ETSU 2018 PMHNP
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| What IS Psychopharmacology? | Study of the Mediation & Modulation of Behavior through both direct means (exogenous drugs) and indirect means (endogenous signaling substances)
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| Direct Means - Exogenous | Drugs can directly mediate & modulate behavior through direct impact on CNS functioning
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| Indirect Means-Endogenous Signaling Substances | Small Molecular Weight Molecules in the brain
Hormones: Neurotransmitters, Neuromodulators
Cellular Secondary Messengers: Specific enzymes needed to produce a specific substance
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| What is Goal of Psychopharmacology? | Mediation & Modulation of behavior
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| What is Target Symptom | Specific, precise, and individualized symptom (behavior) that can reasonably be expected to be improved or eliminated through medication use
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| Essential #1: History | -Use open ended questions
-Clarify (ie. when a client c/o poor sleep, ask specifics)
-Obtain chronological symptom history
-Identify Target Symptoms
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| Essential #2: Thorough Assessment | -Physical Exam
-Mental Status Exam
-Standardized Rating Scales
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| Testing | Mental Status Examination
Write–a-Sentence Test
Draw-a-Clock Test
Copy-a-Three-Dimensional-Figure-Test
Standardized Instruments (Zung Depression Scale, Beck Anxiety Scale, PANSS)
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| Mental Status Examination (MSE) | It gives the clinician a better understanding of the client’s current status/ lvl of fx. Should be used at the initial eval & ea follow-up visit in order to assess response to treatment.
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| Essential #3: Laboratory Testing | Complete Blood Counts, Thyroid function tests, Electrolytes, Glucose, Renal function, Hepatic function, Urinalysis, Urine drug screen, STD screen and hepatitis panel in high-risk populations, ****Pregnancy test
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| Complete Blood Count (CBC) | Red blood cell count (RBC), Hematocrit (Hct), Hemoglobin (Hgb), Platelets, Mean Corpuscular volume (MCV), Mean corpuscular hemoglobin (MCH), Mean corpuscular hemoglobin concentration (MCHC), Red cell distribution width (RDW), WBC, Differential: neutrophils, eosinophils, basophils, lymphocyte, monocytes
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| CBC cont. | RBC: Males: 4.4 – 6.1 mil/mm3, Females: 4.2 – 5.5
Hct: Male: 40.7-50.5%, Female: 36.1-44.3%
Hgb: Male: 13.8-17.2 gm/dl, Female: 12.1-15.1 gm/dl
Platelets: 150-400 K/mm3
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| WBC | Normal: 4,000-11,000
Variability: Increased WBC = Leukocytosis
Shift to the left = increase in immature neutrophils called bands
Shift to the right=increase in very mature neutrophils
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| WBC (Remember 500) | Less than 500 WBC = panic
Less than 500 neutrophils = bacterial infection
Less than 500 lymphocytes = viral infection
Less than 5.0 Hgb = heart failure and death
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| Why order a CBC? | Used to detect: Polycythemia, Anemias, Infections, Monitor fluid status, blood loss, Inflammation, Need to conduct further tests such as bone marrow biopsy
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| Liver Function Tests | Total bilirubin & direct bilirubin values are elevated in hepatocellular injury, variety of meds and substance use/abuse.
Liver damage: abnormal LFT’s & may impair clearance of a drug, Increased LFTs may be seen with any drug that utilizes hepatolic metabolism
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| Liver Function Tests cont. | Serum Enzyme: Alkaline Phosphate: 13-39 U/ml
Aspartate aminotransferase (AST, was SGOT): 5-40 U/ml
Alanine aminotransferase (ALT was SGPT): 5-35 U/ml
Lactate dehydrogenase (LDH): 200-500 U/ml
5’-nucleotidase: 2-11 U/ml
Gamma glumatic transpeptidase (GGT)
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| Liver Function Tests cont. | ALT: increased when hepatic cells have been inflamed or died
AST: Also reflects hepatic cell damage though less specific for liver disease (increased in MI)
GGT: Meds/ETOH will cause increases in GGT
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| Thyroid Panel | Thyroid hormone: thyroxine T4 or triodothyronine T3
Thyroid-releasing hormone (TRH) stimulates the release of TSH, TRH increases with exposure to cold, stress, decreased levels of T4
*Thyroid tests : TSH, T4 (free or total), T3 (free or Total)
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| TSH | Thyroid-stimulating hormones (TSH)
Increases release of stored thyroid hormones
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| Subclinical Hypothyroidism | Subclinical Hypothyroidism:
Normal free T3 &T4
Suppressed TSH
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| Essential #4: Explore client’s concerns about using medications | -What are the client’s thoughts about medication use?
-Clarify misconceptions &/or myths of med use
-Discuss realistic expectations
-Compliance issues
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| Essential #5: Medication Education | -EDUCATE, EDUCATE, EDUCATE!
-DOCUMENT, DOCUMENT, DOCUMENT!
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| Essential #6: Follow-up | -Schedule appropriate follow-up care
-Give contact information
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| Essential #7: Make medication adjustments appropriately | Know correct dosing of meds and when a dose change might be warranted
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| Essential 8 Polypharmacy | Polypharmacy and off label use. Remember off label means using a medication that does not have FDA approval for it’s use in the disorder you want to treat.
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| Selective Toxicity | using the best medication with the least side effects
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| Drugs fit into two large categories | Agonists-produce effect (or turn on)
Antagonists-block effect (or turn off)
Partial Agonists
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| Pharmokinetics | What happens between taking & leaving.
Variable in how long trip through body it takes, how long till effect occurs, how long will effect last.
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| Drug Absorption | As a drug is distributed in the body, it comes in contact with numerous membranes. Drugs pass some membranes but not others.
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| Drug Distribution | Several factors influence drug distribution:
Membrane permeability, Plasma protein binding, Depot storage
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| Membrane Permeability | To enter an organ, a drug must permeate all membranes that separate the organ from the site of drug action. Ex. drugs that are lipophilic (fat loving) such as benzodiazepines, readily cross the blood-brain barrier
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| Plasma protein binding | Binding of drugs to plasma protein such as albumin.
Reduces the amount of free drug in the blood.
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| Depot Storage | Lipophilic drugs accumulate in fat and released slowly from fat stores. Antipsychotics are highly lipophilic so they tend to hang around in your system for 1-3 months after they are discontinued.
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| Metabolism Elimination | P450 system
Some drugs are excreted after they have been metabolized while others are excreted unchanged.
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| Half Life | Time required for the serum concentration of drug to decrease by one-half (how rapidly half the drug is excreted). Generally, 4-5 half lives = steady state
Blood levels will be reliable generally after 5 half lives
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| Steady State | Point at which a specific dose of drug given over a several-day period produces consistent blood level
Predicts likely point therapeutic response
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| Half lives | Medications with longer ½ lives take longer to reach steady state.
The shorter the ½ life of antidepressants, the more likely patients will experience discontinuation symptoms.
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| Half lives cont. | (ie. Effexor has a very short ½ life so it does cause discontinuation symptoms while the ½ life of Prozac is very long, therefore there are no discontinuation symptoms assoc. with Prozac.
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| Cmax: | patient ingests a drug, it gets absorbed then reaches a peak concentration which is Cmax.
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| Tmax: | the time required for a particular drug to reach Cmax is called Tmax.
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| Cmin | after Cmax, the concentration of the drug graduallly comes down, eventually reaching a Cmin or trough concentration, just before the next dose is taken.
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| AUC (area under the curve): | entire amount of drug that is present in the blood over a given period of time so AUC is a measure of the total amount of drug absorbed by the body
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| Area under the curve (AUC) cont. | ER (extended release) formulation leads to an auc comparable to BID or TID dosing of IR (immediate release formulation).
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| Pharmacodynamics | How do drug and receptors in body interact:
Affinity: How much receptors like each other
Dose-Response Curvature (3 curves, see next slide)
Side-Effect, Interactions
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| Dose-Response Curvature Linear | the more you take, the better you feel up to the point it can harm you. Meds with linear response can be increased if not seeing a therapeutic response.
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| Curving linear: | Patients will improve and then max out; then the more they take, the worse they feel. For example, tricylic antidepressants have a curving linear response. If a patient is not responding to a tricylic, don’t increase the dose because it could make them feel worse.
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| Plateau: | Patients will improve up until a certain point and then they will plateau, they will not get any better.
Example: SSRI antidepressants
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| Hormetic Effect (Arndt-Shultz Law) | Describes the relationship between dose and response
Hormetic effect: there is not always a simple linear relationship between the dose of a drug and the clinical response
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| Hormetic Effect (Arndt-Shultz Law) cont | It is not always the case that the higher the dose, the more effective the drug will be.
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| Hormetic Effect (Arndt-Shultz Law) cont | Because of the hormetic effect, the higher doses beyond a certain point may actually be less effective.
50% of drugs demonstrate the hormetic effect
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| FDA Trials | Phase I: test drug for safety in animals then in human volunteers.
Phase II: test drug in groups of patients.
Phase III: test drug in very large groups of patients
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| Bioequivalence | (determined by administering drug to volunteers and obtaining average Cmax, half lives, and AUC.
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| Generic bioequialence | 80%-125%: the bioequivalence of generic must be between 80-125% of original brand.
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| ***please note many psychiatrists and patients complain about problems when switching from name brands to generic. | Ie. Clozaril and Depakote
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