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Psychiatry

Links

• local: Neurology and Rehab, ADHD, ADHD-X, and Related Conditions

ADHD

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

Antidepressants

• * serotonin profile
• noradrenergic profile

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

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
• probably 2nd or 3rd line as of 2001?
• advantages: very low incidence of sexual dysfunction, strong anxiolytic effects
• side-effects: sedating, rare agranulocytosis, increased lipids

SSRI

(See Serotonin Syndrome)

* fluoxetine (Prozac)

• 10-40 mg qD
• 168 hour half-life! avoid in elderly
• agitation, GI upset common
• weight loss

* sertraline (Zoloft)

• 50-150 mg qD
• insomnia, agitation, GI upset, weight loss

* paroxetine (Paxil)

* serzone (Nefazadone)

• low incidence of sexual dysfunction, sleep disturbances
• resembles Desyrel in some ways, otherwise unique chemical structure
• sedating
• developing a reputation for being less effective than other SSRIs?

Cost

• low price (generic): elavil, imipramine, desipramine, sinequan, trazodone, wellbutrin
• mid price: nortriptyline (brand name is $$$$)
• high price: Prozac, Zoloft, Nefazadone, Paxil

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: Zoloft/Paxil > 1st generation > Prozac > 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