Psychopharmacology Tips

Rosebush and Mazurek (2004) recommend that unless there is a contraindication to using the intramuscular route, such as a known bleeding condition, patients with catatonia should receive lorazepam 2 mg im initially. Response is typically seen within 1-3 hours. If there is no response after 3 hours, the same dosage should be repeated, and again a 3-hour period should be allowed to elapse. If, once again, there is no response, a third injection may be given. The young, elderly, or medically compromised should have the dose reduced to 1 mg each time.

Ref: - Rosebush, P.I. & Mazurek, M.F. (2004) Pharmacotherapy. In: Catatonia: from psychopathology to neurobiology, (Eds.) Caroff, S.N., Mann, S.C., Francis, A. & Fricchione, G.L. pp 141 – 150, Washington: American Psychiatric Publishing.

A prospective study of depressed patients found that panic attacks are correlated with a poor outcome (Coryell et al., 1988). There is some evidence that such patients may do better with MAOIs (O’Reardon and Amsterdam, 2001)

Ref: -

Coryell, W., Endicott, J., Andreasen, N.C., et al. (1988) Depression and panic attacks: the significance as reflected in follow-up and family study data. American Journal of Psychiatry, 145, 293-300.

O’Reardon, J.P. & Amsterdam, J.D. (2001) Overview of treatment-resistant depression and its management. In: Treatment-resistant mood disorders, (Eds.) Amsterdam, J.D., Hornig, M. & Nierenberg, A.A. pp 30 – 45, Cambridge: Cambridge University Press.

Schweizer et al. (1990) has shown that there was no significant difference in response rates if non-responders to fluoxetine at three weeks were randomized to either fluoxetine 20 mg/day or 60 mg/day for a further 5 weeks. This indicates that, at least in the first 8 weeks of treatment with fluoxetine, ‘tincture of time’ may be more important than dosage increase.

Ref: - Schweizer, E., Rickels, K., Amsterdam, J.D., et al. (1990) What constitutes an adequate antidepressant trial of fluoxetine? Journal of Clinical Psychiatry, 51, 8-11.

Patient variables like older age and female sex have been associated with a poorer response to antidepressant treatment. Illness variables associated with a poor response include unipolar illness, psychotic depression, neurotic premorbid personality, past thyroid dysfunction, familial predisposition to affective disorders, multiple loss events, and a low socioeconomic classification.

Ref: - Souery, D., Lipp, O., Massat, I. & Mendlewicz, J. (2001). The characterization and definition of treatment-resistant mood disorders. In: Treatment-resistant mood disorders, (Eds.) Amsterdam, J.D., Hornig, M. & Nierenberg, A.A. pp 3 – 29, Cambridge: Cambridge University Press.

Ayd (1972) observed that 70 % of depressed patients failed to take between 25 and 50 % of their prescribed dosage on a four times daily regimen, while only 7 % of patients omitted a once daily dose.

Ref: - Ayd, F.J. (1972) Patient compliance. International Drug Therapy Newsletter, 7, 33-40.

Imipramine, desipramine and nortriptyline should be monitored using plasma levels, as their plasma levels have been demonstrated to relate accurately to clinical outcome (Roose and Glassman, 1994). Moreover, blood levels should be measured for nortriptyline because a significant proportion of general population are slow metabolizers of the drug (Souery et al., 2001).

Ref: -

Roose, S.P. & Glassman, A.H. (1994) Treatment with tricyclic antidepressants: defining the refractory patient. In: Refractory depression: Current strategies and future directions. (Eds.) Nolen, W.A., Zohar, J., Roose, S.P. & Amsterdam, J.D. Chichester, UK: John Wiley.

Souery, D., Lipp, O., Massat, I. & Mendlewicz, J. (2001). The characterization and definition of treatment-resistant mood disorders. In: Treatment-resistant mood disorders, (Eds.) Amsterdam, J.D., Hornig, M. & Nierenberg, A.A. pp 3 – 29, Cambridge: Cambridge University Press.

As many as 50% of patients who do not respond to one SSRI may respond to another. However, melancholic inpatients who do not respond to an adequate trial of an SSRI appear to have a much lower chance of responding to another SSRI.

Ref: - Schatzberg, A.F., Cole, J.O. & DeBattista, C. (2003) Manual of Clinical Psychopharmacology. Washington, DC: American Psychiatric Press.

The following remedies may be helpful in the management of acute benign hiccups in psychiatric settings:

• Irritation of the nasopharynx by tongue traction, lifting the tongue with a spoon or eating one teaspoon of dry granulated sugar.
• Interruption of the respiratory cycle by breath holding, Valsalva’s maneuver, sneezing, or rebreathing into a bag.
• Irritation of the diaphragm by holding knees to chest

Various drugs have been suggested to be useful in management of hiccups. Chlorpromazine, 25-50 mg orally or intramuscularly, is most commonly used. Other drugs reported to be effective include anticonvulsants (phenytoin, carbamazepine), benzodiazepines (lorazepam, diazepam), metoclopramide and baclofen.

From McQuaid, K.R. (2004) Alimentary tract. In: Current Medical Diagnosis and Treatment 2004, (Eds.) Tierney Jr L. M., McPhee, S. J. & Papadakis, M. A. pp 515-622, New York: Lange Medical Books.