Psych Meds for Harm Reduction
Providers
Barry Zevin MD
Tom Waddell Health Center
San Francisco Department of Public Health
Homeless Programs
Board Certified Internal Medicine
Board Certified Addiction Medicine
Barry_Zevin@sfdph.org
Disclosures And Disclaimer
• Barry Zevin accepts no payments,
samples, or gifts from any
pharmaceutical companies
• The opinions expressed here are those
of the presenter
• All information regarding medications
expressed here should be checked
out!
Medications for Mental Health
Disorders
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Basic Pharmacology Concepts
Medications for Depression
Medications for Anxiety
Medications for Psychosis
Medications for Bipolar Disorders
Medications for ADHD
Medications for Sleep
Questions / Discussion
Medications for Addiction Disorders
– Come back for presentation tomorrow at 11am
Salon D
Basic Pharmacology
• Medications receive FDA approval for specific
indications but are also very commonly used
for other indications (off label)
• Any substance can have adverse effects if
used in the wrong way at the wrong time
– Even water can kill you
– Any drug can cause an allergy and if severe it
(and closely related drugs) should not be used
– Many drugs can have idiosyncratic (unpredictable)
liver, kidney, or other toxicity
• Some side effects are relatively mild but so
common that they are important
• Some side effects are rare but so severe that
they are important
Basic Pharmacology
• What is a “psych med”?
• Why do or don’t medical providers
prescribe psych meds?
• Why do or don’t people take psych
meds?
• Harm reduction vs. harm production
– Are psych meds part of harm reduction?
– Can psych meds produce harm?
Basic Pharmacology
• Reducing Risk for Prescribed Drugs
– Rationale for Using the Medication
– Informed Consent
• True informed consent not the fake kind
– Follow Up
• Is it working? Could it be working better? Make
changes when needed
Basic Pharmacology
• What I’m not going
to talk about
Basic Pharmacology
• In general medication should be started at the
lowest possible dose and gradually increased
to the lowest effective dose
– In some urgent situations higher doses must be
used right away
– Many adverse effects are dose dependent
– Some medications require monitoring of blood
levels for effective levels and to prevent toxic
levels
• In general, when stopping a medication,
slowly decreasing the dose decreases the
risk of discontinuation symptoms
– In some cases of adverse reactions medications
must be stopped immediately
Basic Pharmacology
• Medications can interact with each
other, some foods, or street drugs in
ways which change how they act, how
long or short they act, how toxic they
are, and how high a dose is needed
• Medications can act synergistically in
causing adverse effects including risk of
overdose
Medications for Depression
• SSRI
• Other Meds
• TCAs
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Atypical anti-psychotics
Antidepressants (and other meds) and suicide
– Overall medications appear to reduce suicide
attempts and completed suicides
– Studies of antidepressants in children and
adolescents show risk of increased suicide esp.
when 1st starting medications
• This may also be true in adults
Medications for Depression
• SSRIs
– Fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil),
citalopram (Celexa), escitalopram (Lexapro), etc.
• Tricyclic Anti-Depressant
– Amitryptaline (Elavil), Nortryptaline (Pamelor), Desipramine
(Norpramin), Doxepin (Sinequan), etc
• Other anti-depressants
– MAO Inhibitor
• Phenalzine (Nardil), tranylcypromine (Parnate), etc.
– SNRI
• Vanlafaxine (Effexor), duloxetine (Cymbalta), desvenlafaxine (Pristiq)
– Bupropion (Wellbutrin)
– Mirtazapine (Remeron)
– Trazadone
• Placebo
SSRIs
Main Intended Effects
• Anti-depressant
• Anti-anxiety
• Anti-OCD
Other Intended Effects
• Sleep
• Activation / energy
SSRIs
Common Side Effects
• Sexual side effects
– Orgasm delay or
anorgasmia
– Low libido, ED
• Stomach discomfort,
jitteriness in 1st 1-2 wks
• Mild sedation
• Insomnia
• Uncomfortable effects
when abruptly stopped
– Esp. paroxetine (Paxil)
• Emotional Blunting
Rare but Severe Side
Effects
• Serotonin syndrome
– At very high doses or
when used in
combination with
other meds effecting
serotonin system
• MDMA, (PMA),
amphetamines,
fentanyl, tramadol,
cocaine, LSD
TCAs
Main Intended Effects
• Anti-depressant
Other Intended Effects
• Sleep
• Pain relief
• Anti-itching
– Doxepin
• Anti-anxiety
TCAs
Common Side Effects
• Anti-cholinergic
– Dry mouth, sedation,
urinary retention,
• Sedation
Rare but Severe Side
Effects
• Acute anticholinergic
syndrome (delirium)
– High dose or combination
of anti-cholinergics
(promethazine, datura,
brugmansia,)
• Heart rhythm effects
including death
• Death in overdose
Other anti-depressants
Main Intended Effects
• Anti-depressant
• Anti-anxiety
– Not bupropion
(Wellbutrin)
• Fight neuropathic
pain-SNRIs
Other Intended Effects
• Sleep
• Weight gain
– mirtazapine
(Remeron)
Other anti-depressants
Common Side Effects
• Sedation
• Weight gain
– Mirtazapine (Remeron),
etc.
• Over-activation
– Bupropion (Wellbutrin),
etc.
Rare But Severe Side
Effects
• Priapism - erection that
won’t go away
– Trazadone
• Seizures
– Bupropion (Wellbutrin)
• Potentially fatal
interactions with food
and other medications
– MAO Inhibitors
Placebo
• Main Intended
Effects
– Anti-depressant
– Anti-anxiety
– ???
• Other Intended
Effects
– Eliminate “side
effects”
Placebo (Nocebo)
• Common Side
Effects
– Expected adverse
effects are more
likely to occur
– Often interfere with
effective treatment
• Rare But Severe
Side Effects
– ???
Medications for Anxiety
• SSRIs (and other anti-depressants)
• Benzodiazepines
– Diazapam (Valium), lorazapam (Ativan),
alprazolam (Xanax), clonazapam
(Klonapin)
• Other
– Buspirone (Buspar)
– Atypical anti-psychotics, anti-psychotics (major tranquilizers)
Benzodiazepines
Main Intended Effects
• Anti-anxiety
• Anti-panic attack
• Sleep
Other Intended Effects
• Decrease “agitation”
in any condition
• Treat alcohol
withdrawal
• Treat intoxication
due to stimulants
• Amnesia
Benzodiazepines
Common Side Effects
• Sedation
• Interferes with
memory and
learning
• Unpleasant
withdrawal when
stopped abruptly
Rare but Severe Side
Effects
• Addiction especially in
people with other
addictive disorders
• Fatal overdose when
mixed with alcohol or
other sedatives or
opioids
• Severe withdrawal
including seizures and
delirium
• Falls and fractures esp.
in elderly
Medications for Psychosis
• Atypical anti-psychotic
– Olanzapine (Zyprexa), quetiapine (Seroquel),
risperidone (Risperdal), aripiprazole (Abilify),
ziprasadone (Geodon), paliperidone (Invega),
clozapine (Clozaril)
– Injectable long lasting atypical- risperdal consta,
Invega Sustenna
• Older anti-psychotic
– Chlorpromazine (Thorazine), haloperidol (Haldol),
thioridazine (Melloril), etc.
Atypical antipsychotic
Main Intended Effects
• Anti-psychotic
• Anti-mania
• Mood stabilizer
Other Intended Effects
• Anti-depressant
• Decrease agitation
due to any cause
• Anti-anxiety
• Sleep
• Practically anything
anybody can think of
Atypical anti-psychotics
Rare but Severe Side
Effects
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Common Side Effects
Weight gain
Diabetes
Abnormal lipids
(cholesterol, LDL, etc)
Sedation
Sexual side effects
Movement disorders
– Akithisia, tremor, dystonic
reactions, repetitive
movements
– Less common than older
antispychotics
• Prolong QT interval causing
fatal heart arrythmia
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– Esp when combined with
other medications that
prolong QT interval (e.g.
methadone)
Depersonalization / feeling
like a zombie
Tardive dyskinesia
Neuroleptic malignant
syndrome
Excess prolactin production
Increased risk of stroke and
death in elderly
Older anti-psychotics
Main Intended Effects
• Anti-psychotic
• Anti-mania
Other Intended Effects
• Decrease any kind
of agitation
Older anti-psychotics
Common Side Effects
• Movement disorders
– EPS, TD, Akithesia
• Sexual side effects
• Sedation
• Weight gain
Rare but Severe Side
Effects
• Neuroleptic
malignant syndrome
• Irreversible TD
Medications for Bipolar
Disorders
• Lithium
• Anti-epileptic drugs
– Lamotragine (Lamictal), divalproex
(Depakote), topiramate (Topamax),
carbamazepine (Tegretol), oxcarbazapine
(Trileptal)
• Atypical anti-psychotics
Lithium
Main Intended Effects
• Anti-manic
• Mood stabilizer
Other Intended Effects
• Anti-depressant
Lithium
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Common Side Effects
Tremor
Diarrhea, nausea
Weight gain
Inability to concentrate
urine
– Increased urination
– Increased need to drink
water
– Easy tendency to
dehydration
• Thyroid dysfunction
– hypothyroidism
Rare but Severe Side
Effects
• Toxic levels can be
fatal
– Can occur quickly in
overdose or if at
normal dose patient
becomes dehydrated
• Kidney failure
Anti-epileptic drugs
Main Intended Effects
• Mood stabilizer
• (prevent seizures)
Other Intended Effects
• Decrease impulsivity
and aggressiveness
• Adjunct to pain control
• Decrease craving and
relapse in alcoholism
– topiramate (topamax)
• Prevent migraine
– Divalproex
(Depakote),topiramate
(topamax)
• Many other possible
effects being studied
Anti-epileptic drugs
Common Side Effects
• Cognitive slowing / brain
fog
– Esp topirimate (Topamax)
• GI effects
– Abdominal pain, nausea
and vomiting
• Sedation
• Weight gain
• Weight loss
– topiramate (Topamax)
• dizziness
Rare but Severe Side
Effects
• Severe skin rash
– Esp. lamotrigine
(Lamictal)
• Blood and liver
problems
– Esp. carbamazepine
(Tegretol)
• Confusion, Ataxia,
Delirium
– Esp. at high doses or
overdose
Medications for ADHD
• Psychostimulants
– Methylphenidate (Ritalin, Focalin, etc),
mixed amphetamine salts (Adderall,
Adderall XR), others
• Others
– Atomoxetine (Strattera)
Medications for ADHD
Main Intended Effects
• Improve
concentration and
focus
• Decrease
hyperactivity
Other Intended Effects
• Anti-depressant
• Decrease substance
abuse
Medications for ADHD
Common Side Effects
• Tremor
• Poor sleep
• Feeling of being
slowed down
Rare but Severe Side
Effects
• Psychosis / mania
• Addiction potential
esp. in those with
underlying addiction
problems
Medications for Sleep
• Benzodiazepines
– Temazapam (Restoril), Flurazapam (Dalmane)
• Benzadiazepine - like
– Zolpidem (Ambien), zaleplon (Sonata),
eszopiclone (Lunesta)
• Anti-Histamines
– Diphenhydramine (Benedryl), hydroxyzine
(Atarax)
• Melatonin receptor agonist
– Melatonin, ramelteon (Rozerem)
• Antidepressants
– Trazadone, amitryptaline (Elavil)
• Atypical antipsychotics
Medications for Sleep
Main Intended Effects
• Faster onset of
sleep
• Maintain sleep
• Normalize sleep
architecture
– Claimed for
trazadone, ramelteon
(Rozerem)
Other Intended Effects
• Anti-anxiety
• Decrease allergic
symptoms
Medications for Sleep
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Common Side Effects
Sedation / hangover
effect
Anticholinergic effects
with antihistamines
Memory effects and
amnesia
Tolerance
Confusion, falls,
delirium in elderly /
chronically ill
Rare but Severe Side
Effects
• Potentiation of other
sedatives with overdose
• Potential for addiction
– Esp. benzodiazepines in
patients with underlying
addiction disorders
– Potential trigger for
relapse in patients with
alcoholism in recovery
Thank you to my colleagues at
Tom Waddell Health Center
and
Harm Reduction Therapy Center
and especially to my patients who I learn
from every day