|1

Introduction in Clinical Psychology

(BE2-22)

Psychopharmacology

Marije aan het Rot

 |2

Place of the lecture in the course

› Anxiety disorders
› Mood disorders
› Psychotic disorders
› Substance use disorders

› Medication treatment!
› Substance use!
 |3

Psychopharmacology

1. The use of psychoactive medications in treating

psychopathology

2. The study of medication- or substance-changes in

mood, thinking, and behaviour
 |4

Psychiatrists

› Treat patients with

psychoactive
(=psychotropic)
medications

› Completed 4-year
specialized training in
psychopharmacology
 |5

Central question

If psychiatrists are mental health care

specialists with extensive knowledge about
psychotropic medication treatment, then why
should psychologists working in mental
health care also have knowledge about
psychotropic medications and about
psychopharmacology?
 |6

American Psychological Association

› Practice Guidelines Regarding Psychologists’
Involvement in Pharmacological Issues

• Information
• Collaboration
• (Prescription)

http://www.apa.org/practice/guidelines/pharmacological-issues.pdf
 |7

After today you can…

13. Discuss the use of the psychological and biological
interventions available to people with anxiety,
mood, psychotic, and substance use disorders
 |8

Guideline 1

Psychologists are encouraged to consider objectively the

scope of their competence in pharmacotherapy, and to
seek consultation as appropriate before offering
recommendations about psychotropic medications.
 |9

Consider the scope of your competence

› What mental disorder are SSRIs primarily used for?
› Which neurotransmitter is involved in its action?
› What does the acronym stand for?
› Can you name a common side effect?
› Which of the following are SSRIs?
• Agomelatine
• Citalopram
• Diazepam
• Duloxetine
• Fluoxetine
| 10
 | 11

Guideline 2

Psychologists are urged to evaluate their own feelings

and attitudes about the role of medication in the
treatment of psychological disorders, as these feelings
and attitudes can potentially affect communications
with patients.
| 12
 | 13

De las Cuevas et al (2011) Open Journal of Psychiatry

 | 14

Guideline 3

Psychologists involved in prescribing or collaborating

are sensitive to the developmental, age and aging,
educational, sex and gender, language, health status,
and cultural/ethnicity factors that can moderate
the interpersonal and biological aspects of
pharmacotherapy relevant to the populations they
serve.
 | 15

Patient factors and treatment response

Pharma- Pharmaco- Pharmaco-

ceutical kinetic dynamic
phase phase phase

Medication Medication Medication

protocol levels effects
 | 16

Interindividual variability in medication levels

250mg

100mg
 | 17

ABSORPTION DISTRIBUTION

action

ELIMINATION METABOLISM
 | 18

Elimination (clearance) and age

Diazepam half-life
Adult: 20-70 hours
Elderly: up to 10 days

http://icp.org.nz/icp_t4.html
http://icp.org.nz/icp_t12.html
 | 19

Metabolism (transformation) and genetics

PMs: poor metabolizers; EMs: extensive metabolizers; UMs: ultrarapid metabolizers

http://icp.org.nz/icp_t8.html
Liver
| 20
 | 21

Guideline 4

Psychologists are urged to identify a level of knowledge

concerning pharmacotherapy for the treatment of
psychological disorders that is appropriate to the
populations they serve, and to engage in educational
experiences to achieve and maintain that level of
knowledge
 | 22

Example from Master student report - 1

› Man (37 years old) presented at outpatient clinic with a

referral from his family doctor

› Family doctor “considered” depression with panic

› Patient file indicates he has been taking citalopram

p.o. (20 mg q.d.) since a not clearly definable point in
time
| 23
 | 24

Medication factors and treatment response

Pharma- Pharmaco- Pharmaco-

ceutical kinetic dynamic
phase phase phase

Medication Medication Medication

protocol levels effects
 | 25

DRUG ACTION

action

DRUG EFFECT
 | 26

Drug action versus drug effect

Drug Drug-Receptor
Complex

Drug-binding
domain k1

Effector
domain k2
Receptor

Effect
Example from Master student report - 2
› Woman (54 years old) is addicted to alcohol and
medications and referred for treatment
› Her daily medication use until starting treatment:
1. Amlodipine 10 mg
2. Diazepam 4 mg
3. Duloxetine 240 mg
4. Omeprazole 40 mg
5. Paracetamol 4-8 tablets
6. Simvastatine 20 mg
7. Zolpidem 40 mg
 | 28

Psychotropic drug actions

Substance Receptors

Diazepam GABA type A receptors

Duloxetine Serotonin / norepinephrine transporters

Zolpidem GABA type A receptors

Alcohol / ethanol GABA type A receptors

 Drug-drug interaction
| 29

Additive: 1+1 = 2 Synergistic: 1+1 > 2

Example from Master student report - 2
› Woman (54 years old) is addicted to alcohol and
medications and referred for treatment
› Her daily medication use until starting treatment:
1. Amlodipine 10 mg
2. Diazepam 4 mg
3. Duloxetine 240 mg
4. Omeprazole 40 mg
5. Paracetamol 4-8 tablets
6. Simvastatine 20 mg
7. Zolpidem 40 mg
 | 31

Tolerance: decrease in therapeutic index

Dose
| 32
 | 33

Tolerance: potentially dangerous!

 | 34

What level of knowledge is appropriate?

Questions to consider:
1. What proportion of your patients takes medication?
2. How severe are the side effects?
3. How old are the patients?
4. Is specialized psychiatric care available?
 | 35

Summary – Part 1

› Master students of Clinical Psychology are frequently

exposed to issues related to psychopharmacology.

› Knowledge about psychopharmacology is recommended

by the American Psychological Association.

› Pharmacokinetics and pharmacodynamics explain the

occurrence of both therapeutic and adverse effects.
 | 36

Break
 Before the break…
| 37

Pharmacokinetics and pharmacodynamics explain both therapeutic and

adverse effects

Psycho-
active Neurotransmitter
drugs receptors and
transporters
 | 38

Guideline 5

Psychologists strive to be sensitive to the potential

for adverse effects associated with the psychotropic
medications used by their patients
 | 39

Causes of adverse effects

› Patient’s reaction to
medication protocol
 | 40

Example from Master student report - 3

› Women (28 years old) was diagnosed with Crohn’s

disease during adolescence

› Was prescribed prednisone after gastrointestinal

surgery

› After 6 months of use, she developed symptoms of

depression
 | 41

Causes of adverse effects

› Patient’s reaction to
medication protocol
› Drug-drug interaction
 | 42

Example from Master student report - 4

› Woman (50 years old) with PTSD is referred for EMDR

› Has been taking paroxetine since 1994

› Also takes medications for allergies and stomach

problems
 | 43

Causes of adverse effects

› Patient’s reaction to
medication protocol
› Drug-drug interaction
› Ill-advised polypharmacy
 | 44

Example from Master student report - 5

› Man (88 years old) has had two strokes, lives in a care
home for the elderly, is depressed, and may be
developing dementia

› Uses aspirin (30 mg), venlafaxine (150 mg),

mirtazapine (15 mg), and olanzapine (5 mg) daily
 | 45

Causes of adverse effects

› Patient’s reaction to
medication protocol
› Drug-drug interaction
› Ill-advised polypharmacy
› Use of excessive dosages
 | 46

Causes of adverse effects

› Patient’s reaction to
medication protocol
› Drug-drug interaction
› Ill-advised polypharmacy
› Use of excessive dosages

› Drug-diet interaction
› Medical condition

› Poor patient adherence

(compliance)
 | 47

Guideline 9

Psychologists are encouraged to explore issues

surrounding patient adherence and feelings about
medication
 | 48

Poor adherence - the patient’s problem?

Poor Adverse
adherance effects
 | 49

Example from Master student report - 6

› Man (44 years old) is referred for treatment because of

problems with aggression.

› Was prescribed paroxetine last year. However, he says

this made him feel hyper and so he quit.
 | 50

Example from Master student report - 7

› Man (20 years old) is referred for treatment due to

exacerbation of anxiety and panic symptoms.

› Reported that he benefitted from citalopram in the past.

However, he stopped taking it due to experiencing
“sharp increases in energy” which he interpreted as
signs of bodily dysfunction. He constantly worried
about them.
| 51
 | 52

Guideline 10

› Psychologists are urged to develop a relationship

that will allow the populations they serve to feel
comfortable exploring issues surrounding medication
use
 | 53

How to facilitate medication discussions?

› Build a therapeutic alliance
› Address personal opinions about medication use
› Appear competent about psychopharmacology
› Evaluate the level of adherence carefully
› Check understanding of the medication protocol
› Provide information and advice
› Help simplify the medication protocol
› Discuss patients’ beliefs
› Conduct follow-up tests
 | 54

Guideline 11
To the extent deemed appropriate, psychologists
involved in prescribing or collaboration adopt a
biopsychosocial approach to case formulation.

Psycho-
logical
Biological

Social
 | 55

Intake

› …
› Do you take any medication or
vitamins?
› How much and how often do
you take …?
› Has there been any change in
the amount you have been
taking?
› …
 | 56

Diagnostic interview

› …
› Just before this began, were you using any
medications?
› Any change in the amount you were using?
› …
 | 57

Etiological substances for depressive episodes

› Alcohol › Anxiolytics
› Amphetamines › Antihypertensives
› Cocaine › Oral contraceptives
› Hallucinogens › Corticosteroids
› Inhalants › Anabolic steroids
› Opioids › Anticancer agents
› Phencyclidine › Analgesics
› Sedatives › Anticholinergics
› Hypnotics › Cardiac medications
 | 58

Neuropsychological assessment

› Examples:
• Stimulants and concentration
• Antipsychotic medication and working memory
 | 59

Example from Master student report - 8

› Woman (20 years old) has been referred for treatment

because of panic attacks
› Assessment of personality traits, coping styles, and
symptom levels
› During intake client initially denies drug use but later
admits she smokes weed regularly
› Tests results are interpreted cautiously given possible
recent drug use
 | 60

From case formulation to treatment

› Bipolar disorder, schizophrenia  medication first

› Specific phobia, PTSD  psychotherapy first

› Depression, generalized anxiety disorder  either/or

› Depression with suicidality  both

 | 61

Example from Master student report - 9

› Man (20 years old) received cognitive-behavioral

therapy for anxiety in 2005.
› Because his symptoms were very severe at the time, he
was given paroxetine to be able to complete the
treatment.
› His symptoms decreased.
 | 62

Biopsychosocial approach to treatment!

Psychological

Biological

Social
 | 63

Guideline 17

Psychologists are encouraged to maintain appropriate

relationships with providers of biological
interventions.
 | 64

Example from Master student report - 10

› Man (20 years old) is referred to psychologist for social
anxiety; he is especially tense on working days and uses
oxazepam for this
› Session 4 of cognitive therapy: client seems relaxed but
also talks slowly
› Student (psychologist-in-training!) discussed
this with supervisor and psychiatrist
› Session 5: student brought up medication use during
therapy, including the risk for tolerance
| 65
 | 66

Summary – Part 2

› Mental health care psychologists can help improve

adherence to medication treatment

› Mental health care psychologists are encouraged to

approach a biopsychosocial approach during case
formulation and treatment

› Knowledge of psychopharmacology stimulates a good

rapport with psychiatrists
 | 67

Thank you for your attention