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Evidenced Based Practices & Treatment Innovations in Behavioral Health
Daniel Castellanos, MD Medical Director, South Florida Behavioral Health Network
Disclosures
Dr Castellanos is Professor & Founding Chair, Department of Psychiatry & Behavioral Health, The Herbert Wertheim College of Medicine, Florida International University
No relevant financial disclosures
Recognize different mental health treatments used throughout history
Identify the levels of scientific evidence that determine what
constitutes evidenced based care
Recognize Evidence Based Practices (EVPs) for common behavioral
health disorders
Identify types of newer and innovative behavioral health treatments for
common behavioral health disorders
Objectives
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Although hydrotherapeutic treatment for mental illness had ancient roots, it received increased attention in the 19th century, when the water cure craze spread throughout the western world
Developed and popularized by Vincenz Priessnitz it promised relief from the common ills of the day. Gout, rheumatism, tuberculosis, melancholy, indigestion were all treatable with water
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Use of hydrotherapy in American psychiatric hospitals grew rapidly in the first two decades of the 20th century
It was an era with few successful treatments for mental disorders, so in many instances prolonged baths and wet packs replaced physical restraints for agitated patients
Continuous bath, Bloomingdale Hospital. Photo courtesy of Weill Cornell Medical Archives Castellanos 2014
Between 1917 and 1935, four methods for producing physiological shock were discovered, tested and used in the psychiatric practice in Europe: Malaria-induced fever to treat neurosyphillitic paresis (Julius
Wagner-Jauregg, 1917) Insulin-induced coma and seizures to treat schizophrenia,
(Manfred J. Sakel, 1927) Metrazol (Pentylenetetrazol )-induced seizures to treat
schizophrenia and affective psychoses (Ladislaus J. von Meduna, 1934)
Electroconvulsive shock therapy (Ugo Cerletti and Lucio Bini, 1937)
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Patients were given regular insulin injections to produce five or six diabetic comas a week for weeks at a time
Insulin therapy continued until the patient improved, or until 50 to 60 comas had been induced
Commonly used in psychiatric institutions in the 1940s and 1950s to treat schizophrenia and other mental illness
Insulin shock therapy was regarded as the treatment of choice for schizophrenia for about twenty years
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Ugo Cerletti was convinced that metrazol-induced seizures were useful for the treatment of schizophrenia, but far too dangerous and uncontrollable to be applied (there was no antidote to stop the convulsions at the time, as it happened with insulin). Furthermore, they were highly feared by the patients
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Dr. Walter Freeman of George Washington University and Dr. James Watts of Yale brought Monizs leucotomy to the US
They kept encountering problems like the knife breaking off in peoples brains, unexplained seizures, and total disorientation
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Prefrontal Leucotomy: Holes drilled in the skull. Surgeon would sever the nerves using a pencil-sized tool called a leucotome. It had a slide mechanism on the side that would deploy a wire loop(s) from the tip. The surgeon could sever the nerves by removing cores of brain tissue, slide the loop back in, and the operation was complete
Prefrontal Lobotomy: Also utilized drilled holes, but in the upper forehead instead of the top of the skull. It was also different in that the surgeon used a blade instead of a leucotome
Transorbital lobotomy
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Psychotherapy
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Early 1900s Sigmund Freud
1905-1950 Adolf Meyer 1900s-1950s
Carl Jung
1930s-1970s BF Skinner
Today - EVPs
Evolution of Psychotherapy
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Evidence Based Practices
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Levels of Scientific Evidence
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Randomized
controlled trials
Non-randomized controlled trials; large meta-analysis
Observational studies with controls
Observational studies without controls; case series
Case reports; anecdotal reports; clinical consensus
Source: Adapted from US Dept of Health and Human Services; http://www.ahrq.gov/
Highest
Lowest
Evidence Based Practices (EBPs)
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Definition:
Applying the best available research results (evidence) when making decisions about health care.
Health care professionals who perform evidence-based practice use research evidence along with clinical expertise and patient preferences.
Source: US Dept of HHS, Agency for HealthCare Research & Quality
Evidence Based Practices (EBPs)
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Example:
A behavioral health care provider recommends cognitive behavioral
treatment (CBT) for a person with severe generalized anxiety disorder.
The behavioral health care provider makes this recommendation because
RCTs shows that CBT is effective in treating anxiety.
Evidence Based Practices (EBPs)
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Promising practices:
Certain practices supported by current clinical wisdom, theories, and professional and expert consensus
These practices may lack support from studies that are scientifically rigorous in research design and statistical analysis or
Available studies may be limited in number or sample size or
They may not be applicable to the current setting or population.
Source: www.SAMHSA.gov
Treatment Guidelines
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Treatment guidelines incorporate EBPs - PTSD example:
Recommended for Practice
Psychosocial: cognitive behavioral therapy to teach distraction and other
techniques; individual or group counseling and psychotherapy sessions; support
group meetings
Likely To Be Effective
Medications:
Benzodiazepines (lorazepam, diazepam, alprazolam) Azapirones (buspirone) Antihistamines (hydroxyzine) Antidepressants (paroxetine, sertraline, escitalopram, venlafaxine,
mirtazapine)
Atypical neuroleptics (olanzapine, risperidone)
Treatment Guidelines
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Treatment guidelines incorporate EBPs - PTSD example:
Effectiveness Not Established
Art therapy
Exercise
Meditation
Massage therapy
Progressive muscle relaxation
Therapeutic touch
Reiki
Foot reflexology
Homeopathy
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Insert FMHI Guidelines
Florida Best Practice Medication Guideline for Schizophrenia
Trauma Informed Care
According to SAMHSAs concept of a trauma-informed approach,
A program, organization, or system that is trauma-informed:
Realizes the widespread impact of trauma and understands potential paths for
recovery;
Recognizes the signs and symptoms of trauma in clients, families, staff, and
others involved with the system;
Responds by fully integrating knowledge about trauma into policies, procedures,
and practices; and
Seeks to actively resist re-traumatization.
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Trauma Informed Care
A trauma-informed approach can be implemented in any type of service setting
or organization and is distinct from trauma-specific interventions or treatments
that are designed specifically to address the consequences of trauma and to
facilitate healing.
From SAMHSAs perspective, it is critical to promote the linkage to recovery
and resilience for those individuals and families impacted by trauma. Consistent
with SAMHSAs definition of recovery, services and supports that are trauma-
informed build on the best evidence available and consumer and family
engagement, empowerment, and collaboration.
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Trauma Informed Care
A trauma-informed approach reflects adherence to six key principles rather than a
prescribed set of practices or procedures. These principles may be generalizable
across multiple types of settings, although terminology and application may be
setting- or sector-specific:
Safety
Trustworthiness and Transparency
Peer support
Collaboration and mutuality
Empowerment, voice and choice
Cultural, Historical, and Gender Issues
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Evidence Based Practices (EBPs)
Examples
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EBPs for Depression Acceptance and Commitment Therapy (ACT):
ACT is a contextually focused form of cognitive behavioral
psychotherapy that uses mindfulness and behavioral activation to increase
clients' psychological flexibility--their ability to engage in values-based,
positive behaviors while experiencing difficult thoughts, emotions, or
sensations.
Adolescent Coping With Depression (CWD-A):
The CWD-A course is a cognitive behavioral group intervention that
targets specific problems typically experienced by depressed adolescents.
These problems include discomfort and anxiety, irrational/negative
thoughts, poor social skills, and limited experiences of pleasant activities.
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EBPs for Depression Attachment-Based Family Therapy (ABFT):
ABFT is a treatment for adols that is designed to treat clinically diagnosed
major depressive disorder, eliminate suicidal ideation, and reduce
dispositional anxiety.
Cognitive Behavioral Therapy for Late-Life Depression :
CBT for Late-Life Depression is an active, directive, time-limited, and
structured problem-solving approach program that follows the conceptual
model of CBT.
Computer-Based Cognitive Behavioral Therapy, Beating the Blues:
Computer-Based CBT, Beating the Blues (BtB), is a computer-delivered
series of CBT sessions for adults with mild to moderate depression and/or
anxiety.
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EBPs for Depression Dialectical Behavior Therapy(DBT):
DBT is a cognitive-behavioral treatment approach with two key
characteristics: a behavioral, problem-solving focus blended with acceptance-
based strategies, and an emphasis on dialectical processes.
IMPACT (Improving Mood--Promoting Access to Collaborative
Treatment):
IMPACT is an intervention for adult pts who have a diagnosis of major
depression or dysthymia, often in conjunction with another major health prob.
Interpersonal Psychotherapy for Depressed Adolescents (IPT-A):
IPT for Depressed Adols is a short-term, manual-driven outpatient treatment
intervention that focuses on the current interpersonal problems of adols with
mild to moderate depression severity. Castellanos 2014
EBPs for Depression Cognitive Behavioral Therapy for Adolescent Depression (CBT):
CBT for Adolescent Depression is a developmental adaptation of the classic
cognitive therapy model. CBT emphasizes collaborative empiricism, the
importance of socializing patients to the cognitive therapy model, and the
monitoring and modification of automatic thoughts, assumptions, and
beliefs.
Mindfulness-Based Cognitive Therapy (MBCT):
MBCT is a program for adults with recurrent major depressive disorder.
MBCT represents an integration of components from two interventions:
Mindfulness-Based Stress Reduction, which is based on the core principle of
"mindfulness" and CBT for depression.
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EBPs for Anxiety Acceptance-Based Behavioral Therapy for Generalized Anxiety Disorder:
ABBT for Generalized Anxiety Disorder (GAD) is a form of psychotherapy
for adults who have a principal diagnosis of GAD. The treatment is designed
to decrease symptoms of worry and stress, so clients experience a reduction in
GAD symptoms and comorbid depression or mood-related symptoms.
Coping Cat:
Coping Cat is a cognitive behavioral treatment that assists school-age children
in (1) recognizing anxious feelings and physical reactions to anxiety; (2)
clarifying cognition in anxiety-provoking situations (i.e., unrealistic
expectations); (3) developing a plan to help cope with the situation (i.e.,
determining what coping actions might be effective); and (4) evaluating
performance and administering self-reinforcement as appropriate.
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EBPs for Anxiety
Dialectical Behavior Therapy(DBT):
DBT is a cognitive-behavioral treatment approach with two key
characteristics: a behavioral, problem-solving focus blended with acceptance-
based strategies, and an emphasis on dialectical processes.
Eye Movement Desensitization and Reprocessing Eye Movement (EMDR):
Desensitization and Reprocessing is a one-on-one form of psychotherapy that
is designed to reduce trauma-related stress, anxiety, and depression symptoms
associated with PTSD and to improve overall mental health functioning.
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EBPs for Trauma/PTSD Child-Parent Psychotherapy (CPP):
CPP is an intervention for children 0 - 5 who have experienced at least one
traumatic event and, as a result, are experiencing behavior, attachment, and/or
mental health problems, including PTSD.
Trauma Recovery and Empowerment Model (TREM):
TREM a fully manualized group-based intervention designed to facilitate
trauma recovery among women with histories of exposure to sexual and
physical abuse.
Trauma-Focused Cognitive Behavioral Therapy (TF-CBT):
TF-CBT is a psychosocial treatment model designed to treat posttraumatic
stress and related emotional and behavioral problems in children and
adolescents.
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EBPs for Trauma/PTSD Cognitive Behavioral Intervention for Trauma in Schools (CBITS):
The CBITS program is a school-based group and individual intervention
designed to reduce symptoms of posttraumatic stress disorder (PTSD),
depression, and behavioral problems; improve peer and parent support; and
enhance coping skills among students exposed to traumatic life events, such
as community and school violence, physical abuse, domestic violence,
accidents, and natural disasters.
Eye Movement Desensitization and Reprocessing Eye Movement (EMDR):
Desensitization and Reprocessing is a one-on-one form of psychotherapy
that is designed to reduce trauma-related stress, anxiety, and depression
symptoms associated with posttraumatic stress disorder (PTSD) and to
improve overall mental health functioning. Castellanos 2014
EBPs for Behavioral Disorders
Multisystemic Therapy (MST) for Juvenile Offenders:
MST for Juvenile Offenders addresses the multidimensional nature of
behavior problems in troubled youth. Treatment focuses on those factors
in each youth's social network that are contributing to his or her antisocial
behavior.
Multisystemic Therapy With Psychiatric Supports (MST-Psychiatric):
MST-Psychiatric is designed to treat youth who are at risk for out-of-
home placement (in some cases, psychiatric hospitalization) due to serious
behavioral problems and co-occurring mental health symptoms such as
thought disorder, bipolar affective disorder, depression, anxiety, and
impulsivity.
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EBPs for Behavioral Disorders
Brief Strategic Family Therapy (BSFT):
Brief Strategic Family Therapy is designed to (1) prevent, reduce, and/or
treat adolescent behavior problems such as drug use, conduct problems,
delinquency, sexually risky behavior, aggressive/violent behavior, and
association with antisocial peers; (2) improve prosocial behaviors such as
school attendance and performance; and (3) improve family functioning,
including effective parental leadership and management, positive
parenting, and parental involvement with the child and his or her peers
and school.
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EBPs for Substance Use Disorders
Family Behavior Therapy:
Family Behavior Therapy is an outpatient behavioral treatment aimed at
reducing drug and alcohol use in adults and youth along with common co-
occurring problem behaviors such as depression, family discord, school
and work attendance, and conduct problems in youth.
Brief Strategic Family Therapy (BSFT):
BSFT is designed to address adolescent behavior problems (such as,
substance use); improve prosocial behaviors; and improve family
functioning.
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EBPs for Substance Use Disorders
Multidimensional Family Therapy (MDFT):
MDFT is a comprehensive and multisystemic family-based outpatient or
partial hospitalization (day treatment) program for substance-abusing
adolescents, adolescents with co-occurring substance use and mental
disorders, and those at high risk for continued substance abuse and other
problem behaviors such as conduct disorder and delinquency.
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EBPs for SMI
International Center for Clubhouse Development (ICCD) Clubhouse
Model:
The ICCD Clubhouse Model is a day treatment program for rehabilitating
adults diagnosed with a mental health problem. The goal is to contribute to
the recovery of individuals through use of a therapeutic environment that
includes responsibilities within the Clubhouse (e.g., clerical duties, food
service, transportation, financial services), as well as through outside
employment, education, meaningful relationships, housing, and an overall
improved quality of life.
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EBPs for SMI
Psychiatric Rehabilitation Process Model:
The Psychiatric Rehabilitation Process Model is a process guiding the
interaction between a practitioner and an individual with severe mental
illness. Manual driven, the model is a client-centered, strengths-based
intervention designed to build clients' positive social relationships,
encourage self-determination of goals, connect clients to needed human
service supports, and provide direct skills training to maximize
independence.
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EBPs for Co-Occurring Disorders
Multidimensional Family Therapy (MDFT):
MDFT is a comprehensive and multisystemic family-based outpatient or
day treatment program for substance-abusing adolescents, adolescents with
co-occurring substance use and mental disorders, and those at high risk for
continued substance abuse and other problem behaviors such as conduct
disorder and delinquency.
Family Behavior Therapy:
Family Behavior Therapy is an outpatient behavioral treatment aimed at
reducing drug and alcohol use in adults and youth along with common co-
occurring problem behaviors such as depression, family discord, school and
work attendance, and conduct problems in youth.
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EBPs for Personality Disorders
Dialectical Behavior Therapy(DBT):
DBT is a cognitive-behavioral treatment approach with two key
characteristics: a behavioral, problem-solving focus blended with
acceptance-based strategies, and an emphasis on dialectical processes.
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Evidence Based Practices (EBPs)
Dialectical Behavior Therapy
(DBT) One example in detail
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Dialectical Behavior Therapy (DBT)
Why DBT Is an Evidence-Based Program?
Theoretically based
Scientifically evaluated through rigorous research
Found effective in achieving positive results as intended
Evaluation results have been subjected to peer review
Recognized by Federal or other types of organizations as an evidence-based
program
As of this date, eighteen randomized controlled trials published on DBT
demonstrate its utility across client groups with severe and complex disorders.
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Dialectical Behavior Therapy (DBT)
As of this date, eighteen randomized controlled trials published on DBT
demonstrate its utility across client groups with severe and complex disorders.
Since 1987, DBT evaluation studies conducted by Dr. Linehan and her
colleagues have been published in dozens of scientific journals, including 29
randomized clinical trials conducted across 21 independent research teams.
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DBT-Comparative Effectiveness Research & Systematic
Reviews
In addition to outcome trials, DBT has been systematically reviewed and
compared to other psychotherapeutic approaches in comparative effectiveness
research (CER) studies, which compare the benefits and harms of different
interventions and strategies to prevent, diagnose, treat, and monitor community
health and the nations health care system.
Notably, the vast majority of DBT outcome studies have been CER trials since
the evaluations took place in settings where clients were already receiving
treatment.
The superiority of DBT over other commonly used approaches, such as CBT,
psychotherapy, and group therapy, have been found in several studies.
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Dialectical Behavior Therapy (DBT)
DBT is a cognitive-behavioral treatment approach with two key characteristics:
A behavioral, problem-solving focus blended with acceptance-based strategies
An emphasis on dialectical processes. "Dialectical" refers to the issues
involved in treating patients with multiple disorders and to the type of thought
processes and behavioral styles used in the treatment strategies.
DBT emphasizes balancing behavioral change, problem-solving, and emotional
regulation with validation, mindfulness, and acceptance of patients.
Therapists follow a detailed procedural manual.
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Dialectical Behavior Therapy (DBT)
DBT has five components:
(1) capability enhancement (skills training);
(2) motivational enhancement (individual behavioral treatment plans)
(3) generalization (access to therapist outside clinical setting, homework, and
inclusion of family in treatment)
(4) structuring of the environment (programmatic emphasis on reinforcement of
adaptive behaviors)
(5) capability and motivational enhancement of therapists (therapist team
consultation group).
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Dialectical Behavior Therapy (DBT)
Adaptations of DBT have been developed for:
Suicidal adolescents
Individuals with substance use disorders
Individuals with eating disorders
Individuals with comorbid HIV and substance use disorders
Developmentally delayed individuals
Older adults with depression and one or more personality disorders
Individuals with schizophrenia
Families of patients
Women experiencing domestic violence
Violent intimate partners
Individuals who stalk
Inpatient and partial hospitalization settings for adolescents and adults
Forensic settings for juveniles and adults
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DBT involves four components:
Individual: The therapist and consumer discuss issues that come up during the week (recorded on
diary cards) and follow a treatment target hierarchy. Self-injurious and suicidal
behaviors take first priority.
Second in priority are behaviors which, while not directly harmful to self or others,
interfere with the course of treatment. These behaviors are known as therapy-interfering
behaviors.
Third in priority are quality of life issues and working towards improving ones life
generally. During the individual therapy, the therapist and patient work towards
improving skill use. Often, a skills group is discussed and obstacles to acting skillfully
are addressed.
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DBT involves four components:
Group:
A group ordinarily meets once weekly for two to two-and-a-half hours and learns to use
specific skills that are broken down into four skill modules:
core mindfulness
Interpersonal effectiveness
Emotion regulation
Distress tolerance.
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DBT involves four components:
Phone Coaching:
As needed, consumers may contact their therapists for additional support between
sessions.
This support is generally available 24/7, but DBT places certain restrictions to curtail
abuse or overuse of the therapists availability, such as letting consumers know that after
a suicide attempt they will not have immediate contact with their therapist.
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DBT involves four components:
Consultation Groups:
Therapists meet weekly to provide support, discuss cases, and practice DBT skills
themselves.
These groups increase motivation, improve therapist skills,provide support, and keep
therapists in fidelity to the model.
Linehan asserts that any therapist acting in isolation is not doing DBT.
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DBTs Four Modules
DBT basic skills are taught in four separate modules.
Module One: Mindfulness
Module Two: Distress Tolerance
Module Three: Emotional Regulation
Module Four: Interpersonal Effectiveness
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Dialectical Behavior Therapy (DBT)
Adaptations of DBT have been developed for:
Suicidal adolescents
Individuals with substance use disorders
Individuals with eating disorders
Individuals with comorbid HIV and substance use disorders
Developmentally delayed individuals
Older adults with depression and one or more personality disorders
Individuals with schizophrenia
Families of patients
Women experiencing domestic violence
Violent intimate partners
Individuals who stalk
Inpatient and partial hospitalization settings for adolescents and adults
Forensic settings for juveniles and adults
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Psychopharmacolgy
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1950s-Present
Psychopharmacolgy Revolution
1944: Stimulants (1960 marketed as Ritonic)
1948: Lithium:
1817 -first discovered as an element
John Cade, MD first used as treatment for mania
1951: Chlorpromazine (Thorazine): Discovered in France
1952- became available for clinical use
1950s: Clozapine (Clozaril): Discovered 1970s - introduced into clinical practice
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Psychotropic Medications II
1958: Imipramine (Tofranil): Synthesized -1898. 1954- studied in the treatment of schizophrenia. 1958- became available for clinical use.
1950s: Haloperidal (Haldol): Discovered. 1959 - First approved for clinical use.
1974: Fluoxetine (Prozac): First described in scientific journal. 1987-Approved by FDA.
1993: Risperidone (Risperdal): FDA Approved.
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Psychotropic Medications III
2013: 2 new antidepressants approved:
Vortioxetine (Brintellix)
Levomilnacipran CR (Fetzima)
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Promising new medication treatments Ketamine (Ketalar):
An anesthetic
Treatment Resistant Depression (TRD) & OCD
Works very quickly
Potential for abuse (Special K)
Agolmelatine (Valdoxan):
Approved in Europe since 2009 for depression
Works on melatonin
Riluzole (Rilutek):
Approved for ALS (Lou Gehrigs Dis)
Promising results in TRD
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Promising new medication treatments
GLYX-13:
In current FDA trials with Fast Track designation
Rapid-acting antidepressant activity with excellent safety
Psychobiotics:
Live organisms (probiotics)
Certain probiotics when ingested may produce mental health benefits
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Other Newer, Emerging Treatments
2005 Vagus-Nerve Stimulation (VNS)
Indicated for Treatment Resistant Depression:
Depression has lasted two years or more
If it is severe or recurrent
Treatment failure at least four other treatments
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2008 Transcranial Magnetic Stimulation (rTMS)
Indication: Adults with MDD who have failed to achieve satisfactory improvement from one prior antidepressant medication at or above the minimal effective dose and duration in the current episode
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2013 Deep Brain Stimulation (DBS)
Not FDA approved
Optimal location appears to be ventral capsule/ventral striatum stimulation at the junction of the anterior commissure, anterior capsule, and posterior
ventral striatum
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Other Innovations
in
Behavioral HealthCare
Technology
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E-Therapy Example
Margaret Sibley, PhD Assistant Professor, Department of Psychiatry &
Behavioral Health, FIU
Title: Increasing Behavioral Treatment Utilization in Adolescents with
ADHD: The Role of ETherapy
Outpatient treatment for families of adolescents with ADHD through
video conferencing
All aspects of treatment and assessment process are conducted without
the family having to set foot in the clinic
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Innovations in Behavioral HealthCare Technology
Use of computerized applications
Smart Phone APPs develop for various daily uses by the consumer
Can involve specific treatment interventions (eg, cognitive behavior therapy sessions)
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Digital medicine
Managing consumer health by the use of : Ingestible sensors Wearable and implantable physiological sensors Mobile communication technology Web-based patient communities
Represents a new and rapidly evolving paradigm in healthcare
Eg; Proteus Digital Health
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Digital medicine
Digital medications:
Contain the same medications available today
In addition, each pill also contains a tiny ingestible sensor which communicates about medication-taking behaviors in real time
Utilizes digital health feedback system
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Digital medicine
Digital medications II:
First application of the ingestion sensor is to measure a consumers adherence to oral medication therapy regimens (medication levels)
Other uses include how the body is responding (eg, blood pressure, pulse, etc) and many others
Will allow consumers, families & physicians to take appropriate action in response to a consumers adherence pattern and specific health metrics
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Digital medicine
Stretchable electronics (patches):
Contain sophisticated, integrated sensing systems
Possible functions: Transdermal delivery of medication Monitor therapeutic levels of medication Monitor various health functions: pulse; blood pressure; stress;
activity (including movements), etc Detect street drug levels Others
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Digital medicine Stretchable electronics (patches):
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Digital medicine Stretchable electronics (patches):
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Optogenetics
&
Pharmacogenomics
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Optogenetics
Neuroscientists target a single neuron in the brain of a mouse merely by turning on a light
This is done by using a light activated gene and inserting it into the genome of a mouse to be able to easily identify when the particular neuron is firing in the brain
The purpose is to control a brains activity with light
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Optogenetics
Optogenetics is a hot and controversial topic
This could have far reaching benefits with humans to help better understand the complex network of neurons that make up the brain
Identifying these neurons may sometime help people detect flaws or deformities in the various neurons in the brain that cause disorders like schizophrenia
Time will tell as to whether this approach is effective
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Pharmacogenomics
Pharmacogenomics:
The study of how genes affect a persons response to medications
Addresses the human variability in medication response
If it were not for the great variability among individuals, medicine might as well be a science and not an art
Sir William Osler, 1892
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Pharmacogenomics
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Pharmacogenomics
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Take Home Points
Current emphasis on:
Standardized assessments (eg, validated rating scales) and interventions
The use of EVPs
New technologies are assisting in provision of psychosocial interventions
Emerging treatments involve:
Digital medicine (digital medications & stretchable electronics)
Pharmacogenomics
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Parting Thoughts
Real knowledge is to know the extent of one's ignorance. Confucius