Dr. Strada presents: Geriatric Psychopharmacology:

10 Frequently Asked Questions (FAQs)

Can I trust that everything I say to you stays between you and me?

Mostly yes, EXCEPT in instances where you are an imminent danger to yourself, a danger to someone else, or are expressly unable to care for yourself anymore due to your psychiatric illness. In those instances I am legally obligated to breach confidentiality to protect you, the person you intend to harm or people that surround you. We keep notes like all other medical provider but they are completely confidential and mostly done for insurance purpose.

If you have so many patients, how do I know I will receive a care that is individually for me?

The training in this field teaches us to multitask. We look at each individual person and their experience, don’t associate them with a particular diagnosis and disease. In my case I give the same empathy, attention, thought, equivalent place value on each and every interaction. If at any point you feel that the provider might not be listening to you; is ok to express you feeling to make sure both parties are in the same page.

Are you willing to push medication on me?

In the case a patient is referred to me for posible medication it will present as a medication evaluation. The word evaluation means that I will ask many questions and try to collect as much information possible such as family history, social history, hospitalizations, previous diagnosis/treatment plans and any adverse reaction to posible medicine in the past just to name a few f the questions. If I think the medication will benefit you I will present my case to you as well as alternatives that don’t involve medication. It is ultimately your choice and I’m just here to present what is the best and help you the most.

Will I be on the medication forever?

The time length a patient is on a medication mainly depends on the type of diagnosis. For example, a patient with schizophrenia will generally require a long-term treatment plan that the patient will tolerate well, benefits outweigh risk and will prevent a relapse of the symptoms. We might have patient that have a experienced a depression episode for the first time in the life and will only require 6 month of medicine; will try to come off the medication with my guidance/monitoring only.

How do I know your advice is good enough that I should take it?

Providers are not technically considered advice-givers. Think of us as tool-givers to help you identify existing strengths within you, but you will actually do most of the work. Consider the clinic as a safe place and a work shop where you can work through things you have been struggling by trying different tools and see which one works best for you. Is completely normal and acceptable for patients to gut check your experience on the internet; let me warn you that there are far too many pages with false information that is misleading. The best way to clarify concern or question is to ask providers directly.

If I’m being prescribed medication, do I need to have therapy as well? 

Unfortunately, there is no magical drug that will make disappear instantly things you have been struggling to work with. For example, antidepressant medication can take on average 6 week to start noticing their effects. Also, studies suggest the the combination of medication + therapy is more effective than medication alone. Therapy is directed and tailored to the diagnosis that the patient and their preference. For example, a patient with OCD will have an exposure response prevention.

If I see you in the mall or a public space what should I do?

If by any chance I see one of my patients we typically don’t acknowledge each other. I make sure to talk with my patients in the first visit that if that happens I will not wave, call their name or have any type of conversation. There is a stigma of mental health providers that everyone who visit one is severely mentally ill that is required to be hospitalized. I wouldn’t ever put any of my patients in that position in such a complicated society. Also, mental health providers understand that the information that has been discussed in the visits will make patient feel vulnerable if their provider acknowledge them in public. Is very important to discuss with your mental health provider the possible scenario.

What should I do if I don’t like you as a provider, I am obligated to stay with you?

If there are other options accessible to you I would encourage to search for a provider if you feel you are not connecting with me. Studies suggest the Therapist-Provider relationship is essential for positive outcomes in the treatment. The first few visits are designed to establish patient-provider relationship and also for data collection.

Why I wake up of a dream screaming and recall details sometimes I don’t recall?

Nightmare disorder:

Recurrent frightening dreams during the 2nd half of the sleep cycle (usually during the middle of the night or early morning). Patients will remember the dream after awakening. It will cause functional impairment or distress. The treatment is reassurance if mild. If it is associated with PTSD an antidepressant or prazosin will be very helpful.

Sleep terror disorder:

Presents with recurrent screaming/crying suddenly upon awakening. This will usually take place during the first part of the night. Patient will experience increase heart rate, rapid breathing, and excessive sweating during episodes. Patient wont recall details of the dream. Treatment is education, reassurance and removal of dangerous object in the room.

Can you hospitalize me against my will?

If a patient is an active psychiatric episode and presents imminent harms to self or another person, then a health care provider can initiate the process of involuntary hospitalization. The criteria will vary by state and can range from not being able to care for her/himself to hurting him/herself. Patient will not be forced to undergo treatment for their mental illness, except for those required on an emergency basis. Being hospitalized should not be seen as a punishment, rather should be consideration and commitment for the patients safety and well-being.

References:
https://www.self.com/story/awkward-questions-new-therapist
https://www.amboss.com/us/knowledge/Sleep_and_sleep_disorders
https://www.verywellmind.com/can-i-be-committed-to-a-mental-hospital-against-my-will-1067263

10 myths about psych/mental heal debunked

Let us talk about our pick on 10 common myths around mental health heal that can or have generated the wrong perception about our mental health. Before going ahead, I would also like to add that during these COVID times, it is essential to understand that many mental health issues will likely keep rising more due to economic, health and social problems and we need to have a clear understanding that our mind works like our body: Some wounds heal completely and others may vary depending on the severity, but with help… things may work for the better. Now let us proceed to debunk myths!

• Myth: Mental health issues will not affect me or are rare.

-Fact: They are actually quite common and may affect you without knowing it. The government published a study that shows about 1 in every 5 American adults will experience a mental health issue, at some point in their lives. Children are not immune to them, either, as 1 in 10 young people have experienced depression and about 1 in 25 have lived with another serious mental illness. Just consider that SUICIDE is the 10th leading cause death in the USA. That is far more than homicides each year. Remember: mental issues are not always visible, or easy to spot.

• Myth: There is no hope for people who develop mental disorders as they will never recover.

Fact: Even as a student (everyone in the medical field is technically a student forever) we have already seen people recover from mental illness. Studies have shown that most people do get better, or make a full recovery and can function very well in society. With the appropriate treatments, services and support, recovery, or improvement in quality of life can occur.

• Myth: I can take a pill and not waste time with therapy and self-help.

Fact: Everyone is different and requires treatment according to their needs. Whether it is psychotherapy, medication, or both, varies per person, diagnosis, and treatment plan.

• Myth Mental health disorders are often life-long and difficult to treat

Fact: Not true, as always it varies per person and needs. Some disorders require medications for a period of under a year and some may be extended. Some medications can trigger withdrawal symptoms that can be worse that the original problem. It is important to discuss these issues with your doctor before being placed on a medication for a mental disorder and plan the length of time and tapering of the medication and also discuss therapies available.

• Myth: I can handle my own health problems, and if I can’t ,then I am weak.

Fact: People may have mild mental problems, but do not seek help for it as they have used traditional coping mechanisms (exercise, balanced diet, work, self-help, family/friend time, etc) and can continue with their normal life. Many problems can be mild and be easily solved by these traditional mechanisms.

But when your coping mechanisms are not enough to solve your problems or that your problems overwhelm your coping efforts that is when help is required. This is when your problems do not allow or limit you from doing your regular daily activities. We need to accept our human limitations and seek help when our coping skills are not enough for our problems. It is always better to treat early our problems early rather than later as they may get worse untreated. Just the act of seeking help proves you are not weak.

• Myth: Mental health problem are purely biological or genetic in nature.

Fact: Biological and genetic factors can influence but do not tell the whole picture. Your interaction with the environment and other biological factors can influence the way our mind works. Some mental health diseases can have genetic predisposition but might not necessarily mean you will manifest it.

• Myth: Mental illness can be treated by a preferred medical doctor (primary care physician)

Fact: They can help you with the treatment, but they generally do not have the vast experience as a specialist in the mental health care such as a psychiatrist or psychologist that can provide superior care in this area. This is why in medicine there are many specialties, to address specific issues and needs with the correct treatment and medications.

• Myth: Psychiatry only involves crazy people

Fact: Not necessarily, many patients have other illnesses that are not related to mental health and after correcting the problem or imbalance, they improve. Most patients have a mental illness as a side effect of another health condition.

• Myth: Psychiatrists don’t offer “talk therapy”

Fact: This is a common effective treatment used by psychiatrists. It is used alone or accompanied by other forms of treatments and therapy. Feel free to talk to them, they are there for you.

• Myth: Prevention does not work. Mental illnesses cannot be prevented.

Fact: Prevention is key, focusing on addressing risk factors that can affect the chances that young children or adults develop mental health problems can help to lead a healthier life. Promoting socio-emotional wellbeing in the youth leads to better productivity, lower crime, more success academically and economically, better lifespan and better quality of life.

Sources:
https://www.cognitive-psychiatry.com/common-myths-about-psychiatry/#:~:text=%2010%20Common%20Myths%20About%20Psychiatry%20%201,patients%20we%20see%20have%20an%20actual...%20More%20 ;

https://www.mentalhealth.gov/basics/mental-health-myths-facts ;

https://mhs.tcnj.edu/top-10-myths-about-mental-health/ ;

Ways to cope with and treat Depression
Written and published with permission by Endrina Mangual Valladares

Globally, more than 264 million people of all ages suffer from depression. It's also the world's leading cause of disability. The diagnostic criteria stated in the DSM-5 for depression are: the individual must be experiencing five or more symptoms during the same 2-week period and at least one of the symptoms should be either: depressed mood or loss of interest or pleasure. Depressed mood most of the day, nearly every day. People may experience: anxiety, general discontent, guilt, hopelessness, loss of interest or pleasure in activities, mood swings, agitation, irritability, restlessness, or social isolation, insomnia or restless sleep, lack of concentration, slowness in activity, or thoughts of suicide, changes in weight. Some times these symptoms are not easily noticed by the people surrounding the affected and this can make them feel even more alone. There are different ways to cope and treat depression; psychotherapy, medication, brain stimulation and mind-body medicine. 

For psychotherapy a psychiatrist, psychologist, therapist or licensed clinical social worker uses a variety of techniques to help you with shift your negative thinking. For medication we have antidepressants, mood stabilizers or antipsychotic pills. Some FDA approved medications are Fluoxetine and Escitalopram. Some mood stabilizers used for depression are Lithium and Valproic acid. The FDA has also approved Aripiprazole and Quetiapine slow-release tablets as adjunctive treatment for depressive disorders, and the combination of Olanzapine and Fluoxetine for the treatment of treatment-resistant depression. Some patients for who medication, or psychotherapy has not been successful may want to try electroconvulsive therapy (ECT). Other first-line indications for the procedure include people who are catatonic or suffering from a form of depression known as psychotic depression (depression associated with delusions and hallucinations). Research has shown that lifestyle changes like exercise, good nutrition, improving sleep and avoiding procrastination by keeping up with chores can boost the effects of therapy or medication. It is always important to develop a strong support network, reduce stress levels, and learn to curb any negative thinking.

References:

https://www.medscape.com/answers/286759-14692/what-are-the-dsm-5-criteria-for-diagnosis-of-major-depressive-disorder-clinical-depression

https://www.webmd.com/depression/guide/detecting-depression#1

https://www.fda.gov/consumers/free-publications-women/depression-medicines

https://www.mayoclinic.org/tests-procedures/electroconvulsive-therapy/about/pac-20393894

https://medshadow.org/5-treatments-for-depression-without-meds/

This is a checklist for How to perform a legal name change and gender marker in Orleans Parish, Louisiana: 

- [ ] GO to Civil Court @421 Loyola St New Orleans, LA. Hours: 10am-12pm and 1pm-3pm.

- [ ] PARK across the street @Premium parking $7.25/hr, through mobile, or the app. DO NOT take food, or drink inside.

- [ ] DO take Driver’s license, or State-issued ID (I also took my social security card and passport but did not need them.)

- [ ] ENTER Suite 100 (all the way to the left and down the hall. You are going to the “Self-help area” which is the first office #101 on the left once you enter the suite.

- [ ] Tell them you would like to PETITION for a NAME CHANGE.

- [ ] FILL out the form they supply. They will also NOTARIZE it right then and there. Reason for name change listed: “Gender confirmation.”

- [ ] TAKE the notarized form up to the 4th floor. Pro tip: The elevators are a little hinky so you might want to take the stairs.

- [ ] ENTER the office directly across from the stairs. They, will look over your form and tell you to pay the cashier at the office to the far left.

- [ ] The cashier had me COMPLETE the top part of another form they supplied.

- [ ] LIST “Leon Cannizzaro” as the defendant and your current name as the plaintiff. Pro tip: TAKE a blue ink pen!

- [ ] PAY the cashier $505, they will only accept CASH, or MONEY ORDER for the exact amount. They will give you one certified and one regular copy.

- [ ] TAKE extra CASH if you want another certified copy $9 ($3/page) and/or a regular copy $3 ($1/page) but you can wait for the final copy.

- [ ] You will have a chance to do this with the judge’s approval so don’t sweat it, if you don’t get any.

- [ ] TAKE your receipt and form to the filing office 2 doors down from the cashier. This is where they will provide you with the copies and you will LEAVE the original to be filed there.

- [ ] GO to the District Attorney’s office @619 S. White St New Orleans, LA. Hours: 10am-12pm and 1:30-3pm.

- [ ] If you catch Jay Main during those hours great. If not, you can leave the form there and they will have you call him around 1:30pm when he returns from lunch. I was told that he will call to verify spelling is all correct.

- [ ] When I called Jay Main’s office @504-822-2414 for 1:30pm. He said, “yes, I see the petition for [full birth name] to change to [full chosen name], keeping your last name?” I confirmed and he said to call in 7-10 days to confirm completion.

- [ ] This is where you WAIT for him to file a “reply” which he first said to check back in a week. Then, said a week from Friday making it 10-day turnaround (it ended up sitting at this office for months, hopefully that won’t happen to you.)

- [ ] Call them back when they indicate and if all is completed, GET your Approved Name Change @the DA’s office (see above.)

- [ ] Then, take the ANC form back to the last place you left the form @Civil Court (see above.)

- [ ] Here is where you want cash to BUY some certified and regular copies. Though, they gave (my wife) a few for free.

Hope this helps!

Sharing is Caring,
Dr. Jon Chandler

AKA: First-Generation, Conventional, or Traditional Antipsychotics, Classical Neuroleptics,or Major Tranquilizers.

This class of medications is most often utilized in the treatment of psychotic (positive) symptoms during the course of Schizophrenia.

Here is a list of First-Generation Antipsychotics organized by potency: 

Low Potency:

• Chlorpromazine (Thorazine)
• Chlorprothixene (Taractan)
• Levomepromazine (Levoprome)
• Mesoridazine (Serentil)
• Thioridazine (Mellaril)

Medium Potency: 

• Loxapine (Loxitane)
• Molindone (Moban)
• Perphenazine (Trilafon)
• Thiothixene (Navane)

High Potency:

• Droperidol (Inapsine)
• Flupentixol (Fluanxol)
• Fluphenazine (Permitil, or Prolixin)
• Haloperidol (Haldol)
• Pimozide (Orap)
• Prochlorperazine (Compro)
• Trifluoperazine (Stelazine)

Common Side Effects:

• Extrapyramidal Symptoms (EPS) like:
• Acute dystonic reactions: muscular spasms of neck (torticollis,) eyes (oculogyric crisis,) tongue, or jaw
• Akathisia: A feeling of motor restlessness
• Pseudoparkinsonism: drug-induced parkinsonism (cogwheel rigidity, bradykinesia/akinesia, resting tremor, and postural instability.
• Tardive dyskinesia: involuntary asymmetrical movements of the muscles, this is a long term chronic condition associated with long term use of antipsychotics and is sometimes irreversible even with cessation of medication.

Anticholinergic medications are used to treat EPS:

Anti-Muscarinic agents

• Atropine
• Benztropine (Cogentin)
• Biperiden
• Chlorpheniramine (Chlor-Trimeton)
• Dicyclomine (Dicycloverine)
• Dimenhydrinate (Dramamine)
• Diphenhydramine (Benadryl, Sominex, Advil PM, etc.)
• Doxylamine (Unisom)
• Glycopyrrolate (Robinul)
• Ipratropium (Atrovent)
• Orphenadrine
• Oxitropium (Oxivent)
• Oxybutynin (Ditropan, Driptane, Lyrinel XL)
• Tolterodine (Detrol, Detrusitol)
• Tiotropium (Spiriva)
• Trihexyphenidyl
• Scopolamine
• Solifenacin

Anti-Nicotinic agents

• Bupropion (Zyban, Wellbutrin) – Ganglion blocker
• Dextromethorphan - Cough suppressant and ganglion blocker
• Doxacurium - Nondeplorizing skeletal muscular relaxant
• Hexamethonium - Ganglion blocker
• Mecamylamine - Ganglion blocker and occassional smoking cessation aid[2]
• Tubocurarine - Nondeplorizing skeletal muscular relaxant

Buuuuuuuut, there is such thing as “too much of a good thing” since Anticholinergic medications can cause:

Acute Anticholinergic Syndrome:

• Ataxia-loss of coordination
• Decreased mucus production in the nose and throat; consequent dry, sore throat
• Xerostomia, or dry-mouth with possible acceleration of dental caries
• Cessation of perspiration; consequent decreased epidermal thermal dissipation leading to warm, blotchy, or red skin
• Increased body temperature
• Pupil dilation (mydriasis); consequent sensitivity to bright light (photophobia)
• Loss of accommodation (loss of focusing ability, blurred vision – cycloplegia)
• Double-vision (diplopia)
• Increased heart rate (tachycardia)
• Tendency to be easily startled
• Urinary retention
• Diminished bowel movement, sometimes ileus (decreases motility via the vagus nerve)
• Increased intraocular pressure; dangerous for people with narrow-angle glaucoma
• Shaking

Possible effects in the central nervous system resemble those associated with delirium, and may include: 

• Confusion
• Disorientation
• Agitation
• Euphoria or dysphoria
• Respiratory depression
• Memory problems
• Inability to concentrate
• Wandering thoughts; inability to sustain a train of thought
• Incoherent speech
• Irritability
• Mental confusion (brain fog)
• Wakeful myoclonic jerking
• Unusual sensitivity to sudden sounds
• Illogical thinking
• Photophobia
• Visual disturbances
• Periodic flashes of light
• Periodic changes in visual field
• Visual snow
• Restricted or “tunnel vision”
• Visual, auditory, or other sensory hallucinations
• Warping or waving of surfaces and edges
• Textured surfaces
• “Dancing” lines; “spiders”, insects; form constants
• Lifelike objects indistinguishable from reality
• Phantom smoking
• Hallucinated presence of people not actually there
• Rarely: seizures, coma, and death
• Orthostatic hypotension (sudden dropping of systolic blood pressure when standing up suddenly) and significantly increased risk of falls in the elderly population. 

**!!GOLDEN NUGGET!!**

A mnemonic for Anticholinergic Syndrome: 

• Hot as a hare (hyperthermia)

• Blind as a bat (dilated pupils)

• Dry as a bone (dry skin)

• Red as a beet (vasodilation)

• Mad as a hatter (hallucinations/agitation)

• The bowel and bladder lose their tone and the heart goes on alone (ileus, urinary retention, tachycardia)

The good news is that Acute Anticholinergic Syndrome is completely reversible and subsides once all of the causative agent has been excreted.

• Physostigmine is a Reversible Cholinergic Agent that can be used in life-threatening cases.
• Piracetam (and other racetams), α-GPC and choline are known to activate the cholinergic system and alleviate cognitive symptoms caused by extended use of anticholinergic drugs

With all of that going on it is no wonder that most doctors have switched to the Second-Generation, or Atypical Antipsychotics. That’s not to say that the Typicals are not used, at all. It’s just that Atypicals better treated both the positive AND negative symptoms of Schizophrenia Spectrum Disorders.

Tags: Conventional Antipsychotics, Typical Antipsychotics, Traditional Antipsychotics, Classical Neuroleptics, Major Tranquilizers, schizophrenia, psychosis, atypical, antipsychotic, Low Potency, Chlorpromazine, Thorazine, Chlorprothixene, Taractan, Levomepromazine, Levoprome, Mesoridazine, Serentil, Thioridazine, Mellaril, Medium Potency, Loxapine, Loxitane, Molindone, Moban, Perphenazine, Trilafon, Thiothixene, Navane, High Potency, Droperidol, Inapsine, Flupentixol, Fluanxol, Fluphenazine, Permitil, Prolixin, Haloperidol, Haldol, Pimozide, Orap, Prochlorperazine, Compro, Trifluoperazine, Stelazine

AKA: Second-Generation, Atypical Antipsychotics, or simply SGAs.

These medications tend to be superior to that of Typical Antipsychotics because they treat BOTH positive and negative symptoms of Schizophrenia Spectrum Disorders.

Q: What the heck are positive vs. negative symptoms of Schizophrenia?

A: Simply put, positive symptoms are psychotic behaviors like:

• Delusions and paranoia
• Disordered thoughts and speech
• Tactile, auditory, visual, olfactory and/or gustatory hallucinations
• While negative symptoms are disruptions to normal behaviors and emotions and can sometimes be confused with clinical depression, with symptoms like:
• Flat, or dull affect (showing no emotion, monotone voice)
• Lack of pleasure in everyday life
• Lack of ability to begin and sustain planned activities
• Speaking little, even when forced to interact
  
  

Since both negative and positive symptoms exist within Schizophrenia, these newer, Atypical Antipsychotics are the treatment of choice, here is a list:

• Aripiprazole (Abilify)
• Asenapine Maleate (Saphris)
• Clozapine (Clozaril)
• Iloperidone (Fanapt)
• Lurasidone (Latuda)
• Olanzapine (Zyprexa)
• Olanzapine/Fluoxetine (Symbyax)
• Paliperidone (Invega)
• Quetiapine (Seroquel)
• Risperidone (Risperdal)
• Ziprasidone (Geodon)

 Common Side Effects:

• Dry mouth
• Blurred vision
• Constipation
• Dizziness or lightheadedness
• Weight gain

Sometimes atypical antipsychotics can cause:

• Problems sleeping
• Extreme tiredness and weakness.

With long-term use, atypical antipsychotics can also carry a risk of:

• Tardive dyskinesia

Though atypical antipsychotics are usually given for Schizophrenia Spectrum Disorders, they have become increasingly popular as an adjunct (or in addition) to an SSRI, or antidepressant. In fact the FDA recently approved Abilify for people who do not respond to antidepressants alone. You’ve all seen the commercials where the Antidepressant and Abilify become friends…?

Tags: Abilify, adjunct, antipsychotic, Aripiprazole, Asenapine, Atypical Antipsychotics, Clozapine, Clozaril, delusions, Fanapt, Geodon, hallucinations, Iloperidone, Invega, Latuda, Lurasidone, Maleate, negative symptoms, newer antipsychotics, non-conventional antipsychotics, Olanzapine, Olanzapine/Fluoxetine, Paliperidone, positive symptoms, Quetiapine, Risperdal, Risperidone, Saphris, schizo, schizophrenia, Second-Generation Antipsychotics, Seroquel, SGAs, Symbyax, Ziprasidone, Zyprexa