Psychopharmacology Highlights from the 2018 APA Annual Meeting

We were at the 2018 APA Annual Meeting in New York. In this brief article, we summarize practical takeaways from selected presentations. This update summarizes algorithms for adult ADHD and MDD, the use of psychotropic medications in breastfeeding, the role of pharmacogenetic testing in clinical practice and an immunotherapy approach to schizophrenia treatment.

Adult ADHD: An Evidence-Based Psychopharmacology Treatment Algorithm

Presenters: David N. Osser, MD, Bushra Awidi, MD, Robert D. Patterson, MD

• Adult ADHD is associated with lower life expectancy,  more than double the risk of death than adults without ADHD
  • Mostly attributed to motor vehicle accidents and risk-taking behavior
• Absolute contraindications to the use of stimulants
  • Untreated glaucoma (any type)
  • Angle closure glaucoma (treated or not)
  • Pheocromocytoma
  • Treat the above conditions first, then obtain medical clearance before attempting other agents for ADHD
• Start with immediate release formulation for either class (methylphenidate, amphetamine)
  • There are no head to head comparisons between IR methylphenidate or its variants and IR dextroamphetamine or its salts
  • Choose based on experience or patient preference/tolerability
• Methylphenidate dosing
  • Mean efficacious dose 1-1.3 mg/kg/day, according to a 2005 RCT
    • This exceeds FDA-approved doses in some cases
  • Response to methylphenidate in adults may only develop when robust daily doses are used
  • Do not give up on it prematurely
• Atomoxetine
  • Response is more gradual
    • Clinically meaningful response shown at 4-6 weeks
    • Maximal response takes several weeks

The Psychopharmacology Algorithm Project at the Harvard South Shore Program: An Update on Unipolar Non-Psychotic Depression

Presenters: Robert D. Patterson, MD, Christoforos Iraklis Giakoumatos, MD, David N. Osser, MD

• SSRIs are the first-line treatment for depression
  • Escitalopram and sertraline preferred among the SSRIs
• Consider bupropion when patients wish to avoid having the risk of sexual side effects
• For depression with mixed features, the recommendation is lurasidone
• Major depressive disorder with melancholic features is a type of severe depression, characterized by anhedonia and/or loss of interest in usually pleasurable stimuli
• If imminent risk of harm to self & contraindications for ECT, or the patient refuses ECT or ECT is unsuccessful, consider ketamine to lower acute risk and help stabilize the patient until another form of treatment can be implemented
  • Ketamine infusion can produce rapid results that can last up to 6 weeks

The Benefits of Using Algorithms in Psychiatric Practice

We talked with one of the presenters of the psychopharmacology algorithms about the benefits of following a structured approach to psychopharmacology. Dr. Robert Patterson explains why algorithms are good for patient outcomes and how they support clear decision making.

Listen to the interview here:

Breastfeeding Mothers and Psychotropic Medications: An Update

Presenters: Mercedes Driscoll, MD, Rita Rein, MD, Lisa Young, MD., Lindsay Works, DO.

• Medications that are safe in pregnancy are not always safe in breastfeeding
• Sertaline
  • Most extensively studied in many breastfeeding women
  • Preferred antidepressant in lactation
• Paroxetine
  • Contraindicated during pregnancy
  • Most authoritative reviewers consider paroxetine one of the preferred antidepressants during breastfeeding
• Antipsychotics
  • Haloperidol
    • No known adverse effects in pregnancy
    • Compatible with lactation
    • Very limited long term data
    • Be careful when used with other antipsychotics
  • Systematic reviews of second-generation antipsychotics (SGA) suggest that olanzapine seem to be a first-line agent during breastfeeding
• Lithium
  • Commonly recommended to avoid during lactation due to high excretion in breastmilk
  • If infant is breastfed close monitoring is mandatory
  • Monitor maternal serum levels and decrease if necessary
• Lorazepam
  • Low levels in breastmilk, a short half-life relative to many other benzodiazepines, and is safely administered directly to infants
• Oxazepam
  • Low levels in breastmilk, a short half-life relative to many other benzodiazepines, and is administration directly to infants
  • Oxazepam would not be expected to cause any adverse effects in breastfed infants with usual maternal dosages
  • No special precautions are required

Pharmacogenomic Testing and Adverse Effects of Psychotropic Medications

Presenters: Rajnish Mago, MD

• Dosage modification based on genetic polymorphisms has been recommended in the Prescribing Information for many psychotropic medications
  • In addition to the pharmacogenomics, a knowledge of pharmacology and the phenomenology of the patient need to be considered in interpreting pharmacogenetic testing results
• In addition to the CYP enzymes, pharmacogenetic testing is increasingly yielding information on other pharmacokinetic factors like the UGT enzymes and P-glycoprotein
• Of pharmacodynamic factors, polymorphisms of the 5-HT2A and 5-HT2C receptors have the most data to support their use in clinical practice

Immunotherapies in Schizophrenia and Bipolar Disorder

Presenters: Mark Weiser, MD, Faith Dickerson, PhD, MPH., Ragy Girgis, MD., Mikhail Pletnikov, MD., PhD.

• The inflammatory hypothesis of schizophrenia involves abnormal levels of cytokines and other inflammatory markers
  • Abnormal cytokine levels: IL-1,IL-2,IL-6
• There are anti-inflammatory interventions that have been studied over the years
  • None of these interventions have consistently shown to be efficacious in schizophrenia
    • Mynocycline
    • NSAIDs
  • Fingolimod showed anti-inflammatory response, but did not show clinical improvements
• Monoclonal antibodies are being currently tested in ongoing clinical trials
  • Rituximab. Molecular target: CD20
  • Infliximab. Molecular target: TNF-alfa
  • Canakinumab. Molecular target: IL-1
  • Toclizumab. Molecular target: IL-6
  • Siltuximab. Molecular target: IL-6