Good evening, everybody, and welcome to tonight's webinar. My name is Bruce Stevenson, and I have the honour and privilege of chairing this evening's webinar. I'd like to start off by saying a big thank you to our sponsors, Fort Healthcare.
It is their generous sponsorship that allows us to bring you this webinar this evening and the fantastic information that we are going to get from our amazing speaker tonight. Little bit of housekeeping before we move on to our presenter. For those of you that have not joined us before, we are recording the sessions.
The recorded version will be up on the website in the next 24 or 36 hours, and, we cannot go back on slides during the presentation, but you are welcome to go back and watch the recorded version, and then you can fast forward and rewind and pause to your heart's content. If you have any questions for us, please hover your mouse over the screen. You'll see that a little control bar pops up.
It's normally a black bar at the bottom, and there's a Q&A box there. Just click on that, and then type your questions in there, and we will keep all of those over to the end, and we will get through as many of those as what we possibly can. Without further ado, let me introduce the speaker for this evening.
Doctor Kathryn Johan, is, has been a vet for over 25 years and is a double board certified specialist in veterinary behaviour medicine who believes that the mental and emotional health of veterinary patients is equally as important as their physical health. Catrin owns and runs a small animal veterinary practise, the German Veterinary Clinic in Abu Dhabi in the UAE. Which is the first ISFM gold standard cat-friendly clinic, fear-free, accredited veterinary practise, and zero pain practise in the Middle East.
Catherine is also the proud owner of Trinity Veterinary behaviour, an online platform dedicated to facilitating pet owner and vet to vet clinical behavioural consultations, as well as providing amazing educational resources, membership, and coaching for pet care professionals on all things veterinary behaviour medicine. Catrin, welcome to the webinar, Witte, and it's over to you. Thank you so much for the introduction and good evening everybody, or good day if you're watching this back on the replay.
So I'm super excited to talk to you this evening about psychopharmacology, and I guess the, the first question is why this topic. And I think there are a number of reasons that this topic is, is really relevant and really important right now. I think first and foremost, we are seeing more and more anxious pets in our practises.
I've just come back from a couple of days at BVA Live, and the number of vets that spoke to me that said they are seeing increasing numbers of anxious pets in their practise was really quite astounding. Secondly, I think we're also being called upon as vets more and more to potentially prescribe psychopharmacology, and I think many of us don't have a lot of knowledge, experience. I certainly wasn't taught about psychopharmacology at vet school.
I'm sure many of you weren't either. And we now have either caregivers or perhaps allied professionals who are coming to us as vets and, recommending medication or suggesting medication. And then we're a little bit, I guess flummoxed because we perhaps don't feel comfortable or don't have the knowledge, or the confidence to safely and effectively prescribe these medications.
So, the topic of tonight's webinar is psychopharmacology, one of the puzzle piece in the veterinary behaviour treatment plan. And I think the first really important thing to say is that behaviour medications are not a stand-alone treatment. They're not a miracle fix, they're not the golden bullet, they're not, you know, a magic, treatment, they're always to be seen as part of a multi-modal treatment plan when it comes to behaviour medicine.
So we've got so many other things that we want to think about. We want to think about environmental management, perhaps behaviour modification or training in inverted commas, that learning piece. We need to educate the caregivers, we need to consider other modalities such as diet, supplements, pheromones.
We must, must, must always think about physical health conditions. Contributors, we all know that chronic pain is, is really becoming quite important, but there are other things such as GI health, skin health, neurological health that can all contribute to, behavioural presentations. We also need to make sure that the individual's, needs are being met, and so on.
So you can see there's a whole host of things that goes into the veterinary behaviour treatment plan. And psychopharmacology is really only one of those puzzle pieces. So who can diagnose animal behaviour problems and who can prescribe veterinary psychopharmaceutical medications?
And this is where things start to get a little bit interesting. So obviously it's us vets that can do both of those things. However, we have so many paraprofessionals, whether they're trainers or non-veterinary behaviourists, we all know that it's a very much an unregulated term.
Who are oftentimes advising caregivers around these medications, and that can be a bit of a grey area, because many of these allied professionals have really good knowledge about the medications, but they absolutely can't prescribe, they can't recommend on dosages, they can't even really recommend medications, they're not aware of that patient's full medical history, potential medication interactions, and so on. So it really does fall down to us as vets to be the responsible professional when it comes to these medications, and that's why we absolutely have to know at least as much or even more than the allied professionals about these medications when caregivers come to us, for help and support. So, what is psychopharmacology?
And there are a number of different other words that these medications can be called by, so psychotropic medications you might have heard of, or psychoactive medications. I think most commonly and colloquially we'll refer to them as behaviour meds. But basically, they are medications that affect the mind.
So defined as medications or other substances that affect how the brain works and causes either temporary or long-lasting changes in mood, awareness, thoughts, feelings, and therefore behaviour. And this piece about temporary or long-lasting changes is really, really important, depending on the medication types we choose, and we'll go into that in a little bit more detail. But what I really want you to take away from this particular slide is that these medications are not inert.
They're, they're quite potent medications. They absolutely can affect how the brain works. They affect neurotransmission, that's gonna be a big piece of today's webinar.
And again, they need to be used with knowledge and care and supervision. So again, it's another sort of reason why we as vets absolutely have to have that knowledge, and we absolutely have to be involved when it comes, to recommending these types of medications. We also need to be really aware that within the, the class of psychopharmacology or psychopharmaceutical medications, we have medications of human abuse.
So if we think for example about benzodiazepines, we can think about some of the stimulants potentially. So we have to be absolutely aware of that. We have to be aware of the humans that are within the sort of the realm of our patients, and we absolutely have to be mindful when we're thinking about prescribing, whether we can safely do so, whether we can keep everyone safe that's kind of in that sort of sphere of influence of that animal.
And again, another reason why we have to be involved here. I also just want to point out that we have individual country differences, so I'm sure there are going to be many practitioners joining us from all around the world for this webinar. And we have to be aware that different countries have different licencing of individual medications.
Now, many of the licenced veterinary psychopharmaceutical, medications are licenced for the same presentation or the same diagnosis, or the same indication, I should say. But that might vary slightly from country to country, and we might have medications that are licenced in some countries but not in others. Some medications that we use are fall under the bracket of scheduled medications, so I mentioned the benzodiazepines earlier, but also medications such as gabapentin and pregabalin.
Which we're using more and more commonly fall under different schedules in different countries, so we need to be really aware of that. With that come legal aspects and legal considerations and, personal liability. So everybody needs to be aware that when they're using these medications, that they do so for their individual patient that is under their care, and that they know the medical history of, where things like medication interactions and.
Comorbid comorbid diseases and so on become really important. And really importantly, this is such a young field and it's an ever-changing field. So if I think back to the beginning of my residency, which is, which was in 2019, already since then, in those kind of seven years alone, we've had so many changes within the field of psychopharmacology.
We've had new medications being licenced, Boncat most recently and TESSE, for example. But we've also started perhaps using medications that maybe we weren't using those 7 years ago. So for example, when I was starting my residency, medications such as venlafaxine were just emerging in the veterinary field, and now they're really quite commonplace.
But as we kind of learn more, understand more, and as there are more developments, you know, we have to kind of keep abreast of these, these changes. OK, what are we gonna talk about today? So we're going to start off a little bit by speaking about who and when.
So what patients might be really good candidates for psychopharmacology and in what contexts. So it's a little bit about patient choice, when do we even think that this might be the right thing to start considering, and I'm gonna talk you through a couple of really easy sort of ways to remember that or think about that, if you're thinking about is this a good candidate for psychopharmacology or not. We're gonna talk a little bit about the constraints of using psychopharmacology and when might treatment failures occur.
Then we're going to dive a little bit into the neurotransmission. We're not gonna go terribly deep into this, but I want you to understand that choosing psychopharmacological medications is really all about neurotransmission, and we do need to understand a little bit about it. But again, it's going to be really clinically relevant, it's gonna be really practical, so we're not gonna go too deep into, neurobiochemistry, but it's gonna be really important.
And then finally we're gonna talk a little bit about long acting versus short acting medications. And this is one thing, if I wish, if I could wish for, one thing that every vet knows about psychopharmacology, it's probably this, the difference between long acting and short acting medications, when we might use one over another, can we combine them, how do we use them? So we'll talk a little bit about that.
All right. Let's start about patient choice. So who would be a good candidate for behaviour medications?
Well, for sure, that would be patients showing signs, so behavioural signs that we would associate with emotional states, so negative emotional states, such as fears, phobias, panic disorders, chronic anxiety states, conflict behaviours and stress. So I think fears and phobias are probably relatively easy to understand. So we all know those dogs that have separation related phobias or noise phobias and the behavioural signs that we can see associated with these can be really quite extreme.
So you can see the picture of this little doggy here who's trying to chew his way out of a door, either as a result of separation related behaviours or a noise. Perhaps we can also talk about panic behaviours when we talk about some of these things. So again, that dog that desperately tries to be reunited with their caregiver.
I've had one patient that's actually jumped through a closed window just to be reunited with their caregiver. And you can understand the kind of behavioural motivation and the kind of panic that might underlie some of these behavioural signs. Chronic anxiety states, I think we're all, pretty familiar with this.
So these are the patients that come in. That show anxieties or perhaps fears in multiple contexts, multiple situations, so that spend most of their waking hours or most of their waking day in a state of anxiety, where that anxiety becomes all pervasive to the point where it, impedes on everyday normal activities and it impairs learning, for example. So these chronic anxiety or.
Emotional, disorder states. Conflict is quite interesting. So conflict is often to do with social relationships, and can be an animal that is conflicted in terms of what behaviour to choose.
So if we are talking about social relationship, for example, with a caregiver, this could be a dog that's really closely bonded to their caregiver. So social bonds and relationships, especially for dogs. Really, really important, hugely valuable, but where maybe that same caregiver is using punishment from time to time or aversive methods, and that puts the dog in a state of conflict between wanting to be close to that caregiver because of that social bond, but also not being quite sure, around the predictability of that caregiver's behaviour.
So, conflict states can be really difficult for, for some animals to deal with. And then stress is something that we often think about in cats, but of course all species of animals can experience stress. But I think cats display stress so well in inverted commas, because there we often see the physical manifestations of that emotional disorder.
So we'll see cats with FIC for example, or upper respiratory disorders or over grooming. Of course we always have to make sure that we're looking for . Physical health signs or we're ruling in or out physical health signs when it comes to some of these behavioural signs, but stress would be another one.
The other kind of emotional state or the emotional, I don't want to call it a disorder, but I guess the emotional state I would think about would be patients that show extremely high arousal levels. And we sometimes classify that as reactivity or impulsivity, that kind of very sort of fast or short latency to arousal when behaviours go from kind of 0 to 100 really, really quickly. And just to demonstrate this a little bit, I've got these two, what we call the circumplex of emotions, so both, both canine and feline.
And if you think about the arrows going from up to down, that would be your emotional arousal. So we can have high emotional arousal or low emotional arousal. And then if you look from left to right, we have valence.
So on the left hand side, we have negative emotional state, and on the right-hand side, we have positive emotional state. And whenever we have these really high arousal states or this very sort of fast, shooting up that ladder to a high high arousal state is where we might consider psychopharmacology. And that could be particularly if we have negative valence, so we've got higher arousal and negative emotional state where we usually then talk about fear or frustration.
But sometimes we can see really high arousal levels with seemingly positive valence, and that for dogs can be things like barking, lunging, pulling on the leash, jumping up, so. And then it, it kind of is up to us as clinicians to determine how close that animal is to that left hand side of the spectrum and where, you know, where in that sort of spectrum we want to come in with psychopharmacology. I always say to my caregivers or vets that I speak to, what we're, what we're trying to achieve is an animal that spends most of their time in the bottom right hand quadrant, which is calm.
So for cats that would be sleeping, resting, lying curled up. Those typical feline behaviours for dogs that would be a calm focus, being responsive to cues, calm walking on the lead, you know, behaviours that are very, species specific or breed specific or even individual specific, such as chewing or digging. I know people don't love digging, but digging is actually a, a, you know, an innate canine behaviour.
So, If we have a patient that we find it's, they're finding it difficult to access that bottom right hand quadrant and they're spending a lot of time above that midline in that sort of high arousal state, those could be times that we consider psychopharmacology, especially if they're high arousal and they're negative emotional valence. So what about what we would term as true pathologic disorders? So, for example, abnormal repetitive behaviours.
So there we have true neurotransmitter imbalances, and that is definitely, a case where, where psychopharmacology is, is very likely indicated. Cognitive dysfunction syndrome, we're seeing more and more in both dogs and cats. I think we're recognising it better, which might be why we're seeing it more.
But cognitive dysfunction could also be really respondent to psychopharmacology in terms of improving behavioural signs. And then we can sometimes also use psychopharmacology to support the treatment of other physical disease. So pain, especially chronic pain is a really classic example here.
So we've got quite a lot of medications, so I'm thinking for example about gabapentin or venlafaxine maybe that target both emotional state as well as addressing analgesia, providing pain relief and so on. So sometimes we can choose a psych psychopharmaceutical agent to aid with that. So that was a little bit the who.
Now we're gonna chat a little bit about the when. So what could be the types of contexts that we think about using medications. So the first that I would always think about is to improve the welfare, of course, initially of our patients, of the animals, but sometimes that also involves the welfare of the caregivers.
So when we have caregivers that are unable to leave the home because their patient, sorry, their pet suffers from separation. Distress or separation, panic disorders, then that massively impacts their welfare. Or if we have a caregiver that is being exposed to aggressive behaviours from their pet, then again, that affects their welfare, and these might be times when we start to think about psychopharmacology.
We can also think about behaviour meds when that relationship is about to break down. So that really important human-animal bond, that really important relationship is on the verge of breaking down due to these unwanted behaviours, and the pet is facing either rehoming or potentially even euthanasia. Now, I'm not saying that euthanasia in some cases is not the right answer.
It absolutely can be the right choice and the right answer in some cases. However, there are other cases where I think there's a lot we can do, both with and without psychopharmacology that can really help to restore that, that human-animal bond. And the most common example I kind of think about here is our cats peeing outside the litter box.
That is such a common reason for relinquishment or even euthanasia in cats, and there is actually quite a lot we can do, both with psychopharmacology as well as without. So. If we think that we can make a change quickly with the help of psychopharmacology in some of these cases, while we're addressing the environment, while we're addressing all of the other pieces of that treatment puzzle, then that might be a situation where we could actually prevent rehoming or even save a life.
So this is a really interesting one. So we might think about psychopharmacology when learning isn't happening. So when we think that behaviour modification or training alone is unlikely to improve behaviours, or in cases that haven't responded appropriately to training, or those learning pieces.
And this is often when I work together with trainers or allied professionals, when they say, You know, normally, I'm a really good trainer, my strategies work, you know, we, we, we're really successful at changing behaviour in a really positive way over the long term. But in this particular patient, it's just not working. And that could be because that patient has an anxiety disorder because their brains just aren't in a place where they're easily able to learn.
And that is sometimes where psychopharmacology can be really, really game changing. Because by reducing anxiety levels, by reducing stress levels, we're actually able to create a patient that is then. Able to engage with these amazing trainers and behaviour modification plans, and that's when new learning, more appropriate learning happens, and where we might, over time, then be able to come off psychopharmacology.
So that's a bit of a question in itself, how long do our patients stay on these medications for, but these are the situations where we can implement appropriate learning, where maybe there is, an option down the line to consider weaning off. So another context would be where it's difficult or dangerous to proceed without. So we, where we have risk of injury or self-harm.
So especially where we have patients that might be self-harming themselves. So this little cat on the bottom right hand side here is actually one of my residency cases, a little cat called Christmas. And he, this is exactly what he looked like when I first met him.
He had alopecia literally everywhere. So you can see like insides and outsides of the forearms, the ventral abdomen, but also kind of the, the sides of the abdomen, both thighs, both outside and inside. And yes, absolutely, we have to 100% rule out any kind of, you know, physical health causes, but that's quite severe sort of.
Self trauma. Now, he didn't get to the point where he was actually opening up wounds or causing wounds. But some of my patients do do that.
But that's how extreme sort of the presentations can be. We all know the patients that kind of chew their tail tips. Now, that can be, again, due to, neurological pain or, You know, other kind of physical health pieces, but sometimes we have abnormal repetitive behaviours that can cause self trauma, acrylic dermatitis, and so on and so forth.
And then of course we want to be thinking about harmful behaviours to others, so where we have aggressive behaviours, whether that's to, people that are in the home, outside of the home, maybe other animals, maybe other pets within the home. So those are all things that we need to consider. And then finally, this is again a bit of an interesting one, if we want to help the animal cope with the environment they live in.
Now, there, there is a little bit of an ethical debate to be had here, because surely if we could change the environment sufficiently, we might not need psychopharmacology. In the UAE I see a lot, a lot, a lot, a lot of intercat aggression cases, and I know. That by maybe removing one of the cats, rehoming one of the cats, finding a different solution for one of the cats or the other cat, or maybe even a couple of the cats, I could most likely resolve that situation, and we probably wouldn't need to resort to psychopharmacology at all.
We can reduce the stress in the home, you know, we can make sure that everybody's happy, in their kind of new homes, and that would probably be a good resolution. To that situation. However, there are some caregivers that absolutely, are adamant that they don't want to rehome their pets, or where it's not an option, where there, there's, there maybe is no easy solution to rehome, there's maybe no friends or family members or colleagues that would easily adopt that cat.
The situation in the in the UAE is a little bit different there. We don't have, sort of, you know, government charities or shelters even. So that can be a tricky situation.
So that's then when we have the conversation about, well, if you want to keep all of your cats in the home, then we're going to have to somehow manage their stress. And yes, absolutely, we can, you know, we can talk about optimising the environment and resources and use pheromones and diets and supplements. But sometimes the level of stress and The resulting behaviours and the level of aggression between the cats can be so severe that we have to consider psychopharmacology.
So that's a bit of an interesting one, but definitely one that is to be debated and that certainly is also to be, to be debated with the caregivers, because sometimes I've also said, listen, We, you know, we potentially could keep all the cats in the home, but it does mean that we're going to need to medicate at least one or maybe more than one of the cats. And that in itself can sometimes be incentive for the caregivers to seek options to rehome. OK.
So this is one of my charts that I have on my consult room table all the time. And it's just a bit of a, a sanity check for me when I'm thinking about, is this a patient that I think would be suitable for psychopharmacology? Do we think this is a, a context that is, is really, lends itself to psychopharmacology?
So I kind of go through this list. Now, this is by no means exhaustive. It just gives me a few sort of impetti to think about things.
Ability to manage the environment. So that's what we kind of spoke about just now, but that can also be extended to other environments. So, we know, for example, that many dogs struggle with busy urban environments.
Every time you turn around the corner, there's something, right? There's a trigger, there's another dog, there's a child, there's a scooter, there's a, you know, a loud car, whatever it might be. And sometimes we don't have the ability to manage that.
Yes, we can choose to walk them early or late, but even then, sometimes, we're just not in control of the environment. So if we are really not able to to manage the environment well, then we might think about prescribing. Latency to arousal.
So that goes a little bit back to that circumplex of emotions that I spoke about earlier. So if we have these animals that have these really short fuses in inverted commas, you know, the ones that perhaps give very little warning or the warning isn't particularly obvious to the caregivers, that arouse quickly, that are very impulsive, . That is, is very short, that latency, then we might think about prescribing in order to elongate that ladder.
So we sometimes talk about that, right? Like the elongation of the ladder in order to give us more time to read body language signs, to be able to change something in the environment, to prevent, something from happening. Recovery from triggering events.
So if we have really long recovery times, I'm sure you're all aware of, you know, the imported dogs that have come into the country that spend the first two weeks literally in their travel crate, might come out to eliminate or to eat something and then just stay in, in their crate. So that's poor recovery from a triggering event that might have been a road trip from somewhere in Europe. I also have cats, in an inter-cat aggression case where there's been a fight in the household.
That, you know, one cat hides under the bed for ages, for like days before they come out. That can be the same with noise events. I've got 11 of my patients who's very, very noise sensitive, who when he first started showing those signs, he literally spent 23 hours a day in the basement, hidden under, a little shelf, and that's where he would stay.
So again, that's poor recovery or long recovery. So those are situations where we might think about prescribing. How predictable is the environment, how predictable is the context.
If we know that a particular dog might growl or grumble only when approached whilst they're lying on their bed, then that's something that we, we perhaps are able to, to manage. It's quite predictable. We know not to go near them when they're resting on their beds because that's either an important space for them or maybe.
They're painful or maybe they're just sleeping. So when we have that predictability of the environment and the context and the behaviour, we might not need to prescribe. When behaviours start to become unpredictable, again, it's a little bit about elongating that ladder and maybe creating a little bit more predictability.
Risk to self and others, we've already spoken about, and the welfare piece we've also already spoken about. OK, we're gonna move on to our next points, which is all to do with constraints. So what are some of the constraints when we're thinking about prescribing?
And I've kind of portioned this into three pieces, so we're gonna start off by talking about the legal constraints, then we're gonna talk about animal related factors, and then finally we're gonna speak about owner or caregiver related factors. So, legal constraints, for those of you practising in the UK, you will be very familiar with the prescription cascade. So we know that if we have a medication that's licenced for the species and for the specific condition, then we must use that first.
And if we don't, then we need to follow our cascade, and we need to choose medications according to that. Now, that sometimes can be, quite difficult and a little bit restrictive, especially if we think that maybe we, we would like to start on a different medication. So I'm going to mention reconcile here, of course, because that is a medication that's licenced for separation anxiety.
And in dogs, so that is oftentimes the medication that we're going to reach for first because we have this licenced, medication, and in many, many cases, reconcile is a brilliant first choice. However, there might be some cases where we might like to reach for something else first, and the cascade can be a bit of a cas a constraint for us there. We're also a little bit constrained by data.
How much evidence do we have? We know notoriously in behavioural medicine, we don't have huge amounts of the type of data that we'd like, i.e., placebo controlled, double-blinded studies.
We depend a lot on, case. Reports and case series, or retrospective or prospective studies, which are, which all have their validity, but we just need to remember, you know, what our body of evidence is and how comfortable we feel when we're prescribing. Then we have to remember those, the schedules or the control of some of the medications we might want to use and what that means from, a safety point of view and also perhaps an ease of dispensing or ease of prescription point of view.
And then we want to think about consistent availability. And I always thought this is something that only I face in the UAE, but actually in the UK recently, we had a real shortage of clonidine, and clonidine is a, a really useful medication that some of my patients were on. And all of a sudden we didn't have clonidine anymore.
So now we're thinking about what might be alternatives. Do we even have any suitable alternatives? So what does that mean for that patient if we don't have consistent availability, if we have shortages of some medications in the UA.
It's often the case that I'll have access to some medications for a while and then all of a sudden we'll have a shortage, especially in the most recent sort of political situation. So that's something to bear in mind, how consistently can I get hold of this medication, and if I can't, what does that mean for my patient? So, what about our animal related factors, and we have quite a few here.
So we always, always, always want to rule in or out contributing medical causes. So that's really, really important. We can't just go ahead and prescribe if we haven't done that physical exam and that kind of diagnostic, physical medical approach.
We wanna consider our signalment, what's the. Age, what's the size, also what's the species, what medications do I have available for each, and what size of tablets, what strength of tablets do I have. If I have a little teeny tiny chihuahua like this one that's maybe 3 4 5 kg, and I can only get hold of really large strength tablets, be it 20 milligrammes, you know, 80 milligrammes, in the case of, of Chlomicalm, for example, 64 milligrammes.
In the case of reconcile, how am I going to make that medication available? Do I have compounding pharmacies close to me? Can I use an oral solution, for example?
Similarly, if I've got, you know, a 50 60 kg dog, and, you know, we're thinking about psychopharmacology, what does that mean in terms of financial? Indications or implications, you know, again, if we're thinking especially about the licenced medications such as Reconcile or Clombium, we know that these can become costly, especially in the large breed dogs. Do we have pre-existing disease?
If so, is that patient on chronic medications? If so, does that mean that we are, we're at risk of adverse drug interactions, so we have to be really mindful of that. And again, really important for us vets to be involved and knowledgeable about these medications.
Size and strength of tablet, I've already spoken about. And then how easy is it even to medicate this pet? So obviously, you know, with cats, that's something that we always think about, but I've had a couple of dogs where we've had real treatment failure because we simply weren't able to get the meds into the dog, for, you know, a number of different reasons.
So that's something that we have to think about, you know, could that be a constraint that I physically can't get the medication into that, into that patient? We have to get a diagnosis first. Really, really important.
And when we talk about a diagnosis, we're not using sort of non-specific signs such as the dog's barking a lot or the dog's aggressive. We're actually thinking about behavioural signs, and we're, we're gonna go through some of these in a second. But we're thinking about emotional motivations, we're thinking about what is driving behaviours, what are the contexts of these behaviours, and what would be a diagnosis if we were thinking about that rather than some of the sort of non-specific signs that we might be thinking about first.
And our rationale for using medications is always based on their actions at the neurotransmitter level in the brain. And again, we'll talk about this a little bit more. So really, really important that we don't, that we're really mindful of choosing medications based on what we, it is that we want them to achieve in the brain, rather than choosing them for, especially non-specific signs, right, like barking or aggression.
OK, what about some of the caregiver related restraints? So it's really, really, really important to me that we have regular access to the caregivers and that we're able to monitor these patients, even if that's through communication. Especially when they're starting medication, but also whilst they're on medication.
So if we don't think that that caregiver is going to be open to reporting back, to allowing us to check in with them, you know, open to sort of, being our eyes on the ground and observing behavioural signs, being really clear about, you know, whether there are changes that are happening on medications. Whether they're desired changes or undesired changes, if we don't think that that caregiver's open to that, we might consider, we might think twice about whether medication is, is appropriate in this case. Financial constraints, we've already talked about.
And then the beliefs and the values of the caregiver. So this can be so interesting. So I have many, many clients that approach me because they want the medication.
That's a little bit kind of, I guess, what I'm known for and what people come to me for. So I don't maybe encounter this as much, but certainly early on in my residency and still with some, with some caregivers, they might not be open to medication. They might have a friend or a family member that had a not so great experience with psychopharmacology.
They might not be in favour of, of, of chronic medications in general, so we need to kind of tread carefully and we need to. We need to ask those open questions, and we need to try and understand whether there are any barriers there or whether there are any belief systems that we need to have a really open conversation about. Of course, risk of abuse, I've mentioned that a couple of times, so that's something we need to be mindful of.
And then we have to be able to safely give the medication without causing stress to either the caregiver or the patient. So if our entire aim is to reduce stress, we want to make sure that giving the meds isn't a stressful event, otherwise we're kind of having the opposite effect of what we're trying to achieve. And sometimes that can be really stressful for the caregivers because they feel like, oh, they need to give these meds, and the dog or the cat in particular isn't taking them, so they feel like they're failing a little bit.
In those situations, but also it can be stressful for the patients themselves. Think about caregivers, you know, that are maybe pinning their cats down or scruffing them and using a pill popper to give medications. That's definitely not going to be conducive to our treatment plan when, when we're having those interactions.
So those are also some of the things we want to think about. So why might we have treatment failure failure? Why might these meds not work?
Well, client compliance, they might take the meds, but maybe we didn't address those belief systems, so they've taken the meds and they're not actually giving them. Or they're not able to medicate their patients, or maybe we've made the wrong diagnosis, or maybe the behavioural signs, maybe we didn't recognise them clearly, maybe they're shifting and changing, and actually we've got a different underlying motivation. Maybe we haven't got fear, maybe we've got frustration instead, and we didn't maybe recognise that.
So that's something that we need to think about. Maybe we've selected an inappropriate medication, maybe this patient needs to be on a long-term medication. Such as fluoxetine or reconcile, and we've maybe, we're, we're giving short acting medications that don't span a 24 hour period, so that's a possibility, or we've just chosen from a, from an inappropriate medication class.
This next point is really important. Maybe we haven't allowed enough time for treatment to take effect, and this is classic when we're thinking about some of our long-term medications. So our SSRI's, of which, which, fluoxetine reconcile is one, our tricyclic antidepressants, that's clomipramine, our SNRIs, our monoamine oxidase inhibitors, all of these medications take about 4 to 6 weeks to start working.
And I've seen so many patients where medication was started, after 2 or 3 weeks, we haven't had the true anxiolytic effects. We've maybe had some side effects that, you know, maybe were. You know, really sort of upsetting to the caregiver or maybe the side effects were actually really nice for the caregiver, and now the side effects are lifting.
So all of a sudden we're thinking the medication's not working anymore, so we stop the medication after 2 or 3 weeks, and we don't give the medication an appropriate time to work. So that's a really, really common one. Next point, again, really important, and I mentioned it earlier, if medications have been used as a standalone, rather than in combination with all of those other puzzle pieces, then that's potentially gonna lead to treatment failures.
So those clients that come and they just want the meds, they just want a med, they just wanna give a pill and have their pet's behaviour, improve, that's very unlikely to happen in many, many cases. And therefore, those caregivers might see that as a treatment failure. And then finally, if we haven't diagnosed or addressed an underlying physical medical disease.
So if I'm using psychopharmacology and all the other puzzle pieces, but I'm not cognizant of chronic pain, or I perhaps don't think there is chronic pain there, or I maybe suspect there is, but I'm not addressing it properly, then it's really unlikely that we're going to make big progress, in terms of our sort of behaviour treatment plan and changing that behaviour in a really meaningful way. So It's also really important to know what medication can and cannot do. And these are sometimes really big concerns from the caregivers.
So what medications cannot do, I'm gonna go to 0.2 1st, is change personality. So this is really a really common kind of worry that caregivers have.
Are they going to turn into somebody else, or even worse, are they going to turn into a zombie? And medication doesn't change personality. And the way I often.
Kind of explain it or describe it is what we're actually trying to do is we're trying to help that patient's true self or true personality emerge without that kind of cloud of fear or anxiety. So we want them to be even more goofy, even more silly. We want them to be, you know, lovable and sociable and interactive.
To bring out that kind of true, happy personality, which is there for us in many cases, is there for a lot of time, a lot of the time, and is what the caregivers really love. It's just sometimes those pets behave in a way that the caregivers find really challenging, and that's then what becomes problematic. So meds can't change personality.
They also can't change the relationship with the stimulus, and this is really important when we're sort of managing expectations. So if I start medication, it is not going to all of a sudden make the dog that was previously scared of other dogs, all of a sudden totally fine with all other dogs. It's not possible, the medication can't do that.
So the medication is not going to magically, . Yeah, create that change without the learning taking place. And that's sometimes where I see frustration coming up in caregivers, oh, but he still reacts to the kids on their bikes in the street.
So, that's really where we then need to, to bring in that behaviour modification element of the treatment plan to help the dog learn a different response, process some of those stimuli differently, and have different, behaviours or different reactions to those triggers. So what we're trying to do is we're trying to dial down the volume of the intensity of the behaviours or the behavioural reactions, but we're not going to magically change how that dog or cat feels about the things that they've been previously scared or worried about. And then finally, we can't help every behaviour problem.
So again, we have to realistically manage expectations. In human psychiatry, we probably have about a 20%, non-responder, quota. And I'd say that's maybe about right in, in my veterinary patients that I've seen sort of in my caseload, I'd say it's maybe somewhere, yeah, between 15 and 20%.
I think that is probably correct. So, some patients just won't respond to medications, some patients won't respond to the 1st, or maybe the 2nd or maybe even the 3rd medication. Oftentimes by then, the caregiver might have lost a little bit of faith or courage, and we kind of lose those patients.
So, yeah, we just have to be, be realistic that not everybody will respond and that we might have a proportion that we have to kind of take a different approach with. And then this again, I just kind of touched upon it, but it's really important to say this, it's never the goal or intention of medications to turn that pet into a zombie or put them in an apathetic state, right? I think, So many caregivers are worried that their dog is literally just going to be lying in the corner, not behaving at all anymore, almost sedated in this zombie-like state, and that all we've done is shut down behaviour rather than change behaviour in a meaningful way.
So, and that's something that I often say, almost preemptively, I kind of know the question's gonna come because the question. That question always comes, and, you know, when they ask me about medications, that's one of the things I sometimes lead with. It's not my intention to turn your pet into a zombie, that's not what we're doing here.
We are actually trying to change emotional state and to help them live, you know, a happier life from a mental and emotional ill health point of view. Alright, we are going to move on to a little bit of neurotransmission. I'm gonna say this is probably like my favourite part of this all because it's so fascinating and it's so important.
So psychopharmacology is all about neurotransmission. And these are the, the 6 key neurotransmitters that we tend to target when we use our psychotropic drugs. So, on the left in green, we've got noradrenaline.
In pink, our multitasking friend, serotonin. So serotonin has so many different effects, you know, that we, I've kind of displayed in here as this octopus with all these kind of little multitasking abilities. In yellow, we've got acetylcholine, probably the least, I guess the neurotransmitter we, I think least about or we tend to think least about, but still really, really important in some aspects such as cognitive function, and we want to know because some of our medi medications have anticholinergic side effects.
So that might be useful in some cases, it might not be useful in other cases. So we do want to think about acetylcholine, but I think it's perhaps a sort of one of the ones we think less about. In blue, GABA, our calming friend.
In orange, glutamate, our fiery friend, so our main excitatory neurotransmitter. And then in purple, we've got dopamine. So those are the six neurotransmitters that I'm always thinking about when I'm thinking about behavioural signs and when I'm thinking about medications.
And we have a really nice little Venn diagram here that gives us a bit of an idea, about, so these are the three monoamine neurotransmitters we call them. So noradrenaline, dopamine, and serotonin. And it gives us a bit of an idea of the types of behavioural signs or the types of behaviours that some of these, neurotransmitters may affect.
So dopamine, we know, is really important for pleasure, for drive, for reward, for motivation. But also crosses over with some of the others when it comes to attention, alertness, appetite, mood cognition. Serotonin has a lot of effect on anxiety, aggression, irritability, impulsivity, so you can see that in the crossover with noradrenaline there.
But it's also a really important neurotransmitter when it comes to repetitive, so abnormal repetitive behaviours or stereotypical behaviours, what we might term as compulsions. And then noradrenaline is a really interesting one. So noradrenaline is really important for vigilance, concentration, and arousal.
And sometimes we want that, right? We need a little bit of arousal, especially if you think about working dogs or sports dogs. They have to concentrate, they need to be motivated and alert, and they need to show attention.
But when that kind of tips over, then we have this hyper vigilance and this hyper irritability and this hyper alertness, and that can then also contribute to anxiety and aggression and impulsivity. We've got the same little Venn diagram for our two other friends, so these are our amino acid neurotransmitters. So GABA and glutamate.
So GABA's our major inhibitory or calming neurotransmitter, and glutamate, as I mentioned, our major excitatory, neurotransmitter, which unfortunately is also the most widespread neurotransmitter in the brain. And glutamate, if you think about it, is also epileptogenic. So if we have excessive firing due to glutamate, we can reach seizure states.
So that gives you a little bit of an, an idea of, of, you know, how important glutamate is. Glutamate can have some real positive effects. So glutamate is massively important for learning and memory formation.
But probably most of the time, if we have too much glutamate, we're gonna also get these things such as anxiety, vigilance, impulsivity, and arousal. And similarly, if we don't have enough GABA, we might also get that. So GABA is that, that neurotransmitter that's responsible for calm and cognition.
And if we don't have enough GABA, then we're tipping it into sort of the, the glutamate path where we get this kind of all our sort of unwanted behaviours. Now, this is a little graphic that I always have, also always have lying beside me during my consultations, and it just lists some of the most commonly seen behavioural signs. So, number 8, fear anxiety, right?
We see that a lot. Number 7, aggressive behaviours. Number 1, hypervigilance and hyperattentiveness.
Number 2, arousal and irritability. 3, impulsivity, explicsivity. Now, they're all Pretty similar, but sometimes we might have a patient that maybe shows one a little bit more over another.
Number 6, compulsions and repetitive behaviours. So that's a very sort of specific subset of our patients, I guess, that show these. But then also number 4, this kind of depressive state.
Now, we don't really talk about depression in our patients, but we for sure know some of those dogs that are very withdrawn, you know, that are, they don't want to engage in social contact. They don't potentially even want to. Engage with their environment, the normal things that dogs would do like sniffing and digging and maybe even playing.
So, sometimes we can see that. Of course, we always need to make sure that that patient isn't in pain or discomfort, and that's the reason for the withdrawal. But we also do want to think about it from, from this point of view.
I had a patient actually just recently who very much fell into this category, and we did all the medical workups and, you know, it was a truly, I guess, behavioural, presentation in the end. And then you can see with all of these sort of signs, what we might think in terms of neurotransmitters. So in a lot of these, fear, anxiety, aggression, impulsivity, arousal, attentiveness, we oftentimes have high levels of noradrenaline, glutamate, and low levels of serotonin and GABA.
So when we're making our medication choices, we're gonna choose a medication. That increases serotonin levels, that increases GABA levels, and that potentially reduces noradrenaline or re-regulates adrenaline levels and reduces glutamate. And that, that is the case for many, many of the behaviour patients that we've seen.
Sometimes we'll have, you know, some of the slightly, sort of unusual ones, such as number 6, our compulsions or repetitive behaviours. We normally associate that with high dopamine levels, and again, low serotonin levels, so that's why we perhaps choose medications sort of based a little bit more on that. And then in our number 4, we, again, we might have low dopamine, low noradrenaline.
So see here where we've got low noradrenaline, Remember that was also noradrenaline was important for that kind of attention and alertness and so on. And low serotonin. So that gives you a little bit of an overview, and then we choose our medications based on this.
So we're gonna go over into the final piece of the webinar, which is our long-term versus short-term medications. So long-term medications, also known as baseline medications or daily medications, are those medications exactly, you know, as it says, the name says on the tin. They're intended to be given.
For a long period of time and on a daily basis, and we've got kind of 6 classes within this. We've got our tricyclic antidepressants, we've got our SSRIs, which of course fluoxetine is one of. I think I've got a slide in a second that shows you, all of the other SSRI's.
We've got the SNRIs, venlafaxine, I mentioned that earlier, is a medication that's becoming really useful. We've got our monoamine oxidase inhibitors, selegiline. Selgin is the, the, the, it's kind of the licenced version in, in UK and Europe, April in the US.
Selegiline, we, we very commonly use for canine and feline cognitive dysfunction, but in Europe, they also use selegiline for, other emotional disorders. Azapirones, that's a very useful, medication, especially for cats. So buspirone, and then another one that you will all know, epitoin or Pexion.
Can be kind of, it can be a baseline medication, a long-term medication, or it can be used for longer periods of time in specific, in during specific periods. So let's say fireworks season, for example, right, you might want, want to give Pexion for a prolonged period of time in this period because you've got fireworks every night and you want something that's a little bit more daily and reliable than our short acting meds. So we've got a number of SSRIs, so I just thought I'd do a quick overview because I think the SSRI's are probably the medication class that we use most commonly.
So we have fluoxetine, which is our reconcile. We have paroxetine, sertraline, fluvoxamine, escitalopram, and citalopram. And what's really important to know is they all have one thing in common, and that is that they inhibit the SET transporter.
So they inhibit. Serotonin reuptake through the serotonin transporter back into the pre-synaptic neuron. So, they all do that, but they all also have slight differences.
And it's those slight differences that make them really useful for that sort of individual patient approach, where you're able to maybe choose a different SSRI because, so sertraline. For example, I'm just gonna give one example. Sertraline, for example, has additional dopaminergic effects.
So if I'm thinking about a canine cognitive dysfunction patient and I maybe don't want to use selegiline because the, the, the pet is on maybe another medication that might be contraindicated, I might choose sertraline for that patient because of its additional dopaminergic activities, because we know in cognitive dysfunction, it's dopamine that is often depleted. So, a little bit more about the baseline meds. They're intended for long-term use.
And when I say long-term use, probably at least 12 months, maybe, maybe more, maybe lifelong. And that is because we tend to see an improvement, an increase of effects over that 12 month period. So you'll often get patients that do a lot better at 3 months and then a lot better maybe at 6 months.
And then again, they've got like this another kind of, sort of a big improvement step after 9 months, for example, but I've definitely seen my patients do that. Most antidepressants, also most of these medications, and that includes the antidepressants and the monoamine oxidase inhibitors, take that 4 to 8 week period to start working. So do not stop before that, and we spoke about that already a little bit.
And this is kind of a typical sort of, I guess, pathway that these medications would follow. So we often see side effects in the first week or two. And side effects most commonly would be a little bit of dulling or lethargy, maybe some appetite decrease.
But then the side effects will often lift after those first weeks. And interestingly, in weeks 3 and 4, the owners may then perceive a worsening in their pet's behaviour, because imagine you've got this hyper aroused, super hyper, super irritable, hyper aroused, hyperattentive, hyper vigilant dog that paces and pants and can't rest and can't settle, has poor sleep. That's quite common in our behaviour patients.
And all of a sudden, you get a bit of a side effect, which is a bit more resting, a bit more sleep, a bit more dullness, a little bit of lethargy. And the, the, the caregivers are thinking, oh my God, this is amazing, this is a miracle medication. Then in weeks 3 and 4, those side effects lift, and we don't have those anymore, and those behaviours re-emerge.
So now the owners perceive worsening, that's it's stopped working, it was so good for the 1st 2 weeks, now it's stopped working. My dog's possibly gotten used to the medication, right? That's something that we often hear when actually, in fact, that's just those side effects lifting.
And then from week 4 onwards is when we start to see the true anxiolytic effects of those medications. OK, the second group we have are our short acting or event medications. So in this class, we have our gabapentinoids, so gabapentin and pregabalin.
We have a licenced version of pregabalin for cats, which is Boncat. We've got Alsari, so that's serotonin antagonist and reuptake inhibitor, that's trazodone. We've got our alpha 2 agonists, there are quite a few in this group, so we've got ilo, which is our dexametitomidine or a transmucosal gel, we've got Tessi, taccipiidine, clonidine, and we also have detoidine, which is the equine dormoedon gel that can be really useful in some cases.
In this class, we also have our benzodiazepines and potentially some others. Now I'm just gonna mention Aceromazine here because Aceromazine is not what we would class to be a behaviour medication. Aceromazine is a sedative.
We all know that from, from, from its use as a pre-med. It does have dopaminergic effects, but that's actually what caused the effects. So Aceromazine stops the pores from moving.
So we have this kind of reduced motor activity, and that's where kind of the sedation part comes from. But we don't have any anxiolytic effects. So you could use Aceromazine in combination with something else that does have anxiolytic effects if you wanted a little bit more control over that motor activity, but I would never recommend using Aceromazine on its own.
OK. And then finally, we're gonna move on to how do we use these medications? When would we use baseline or long-term?
When would we use event or short acting, and is there ever a case where we can use them both together? So our baseline meds would be for long-term use, where maybe we don't have huge urgency, but where behaviours are generalised and recurrent. So they're occurring every day, you know, for prolonged periods during that day, for many hours within that day.
And we're thinking about our abnormal repetitive behaviours, chronic fear states, chronic anxiety states, chronic stress states, and where phobias and panic behaviours turn up regularly or show up regularly. Our event medications or short acting medications, or sometimes also PRN or as needed medications, those we would use in acute situations that are predictable and where we've got an urgent need to get immediate control over this pet's behaviour. So veterinary visits, noise events where we can predict that that the fireworks are going to start at 6 p.m., we know it's going to happen, owner departures and separation related behaviours, in some cases, walks where we can predict that.
As soon as the dog goes out on a walk, they're going to have an acute response. So that would be fears, phobias, and panic behaviours in certain contexts. And then sometimes we can also combine the two, right?
And I often talk about that as layering. So you'd have your, your baseline medication as your bottom layer, and then you might layer on top an event or short acting medication. So again, we think we're talking about longer term use, right, because we have our baseline medication involved here.
But it might be if it's a little bit more urgent, we want to get a little bit more urgent control over this behaviour. So maybe we have a risk of relinquishment or a risk of euthanasia, and we know our reconcile is going to take 4 to 6 weeks to start working. So in the, in the meantime, we want to use something.
Short acting to bridge that gap. So we use that as a bridging medication. Or we've got a dog that has a chronic anxiety disorder and is on fluoxetine, but also gets really scared at the vet, so then we can layer a short acting medication over the top.
Or sometimes we have a, a patient that's on a baseline medication, and that baseline medication is achieving maybe 60 or 70% improvement. And we'd like to get just a little bit more, so we might on a daily basis, layer on top something else like trazodone or clonidine, for example. And again, we would use that in abnormal repetitive repetitive behaviours, fear, anxiety, stress, phobias, and panic.
So kind of the, it's very similar to our, our baseline or long-term medications. So That is all I have in terms of making medication choices. If you are interested in learning a little bit more about psychopharmacology, I have a really nice course, that you can have, a look at or a think about.
It is a, a 6 module course over 11 hours. We also have some live group Zoom calls as part of the course. Because it was BVA last week, I'm gonna still offer the discount code BVA 30 for, for a 30% discount.
I also want to gift you this free resource bundle. So if you scan the QR code, it's entirely free. You get a client handout on separation-related behaviours, and also my masterclass on those other puzzle pieces, aside from psychopharmacology that make up that behaviour, treatment plan.
And then finally, I also have a podcast, which is, again, also completely free of charge that some of you might find useful. Thank you so much for your attention. I think I've gone a little bit over, I hope that's not too bad, but yeah, I just get too enthusiastic when I talk about this.
Catrin, it's not a problem at all, and your passion is part of why we love listening to you. So, thank you so much for all your enthusiasm and all your knowledge that you've given tonight. I know my mind is blown with all the information, and it is going to take quite some time to take it on board.
And, it's situations like this where I'm always grateful that the webinar has been recorded because we can go back and we can watch and watch and watch again. So thank you for your time. We really do appreciate it.
My pleasure. A big thank you as well to our sponsors tonight, Fort Healthcare. Without them, we would not have been able to have brought you this webinar.
So, very, very big thank you to them. Catherine, we do have, quite a few questions that have come through, but because we've run over, what I'm going to do is I'm going to ask Beck, to get those emailed over to you, to address that way because we just don't have the time this evening, I'm afraid. What we do have time for is for me to comment on how many thank yous, excellent, brilliant, so great to have this information.
All of these comments coming through to you. So thanks, Catherine, really appreciate it. Thank you so much.
To all of you that have attended tonight, I hope you've enjoyed this webinar as much as I have. And remember, like me, you're going to want to get that, recording, which is gonna be up on the website in the next day or two, and, you can then go back and re-listen to all the information that was flooding into us tonight because it is all brilliant, brilliant information. So thank you for your time this evening in attending, and I really do hope you enjoyed it.
Once again, to our fantastic presenter, Catherine, thank you for your time. We really, really appreciate that. Last but not least, to Beck, my controller in the background, thank you for making everything work, and, really appreciate that as well.
From myself, Bruce Stevenson, it's good night.
