Therapeutic Guidelines Psychotropic

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Welcome to this Australian Prescriber podcast. I'm Dr Justin Coleman, a GP who lives on a little tropical island, Bathurst Island, north of Darwin. And with me today, I'm talking with Dr Nick Carr, who's a St Kilda GP, where I used to travel for work many, many moons ago in Nick's first year there in 1988. And Nick is a member of the writing group for the Psychotropic Guidelines, the Therapeutic Guidelines. Welcome to this humble little podcast, Nick.

Thank you very much for having me.

It's interesting psychotropic and psychotropic, and I live in the tropics, which makes me wonder what the word psychotropic means. Psych of course means mind, and tropic, it is related to my island in the tropics because tropikós means to turn in Greek and it's where the sun turns at the solstice, which makes a tropical island, and in psychotropics it's any drug that turns the mind. So, it affects behaviour, mood, thoughts, or perception. And in fact, the word, I looked it up, it was introduced first in 1948 and in 1948 was the same year as the first use of the words serotonin and alpha receptor and beta receptor. So, those had never appeared in print before 1948. So, it sounds like there was a lot happening to the mind back in those days, although it wasn't all serious. Because 1948 was also the first origin of the words sex-pot and supermodel. I bet you didn't know some of that, Nick.

I'm sitting here in awe of your research and thinking, "I know exactly what I'm going to do when I finish this podcast, go online and look all this up."

That is wonderful. Well, that fascinates me, but perhaps not our listeners who are probably more interested in what you have to say about psychotropics. So, let's talk about the Therapeutic Guidelines, the 8th edition and, in particular, what's new there. Various things we'll talk about, but also particular patient groups, for example, women who are pregnant or considering pregnancy or on contraception. And there's a topic there about use of various psychotropics in that patient group.

But let's go through in order just talking about first of all, anxiety and depressive disorders, which of course are incredibly common and probably the most common things we see as GPs in this area. And the big ticket item for me was certainly that SNRIs have now been relegated to second line whereas previously I think they were sort of equal first line with an SSRI or mirtazapine. What's the story there, Nick?

So, if we're talking first up about depression, you're absolutely right. We used to have an SNRI as one of the first-line options. Under these new guidelines, the recommended first-line options in terms of drug therapy for depression include all of the SSRIs, the things like sertraline, citalopram, escitalopram, the ones you're familiar with. So SSRIs or mirtazapine are now our recommended first-line treatment for depression. We no longer have an SNRI as first-line treatment. And the real reason for that is twofold, really, that SNRIs are potentially more lethal in overdose and they also do have a more complex discontinuation syndrome as well as adverse effect profile. So, they work really well in depression. It's not really an issue around their efficacy. It's more about their risks, their side effects, their withdrawal syndromes. So, in depression, we are now saying SSRIs and mirtazapine as our only first-line choices.

Thank you. And obviously we would add the caveat that, that's not to say that lifestyle modification and psychological interventions, of course, aren't also first line, but we are talking about once you get onto the medication and I think similar for generalised anxiety disorder, is that right?

Yes, with anxiety disorder, we've always had SSRIs as our first line, SNRIs as second line. And your point Justin is really, really important. I've jumped straight into the drug treatment, the psychotropics, but we have other ways of turning the mind, of course, other than just the medication. And particularly with anxiety disorders, we focus really strongly on lifestyle and psychological treatments before going straight to drug treatments. And you've correctly highlighted that in depression, of course, there are huge numbers of things we should be doing other than just prescribing drugs.

Skipping to a drug which we often feel we should prescribe or perhaps even pressured to sometimes prescribe. So, the class, the benzodiazepines, in terms of anxiety, they have less of a role than they used to have. And certainly there's at least two decades now, lots of cautions about them, but what is their role currently in anxiety?

Well, I think avid readers of Therapeutic Guidelines will be aware that we have always been really cautious in our advice about benzodiazepines and, while they can be really effective for both anxiety and insomnia, they have this really, really important risk of tolerance and then addiction, which can be a massive problem with benzodiazepines. So, we give all the usual cautions about if you're going to use benzos, make sure that you use them short term, low dose with plenty of warning about the risks of addiction and trying to make sure that people stop them once the short-term issue is over. I think what's probably changed a little bit in this guideline is a recognition that there are times when benzodiazepines are either necessary or, for an individual patient or whatever those individual reasons are, the most effective treatment. So, with all the cautions that we provide, it doesn't mean we should never be using benzos. They still work for the indications that we've always known.

And I guess that brings us along to insomnia where benzos may also have some limited role. They have been widely used over the years for insomnia and understandably, if someone comes in and they're quite distressed with a lack of sleep, and certainly using them in the short term can be quite therapeutic, I guess. But certainly there's an expanded section in this edition of Therapeutic Guidelines, looking at sleep factors and things that contribute to poor sleep and what we can do about them. And then, I gather there's some new information on the various phases of sleep and some guidance as to what doctors can do about the disturbance to those various phases.

Yes. Well, if people want to find out how to manage insomnia, you'll find that in this latest edition of the Therapeutic Guidelines Psychotropic, that the insomnia chapter's been fairly beefed up and there's some really great stuff in here. If you're looking for what drug to use, you're going to have to go through an awful lot of other information first, which is exactly how it should be. Because we've really emphasised looking at the reasons behind people's insomnia, trying to drill down in detail, whether there's an underlying condition, looking with more guidance about how to consider other disorders and also the principles of sleep hygiene. There's information about some of the more niche areas about sleep disorder, with sleep–wake phase disorders and shift worker disorders. All of these are given more information in this particular edition of the guidelines. And then, if you finally get down to say, I still think I need to prescribe a medication, we can find some really quite detailed guidance between the benzodiazepines, the z-drugs and melatonin. Which one to choose, what dose and when to prescribe them.

There's a general rule that for sleep onset insomnia, you tend to go with a drug with a shorter half-life or immediate-release melatonin. And for those who have trouble maintaining sleep or wake up early, you go for those with are longer half-life or modified-release melatonin. I do notice that the gold standard therapy for insomnia is cognitive behavioral therapy.

Yes, people would be well aware that psychological treatments are very effective for insomnia and the gold standard is a version of cognitive behavior, CBT. The insomnia-based CBT. CBT-I is the gold standard. Obviously this is not something which on a Friday evening, when you've got an insomniac patient in front of you, most GPs are not going to be able to suddenly provide CBT-I. So, we do give the advice about which medications, if you feel you need to prescribe. Importantly with the benzos, there's only one in our list as recommended if you are going to treat insomnia, which is temazepam. We include the two z-drugs drugs available in Australia, eszopiclone and zolpidem, and then melatonin is also discussed and when to use it.

Thank you very much. I'm talking with Dr Nick Carr, a GP whose articles I started reading when I first became a GP myself many moons ago. Let's move on to psychoses. Those with psychotic disorders. And unfortunately in my current role, this is very common and I also have a population at very high cardiovascular risk and very high smoking rates. A key underlying concern with use of antipsychotics is their metabolic effects and the cardiovascular risks involved. And that, I think, has changed some of the recommendations and it’s certainly behind a lot of the recommendations in the new edition.

Doctors listening to this who work in psychosis would be familiar that we've got a lot of new medications available for us now. And one of the ones we've had for a long time, olanzapine, has been widely used. The change in this edition of the guidelines is that we're now recommending that olanzapine is never the first-line choice when treating psychosis. And that will become as quite a surprise to people because it's been a mainstay of clinical practice for a long time. It's not that olanzapine is not efficacious. It works, but its side-effect profile is sufficiently more severe than some of the others for us to relegated it to second line.

So, the focus in this chapter on psychosis has been very strongly shifted to looking at the management of the adverse side effects of medications, making sure we minimise those where best possible with cautious prescribing and then how do we monitor for them? And there's a new table giving some guidelines about what frequency should be used for monitoring things like cardiac side effects with ECGs and then metabolic, checking weight measurements and that sort of thing, and lipid profiles and all the other parameters that we should check when someone's on an antipsychotic.

Just to clarify with the olanzapine, Nick. I think there's long been tables in Therapeutic Guidelines talking about the general side effects of the antipsychotics, but the olanzapine difficulty is specific, as in a metabolic problem, weight gain and that sort of thing.

Yes, we're now familiar with the idea that olanzapine has a much higher rate of weight gain and triggering of diabetes and dyslipidemia and all the potential risk factors that go with that. It's not unique to olanzapine, of course, we know that this happens with other drugs as well, but because it seems to be more common and more severe with olanzapine, that's why it has been relegated to second line. And we've given recommendations about how to monitor those metabolic risk factors in all people on antipsychotics.

Thank you. And moving on now to dementia, and people certainly wonder what they can do to reduce their risk of developing dementia. And I was pleased to see there's a new printed advice and even a handout for the evidence-based things to try to reduce developing dementia. And I must confess to you at this point, Nick, I am a GP who is yet to prescribe my first ever acetylcholinesterase inhibitor for someone to try to prevent dementia. Does that shock you?

Well, I have to say Justin, I think that's probably the right amount of acetylcholinesterase inhibitor for a GP to initiate.

Okay.

My view, it obviously doesn't have to be done under psychiatric supervision, but these are complicated medications with a fairly modest chance of benefits. There are types of dementia, like frontotemporal, where they wouldn't normally be a first-line choice. And for most people with dementia, this needs specialist assessments as to whether they're suitable. Their benefits are modest, they're all we've got unfortunately. We know with dementia that, in terms of treatment options, at this stage we are very limited.

So we do give the advice about the acetylcholinesterase inhibitors and the other drugs like memantine that are available. Perhaps one of the really important things about this particular chapter is a more detailed range of information about how to prevent dementia. So, lots of links about what the research says, about how we can keep ourselves and our brains healthy and reduce the risk of dementia. And again, more detail about how we help when people have the difficulties associated with dementia, particularly the behavioural and psychological problems that are so common in people with dementia and how we manage those.

Well, that is something I must say I have occasionally written fairly short-term prescriptions for and often it's the carer's distress or sometimes the nursing home staff or other residents' distress. If someone is very agitated or aggressive or becoming psychotic, then I think certainly there is a cautious role for using some of those psychotropics in those situations.

No doubt about that, and any GPs who’ve worked in an aged-care setting will know the pressure that can be when you've got someone with a complex behavioural disorder associated with dementia. First line should be behavioural and environmental management. But if a medication is needed, the recommendations are in the book about what to use, but the crucial thing is to not go straight to a medication. And if you are using a medication, to make sure it's used as short term as possible, and certainly needs reviewing after a month or two, we really recommend that we should not be using these medications for behavioural disturbances in dementia for longer than about 12 weeks.

We'll move on now to the last couple of topics. And I was interested to see these because neither of them occurred to me that they would actually have much place in a Therapeutic Guideline because neither of them seemed to have much in the way of pharmacological therapy. But the first of those two is looking at suicidality and suicide risk and clearly, tragically, as I found out fairly recently with one of my patients, prevention of suicide is very difficult and certainly not always possible. What sort of information is in the new section on suicide risk?

So, I'm really glad you brought this up Justin, because one of the things I really want to alert listeners to, if they aren't aware of this, is there is so much information in these guidelines. It's not just the drug formulary telling you what to prescribe, but there's a huge amount of clinical information. And as you correctly say, what could a drug book have to say about suicide risk? Well, of course drugs can be the mechanism that people use for suicide. But what we've done in this edition of the book is going into a lot more detail about what the risk factors are so that people can read through if they're unclear what the risks might be. There's a lot more information about that.

And I think very helpfully, there's a lot more detail about how to assess suicide risk, including using some of the exact words that we should consider when talking to patients, which really helps, I think, people understand how to frame this conversation around suicide risk when we're making the assessment, and recognising that prevention is incredibly difficult, but there are all sorts of resources that we can use to help. There are links to many of those resources. If people are worried about their patients or they're uncertain of their own skills in this area, it's a really crucial chapter. It's got excellent information.

Yeah, I certainly think it can be quite nerve-wracking for a doctor when someone talks about their own suicide risk and it's something which is very important. And I was pleased to see there's also a safety planning section talking about components of a safety plan and there's links to app-based safety plans. The final section, also the second one of which I thought there probably isn't all that much by way of drug therapeutics, is personality disorder. Now definitionally that has changed over time and it will continue to change. There's one suggestion that it affects almost 1 in 10 Australians. Certainly it's something which we GPs tend to see a lot because people with it do tend to attend GPs, large component of the advice here seems to be being nice, stay calm, and remain respectful and be caring and engage in communication. What do we have to say about personality disorder, Nick?

I remember when I first got involved with Therapeutic Guidelines, which was several editions ago, and the question of personality disorder came up and I said, well, we either have to write an entire chapter of detail about personality disorder…

Yes.

…which is just one sentence, which says, "There are no drug treatments for personality disorder, move on."

Yes.

Of course there are drug treatments for the comorbidities that go with personality disorder. So, this chapter is not focused on drug treatments, though we do talk about the increased risk of mood disorder, psychosis and so on and people with personality disorder, and we point to the relevant links for treatment of those. But one of the reasons, again, little bit like with the suicide chapter, this is so much more than just a drug formulary. There's a lot of detail here about the emerging thinking about personality disorder, where we're moving away from trying to do a detailed classification into psychopathic or antisocial and so on. And the new approach outlining in terms of severity of the personality traits that people are experiencing. And then, what do you do with that? And you're absolutely right. I mean, these are almost sort of counselling skills. Who would've thought you'd find that in a Therapeutic Guidelines book? But that's what working with personality disorder is about and that's what makes this chapter compulsory reading for anyone who wants to know a bit more.

Well, I can certainly back that up. I think one of the beauties of each new edition of the Psychotropics and other Therapeutic Guidelines is there is a shift towards this very clearly written, useful evidence-based information, and more and more I actually suggest to my registrars and medical students that, if they want to find out about a particular topic, they don't just look up one drug. They look up the chapter on that topic. And I think this is a fine example of it. So, we've got the 8th edition of the Psychotropics and I've been talking with Dr Nick Carr who's one of the writers, has been for a long time on the Psychotropic Guidelines. And thanks for coming along in this podcast, Nick.

Lovely to talk to you Justin. Thanks for your time.

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My guests views are their own and don't represent Australian Prescriber and my views are certainly all mine.