take bupro-pion because it lowers the seizure threshold. - Nefazodone must be used with extra caution because it may cause liver failure in some patients. - It is important to remember that MAOIs do not mix with other antidepressants and can cause a hypertensive crisis.
Slide 40: Client Education Therapists should inform clients of the following five facts. • 1. Antidepressant medications take time to work. - Advise the client to be pa-tient. - Typically one and four weeks before an antidepressant begins to work. - Some medications, like venlafaxine (Effexor) may begin to work within a couple of days, but this is the exception, not the rule.
Slide 41: Client Education Therapists should inform clients of the following five facts. • 2. Inform the client about the types of side effects to expect. - It is easy to remember the major side effects with antidepressants, as they all start with the letter S: sexual, sedation, seizure, and stomach related symptoms. - In most cases, these side effects are minimal and most of them disappear within a few days. - Try not to spend too much time taking about side effects, because the patient may begin to fear the medication and refuse to take it.
Slide 42: Client Education Therapists should inform clients of the following five facts. • 3. Remind the patient that he or she should never stop the medications abruptly. - This may cause a type of withdrawal known as discontinuation syndrome, which is accompanied by severe flulike symptoms. - If a decision is made to stop a medication, it should be done gradually and under medical supervision. - Watch for an increase in depression or suicidal ideation.
Slide 43: Client Education Therapists should inform clients of the following five facts. • 4. Pregnant clients should probably not take antidepressants (or any other medica-tion) if they can help it. - Consider antidepressant only if the client is severely depressed and cannot function without them. - Typically, antidepressants are most dangerous in the first trimester. - Breast-feeding mothers should consult their physician before they proceed.
Slide 44: Client Education Therapists should inform clients of the following five facts. • 5. Typically, antidepressants will relieve symptoms of depression and associated anx-iety. - Many clients are concerned about taking drugs and will resist the therapist's recommendations. - When working with a severely depressed patient for whom psy-chotherapy alone has not helped, the therapist must help the client to see that med-ication may be a very important part of treatment.

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