Bay PPSSYYCCHHOOPPHHAARRMMAACCOOLLOOGGYY Area NEWSLETTER

Volume 3, Issue 1 March, 2000 PINDOLOL AND SELECTIVE SEROTONIN REUPTAKE INHIBITOR Does the Addition of Pindolol Accelerate or Enhance the Response to Selective Serotonin Reuptake Inhibitor Antidepressants? By Talia Puzantian, PharmD, BCPP sion by blocking 5-HT1A autoreceptors nefazodone), 39 (70%) had a decreased laten- Adapted from Puzantian T and Kawase K in which, when activated, reduce normal firing, cy period of response. Increased efficacy Pharmacotherapy 1999;19(2):205-212. 5-HT synthesis, and 5-HT terminal release. when pindolol was added to a serotonergic ven with several antidepressants with What follows is a summary of available pub- regimen was not as much the focus of these differing mechanisms of action, many lished data that addresses this use. trials as was the effect on latency. However, 16 (59%) of 27 patients had increased efficacy Edepressed patients do not respond, The results of six open trials are summarized with pindolol augmentation. These prelimi- respond only partially, or experience a delay in in Table 1. Although it is difficult to make nary results suggested that the drug exerts a therapeutic response. It has been reported that definitive conclusions because these studies significant effect in terms of accelerating pindolol, a serotonin 1A (5-HT1A) autorecep- were not controlled or blinded and involved response to serotonergic antidepressants such tor antagonist, given in combination with only small samples, by putting the data togeth- as SSRIs or nefazodone, but not tricyclic anti- selective serotonin reuptake inhibitors (SSRIs) er one can see a trend favoring the positive depressants (TCAs). may accelerate and enhance their therapeutic effect of pindolol addition. Of 56 patients tak- effects. The proposed mechanism of action is ing serotonergic agents (SSRI, buspirone, that pindolol enhances 5-HT neurotransmis- Continued on page 2 TREATMENT CAN MODIFY RISK FACTORS FOR SUICIDE Jan Fawcett M.D. who committed suicide within one year of gency services where assessment by profession- Presented at a Grand Rounds in Community assessment with a comparison group yielded al staff was compared with self-report by the Psychiatry, San Francisco, CA several major findings. Among these findings patient on a series of psychological dimensions September 23, 1999 was the presence in suiciding patients of signifi- related to the suicide attempt. While profes- cantly increased comorbid panic attacks (62 per- sional staff reported their assessment of despair Certain clinical risk factors are more effective in cent versus 24 percent), significantly more and feeling overwhelmed, the patients reported assessing acute risk of suicide whereas others severe ratings of "psychic anxiety ", a signifi- severe anxiety and a state of emptiness (disso- are better at assessing chronic risk. Some of cantly higher incidence of "global insomnia" ciative anxiety?) leading up to their suicide these acute risk factors can be modified with (implying very severe insomnia), and acute attempt. A recent study of inpatient suicide treatment if they are recognized. Findings from moderate severity of alcohol abuse. These find- records found the presence of severe psychic our research indicates that most of the standard ings were recently partially replicated by Hall et anxiety, agitation, or both in 79 percent of risk factors mentioned in textbooks are probably al., who studied 100 consecutive cases of suicide patients within one week of their suicide. chronic risk factors. For this reason, recogni- attempts severe enough to require hospital tion of acute risk factors is important in direct- admission. On the basis of a standardized inter- These findings, taken together, suggest that ing timely interventions. view of these patients, 90 percent reported severe anxiety or agitation symptoms occurring severe anxiety and 80 percent reported the in patients with depression may be important What information is available to us concerning occurrence of panic attacks shortly prior to their acute risk factors to assess and address thera- acute risk factors in suicide? The Collaborative suicide attempt. A recent Swiss study reported peutically. While there are no controlled studies Depression Study which compared 13 patients on 30 consecutive suicide attempts seen in emer- to establish that the rapid treatment of severe anxiety symptoms reduces suicide risk, the author's clinical experience suggests that this is INSIDE THIS ISSUE the case. We know from clinical experience that if addressed aggressively, anxiety symptoms can Comparison of Zolpidem and Zaleplon ...... 2 be rapidly ameliorated. Controlled studies on County Insert ...... 3 this question would be very difficult to conduct, Reboxetine ...... 5 but research in this area is much needed. Continuing Medical Education ...... 6 Continued on page 2 Bay Area Psychopharmacology Newsletter

PINDOLOL AND SEROTONIN REUPTAKE INHIBITOR ANTIDEPRESSANTS SUICIDE: TX CAN MODIFY RISK FACTORS Continued from page 1 Continued from page 1 TABLE 1 OPEN TRIALS Another risk factor for suicide that may be treatable is the trait of impulsivity. Impulsivity is a trait asso- STUDY DURATION REGIMEN + PINDOLOL 2.5 MG TID RAPID ONSETa GREATER EFFICACYa ciated with the diagnoses of bipolar disorder, bor- (WKS) derline and antisocial personality disorders, and 2 Paroxetine 20mg/d 5/7 NA alcohol or substance abuse histories. A number of 2 Various NA 6/8 studies have shown that impulsive, violent, suicidal 4 Paroxetine 20mg/d 7/9 NA behavior is associated with measures of low sero- 4 Various NA 10/19 tonin function in the brain. Recently, a number of 4 Buspirone 30mg/d 9/10 NA studies from Europe have suggested that mainte- 4 Desipramine 150mg/d 0/5 NA nance treatment with lithium carbonate may signif- 4 Trimipramine 150mg/d 0/5 NA icantly reduce the likelihood of suicide in patients 4 Fluvoxamine 100mg/d 3/10 NA with both bipolar and unipolar affective disorders. 4 Nefazodone 100mg/d 15/20 NA There is evidence to suggest that lithium carbonate acts by enhancing serotonin function at the second aBased on 50% or greater improvement in HAM-D score (by week 1 or 2 for rapid onset) messenger level in the brain. These data suggest the Five randomized, double-blind, placebo-controlled studies with a total of 330 patients have possibility that lithium carbonate maintenance been published to date, with mixed results (see Table 2). Taken together, the data suggest that treatment, in addition to its stabilizing effect on pindolol is effective in some patients in accelerating the response to serotonergic antidepres- mood in bipolar disorder, may specifically address sants. However, whether there are predictors of favorable response remains to be seen, and fur- the behavioral dimension associated with suicide in ther study in this regard is certainly needed. For example, in one study, patients who were depressed patients. For instance, one study has referred mainly from primary care had more rapid response than those referred by psychiatry. shown that patients maintained on lithium carbon- Similarly, another study failed to show a more rapid onset with pindolol, although patients may ate had lower suicide rates even if their bipolar dis- have had more chronic disease and been more difficult to treat. order was not completely responsive to the treat- ment. The growing body of clinical data with TABLE 2 respect to lithium and the prevention of suicide O OF STUDY DURATION N . REGIMEN + PINDOLOL RAPID ONSETa GREATER EFFICACYa point to the possibility that this treatment may (WKS) PATIENTS 2.5 MG TID address a specific behavioral dimension associated 6 111 Fluoxetine 20mg/d No Yes with suicide, possibly through its effect on serotonin 4 33 Trazodone 100mg/d NA Yes function. Adding to this possibility is the observa- 6 80 Paroxetine 20mg/d Yes/no NA tion that patients taken off of lithium seem to have 6 43 Fluoxetine 20mg/d No No increased suicide risk. 4 63 Paroxetine 20mg/d Yes Yes We have reviewed data suggesting that severe anx- aBased on 50% or greater improvement in HAM-D or MADRS (by week 1 or 2 for rapid onset) iety/agitation symptoms occurring in depression are acute risk factors for suicide, and that they may be b Four patients received pindolol 5mg bid instead of 2.5mg tid; five patients received placebo bid amenable to aggressive anxiolytic treatment. We instead of tid also reviewed the association of impulsivity with Evidence from these studies indicate that pindolol accelerates and perhaps enhances therapeutic suicide and depression, as well as the data suggest- effects with antidepressant drugs that act by way of serotonin neurons, specifically SSRIs. The ing that lithium carbonate maintenance may reduce difficulty in extrapolating these data into real world practice is due to lack of information on suicidal behavior. In this report, I have tried to expected response rates, predictors of response, and controlled trials comparing this with other emphasize the importance of recognizing acute risk augmentation strategies such as lithium or triodothyronine. In light of the fact that pindolol is fair- factors for suicide and, when possible, trying to ly safe and well tolerated, has rapid onset of response, is limited by few contraindications, and is reverse factors with treatment. This approach could relatively inexpensive, it may be a sensible and valuable addition to the options for treating depres- improve the ability of clinicians to assess suicide sion. risk and prevent suicide in their patients. A COMPARISON OF ZOLPIDEM (AMBIEN) AND ZALEPLON (SONATA) By Talia Puzantian, PharmD, BCPP and Glen Stimmel, PharmD Adapted from CNS Special Edition 2000 NON-BENZODIAZEPINE OMEGA-1 RECEPTOR AGONISTS

AGENT ADULT DOSAGE ONSET DURATION T1/2 COMMENTS RANGE (MINUTES) (HOURS) (HOURS) Zolpidem (Ambien), 5-10 mg/d 30-60 2-4 1 Searle

Zaleplon (Sonata), Very short duration of effect allows 5-10 mg/d 30-60 1 1 Wyeth Ayerst dosing during night up to 4 hours before arising References available on request. Page 2 March, 2000 ALAMEDA COUNTY BEHAVIORAL HEALTH CARE

PHARMACY PHACTS: MEDICATION COSTS

Richard Singer, M.D., Medical Director Douglas DelPaggio, PharmD, M.P.A, Dir.of CHART #1 TOTAL ATYPICAL PRESCRIPTIONS 1999 Pharmacy Services Mark D. Watanabe, PharmD, PhD, BCPP 140 Risperdal Zyprexa Seroquel ith the dawning of the year 2000, 120 our Pharmacy Network marked the Wbeginning of its 4th year of opera- 100 tion. The BHCS Pharmacy System currently 80 covers 21 programs throughout Alameda 60 County, encompasses over 50 pharmacies, and is available for more than 7,500 clients receiv- 40 ing services through BHCS. 20

The newer antipsychotics (Zyprexa, Risperdal, 0 Seroquel, Clozaril) account for 67% of the pre- Jan Feb March April May June July Aug Sept Oct Nov Dec scriptions for antipsychotics written during 1999, a figure higher than the MediCal data for FY 1999 (56%). On a monthly basis, BHCS atypical prescriptions written for the indigent CHART #2 BHCS MIA PROGRAM ANNUAL SAVINGS population have risen from 100 (Jan '99) to 180 by the close of 1999 (Chart #1). $500,000 Financially, these agents account for 85% of $433,132 the total spending for antipsychotics, the same percentage as reported by the State for $400,000 MediCal spending. BHCS spent over $300,000 $450,000 on these four newer medications last $234,412 year, although the BHCS MIA Program signif- $200,000 icantly reduced that spending. $100,000 The BHCS MIA Program saved over $430,000 in 1999 (Chart #2), an 85% increase over 1998 $0 savings! During 1999, the program did 1998 1999 encounter some problems with Jannsen Pharmaceutica (Risperdal) making their pro- gram unavailable to all indigent clients seen through county services, and Smithkline Beecham (Paxil) changing their program to a CHART #3 BHCS MEDICATION COSTS 1994 - 1999 more difficult process. As a result, direct BHCS costs for both of these agents have $3,000,000 sharply risen over the past 6 months. $ Spent $ Estimated $2,500,000

Overall, the medication budget is similar to $2,000,000 spending in both 1997 and 1998 (Chart #3). Through the savings provided through the $1,500,000 MIA Program, overall costs have remained static, although more a costly medications are $1,000,000 being prescribed. The year 2000 will bring $500,000 new challenges regarding medication costs, and the newer, more expensive drugs. $0 1994 1995 1996 1997 1998 1999

March, 2000 Page 3 Alameda County THE LPS ACT - FOR BETTER OR WORSE?

here has been considerable activity over In addition, several major themes emerged Another area involved the quantity and content the past several months, accompanied across all forums related to desired changes in of involuntary holds. It included creation of a Tby at least as much controversy, since the current public mental health system rather 24 hour hold; changing the 14 day hold to 28 Assemblywoman Helen Thomson (D-Davis) than the LPS Act itself. days; combining the hearing on an involuntary announced her intention to propose changes to 1. Fund community-based services more hold with the hearing on medication; creation the Lanterman-Petris-Short Act. Established in fully, which may reduce the need for of a 28 day hold to follow, if necessary, the 3 1969 to outline the conditions under which involuntary care. A variety of twenty- day hold; shortening the length of holds while mentally ill people could be involuntarily hos- three different services were listed. making them easier to renew; shortening or pitalized, proposed changes to the law include 2. Provide education of law enforcement, extending the 180 day certification; creating expanding the criteria for involuntary commit- judges, the general public and others an option to renew the 14 day certification for ment, increasing in-hospital detention time, about mental illness, available treatment danger to self. and initiating court-ordered outpatient invol- interventions and the current LPS legal untary treatment. structure. Still other suggestions related to involuntary 3. Enforce the LPS Act more consistently holds included either limiting or expanding A series of community forums have been con- across counties. Better definition of their criteria, such as: ducted across the State by professional facili- "gravely disabled" was specifically 1. clarifying the definitions of "gravely dis- tators, with one held in Oakland 11/15/99. noted. abled" and "danger" They provided the opportunity for people of 2. changing the criteria to take substance different views and experiences to express In addition to the common points of interest abuse into account themselves but another result was several com- and major themes that were more general in 3. changing the law so that involuntary mon points of interest: nature, different forum participants expressed holds are made by trained mental health 1. Rights Protection - civil rights in any specific potential amendments to the LPS professionals and not law enforcement involuntary proceeding, the right to Act.They included the elimination of involun- officers, and/or requiring peer review quality care, the right to have basic tary care as well as the expansion of involun- within 24 hours human needs met, and the right to per- tary care to require mentally ill people to 4. changing the law to take into account sonal dignity in all legal and treatment receive treatment before meeting current crite- quality (with a clear definition) of life situations. ria for involuntary hold, or after hospital dis- and not just safety. 2. Safety - safety of consumers, family charge to ensure compliance with treatment. members and the general public. Others involved expanding the criteria for con- It is the intention of Assemblywoman 3. Quality of Care - concern that insuffi- servatorships to include "danger to self or oth- Thomson to amend the bill early this year. cient voluntary, preventive and accessi- ers", and the expansion of the Patients' Rights Whether any of these or other proposals even- ble services leads to unnecessary invol- Advocate role and having that Agency no tually become part of the LPS Act will be untary treatment or inappropriate treat- longer report to the Local Mental Health debated long and hard and remains to be seen. ment (e.g. criminal justice system). Director.

CLIENT MEDICATION EDUCATION PROJECT

lameda County Behavioral Health ask about their psychiatric Care Services is expanding its provi- medications. Subsequent Asion of medication-focused educa- meetings will review material tional sessions for clients served by BHCS specific to a particular thera- clinics. Through participation in these added peutic class, i.e., one session sessions, to be conducted by BHCS pharma- devoted to antipsychotics, cists, clients will obtain information about the and another to antidepres- benefits of medications used to treat different sants and mood stabilizers. brain disorders. The program will focus on Supplemental medication- how to correctly self-administer medications, specific written information evaluate their therapeutic effects, and be able as currently available from BHCS will also be medications, types of symptoms treated by the to identify significant side effects associated distributed. medications, recommended dosage/expected with different classes of medications. time frames of response, side effect issues, Ideally, the sessions will be held in a small and food or drug interactions (including over- The working template for the project involves group format that allows for useful interac- the-counter and street drugs). a series of at least three instruction sessions tions among clients and staff. Furthermore, to be held at monthly intervals. The first ample opportunities would be available to ask The first phase of implementation will take meeting will be an overview discussion of the questions and discuss information presented. place at two pilot sites, Oakland Community types of important questions clients should Major teaching points would include names of Support Center and Bonita House.

Page 4 March, 2000 Bay Area Psychopharmacology Newsletter REBOXETINE: AN ANTIDEPRESSANT SHOWCASE FOR NOREPINEPHRINE

Mark D. Watanabe, PharmD, PhD, BCPP Activities at these receptors are thought to be tic effect as determined by statistically sig- associated with the various anticholinergic, nificant differences from placebo was also eboxetine is a novel antidepressant sedative, and cardiovascular side effects found to occur earlier with reboxetine com- whose mechanism of action involves often seen with psychotropic medications. In 3 the selective inhibition of norepi- pared to desipramine (14 days vs. 21 days). R addition, reboxetine also appears to exhibit In a study which compared 8-10 mg/day nephrine reuptake with minimal effects on only weak inhibitory effects on monoamine other neurotransmitters. Pharmacia & reboxetine to 20-40 mg/day fluoxetine in oxidase B and no effects at all on monoamine another multicenter protocol which enrolled Upjohn, Inc. anticipates releasing this agent 1,2 sometime in 2000 after receiving final oxidase A. depressed participants from inpatient and approval from the FDA for the treatment of outpatient/day hospital settings over 8 The molecular structure of reboxetine allows weeks, both antidepressants were similarly depression in adults. Its brand name will be it to exist in several three-dimensional orien- Vestra. effective in reducing the severity of depres- tations known as enantiomers, two of which sion (each with greater efficacy over place- will be present as a mixture in the commer- A pharmacologically-based discussion of bo).5 depression has historically focused on the cial formulation (one of which is more phar- activity of two key neurotransmitters, sero- macologically potent than the other). In Because major depressive disorder is gaining tonin and norepinephrine. This is reasonably human volunteers, the elimination half-life recognition as a chronic illness, it is also supportable, given the clinical experience of for both enantiomers were found to be simi- important to identify antidepressants which using known therapeutic agents: Monoamine lar at about 12-16 hours, with the time to demonstrate efficacy in preventing relapse oxidase inhibitors enhance the effects of both reach peak plasma concentrations approxi- and recurrence of illness in addition to their by interfering with their metabolic inactiva- mating 2 hours. It is extensively bound to success in treating an acute episode. To this tion; tricyclic antidepressants are known to plasma proteins, Reboxetine particularly !1- end, a placebo-controlled study was designed inhibit the presynaptic reuptake of both from acid glycoprotein, and ingestion of food does to assess the long-term efficacy and tolera- the synaptic cleft; and serotonin reuptake not seem to have a significant effect on over- bility of reboxetine 8 mg/day in patients with inhibitors (SRIs) are now the most common all bioavailability. Reboxetine is also exten- a diagnosis of major depressive disorder, first-line medications used in the treatment sively metabolized by the liver. Although recurrent, and who had responded to an ini- of depression. A growing body of evidence hepatic impairment may therefore decrease tial 6 weeks of treatment.6 Subjects were fol- suggests that there may be differential effects its metabolic clearance, small studies in lowed for a subsequent 46 weeks in a double- of serotonin and norepinephrine as they patients with alcoholic liver disease have not blind phase and tracked for rates of relapse, demonstrated any additional adverse events; relate to the pathogenesis of target symptoms which was defined as #50% in the total associated with the typical depressive therefore, recommendations for across-the- score on the Hamilton Rating Scale for episode. By this model, the noradrenergic board dosage reductions in this population Depression. The reboxetine group was found system modulates drive, energy, learning and remain unclear. However, since reboxetine to have a markedly lower relapse rate than memory, and the serotonergic system modu- and its metabolites are excreted primarily in placebo (22% vs. 56%). lates mood; both may functionally overlap in the urine, the effect of renal impairment on modulating sleep disturbances and anxiety. reboxetine pharmacokinetics are potentially In all studies, reboxetine was reasonably more profound and significant, suggesting well tolerated. The most commonly reported The introduction of venlafaxine, a dually- that a dose reduction is definitely warranted side effects in the published trials included active agent which selectively inhibits the in patients with renal insufficiency. insomnia (6-13%), increased sweating (8- reuptake of serotonin and norepinephrine, Likewise, because of age-dependent decreas- 18%), urinary hesitancy or retention (8- possibly rekindled an awareness that remedi- es in kidney function, dosages should be 11%), constipation (17-28%), and dry ation of dysfunctional noradrenergic as well reduced in the elderly. mouth (22-45%). There were no notable or as serotonergic systems may be necessary to clinically significant alterations detected in provide additional benefit to patients who Reboxetine itself is metabolized by the vital signs, laboratory parameters, or elec- may not fully respond (or are intolerant) to cytochrome P450 3"4 isozyme (CYP3"4), trocardiogram monitoring.3,5,6 the selective SRIs. Reboxetine, in a sense, and does not cause appreciable inhibition of represents a further swing of the pendulum CYP1"2, CYP2C9, CYP2C19, CYP2D6, As with any newly introduced medication, toward noradrenergic mechanisms because CYP2E1, or CYP3A4.2 additional clinical experience and research is of its potent and selective in vitro inhibition needed to further define the place of reboxe- of CNS neuronal reuptake of norepinephrine In comparative clinical trials, reboxetine 4-8 tine in the antidepressant pharmacopeia. Its (with a 64- to 133-fold weaker potency on mg/day (given on a b.i.d. regimen) was found unique mechanism of action among currently serotonin reuptake and negligible effects on to be superior to placebo and as effective as marketed agents may certainly pique the dopamine reuptake). Reboxetine only has a 100-200 mg/day desipramine after a four- interest of clinicians seeking new alterna- slight affinity for serotonergic 5HT2C, hista- week trial in hospitalized depressed patients3 tives with demonstrated therapeutic efficacy. mine H1, and muscarinic cholinergic recep- and 150 mg/day imipramine after a six-week tors, and no significant affinity for adrener- multicenter trial involving both inpatients References available on request. gic (!1, !2), dopaminergic (D2, D3, D4), or and outpatients being treated for a major serotonergic 5HT or 5HT receptors. 1A 2A depressive episode.4 The onset of therapeu-

March, 2000 Page 5 CONTINUING MEDICAL EDUCATION

Doug DelPaggio, PharmD MPA MILLS PENINSULA HEALTH SERVICES SAN FRANCISCO GENERAL HOSPITAL SAN MATEO COUNTY MENTAL HEALTH SRV. 1783 El Camino Real Sierra Rooms 1001 Potrero Ave., Room 7M30 225 W. 37th Ave., Multi-Purpose Room Burlingame, CA 94010 (650) 696-5313 San Francisco, CA (415) 206-4938 San Mateo, CA (650) 573-2530 Discussion of Life & Death Options with Management Options for Drug-Induced Hypnosis, Terminally Ill Clients, Peter Goldblum, Ph.D. Orgasmic Dysfunction, Glen Stimmel, Pharm.D. Thomas Nagy, M.D. March 7, 2000 12:15 - 1:45 pm March 10, 2000 12 noon - 1 pm March 14, 2000 12:15 - 1:30 pm Update on the Diagnosis in the Management Mood and Anxiety Disorders in HIV Self Mutilation & Borderline Organization, of Depression, Mark Rappaport, M.D. Positive Patients, Dan Karasic, M.D. Jeffrey S. Kline, Ph.D. March 21, 2000 12:15 - 1:45 pm March 24, 2000 12 noon - 1 pm March 28, 2000 12:15 - 1:30 pm Psychotherapy with Cancer Patients, Use of Atypical Antipsychotics in Bipolar Acupuncture Norman Postone, M.D. Disorder, Terrence Ketter, M.D. Jeff Gould, M.D. April 4, 2000 12:15 - 1:45 pm April 21, 2000 12 noon - 1 pm April 11, 2000 12:15 - 1:30 pm The Treatment of Social Phobia Psychosis and Antipsychotics in Late Life, Brain Imaging in Neuropsychiatric Edward Morhauser, M.D. Dilip Jeste, M.D. Disorders, Allen L. Reiss, M.D. April 18, 2000 12:15 - 1:45 pm April 28, 2000 12 noon - 1 pm April 25, 2000 12:15 - 1:45 pm

Success of Failure: The Complexity of The Management of Movement Disorders Dual Diagnosis Summit, Rick Ries, M.D. Assessment Alan Skolnikoff, M.D. Associated with Antipsychotic Therapy, March 16, 2000 8 am - 4 pm May 2, 2000 12:15 - 1:45 pm Richard Trosch, M.D. Health Education Center Travel Through Crime, May 12, 2000 12 noon - 1 pm Bechtel Auditorium 400 Hawthorne Ave. William DeLeon Clinical Culture vs. Evidence in the Oakland, CA 94609 (510) 567-8106 May 9, 2000 12:15 - 1:30 pm Management of the Agitated, Psychotic Improving the Management of Anxiety Patient, Michael Allen, M.D. Disorders, Carolyn N. Gracie, M.D. June 9, 2000 12 noon - 1 pm May 16, 2000 12:15 - 1:45 pm

The Bay Area Psychopharmacology Newsletter is produced quarterly. Editorial Board: Alameda County - Richard P. Singer, M.D., Medical Director, Douglas DelPaggio, Pharm.D., MPA, Director of Pharmacy Services, Mark Watanabe, Pharm.D.; San Francisco County - Peter L. Forster, M.D., Medical Director, Talia Puzantian, Pharm.D., San Francisco General Hospital, Renée Williard, Ph.D.; San Mateo County - Robert Cabaj, M.D., Medical Director, Barbara Liang, Pharm.D., Director of Psychotherapeautics; Santa Clara County - Soleng Tom, M.D., Medical Director, Gary Viale, Pharm.D., Assistant Director of Pharmacy; Managing Editor - Peter L. Forster, M.D.; Production Manager - Sue Contreras.

THIS NEWSLETTER IS SUPPORTED BY UNRESTRICTED EDUCATIONAL GRANTS FROM:

The Bay Area Psychopharmacology Newsletter 2532 Santa Clara Ave., PMB 219 Alameda, CA 94501