L14-Mental Health Flashcards
why NHPs?
-V common & associated w signif disability & stigma
>1/5 cnds living w mental illness
- manage sx of illness or se
- pt preference
- belief that “natural is better”
- info from internet/media
-use of CAM ranges from 16-44 (highest in depression) (note this also includes wellness methods)
Depression
Prevalence and burden?
Impacts?
11% will get it in life time
13%= global disease burden
Impacts phys health
- predisposition to obesity/metabolic disorders
- Increased med co-morbidity
Function
- high impact on social domain
- increased work impairment
Depression
neuroscience - list factors
• Genes
• Stress
• Dysregulation of the HPA axis reduces hippocampal
volumes and prefrontal cortex activity
• Antidepressants increase BDNF → neuronal growth and activity
• Cytokines→inflammatoryresponse
Depression
Risk factors
combo of genetics, bio, psychological, social factors
Depression
Clinical presentation
- S – sleep changes
- A – anhedonia
- D – depressed mood
- A – appetite disturbance
- F – fatigue
- A – agitation (psychomotor) or psychomotor retardation
- C – concentration
- E – esteem
- S – suicidal ideation
Depression Tx options: 1. pharmacotherapy 2. psychotherapy 3. other
- Pharmacotherapy: Rx and NHPs
- Psychotherapy: CBT, psychoanalytic therapy
- Other: yoga, exercise, mindfulness
Depression
List NHPs
- St.John’swort
- SAM-e
- L-Tryptophan and 5-Hydroxytryptophan (5-HTP)
- Others: Omega-3 fatty acids (fish oils)
- St. John’s wort
Sci name?
AI?
=Hypericum perfoatum
-AI: hypericin 0.3-0.5% or hyperforin 5% (hypericin more traditional)
- St. John’s wort
Indications?
-mild to mod depression (where bulk of evidence is)
-anxiety, ADHD, insomnia
(300mg po tid, but need to check based on the product that they use)
- St. John’s wort
MOA?
-similar to conventional antidepressants
>inhibit uptake of 5HT, NE and DA (like SSRI, SNRI, TCA)
>also impacts glutamate and GABA
>direct effects on 5HT receptors
- St. John’s wort
Efficacy?
- controversial!
- vast majority of data suggests benefit at improving mood sx, insomnia and somatic sx in indivs w mild to mod sx
- systematic reviews confirm comparable efficacy to antidepressants and superiority to placebo for mild-mod MDD
- St. John’s wort
T/F: 1st line for mono mild/mod depression
TRUE
-2nd line adjunct for mod/severe (no better than conventional therapy)
- St. John’s wort
____ questionnaire for pt to use.
PHQ9 (patient health questionaire)
-rate their sx & severity
-gives you a score & tells you the severity of the depression
> not a Dx but gives pt an idea
-threshold for improvement for st johns wort= 20%
- St. John’s wort
Safety?
-overall well tol
>common se= GI upset, headache, skin irritation/ photosens, dry mouth (similar to that of conventional)
>risk of 5HT syndrome and hypomania (esp if using other antidepressants or opioids)
>could cause a hypermania event (other Rx options can also cause this)
- St. John’s wort
T/F: safe in preg
false - not established so best to avoid
- St. John’s wort
DI?
- Potent inducer of CYP 3A4q
* Several clinically significant interactions
- St. John’s wort
For anxiety and ADHD?
not robust, hence not generally recommended for these disorders as risk likely outweighs benefits
- SAM-e
AI?
S-adenosyl-L-methionine
-natural substrate in the human body (formed from homocysteine and 5-methylene tetrahydrofolate)
- SAM-e
indication?
-depression, anxiety, fibromylagia, heart disease, OA, dementia, ADHD, migraine
(doses titrated to 1600mg/d but dividied)
- SAM-e
MOA?
- modulation of monoaminergic neurotransmission
- influencing neuronal memb fluidity- which may facilitate signal transduction across membranes
- increases 5HT turn over and increases DA/NE
- SAM-e
Efficacy?
-Rx in Europe (oral or parenteral) for severe conds such as MDD; Canada is OTC supp
-data supports efficacy for tx of sx of major depression >monotherapy for mild-sev MDD= effective
>comparator antidep in mild/mod MDD
-recommended as 2nd line adjunct in mild-mod MDD
- SAM-e
Efficacy? Probs w/ studies
- Done against placebo, if you compare against an Rx, they are no longer more effective)
- Lack of data on maintenance tx or long term tx (therefore unknown if worth it to continue; cost issue)
- SAM-e
safety?
- Overall well tolerated
- Common side effects: GI sse, insomnia, sweating, headache, irritability, restlessness, anxiety, tachycardia
- Potential for serotonin syndrome (rare)
- SAM-e
T/F: product quality is good!
NO
- L- tryptophan
Describe
- essential aa found in many proteins (also pumpkin seeds)
- precursor of 5HT
- L- tryptophan
Indication?
depression, incomnia, PMS, cognitive impairement, ADHD
standard dosing: 2-4mg/d w duration of 3-4m
- L- tryptophan
Efficacy?
-‘may’ potentiate serotonergic neurotransmission which may mediate antidepressant effects BUT no clear evidence and is NOT recommended
- L- tryptophan
Safety?
- Overall well tolerated
- Common se’s: Sedation, dry mouth, GI upset
- Risk of serotonin syndrome
- Potential to increase lithium toxicity - monitor levels
- Potential risk of Eosinophilia-myalgia syndrome (EMS) (1500 reports of EMS and 37 deaths)-> this is why you should not use (and NO proven benefit)
- 5-hydroxytryptophan (5-HTP)
T/F: also called tryptophan, which is produced in body from essential aa L-try
TRUE
- 5-hydroxytryptophan (5-HTP)
Indications?
- Indications: depression, sleep disorders, anxiety, ADHD
- Standard Dosing: 150-800 mg daily for up to one year
- Data is of generally poor quality - not routinely recommended
- 5-hydroxytryptophan (5-HTP)
MOA?
• Increases production of serotonin by the CNS
- fish oils (O3)
indications?
(DHA or EPA)
- depression, coronary heart disease, cancer
- wide range of doses (ie 3-9g/d of O3 fa)
- fish oils (O3)
efficacy?
Contradictory
>Most rigorous meta-analyses found efficacy w/ good effect size
Recommended as 2nd line monotherapy for mild-mod MDD and adjunctive to antidepressants for mod- severe MDD.
- fish oils (O3)
safety?
- well tol
- SE: GI upset, fishy aftertaste, bruising, headache
- increase bleed risk at high doses (caution in pts on antiplate/coag tx OR if they have alcohol dependency)
Insomnia.
Describe.
- most prevalent sleep disorder
- difficulty falling asleep/ staying asleep or non-restorative sleep
- sleep difficulty despite adequate opportunity
- associated w impairment in daytime fxn
- sleep diffiuclty at least 3x/wk and problem for at least 1m
Insomnia.
NHP options - list e.g.
- valerian
- melatonin
- kava
- others
- Valerian
Indication?
-insomnia, anxiety, ADHA
400-900mg depending on formulation; often in tea
- Valerian
Efficacy for insomnia?
- modest efficacy data-> suggests reduce time to sleep onset (latency)
- take up to 2 hours before bed for best results
- Valerian
T/F: Not efficacious for anxiety, depression, ADHD
TRUE
-maybe ok if had insomnia + one of these conditions
- Valerian
Safety?
- well tol
- se: headache, excitability, GI upset
- Kaka
Sci name?
Indication?
- Piper methysticum
- anxiety, insomnia, ADHD
- Kaka
Efficacy?
likely effective for anxiety but not others (ie not insomnia)
- Kaka
Safety?
hepatotox!! (removed from cnd market BUT may order online)
- Melatonin
AI?
N-acetyl-5-methoxytryptamine
-neurohormone naturally produced in brain by pineal gland
- Melatonin
Indication?
- indicated in insomnia, jet lag, shift work disorder, circadian rhyhm disorder, dementia, bipolar disorder
(dose: 203g qhs)
- Melatonin
MOA?
-synthesis and release of melatonin in body stimulated by darkness and suppressed by light suggesting involvement in circadian rhythm
- Melatonin
efficacy?
- For primary insomnia, short term modestly reduces sleep latency (~12 min)
- Does not improve sleep efficiency
- Subjective improvements in sleep quality noted for some (which is important!!
- May be most effective in elderly patients with insomnia who may be deficient in melatonin.
- others
list e.g. and are they efficacious?
• German Chamomile
• Passion flower
• Siberian Ginseng
• Lavender
• Hops
• Limited efficacy data for all of these-> not routinely recommended.
->If used check for drug interactions to minimize safety risks. (and allowing them to stay on may increase their trust in you)
Dementia
NHPs gucci or nah?
List e.g. products
Efficacy lacking
- ginko kiloba (most common)
- ginseng (some potential benefits; improve cognitive fxn)
- Vit E (potential benefit such as slowing disease progression BUT weigh against potential for increased mortality)
- Ginko biloba
AI?
Indications?
- active flavonoids and terpenoids in leaf extracts
- indicated in dementia, cognitive fxn, anxiety, PNS, tardive dyskinesia
- Ginko biloba
MOA?
unknown
- Ginko biloba
efficacy?
- no efficacy in preventing dementia but may improve Sx
- may improve cog fxn in indivs w no complaints of memory impairment
- not more effective in pts w neuropsych sx
- Ginko biloba
safety?
well tol
-se: GI upset, headache, potential bleeding
Medical cannabis
- becoming increasingly popular in indivs w mental illness
- small amount of data
- risks likely outweigh benefits (bc in those w psych disorders it can actually precipitate schiz)
- area that will continue to have lots of attention in future
