“Oil90% drink, 13% lifetime abuse or dependence • Nicotine – 18% of Canadians current daily smokers • Drugs – 3% lifetime abuse or dependence – – – – – – –
Cannabis Opioids – prescription opioids #1 abused drug in Canada Sedative‐Hypnotics – benzodiazepines and barbiturates Stimulants – cocaine, amphetamines, designer drugs Hallucinogens – LSD, psilocybin NMDA Antagonists – PCP, Ketamine Inhalants – gas, nitrous oxide, amyl nitrate, paint
AHS Addictions Services • Adult Addiction Services Provided by: Alberta Health Services ‐ Calgary Zone • Calgary 1177 11 Avenue SW 1177 11 Avenue SW, Calgary, Alberta T2R 1K9 • 403‐297‐3071 • Calgary 1231 34 Avenue NE 1231 34 Avenue NE, Calgary, Alberta T2E 6N4 • 403‐261‐7921 • Centre of Hope 420 9 Avenue SE, Calgary, Alberta T2G 0R9 • 403‐410‐1145
Addictions Services • Addictions Helpline • Dial 1‐866‐332‐2322 (24/7) • Addiction Services ‐ Adult Detoxification Provided by: Alberta Health Services ‐ Calgary Zone • Calgary Alpha House 203 15 Avenue SE, Calgary, Alberta T2G 1G4 • 403‐234‐7388 • Renfrew Recovery Centre 1611 Remington Road NE, Calgary, Alberta T2E 5K6 • 403‐297‐3337
Sleep Hygiene
Stimulus Control
Medications Indicated for Insomnia in Canada1,2 Benzodiazepines
Doses
Half‐life
Flurazepam (Dalmane)
15, 30 mg
40‐250 (75 mean)
Nitrazepam (Mogadon)
5, 10 mg
16‐38 (28.8 mean)
Temazepam (Restoril)
15, 30 mg
4‐18 (8.8 mean)
0.125, 0.25 mg
1.5‐5.5 (2 mean)
Triazolam (Halcion)
Z‐drugs (Non‐benzodiazepine sedative‐hypnotics) Zopiclone (Imovane) Zolpidem (Sublinox) 2011
5, 7.5 mg
3.8‐6.5 (6 mean)
SDT 5, 10 mg
2‐3
3, 6 mg
17 (51 metabolite)
Low dose antidepressant Doxepin (Silenor) 2012
1. Health Canada. Authorized Sleep‐Aid Medications in Canada. http://www.healthycanadians.gc.ca/recall‐alert‐rappel‐avis/hc‐sc/2009/13335a‐eng.php. 2009; 2. MacFarlane. Insomnia Rounds. 2012;1(2):1‐6
Off‐Label Use of Medications for Insomnia Drug Class
Benzodiazepines‐ Anxiolytics
Antidepressants
Atypical Antipsychotics
Agent
Peak Concentration± (Tmax, h)
Mean t1/2 (h)
Dose Range (mg)
Clonazepam
1‐2
35‐40
0.25‐2
Lorazepam
1‐3
12‐15
0.5‐2†
Mirtazapine
~ 2
20‐40
15‐45
Trazodone
1‐2
5‐9
50‐150
Amitriptyline/N ortriptyline
4‐8
15‐20
10‐75
Quetiapine
1‐3
6 ‐12
25‐300
Gabapentin
2‐4
5‐7
100‐900
Pregabalin
1‐2
6
25‐150
Anticonvulsants
±
The onset of action for off‐label medications cannot be provided as these agents are not indicated for insomnia and pharmacokinetics/pharmacodynamics have not been studied in insomnia.
Does Joe have a Diagnosable Psychiatric Illness? • Need to rule out Major Depression, Adjustment Disorders, Anxiety Disorders, • And a word on Acute Stress Disorder
DSM‐5 defines MDD as a period of ≥2 weeks in which a person has 5 or more symptoms Symptoms MUST include: – Depressed mood and/or – Loss of interest or pleasure
Must also experience ≥4 of the following: – – – – – – –
Significant changes in weight and/or appetite Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue or loss of energy Feelings of worthlessness or excessive/inappropriate guilt Diminished ability to think or concentrate, or indecisiveness Recurring thoughts of death or suicide, including plans and attempts
The symptoms cause clinically significant distress or impairment in social, occupational or other important areas of functioning. DSM‐5, Diagnostic and Statistical Manual of Mental Disorders, 5th ed. MDD, major depressive disorder. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed, 2013.
Patient Health Questionnaire‐ PHQ 9 • • •
•
Self‐rated scale is the “HbA1c” of depression. Designed specifically for primary care. Highly sensitive and specific for the diagnosis of depression. Useful in monitoring treatment response
TOTAL SCORE
DEPRESSION SEVERITY
1-4
Minimal Depression
5-9
Mild Depression
10-14
Moderate Depression
15-19
Moderately-severe Depression
20-27
Severe MDD
PHQ-9 is adapted from PRIME MD TODAY, developed by Drs Robert L. Spitzer, Kurt Kroenke, and Janet B.W. Williams. Copyright ©1999 Pfizer Inc
(And so you’re up to date on the latest classification) Evolution of antidepressant agents SSRIs
SNRIs
Novel
Citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline
Duloxetine,* desvenlafaxine, venlafaxine
Multimodal agents (vortioxetine, vilazodone**)
Antidepressant activity improves mood + many have indications for anxiety
Antidepressant activity improves mood + potential improvement in painful physical symptoms + anxiety
Antidepressant activity (improves mood) + other potential actions to improve cognitive symptoms of depression
*Duloxetine carries an indication for treating painful physical symptoms outside of MDD (desvenlafaxine and venlafaxine do not). **Vilazodone is not approved for MDD in Canada. SNRI, serotonin and norepinephrine reuptake inhibitor.
Complementary and alternative medicine(CAM) treatments Physical Therapies • Light therapy • Acupuncture • Yoga • Exercise • Sleep Deprivation
•
•
Nutraceuticals • Omega‐3 • SAM‐e • DHEA • Tryptophan • Folic Acid
Herbal Supplements • St. John’s Wort • Crocus Sativus
The most robust evidence exists for: – light therapy as monotherapy in seasonal MDD – St. John's wort as monotherapy for mild to moderate MDD. There is reasonable evidence for adjunctive use of: – sleep deprivation, exercise, SAM‐e and omega‐3 fatty acids
Ravindran AV, et al. Journal of Affective Disorders 2009; 117:S54‐S64.
THE ANXIETY “SPECIFIER” IN MAJOR DEPRESSIVE DISORDER(MDD) • SPECIFIER – ”With Anxious Distress” • Assess if symptoms present: 1. 2. 3. 4. 5.
Keyed up/tense Unusually restless Difficulty concentrating because of worry Fear that something awful may happen Feeling of losing control of self
• Assess Severity: • • • •
Mild ‐ 2 symptoms Moderate ‐ 3 symptoms Moderate to Severe ‐ 4 symptoms Severe ‐ 4 to 5 symptoms with motor agitation
For Example ‐ Diagnosis: MDD with Anxious Distress (Moderate) American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing
Adjustment Disorder: Criteria Emotional or behavioral symptoms develop in response to a stressor within 3 months of the onset of the stressor(s) plus either or both of (1) marked distress that is out of proportion to the severity or intensity of the stressor, even when external context and cultural factors that might influence symptom severity and presentation are taken into account and/or (2) significant impairment in social, occupational, or other areas of functioning The symptoms do not represent normal bereavement After the termination of the stressor (or its consequences), the symptoms persist for no longer than an additional 6 months.
Adjustment disorders symptoms vary from person to person. Symptoms of an adjustment disorder begin within three months of a stressful event
• Emotional symptoms of adjustment disorders • • • • • • • • • • • • •
Sadness Hopelessness Lack of enjoyment Crying spells Nervousness Jitteriness Anxiety, which may include separation anxiety Worry Desperation Trouble sleeping Difficulty concentrating Feeling overwhelmed Thoughts of suicide
•
1998‐2016 Mayo Foundation for Medical Education and Research.
Adjustment Disorders: Stressful events • • • • • • • • • • • •
Being diagnosed with a serious illness Problems in school Divorce or relationship breakup Job loss Having a baby Financial problems Physical assault Surviving a disaster Retirement Death of a loved one Going away to school 1998‐2016 Mayo Foundation for Medical Education and Research.
Behavioral symptoms of Adjustment Disorders • Signs and symptoms of adjustment disorder may affect actions or behavior, such as: • Fighting • Reckless driving • Ignoring bills • Avoiding family or friends • Performing poorly in school or at work • Skipping school • Vandalizing property •
1998‐2016 Mayo Foundation for Medical Education and Research.
Timeline of symptoms
• 6 months or less (acute). In these cases, symptoms should ease once the stressor is removed. Brief professional treatment may help symptoms disappear. • More than 6 months (chronic). In these cases, symptoms continue to bother you and disrupt your life. Professional treatment may help symptoms improve and prevent the condition from continuing to get worse.
Adjustment Disorders
Specifiers (DSM 5)
With Depressed Mood With Anxiety With Disturbed Conduct With Mixed Anxiety and Depressed Mood With Mixed Disturbance of Emotions
*The symptoms do not represent normal bereavement
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing
Acute Stress Disorder Occurs within one month of a traumatic event ‐ • Development of specific fear behaviours that last from 3 days to 1 month after a traumatic event. • The person has experienced or witnessed death, threatened death, actual or threatened serious injury, sexual violence … • Hearing about the violent or accidental trauma of a loved one, or repeated exposure to traumatic events • Sx include: intrusive thoughts or memories, nightmares, flashbacks, distress when exposed to triggers of the traumatic event, memory disturbance, avoidant behavior, depressed anxious angry mood, hypervigilence, exaggerated startle response, physical symptoms eg headaches
Screening Questions for GAD
• • • •
Are you by nature a worrier? Do you worry more than other people? What do you worry about? Does the worry interfere with your life?
Generalized Anxiety Disorder ‐ GAD‐7 • Self rated • Specific for GAD but useful to detect an anxiety disorder in depression • Can be used to monitor treatment progress
Spitzer RL. Arch Intern Med 2006;166:1092‐1097.
TOTAL SCORE
Provisional Diagnosis
0-4
Minimal anxiety
5-9
Mild anxiety
10-14
Moderate anxiety
15-21
Severe anxiety
*GAD-2 is the first 2 questions of the GAD-7
A Panic Attack is not a codable disorder: List Panic Attack as a Specifier for all DSM disorders • An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and includes 4 of the following symptoms: 1. 2. 3. 4. 5. 6. 7.
Palpitations, pounding heart, or accelerated heart rate Sweating Trembling or shaking Sensations of shortness of breath or smothering Feelings of choking Chest pain or discomfort Nausea or abdominal distress
8. 9. 10. 11.
12. 13.
Feeling dizzy, unsteady, light‐headed, or faint Chills or heat sensations Paresthesias (numbness or tingling sensations) Derealization (feelings of unreality) or depersonalization (being detached from oneself) Fear of losing control or going crazy Fear of dying
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Versus the Diagnosis : Panic Disorder • The person has experienced both of the following: – Recurrent unexpected panic attacks – Followed by ≥1 month of 1 or both of the following: • Persistent concern or worry about additional panic attacks or their consequences OR • Significant maladaptive change in behaviour related to the attacks
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Strategies from CBT: Worry Time • Useful for GAD or when there are overwhelming worries • Spend 20‐30 min a day on Worry Time • Allows you to worry but it also allows you to have a break • Increases control of thoughts and helps you analyze them
Worry Time • Write down the worries‐‐this slows down your thinking, keeps you focused, and gives you a record of the conclusions you have reached • Do not do just before bed • When you start to worry at other times you can put it off until the next worry time
Relaxation
Benefits of Exercise • In type 2 diabetic patients, moderate‐to‐high cardio‐respiratory exercise may lower CV and overall mortality by 45%–70% over 12‐14 years • Seven hours of brisk walking per week can lower the 7‐year mortality rate by 50% • Becoming physically active can lower weight and decrease blood pressure • Exercise increases brain derived neurotrophic factor (BDNF), insulin‐like growth factor (IGF‐1), and vascular endothelial growth factor (VEGF); it is also insulin sensitizing, anti‐ inflammatory, anti‐oxidative, and angiogenic Canadian Diabetes Association. Canadian Journal of Diabetes 2003.; Diabetes Prevention Program Research Group. N Engl J Med 2002. Elmer et al. Prev Med 1995.
What Determines Stress? • Everyone experiences stress differently • What is stressful to one person may not be to another. • When the demand of the situation outweighs the individual’s perceived ability to cope, the event becomes stressful.
Influential Factors Many factors can effect our ability to deal with chronic stress: • • • • •
Social support Connection to the community Relationship with parents/caregivers Financial stability Skills and techniques to manage stress
• Mindshift.org.au • Australian Website focuses on depression Anxiety, ageing, LGTBQ and more
• Anxietybc.com • Excellent Canadiananxiety website that • focuses on anxietymanagement
• Yoga breathing technique http://www.drweil.com/drw/u/VDR00112/The‐4‐7‐8‐Breath‐ Benefits‐and‐Demonstration.html
Depression and Anxiety Resources for your Patients • www.cmha.ca Canadian Mental Health Association • Bounce Back is a free program for adults experiencing mild to moderate depression, stress, or worry, using self‐help materials and telephone coaching: www.bouncebackbc.ca • Living Life to the Full is a fun and engaging mental health promotion course that helps people learn skills to deal with the stresses of everyday life: www.llttf.ca www.depressionhurts.ca www.healthymindscanada.ca www.mooddisorderscanada.ca Canadian Network for Mood and Anxiety Treatments: www.canmat.org www.anxietybc.com (Anxiety Disorders Association of B.C) OBAD – Organization for Bipolar Affective Disorder www.obad.ca
The Mood Gym: www.moodgym.anu.edu.au (Australian National University‐ free self help CBT) • A free interactive internet‐based program designed to prevent and decrease symptoms of depression and anxiety. • Mood GYM aims to teach you how to feel less stressed, depressed and anxious and better able to cope with life. • From Mood GYM you will learn: • How to think about problems and problem solving • Self‐esteem improvement and assertiveness • How to increase the pleasure in life, relax and cope with stressors such as a relationship breakup • Think of Mood GYM as an interactive self‐help book
EASTSIDE FAMILY CENTRE ‐ NO FEE, IMMEDIATE WALK‐IN COUNSELLING • • •
Northgate Mall 255 495 36 St. NE Calgary, AB T2A
Phone: 403‐299‐9696
HOURS OF OPERATION Monday – Thursday – 11 a.m. to 7 p.m. Friday – 11 a.m. to 6 p.m. Saturday – 11 a.m. to 4 p.m. Closed Sunday and all statutory holidays Walk‐in Counselling This service provides a 50‐minute session with a qualified mental health professional. • No‐fee, first served walk‐in counselling. • Assistance with: Mental health concerns, life stressors, family stress, relationship issues • Referrals to other community resources The Centre also provides: Focused Counselling • For youth and their families, this service offers several sessions with the same qualified therapist. •
eTherapy or Counselling via E‐mail
• • • • • •
Crisis Services Need help? Speak with someone now! PHONE (24/7) 403‐299‐9699 or toll‐free at 1‐800‐563‐6106 TEXT 587‐315‐5000 (9 a.m. ‐ 10 p.m.)
Important Services • ACCESS Mental Health: can guide you through the maze of resources 403‐943‐1500 • Drop by the ACCESS booth today for a chat! • Services within the PCN in your Medical Home! • Shared Mental Health‐ Behavioural Health Consultants (BHC) ,Therapists, Psychiatrists
And Ultimately ‐ What Lifestyle Changes are Joe willing to make? • Curb substance use, address sleep issues, regular exercise, couples counselling, life coaching, adopt the strategies you are suggesting etc… • • • •
Downsize – house, car, kids schools and activities… Enlist help from friends and relatives? Make an appointment with the bank to renegotiate? Expand skill set and consider alternate occupations?
• For all of these options we want Joe to be in the very best of physical and emotional health possible under the circumstances!
And a Reminder….. • …no one – not rock stars, not professional athletes, not software billionaires and not even geniuses – ever makes it alone. »Malcom Gladwell, “Outliers”
Ever wonder what happened to Dennis the Menace when he got older?