treatment notes

							TREATMENT

DEPRESSION
    first line: SSRI, SNRI, Bupropion
    50% of patients with depression respond to a first trial of an antidepressant; 70-90% respond to a series of trials
    Other medications: Mirtazeine, TCA, MAO-I -- all limited by side effect profile
    Augmentation: Lithium, thyroid hormone, psychostimulant, Bupropion

DYSTHYMIC DISORDER
    psychotherapies: interpersonal, cognitive-behvioral, psychodynamic, and family/group
    pharmacological: SSRI; pts unresponsive to SSRIs may have good response with SNRIs, bupropion, tricyclics, and MAO-Is

MANIA
   start lithium, divalproex, psychotropic
   if psychotic features, add psychotropic
   if agitate, add psychotropic or benzodiazepine
   if poor response, add/change to another mood stabilizer…consider carbamazepine
   bilateral ECT
   FDA-Approved medications for the treatment of mania
          Lithium – acute & maintenance treatment
          Divalproex – acute treatment & maintenance
          Olanzapine [Zyrexa] (in combo with Li or valproate) – acute mania
          Lamotrigine – maintenance tx of BP I disorder to delay the time to occurrence of mood episode (depression, mania,
               hypomania, mixed episodes in patients treated for acute mood episodes with standard therapy
          Quetiapine [Seroquel] – acute bipolar mania and/or mixed state
          Risperidal – acute bipolar mania and/or mixed state
          Aripiprazole [Abilify] acute bipolar mania
          Ziprasidone [Geodon] – acute manic and/or mixed state

BIPOLAR DEPRESSION – acute treatments
    antidepressants: SSRIs, Buproprion, MAOIs (tranylcypramine, meclohemide), TCAs
    mood stabilizers : Lithium, Lamotrigine, Olanzapine, Olanzapine-Fluoxetine, new atypical antipsychotic meds
    ECT

SCHIZOPHRENIA
    core deficit is INCREASED Dopaminergic ACTIVITY
    treatment directed at symptom management, no cure available
    psycho-social: cognitive behavior therapy/supportive therapy
    ECT – for refractory cases
    pharmacotheraphy:          typical antipsychotic (Thorazine, Haldol, Navane, Prolixin, etc)
                                atypical rx: Clozapine [Clozaril], Olanzapine [Zyprexa], Risperdone[Risperdal], Quetiapine
                                          [Seroquel], Ziprasidone [Geodon]
                                long- acting forms (for non-compliant pts): Haldol, Prolixin, Decanoate, Olanzapine, Risperdone

OBSESSIVE COMPULSIVE DISORDER
    best treatment combination is meds and psychotherapy
    Luvox / Clomipramine specific for OCD
    SSRIs to treat secondary depression
    rx choices: SSRIs, Clomipramine (TCA), MAOIs, major tranquilizer (Risperdone, Olanzapine)
    adjunctive tx: anti-psychotics can help reduce anxiety s/s; Tegretol, other mood stabilizers
    cognitive behavioral therapy, neurosurgery (ant. cingulotomy)

HIV and psychotic symptoms
    acute psychotic disorder (regardless of etiology): use conventional antipsychotic agent, eg. haloperidol 5mg PO or IM
    less acute psychotic disorder and in primary co-morbid psychosis: use atypical antipsychotic agents
    clozapine contraindicated due to agranulocytosis
    zyprexa well-tolerated with few drug interactions and positive studies in HIV+
    quetiapine contraindicated in combination with ketoconazol, ritonavir, and macrolide antibiotics
    no studies done with most atypicals
CVA and MDD
    early, prophylactic treatment leads to an enhanced functional outcome
    SSRI and other antidepressants

DEMENTIA
    anticholinesterase inhibitors: Donepezil (Aricept), Rivastigmine (Exelon), Galantamine (Reminyl)
    NMDA receptor blocker: Memantine (Namenda)

LATE LIFE DEPRESSSION
    antidepressants work (SSRIs are safer)
    combined Rx with psychotherapy and meds – works best for preventing recurrences
    meds may take 6-8 wks to work
    put “depression” on problem list and maintain surveillance lifelong

DELIRIUM
    haloperidol for psychosis/agitation (may give IV)
    monitor fluids and electrolytes
    usually takes days to resolve

ALCOHOL DEPENDENCE
    aversion therapy with disulfiram

SUICIDE INTERVENTION
    ensure immediate safety (ie. do not hesitate to refer for inpatient evaluation)
    treat acute risk factors (eg. current depression, psychosis, or anxiety)
    remove/minimize availability of means (eg. remove guns, pills, etc.)
    treat chronic risk factors (eg. prophylactic/continuation treatment of depression)
    enhance protective factors (eg. engage family, etc.)