14 - Mental Health Flashcards
Why do people use NHPs for mental health?
- Manage symptoms (or trying to manage side effects from other Rx products)
- Patient preference
- Belief that “natural is better”
- Information from internet and/or media (ex. Dr. Oz)
- Use of CAM treatments by individuals with mental illness ranges from 16-44% (most common users are individuals with depression)
What is Depression?
- Mental disorder characterized predominantly by depressive features
- Long-term, relapsing condition
- Associated with high levels of substantial health, psychosocial and financial burden (disability, comorbidity and mortality)
- Recognized as target for chronic disease management
How does depression affect physical health?
- Predisposition to obesity/metabolic disorders
- Increased medical comorbidity
How does depression affect function?
- High impact on social domain
- Increased work impairment
Describe the neuroscience behind depression
- Genes
- Stress
- Dysregulation of the HPA axis reduces hippocampal volumes and prefrontal cortex activity
- Antidepressants increase BDNF - neuronal growth and activity
- Cytokines - inflammatory response
What drugs target the monoamines?
- Serotonin transporters/receptors
- Norepinephrine transporters/receptors
- Dopamine transporters/receptors
What drugs target Glutamate?
-NMDA receptors
What drugs target circadian rhythms ?
-melatonin receptors, serotonin receptors
What drugs target stress hormones and cytokines
- Glucocorticoids
- Neurokinin receptors
- TNF alpha
- Cox2 inhibitors
- IL-6
What drugs target neurogenesis ?
BDNF
What are targets for brain structure and function?
- frontal cortex
- subcallosal cingulate gyrus
- nucleus accumbens
- ventral striatum
- vagus nerve
Risk factors for depression:
What are some “setting” factors?
-gender
-age
-SES
-race
culture
Risk factors for depression:
What are some “biological” factors?
- genetics
- structural dysfunction
- process dysfunction
- regulatory dysfunction
Risk factors for depression:
What are some “psychological” factors?
- cognitive schema
- attention/memory
- pessimism
- rumination
- explanatory style
- problem-solving
Risk factors for depression:
What are some “social” factors?
- early trauma/loss
- attachment style
- life events
- social support network
- social rejection
What criteria is required for a diagnosis of MDD (major depressive disorder) ?
A) 5 or more of the following symptoms, present during same 2-week period, must represent a change from previous functioning. At least one symptom must be depressed mood or loss of pleasure:
- Depressed mood
- Markedly diminished interest or pleasure
- Significant weight loss or gain, increase or decrease in appetite
- Insomnia or hypersomnia
- Psychomotor agitation or retardation
- Fatigue or loss of energy
- Feelings or worthlessness or excessive guilt
- Diminished ability to think or concentrate
- Recurrent thoughts of death, suicidal ideation or suicide attempt
B) Symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning
C) Episode is not due to physiological effects of a substance or another medical condition
D) Not better explained by schizophrenia or other psychotic disorder
E) There has never been a manic or hypomanic disorder
Describe the Clinical Presentation - SADAFACES
S - sleep changes A - anhedonia D - depressed mood A - appetite disturbances F - fatigue A - agitation (psychomotor) or psychomotor retardation C - concentration E - esteem S - suicidal ideation
Pharmacotherapy for MDD?
- Rx medications (antidepressants, antipsychotics, etc)
- NHPs
Psychotherapy for MDD?
- Cognitive behavioural therapy
- Psychoanalytic therapy
Other types of treatment for MDD?
- Yoga
- Exercise
- Mindfulness
What are some NHPs used in depression?
- St. John’s wort
- SAM-e
- L-Tryptophan and 5-Hydroxytryptophan (5-HTP)
- Others (omega 3 fatty acids - fish oils)
Proper name for St. John’s Wort ?
Hypericum perforatum
What is the active component of St. John’s Wort ?
Hypericin standardized for 0.3-0.5%
OR
Hyperforin standardized to 5%
Indications of St. John’s Wort ?
mild to moderate depression, anxiety, ADHD, insomnia
Standard dosing for St. John’s Wort?
300 mg PO TID (range 500-1800 mg/day)
What is the MOA of St. John’s Wort?
- Inhibits the uptake of serotonin, NE and dopamine (works similarly to other drugs that work on monoamines ex. SSRI, SNRI)
- Also impacts glutamate and GABA
- Direct effects on serotonin receptors
Is St. John’s Wort effective for depression?
- Controversial - positive and negative studies exist
- Vast majority of data suggests benefit at improving mood symptoms, insomnia and somatic symptoms in individuals with mild-moderate symptoms
- Systematic reviews confirm comparable efficacy of St. John’s wort to antidepressants and superiority to placebo for mild–moderate MDD
- 1st line mono therapy option for mild-moderate depression
- 2nd line adjunctive treatment for moderate to severe MDD
Some side effects of St. John’s Wort?
- GI upset
- headache
- skin irritation
- photosensitivity
- dry mouth
- Risk of serotonin syndrome and hypomania
St. John’s Wort & pregnancy?
- safety not established din pregnancy
- generally best to avoid and use a treatment with more robust data in this population
What is the most significant potential for harm with St. John’s Wort ?
- The potential for numerous drug interactions
- Likely safe for individuals with mild-moderate depression on little to no other medications
St. John’s Wort is a potent inducer of _______
CYP 3A4
*more than 50% of drugs are metabolized through CYP 3A4
List some other relevant information for St. John’s Wort?
- No better than conventional therapy, not indicated for major depressive disorder
- Similar side effect profile to conventional antidepressants
- Significant potential for drug interactions
- Efficacy for sure in ADHD and Anxiety is not robust, hence not generally recommended for these disorders as risk likely outweighs benefits
Proper name for SAMe?
S-adenosyl-L-methionine
What is SAMe?
a natural substrate in the human body (formed from homocysteine and 5-methylene tetrahydrofolate)
What is SAMe indicated for?
- depression
- anxiety
- fibromyalgia
- heart disease
- osteoarthritis
- dementia
- ADHD
- migraine
What is the dose for SAMe?
Titrated to 1600mg PO daily for depression (can be given in divided doses) - usually given TID
MOA of SAMe?
-S-adenosyl-L-methionine - an amino acid derivative synthesized in the body that is thought to function as a methyl donor in various physiological processes
In depression, thought to work via:
- modulation of monoaminergic neurotransmission
- influencing neuronal membrane fluidity - which may facilitate signal transduction across membranes
- increases serotonin turn over and increases dopamine and norepinephrine
Is SAMe effective?
- Data supports efficacy for treatment of symptoms of major depression
- Systematic reviews found it effective as mono therapy for midl to severe MDD vs placebo or versus comparator antidepressants in mild-moderate MDD
- Lack of data on maintenance treatment or long term treatment
- CANMAT guidelines recommend a second line adjunctive treatment option in mild to moderate MDD
- Data for ADHD less robust - not generally recommended
Common side effects of SAMe?
- GI side effects
- insomnia
- sweating
- headache
- irritability
- restlessness
- anxiety
- tachycardia
- potential for serotonin syndrome (RARE)
List some other relevant issues with SAMe?
- Poor product quality - many different formulations, products, dosing, etc.
- High cost ($60-200/month)
What is L-Tryptophan ?
An essential amino acid found in many proteins
Indications of L-Tryptophan ?
- depression
- insomnia
- PMS
- cognitive impairment
- ADHD
Dosing of L-Tryptophan?
2-4 mg/day with a duration of approximately 3-4 months
Tryptophan is a precursor of _____, which cannot be synthesized, must be supplied through diet
serotonin
Adjunctive tryptophan may potentiate serotonergic neurotransmission which may mediate _______ effects
antidepressant
Is Tryptophan recommended for treatment of MDD?
NO
Common side effects of Tryptophan ?
- sedation
- dry mouth
- GI upset
Tryptophan has the potential to increase ?
lithium toxicity
Tryptophan has the potential risk of ?
EMS - Eosinophilia-myalgia syndrome
What is 5-HTP ?
5 - Hydroxytryptophan
-Produced in the body from the essential amino acid L-Tryptophan
What does 5-HTP do?
Increases production of serotonin by the CNS
What is 5-HTP indicated for?
- depression
- sleep disorders
- anxiety
- ADHD
Dosing of 5-HTP ?
150-800 mg daily for up to one year
Is 5-HTP recommended for MDD?
Data is of generally poor quality - not routinely recommended.
What are fish oils (omega 3 fatty acids) used for?
- depression
- coronary heart disease
- cancer
What are omega 3’s recommended for?
Recommended as second line mono therapy for mild to moderate MDD and adjunctive to antidepressants for moderate to severe MDD.
SE of Omega 3’s?
- GI upset
- Fishy aftertaste
- Bruising
- Headache
- Increased risk of bleeding - use with caution in patients on anti platelet agents and/or anticoagulants
Diagnostic criteria for Insomnia
- Difficulty falling asleep or staying asleep or non-restorative sleep
- Sleep difficulty present despite adequate opportunity and circumstance to sleep
- Impairment in sleep is associated with impaired daytime functioning
- Sleep difficulty occurs at least 3 times per week and has been a problem for at least a month
What is Valerian indicated for?
- insomnia
- anxiety
- ADHD
What does data suggest about Valerian?
Data suggests it may reduce time to sleep onset (sleep latency)
-Improves subjective sleep quality
When should you take Valerian?
Takes up to 2 hours before bedtime for best results
Valerian:
Evidence is strong for insomnia, but not for which other disorders?
- anxiety
- depression
- ADHD
Common side effects of Valerian?
- Headache
- Excitability
- GI upset
Proper name of Kava?
Piper methysticum
Indications of Kava?
- anxiety
- insomnia
- ADHD
Kava likely effective for _____ but not most other conditions
anxiety
Why was Kava removed from Canadian market in 2002?
*Ppl still get this through internet pharmacies tho!!
Hepatotoxicity
What is melatonin?
A neurohormone naturally produced in the brain by the pineal gland
Indications of melatonin?
insomnia, jet lag, shift work disorder, circadian rhythm disorder, dementia, bipolar disorder
MOA of melatonin
synthesis and release of melatonin in the body are stimulated by darkness and suppressed by light, suggesting involvement of melatonin in circadian rhythm
For primary insomnia, short term melatonin modestly reduces ____ ______
sleep latency (approx 12 minutes)
Melatonin may be most effective for who?
elderly patients with insomnia who may be deficient in melatonin
Bottom line for insomnia?
- Many people don’t seek medical advice for treating insomnia
- Often self-treatment with OTC drugs, natural medicines or mind-body therapies is sought
- If using OTC drugs or natural medicines, warn about chronic use, after long-term use, rebound insomnia can often occur when the sleep aid is stopped
- Melatonin probably isn’t appropriate for all patients with insomnia, but it might be beneficial for some
_____ causes many families to be desperate to try anything that may bring improvement
Dementia
_____ _____ is a commonly used product for dementia
Gingko biloba
___ may have some potential benefits and improve cognitive function
Ginseng
Explain how Vitamin E may be effective for dementia
potential benefits such as slowing down disease progression, and delaying time to institutionalization but this must be weighed against potential for increased mortality
Why are their lots of drug interactions with dementia patients?
bc of their age and co-morbidities
Active components of Gingko biloba ?
leaf extracts (flavonoids and terpenoids)
Indications of Gingko biloba?
- dementia
- cognitive function
- anxiety
- PMS
- tardive dyskinesia
MOA of Gingko biloba?
- Mechanism not clearly understood
- No efficacy in preventing dementia
- May improve cognitive function in individuals with no complains of memory impairment
- May improve symptoms of dementia
- Not more effective in dementia patients with neuropsychiatric symptoms
Side effects of Gingko biloba ?
- GI upset
- Headache
- Potential bleeding
Is medical cannabis indicated for anxiety/depression ?
Not right now.
List some mind body treatments
- Yoga
- Exercise
- Meditation
- Tai Chi
Describe the approach to using NHP in individuals with mental health disorders
- Respect patient autonomy
- Understand the role of herbal and/or non-traditional medicine for individuals patients
- Balance risks and benefits
- Consider costs - many patients supported by disability and cannot afford expensive products
- Important to ask patients about natural health products - include in best possible medication history
