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Psychiatry

Links

• local: Neurology and Rehab, ADHD, ADHD-X, and Related Conditions
• remote: AFP 2003 update

ADHD

• moved to ADHD, ADHD-X, and Related Conditions

Antidepressants

• * serotonin profile
• noradrenergic profile

atypical antipsychotics

1. Aripiprazole (Abilify)
   • largely for bipolar agitation
   • akathisia, neuroleptic malignant syndrome, weight gain, tremor, headache

tricyclics

1. * amitryptiline (Elavil)
   • 25 mg hs, increase to 75-150 mg hs
   • levels 125-250
   • sedation, orthostasis, cardiac dysrthymia, weight gain
2. imipramine (Tofranil)
   • 75-300 mg qD
   • good for pain syndromes, panic attacks
   • lots of orthostatic hypotension, lots of weight gain
3. desipramine (Norpramin, Pertofrane)
   • 75-300 mg, start 10 mq qAM and 10 mg qnoon
   • less seizure, glaucoma risk
   • can do plasma levels (150-300 ng/ml good)
   • panic disorder needs 150-300 mg qD
   • minimal wt gain
4. nortriptyline (Pamelor)
   • start 10 mg hs, increase to 40-200 mg
   • good in elderly
   • relatively less sedating
5. *  doxepin (Sinequan)
   • 10 mg hs for sleep, 75-300 hs for depression
   • begin at 1/4 dose and work up q3-4d
   • sedation, weight gain

SSRI

(See Serotonin Syndrome)

• * fluoxetine (Prozac)
  • 10-40 mg qD
  • 168 hour half-life! avoid in elderly
  • agitation, GI upset common
  • weight loss
  • only antidepressant shown to work in children and adolescents, only SSRI approved for children.
• * sertraline (Zoloft)
  • 50-150 mg qD
  • insomnia, agitation, GI upset, weight loss

Paxil (paroxetine) was found increase congenital heart defects in the 1st trimester of pregnancy, so it's now Category D. Its probably time to abandon use of Paxil since it doesn't seem to add anything to sertraline or fluoxetine.

SSRI use in pregnancy also increases the risk of persistent pulmonary hypertension (6 fold?) and has a neonatal withdrawl syndrome. On the other hand, it's not like there are always great alternatives. Depression is a very risky condition.

heterocyclics and other

trazodone (Desyrel)

• 150-600 mg daily
• very sedating, not anticholinergic, minimal orthostasis, minimal weight gain

bupropion (Wellbutrin, Zyban)

• 225-450 mg daily
• unknown mechanism of action
• non-sedating, can cause insomnia. No weight gain. Lowers seizure threshold, otherwise well tolerated. Used for smoking cessation.

mirtazapine (Remeron)

• Mirtazapine A Newer Antidepressant - Jan 1999 - AFP
• a tetracyclic piperazino-azepine: different structure from any other currently used antidepressant
• weight gain
• advantages: very low incidence of sexual dysfunction, strong anxiolytic effects
• side-effects: sedating, rare agranulocytosis, increased lipids

s/e profiles (bad to better)

• wt gain: amitryptiline > doxepin, imipramine > desipramine, nortriptyline, trazodone > (none) Wellbutrin > (weight loss?) Prozac, Zoloft
• sedation: amitriptyline, doxepin, trazodone > Serzone, Remeron> imipramine > desipramine, nortriptyline > (none) Wellbutrin > Prozac, Zoloft
• orthostasis: amitryptiline, imipramine > desipramine, doxepin, nortriptyline, trazodone > (none) Wellbutrin, Prozac, Zoloft
• cardiac arrythmia: amitriptyline, imipramine > desipramine, doxepin, nortriptyline > trazodone, Wellbutrin > (none) Prozac, Zoloft
• seizure: bupropion (Wellbutrin, Zyban) lowers seizure threshold
• sexual dysfunction: SSRI > 1st generation  > Nefazadone, Remeron

Somatization Disorder

Part I. Practical Diagnosis - February 15 & Part II. Practical Management - March 1, 2000 AFP

• provide a label for pt: "pain disorder", "somatoform disorder" are more honest, "chronic fatigue" or "fibromyalgia" work better
• plug pt into feel-good relaxing treatments and harmless placebos
• encourage activity/exercise
• group self-help can work well
• ask how disease affects life is a clue to underlying causes, stresses, etc
• careful use of SSRI agents?

Withdrawl

• narcotic: abdominal cramping, piloerection, lacrimation, rhinorrhea
• cocaine: depression, dysphoria, irritability, anxiety, fatigue, hypersomnia/insomnia, psychomotor agitation. Symmetrel or Parlodel may decrease craving (increase dopamine levels), phenothiazines may worsen cravings.

Alcohol withdrawl (benzodiazepine):

3 stages of withdrawl

1. autonomic (tachycardia, tachyp, fever, diaphoresis), agitation, tremor,
2. hallucinations (tactile, visual, auditory) with insight
3. hallucinations without insight
   • occasional seizure

can manage as outpatient if

1. stage 1 withdrawl (some treat very early stage 2)
2. pt has full-time attendant
3. pt can meet doc daily
4. pt and caregiver are committed

medication management

• Librium (used forever), very long half-life
  • score 5-7: 25-50 mg q2h
  • 8-10: 75 mg q2h
  • >11: 100 mg q2h