Medication Management
Dr Ajith Weeraman
MBBS, MD (Psychiatry), FRANZCP
Consultant Psychiatrist
Epworth Clinic
Camberwell
14th March 2015
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Medication Management
Objectives:
1. Principles of psycho-pharmacology
2. Common mental health conditions
3. Frequent issues in general practice
4. Risks related to medication
5. Cases
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Principles of psycho-pharmacology
- Principle Diagnosis, Co-morbid conditions
- Treatment options for the condition:
Bio-Psycho-Social approach
- Informed consent
- Medication selection
Evidence based, Treatment Guidelines
Age, sex, body weight, special groups
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Principles of psycho-pharmacology- cont.
When are medication used?
What is the optimal dose?
What the maintenance dose?
Monitoring of mental and physical state
Regular risk assessment
Failure to respond to treatment, Why?
Discontinuation of medication
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The phase of Treatment
• Subside acute symptoms
• Relieve symptoms
• Restore previous level of function
(REHABILITATION)
• Maintain stabilization
• Prevent return of acute symptoms
• Continue Rx for the duration of the episode
E.g. Depression – 6/12
First Episode Psychosis – 2 years
Recurrent relapses- many yrs, lifelong
• Relapse prevention
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Common mental health issues
Mood disorders
Anxiety disorders
Psychotic disorders
Drug and alcohol disorders
Personality disorders
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Cases and possible interventions:
1. Commencement of medication
2. Titration of medication
3. Change of medication
4. Combination of medications/ Poly-pharmacy
5. Interaction of medication
6. Interaction of medication and substances/
alcohol:
7. Non-adherence of medication
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Commencement of medication
Case 1:
45 year old professional, female, single, lives alone
Diagnosis: severe OCD, no acute risks, affecting her work and
social life, became unemployed due to ongoing symptoms
and secondary depression
Never treated with antidepressant medication, not willing to
see a psychologist, but willing to see a psychiatrist
Not happy to take antidepressants
Group Discussion
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Case 1, Management:
Had initial assessment and provided treatment options.
Fluctuated her insight, fear of medication side effects
and questioning possible improvement.
Took 3 months to convince her pharmacological
treatment.
Commence Paroxetine 10mg mane and titrate up to
20mg after few months.
Tolerated side effects well, improved significantlymentally, socially, professionally.
No relapses for the last 3 years.
Take home message
psycho-education ++++, provide options, engage,
develop trust, support the patient to understand the
nature of illness, titrate medication up slowly, monitor
regularly
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Titration of medication
Case 2:
78 year old lady, lives with husband, previous psychiatric history +, no drug and
alcohol history
Diagnoses: Generalized Anxiety Disorder with secondary depression, Eating
Disorder NOS, Cluster C Personality traits (dependent, avoidant, anxious)
GP commenced Escitalopram 5mg mane few weeks ago, Zolpidem 10mg nocte
12 months ago
Issues: extremely fearful of increasing the dose, slowly deteriorating for more
than 2 years- physically, socially, psychologically, not safe at home, can not
increase medication due to her fears
Group Discussion
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Case 2:
Management:
GP referred the patient to a private psych inpatient unit.
Admitted to a private psychiatric unit, educated the patient and family,
engage, assess regularly, titrated the dose of Escitalopram by 2.5mg
increments up to 15mg at night, not developed any side effect, started
reducing the dose of Zolpidem
Incorporated CBT, regular day leave with the family and prepare for
discharge
Take home messagePsycho-education ++++, support the patient and family to understand the
nature of illness, titrate slowly, monitor regularly
Avoid long-term use of hypnotics/ Benzodiazepine
Get specialist opinion early
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Change of medication
Case 3:
35 year old gentleman, single, stressed at work due to work load, on medical
leave and subsequently lost his job.
Diagnoses: Major Depressive Disorder, Cluster C personality traits
Was on Mirtazapine 60mg nocte for few months, worsening depressive symptoms
and suicidal ideation
Mirtazapine was ceased abruptly and commenced Paroxetine 20mg mane
Became extremely anxious and depressed, sleep disturbances, Emergency Dept,
Crisis team involvement
Group Discussion
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Case 3: cont.
Issues related to medication change:
- Abrupt discontinuation of highest dose of Mirtazapine and
commencement of Paroxetine
- Possible short term use of Diazepam
- Regular reviews
Management:
Regular MSEx, Reassurance, adding Diazepam.
Later reduce and ceased diazepam
Involvement of a clinical psychologist
Take home message:
educate the patient, involve family, wean of the medication, review the
patient regularly, private admission +/-, involve Crisis Team
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Interaction of medication and substances/
alcohol:
Case 4:
68 year old businessman, lives with wife, adult children
Diagnoses: Major Depressive Disorder, Alcohol Dependence, relationship
difficulties, sexual dysfunction
Issues: ongoing depressive symptoms for years, risk of suicide as father also
committed suicide, Work long hours- 7 days a week
Medication: Mirtazapine 90mg nocte, Venlafaxine XR 150mg mane, Diazepam 510mg PRN
Group Discussion
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Case 4, Management:
Assessed regularly, educate patient and wife, treatment options explained
(including Lithium Carbonate therapy as an adjunct)
Counsel in relation to effects of alcohol ---- ceased alcohol use completely
Regular phone discussions with the GP – only one prescriber
Cease Mirtazapine and diazepam
Titrated up Venlafaxine XR 300mg mane
Life style modifications: work (Mon-Fri), encourage to engage in his previous
pleasure activities
Significant improvement in all domains, no relapses
Take home message:
address alcohol and substance abuse, simplify medication regimen to
minimize interaction, avoid poly-pharmacy, better communication bet
therapists/ patient/ family,
consider Lithium Carbonate
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Non-adherence of medication
Case 5:
30 year old, single man, lives alone, work 3-4 days a week, could not
Diagnoses: Paranoid Schizophrenia, alcohol abuse
Medication: Risperidone 3mg nocte, good response to medication when he takes
them daily
Issues: ongoing Persecutory delusions, alcohol abuse, poor adherence to
medication, could not attend work regularly due to persecutory delusions, risk of
harming others and self, risk of resistance to medication, emerging negative
symptoms
Group Discussion
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Case 5, Plan of management:
Psycho-education,
Address alcohol abuse
Engagement with the treatment plan,
Introduce Webster/ Blister pack
Commencement of Risperidone Consta (depot medication) fortnightly
instead of oral Risperidone to improve medication adherence
Take home message:
Address non-adherence the medication, Treat co-morbid alcohol/ substance
abuse, get specialist opinion in early phase of psychotic disorders to prevent
negative symptoms, multiple relapses
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Thank you.
Dr Ajith Weeraman
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