ANXIETY DISORDERS

 

Background (AFP 2015;91:617; Ann Int Med 2013;159:ITC6-1; NEJM 2015;373:2059)

Definition: Anxiety is a state of psychological distress (apprehension, internal conflict), w/ or w/o a specific focus; may be adaptive (e.g., ↑ alertness & performance) or maladaptive (e.g., assoc w/ hypervigilance, ↓ concentration, physical sx, functional impairment) Epidemiology: 10% prevalence in primary care; often undetected; presents in teens to mid-30s, ↑ risk w/ ⊕ FHx of anxiety d/o; majority of pts w/ GAD have a mood, somatoform, SUD, or (another) anxiety d/o (BMJ 2007;334:579) ~50% of pts w/ major depression may have a comorbid anxiety d/o (JAMA 2003;289:3095)

Differential diagnosis: Hypoglycemia, hyperthyroidism, pheo, carcinoid, anemia, withdrawal (EtOH, opioids, BZD, antidepressants), SUD, excess caffeine; screen for depression (see “Depression”), mania (see “Bipolar Disorder”), suicidal ideation (see “Suicide Risk Assessment”); prior psych hx; FHx

Evaluation and Management (AFP 2005;71:733; 2009;79:785; JAMA 2014;312:78;

NEJM 2004;351:675)

 

Clinical Features and Treatment of Anxiety Disorders (see “Depression” for Specific Properties, s/e of SSRIs, SNRIs)

Generalized anxiety disorder: Functional impairment/significant distress on more days than not over a 6 mo period from excessive, uncontrollable worry about a number of concerns (e.g., finances, health, safety); anxiety is assoc w/ ≥3 of: (1) Restlessness/feeling on edge; (2) Easy fatigue; (3) Difficulty concentrating; (4) Irritability; (5) Muscle tension; (6) Sleep disturbance; r/o PTSD, panic, OCD, or other medical dx Screening: GAD-7 & GAD-2 both developed/validated in the primary care setting; GAD-2 → 2 question screen scored from 0 (not at all) to 3 (nearly every day) w/ score ≥ 3 prompting further eval: Feeling nervous, anxious or on edge? Not being able to stop or control worrying? (Arch Int Med 2006;166:1092; Ann Int Med 2007;146:317) Therapy: CBT as effective as medication; exercise also helps (JAMA 2009;301:1460), relaxation training; Rx: 1st-line → SSRIs (generally, all SSRIs equally effective) or SNRIs; consider benzodiazepine bridge; Sample Rx: Citalopram 10 mg/d, titrate to 40 mg over 2–6 wk as needed, (± clonazepam 0.25–0.5 mg BID during acute phase/SSRI titration). Buspirone is an effective 2nd-line agent. Hydroxyzine is useful in treating insomnia

 

assoc w/ GAD. Drug efficacy may be monitored with GAD-7 scale. Therapy continued for 6– 12 mo after sx resolution; 20–40% of pts will relapse within 1 y.

Panic disorder: Recurrent, out-of-the-blue panic attacks w/ concern about the attacks or their implications, & assoc behavior D; agoraphobia is the most common panic d/o: Anxiety about panic attacks and/or ability to escape from a situation where attack might be difficult or embarrassing (e.g., crowds, queues, stores/malls, restaurants, public transit, appts, cars, planes) leading to avoidance or enduring w/ extreme distress; may also seek presence of reassuring other to accompany pt while in feared situations Panic attack: Discrete, sudden, intense apprehension, impending doom, & discomfort, usually peaking in ≤10 min; often assoc w/ palpitations, chest/abd discomfort, sweats, shakes, hot flushes, chills, SOB/choking feelings, nausea, dizziness, paresthesias, derealization, depersonalization, fear of losing control/dying Screening: Panic disorder severity scale: 7 items assessing attacks, anticipatory anxiety avoidance; can be clinician or self-rated (Depress Anxiety 2002;15:183) Therapy: CBT incl exposure to feared bodily sensations or places; Rx: 1st-line → SSRIs, SNRIs; consider BZD while awaiting response, TCAs (may be s/e limited) (J Clin Psychiatry 2010;71:574); Sample Rx: Sertraline 25 mg QD; ↑ to 50 mg QD in 1 wk, titrate to 100–200 mg over 2–6 wk; note: Long-term PRN BZD are not indicated

Social anxiety disorder: Excessive, unreasonable anxiety related to social situations & potential scrutiny of others that causes functional impairment or severe distress; may be generalized (experienced in multiple types of interactions such as conversations or social gatherings) or nongeneralized (e.g., public speaking) (NEJM 2006;355:1029; 2017) Screening: Mini-SPIN (social phobia inventory) → 3 question screen scored from 0 (not true) to 4 (extremely true), w/ score ≥6 prompting further eval: (1) Fear of embarrassment; (2) Avoiding being center of attention; (3) Worst fears include embarrassment, humiliation (Prim Care Comp J Clin Psychiatr 2009;11:231) Therapy: CBT, individual or group; Rx: Generalized: 1st-line → SSRIs, SNRIs (venlafaxine) e.g.: Sertraline as above, consider augmentation w/ BZDs; Nongeneralized: 1st line → PRN βB

Specific phobias: Excessive or unreasonable fear about an object or situation → immediate anxiety response, avoidance behaviors or enduring w/ extreme distress Therapy: CBT incl exposure therapies (imagined or live exposures); systematic desensitization; Rx: Rare PRN benzodiazepine use

Patient information: adaa.org; anxieties.com; AFP 2003;68:2409 (PTSD); 2005;71:740 (panic); 2006;73:1057; 2010;81:987 (exercise);

JAMA 2011;305:522; 2011;305:1256; 2012;308:729

 

 

Attention-Deficit Hyperactivity Disorder

Background (AFP 2012;85:890; Am J Psychiatry 2006;163:716; 1730; 2059)

Definition: Impairment in ≥2 life settings (school, work, home, social) due to persistent sx of inattention, impulsivity, and/or hyperactivity since

 

childhood (age of onset ↑ from 7 to 12 in DSM-5) and sx not caused by another med or Y condition; determination of functional impairment is highly dependent upon contextual factors; ∴ dx & indications for tx need to be determined on an individual basis

Epidemiology: 7–9% of children & 4–5% of adults; assoc w/ educational/occupational underperformance; poor relationships w/ peers, family members, & authorities; ↑ traffic violations, accidents, & injuries; ↑ rates of substance misuse

Differential diagnosis: Depression, anxiety, panic, mania/hypomania, substance use/withdrawal; ADHD is distinct in that sx are present since childhood & persist during noncomorbid periods

Evaluation (JAMA 1998;280:1086; NEJM 2013;369:1935)

History: Adult ADHD Self Report Scale (psychology-tools.com/adult- adhd-self-report-scale/) is a useful screening tool for adults (available online); interview pt & collateral sources about sx in past 6 mo & childhood; screen for RFs for SCD if treatment with stimulants planned (see “Sudden Cardiac Death”), substance abuse (see “Substance Use Disorders”), & comorbid psych conditions; review steroid, nicotine, caffeine use

Labs: Consider TSH, urine drug monitoring if prescribing stimulants Neuropsych testing: Helpful for eliciting learning disabilities or cognitive impairments, but not necessary for dx (Clin Psychol Rev 2006;26:466)

Treatment (JAMA 2004;292:619; NEJM 2005;352:165; 2013;369:1935)

General principles: Comanagement with psychiatry is typical Stimulant treatment: 1st-line if no contraindicating conditions; greater effect size than nonstimulant treatments (Med Gen Med 2006;8:4); long- acting preparations preferred due to ease of dosing & lower likelihood of abuse (J Am Acad Child Adolesc Psychiatry 2008;47:21; Prim Care Companion CNS Disord 2011;13:pii)

Side effects: Distressing thoughts/feelings, insomnia, anorexia, catecholaminergic effects (↑ HR 3–10 bpm, ↑ SBP 3–8 mmHg, ↑ DBP 2–14 mmHg, & ↑ cardiac contractility) mild in most pts, but monitor VS to screen for outliers Interactions: avoid w/ MAOI antidepressants; serum levels of some agents may be ↑ by treatments that lower acidity (e.g., PPI) Risk factors for misuse: Caucasian, fraternity/sorority membership, lower GPA, immediate-

 

release (vs. ER) (J Am Acad Child Adolesc Psychiatry 2008;47:21) Nonstimulant treatment: Preferred in pts w/ substance use disorders; atomoxetine only FDA-approved member of this class for tx of ADHD,

though bupropion has demonstrated efficacy (Biol Psychiatry 2005;57:793).

Evidence supports off-label use of TCAs (desipramine, imipramine), but may be limited by s/e profile

Cardiac considerations: Risk of sudden cardiac death in both stimulant & atomoxetine tx may be ↑ in pts w/ pre-existing structural heart defects (Circulation 2008;117:2407), but little evidence for serious CV events, incl. MI, stroke, & death in healthy pts (JAMA 2011;306:2673; NEJM

2011;365:1896)

 

ADHD Pharmacotherapy
Generic (Brand Names), Daily Dose Range	Duration (h)
Stimulants: Amphetamines	5
Dextroamphetamine (Dexedrine)	8
Dextroamphetamine ER (Dexedrine spansules)	5
Mixed amphetamine salts (Adderall)	12
Mixed amphetamine salts ER (Adderall XR)	12
Lisdexamfetamine (Vyvanse)
Stimulants: Methylphenidates	4
Methylphenidate IR (Ritalin)	8
Methylphenidate SR/ER (Metadate CD, ER, Ritalin SR, LA)	12
OROS methylphenidate (Concerta)	12
Dexmethylphenidate ER (Focalin XR)
Nonstimulants: Atomoxetine (Strattera); not a controlled substance	24

(Adapted from AFP 2012;85:890)

 

Nonpharmacologic treatment: Cognitive behavioral & group tx (Am J Psychiatry 2010;167:958; JAMA 2010;304:875), ADHD coaching, disability accommodations

Patient information: JAMA 2013;309:1843; chadd.org

 

BIPOLAR DISORDER

Background (Acta Psychiatr Scand Suppl 2009;439:27; AFP 2012;85:483; Lancet

2016;387:1561)

 

Bipolar type I: ≥1 manic episode, usually alternating w/ depressive episodes; prevalence: 1–2%

Bipolar type II: Major depressive episode w/ hypomanic episodes; prevalence: >2%

Manic episode: Abnormal & persistently elevated, expansive or irritable mood, lasting >1 wk (less if hospitalized), and ≥3 of following sx (4 if mood only irritable): (1) Inflated self-esteem or grandiosity; (2) ↓ need for sleep; (3) Talkativeness/pressured speech; (4) Racing thoughts/flight of ideas; (5) Distractibility; (6) ↑ goal-directed behavior (socially, sexually, at work); (7) Psychomotor agitation; (8) Excessive involvement in pleasurable activities with ↑ potential for painful consequences; 2/3rds of manic episodes have psychotic sx (hallucinations, delusions); manic episodes often accompanied by psychotic features (delusions, hallucinations)

Hypomanic episode: Abnormal & persistently elevated, irritable, or expansive mood that lasts ≥4 d w/ 3 or more sx of mania, but w/o significant change in social/occupational functioning, and w/o psychotic symptoms

Depressive episode: “Atypical” sx (hypersomnia, hyperphagia) common; psychotic sx can be present

Mixed features: Features of mania & depression coexist; ↑ risk of suicide

Rapid cycling: ≥4 mood episodes/y, often treatment-resistant; poorer prognosis

Evaluation (Arch Gen Psychiatry 2007;64:543; Prim Care CNS Disord 2011;13:10r01097)

History: >50% bipolar pts p/w depressive episode; taking a careful history for past manic sx important (PsychiatrServ 2001;52:51); screening ?s: “Was there a time when you were feeling so good or hyper that other people thought you were not your normal self, or so hyper that you got into trouble?” “Was there a time when you got much less sleep than usual and still felt rested?” Assess risk of suicide and violence at each visit→ >50% of pts w/ BPAD attempt suicide during their lifetime (J Clin Psychiatry 2005;66:1456)

Workup: TSH, RPR, UTox, B12; Medication monitoring: CBC, ECG, Chem-12, BMI, waist circumference, lipids, fasting glucose

Treatment (Acta Psychiatr Scand Suppl 2009;439:27; BMJ 2012;345:e8508)

 

General principles: Avoid SSRIs b/c their efficacy is unclear; if used, should be used only in adjunct with mood stabilizer; sleep hygiene important; disrupted sleep is a major trigger for mania; individual or group psychotherapy improves outcomes (Arch Gen Psychiatry 2007;64:419); patients may need combination therapy to achieve remission; maintenance therapy is typically continuation of initial regimen used to achieve mood control, and may need to be continued indefinitely

If not on a mood stabilizer: Trial lithium or valproic acid

Lithium: Levels of ~0.8 mEq/L (range: 0.5–1.2); kidney function should be assessed prior to initiation and then 1–2 times a year thereafter; check lithium levels every 6 mo once stabilized; monitor TSH yearly; monitor for weight and BMI Valproic acid: Levels > 45 mcg/mL (range: 50–125); monitor CBC and LFTs at least yearly; valproic acid level at least yearly and when doses change

If psychotic features present: Start antipsychotic; for 2nd-generation antipsychotics, frequent monitoring of BMI, waist circumference, lipids, fasting glucose (see section on Psychosis)

Olanzapine: Start 10 mg, titrate up to 30 mg/d Quetiapine: Start at 100 mg daily Risperidone: Start at 1–2 mg daily

 

DEPRESSION

Background (JAMA 2002;287:1568; 2003;289:3095; NEJM 2000;343:1942)

Definitions (DSM-IV)

Major depressive episode: 5/9 sx (see SIGECAPS, below), incl either depressed mood or anhedonia, which must be present every day, nearly all day, for 2 wk Major depressive disorder: Recurrent major depressive episodes

Dysthymia: 2 y of persistently depressed mood + 2–4 sx (see SIGECAPS)

Epidemiology: Major depression present in 5–13% of primary care pts w/ a lifetime prevalence of ~16% in the general population; depression is the leading cause of disability worldwide (JAMA 2017;317:1517) Differential diagnosis: Ψ: dysthymia, cyclothymia, adjustment d/o w/

 

depressed mood, seasonal affective d/o; organic: Meds (antiarrhythmics, steroids, BZD, βB, others), SUD, thyroid (hypo/hyper), Cushing’s, hypercalcemia, DM, dementia, neuro d/o, infection (mono/flu/HIV/syphilis/Lyme), B₁₂/zinc deficiency, cancer (classically

pancreatic), postsurgical, stroke

Evaluation (Ann Int Med 2016;165:ITC49)

 

Screening for Depression (AFP 2012;85:139; Ann Inter Med 2009;151:784; 2010;152:ITC5–1)
Recommended by USPSTF in practices w/ resources for depression dx & tx PHQ-2: Over the past 2 wk how often have you been bothered by: (1) little interest/pleasure in doing things; (2) feeling down, depressed, or hopeless? Any + response → 96% Se/57% Sp for depression → screen with PHQ-9 for severity (below)
Evaluation of Depression
Symptoms	Depressed mood/anhedonia & SIGECAPS sx: Sleep (↑ / ↓), Interest, Guilt, Energy, Concentration, Appetite (↑ / ↓), Psychomotor sx, Suicidality; ≥5 of 9 sx present nearly every d for ≥2 wk diagnostic
Further hx	Duration; severity; past episodes; psychosocial factors (precipitants & supports); FHx; hx of bipolar sx; psychosis; How sx interfere w/ fxn
Mental status exam: Appearance (grooming, eye contact, behavior); Motor activity (psychomotor retardation/agitation); Speech (quantity, rate, volume, fluency, coherence, spontaneity); Mood (pt subjective report of internal emotional state) & affect (provider’s perception of pt expressed emotion); Thought process & content; Cognition (i.e., MMSE); Insight (self-awareness of problem); Judgment (appreciate consequences)
PHQ-9 Assessment of Depression Severity
Over the last 2 wk how often have you: Felt little interest/pleasure in doing things Felt badly about yourself, felt you are a failure or let your family down Had trouble falling or staying asleep, or slept too much Moved so slowly or were so fidgety that others noticed Thought you would be better off dead or wanted to hurt yourself Felt down/depressed/hopeless Had trouble concentrating Felt tired or had little energy Had a poor appetite or overate
Scoring: 0 = not at all, 1 = several days, 2 = more than half the days, 3 = nearly every day 0–4: Nondepressed, 5–9: Minor depression, 10–14: Mild depression, 15–19: Moderately severe depression, 20–27: Severe depression

Ongoing assessment: Important to review at each visit: sx (SIGECAPS, above), severity (PHQ-9), suicide (see “Suicide

 

Assessment”); MDD is a chronic illness, defined by episodes of variable length & frequency; patients w/ a major depressive episode may expect resolution with time, as well as likely recurrence in the future; treatment is therefore dynamic

Workup: Consider TSH, CBC (anemia), vitamin D level

Treatment (AFP 2006;73:83; 2008;77:785; 2009;80:167; JAMA 2006;295:318; NEJM

2005;353:1819)

 

Evidence-Based Treatments for Depression

Psychotherapy: Equivalent efficacy to pharmacotherapy & effects of the 2 are additive (Arch Gen Psych 2004;61:714); Psychotherapy ideal for mood sx (sadness, guilt, worthlessness) Supportive therapy: Effective & can occur in primary care settings; it involves aiding the pt by identifying triggers, explaining sx, & offering support & guidance Cognitive behavior therapy (CBT): Cognitive tx addresses inaccurate or maladaptive beliefs (Lancet 2013;381:375); behavioral tx attempts to improve sx & functioning through exercises & focused counseling. Improves response and remission in depression (Lancet 2013;381:375).

Pharmacotherapy: Counsel pts it may take 1–6 wk to improve sx, RR ~50–60%; Meta- analysis demonstrates no difference in efficacy among agents (Ann Intern Med 2011;155:772); different agents have different s/e profiles (table); goal should be to have pt take a drug they can tolerate; ideal for neurovegetative sx (energy, appetite Δ, sleep disturbance, psychomotor Δ); 2nd-gen meds (e.g., SSRIs, SNRIs) more tolerable than TCAs & less dangerous in O/D; pts should be followed closely after initiation Duration of therapy: Typically at least 6–9 mo w/ a slow taper; pts who relapse are candidates for longer or lifelong Rx Precaution: ↑ suicidal ideation in young adults (18–24 y) → discuss w/ pt & advise them to call if they have suicidal thoughts

Light therapy: Conventionally used in seasonal affective d/o (depression that recurs & remits seasonally); Rx: 10,000 lux lamp, gradually increasing up to 30–45 min daily; s/e include risk of hypomania (JAMA Psychiatry 2016;73:56)

Electroconvulsive therapy (ECT): May be effective in severe, unremitting depression; used more often in the elderly; s/e: include prominent retro/anterograde amnesia (less during maintenance tx); even so, overall cognitive function generally improves; ECT may temporarily ↑ cardiopulmonary demands despite anesthesia (NEJM 2007;357:1939)

 

Depression Pharmacotherapy by Class/Agent
	Class Characteristics	Drug (dose, mg)	Notes
SSRI	Better tolerated, little risk in O/D S/e: Agitation, insomnia, sexual dysfunction, GI upset, wt gain; ↑ bleeding risk w/ ASA, NSAIDs; risk of serotonin syndrome in combination w/ certain drugs	Fluoxetine SD: 10–20 TD: 20–40	More stimulating; long-acting metabolite; Least amount of wt gain or withdrawal among SSRIs; ↑ drug interactions; helpful for anxiety;

 

		Paroxetine SD: 10–20 TD: 20–40	Helpful for anxiety/OCD. More withdrawal sxa, sedation, sexual dysfunction, wt gain, orthostatic HoTN vs. other SSRIs
		Citalopram, SD: 10– 20, TD: 20–40	Helpful for anxiety; ↓ Na; risk of ↑ QTc;
		Escitalopram SD: 10, TD: 10–20	↓ drug–drug interactions
		Sertraline, SD: 50 TD: 50–100 mg	More diarrheaa; helpful in anxiety/OCD; stimulating
		Vilazodone, 10–40	↓ sexual side-effects
		Vortioxetine, 5–20	May improve cognition
TCA	Similar efficacy to SSRIs but more S/E; anticholinergic, arrhythmogenic & possibly lethal in O/D; Wt gain	Amitriptyline SD: 25– 50, TD: 100–300	Most sedating/anticholinergic; helpful in chronic pain/migraines; SD: 25–50 mg; TD: 100–300 mg
		Imipramine, SD: 25– 50; TD: 100-300	Oldest TCA;
		Desipramine, SD: 25– 50; TD: 100-300	Least sedating/anticholinergic
		Doxepin, SD: 25–50, TD: 100-300	Mod sedating/anticholinergic
		Nortriptyline, SD: 25; TD: 50– 150	Less sedating/anticholinergic; lower orthostatic HoTN compared to other TCAs; helpful in chronic pain/IBS

 

Other Pharmacologic Agents

 

Drug (dose, mg)	Notes
Bupropion SD: 50–75 BID TD: 300–450 TID	Dopamine & noradrenergic reuptake inhibitor; fewer sexual s/e, not assoc w/ wt gain; stimulating; used as adjunct or for smoking cessation; ? helpful in ADHD; ↓ seizure threshold (little risk at low dose); may be fatal in O/D. May enhance response when given with SSRI.
Venlafaxine SD: 37.5 BID; TD: 75–300 BID/TID	SNRI; GI upset, withdrawal sx; stimulating; ↑ doses may cause HTN; concern for ↑ CV events; helpful in chronic pain; may be lethal in OD; ↑ drug–drug interactions
Duloxetine, SD: 30 QHS; TD: 60– 120b	SNRI; s/e similar to venlafaxine w/ less e/o CV effects; contraindicated in liver disease; may worsen DM2; helpful in chronic pain
Mirtazapine, SD: 15 QHS; TD: 15–45 QHS	Acts on norepinephrine, serotonin; ↓ drug–drug interactions; wt gain, sedation (useful in insomnia)
Trazodone, SD: 50; TD: 75–500b	Serotonin antagonist & partial agonist; sedation, postural HoTN, priapism
MAOIs (tranylcypromine, phenelzine, selegiline)	May be fatal in O/D, in drug combinations, or w/ tyrosine-rich food or drink; also cause HoTN, insomnia; rarely initiated by PCPs

PCPs; demonstrated efficacy in atypical depression & elderly. SD, starting dose; TD, therapeutic dose.

aS/E differences supported in meta-analysis (Annals Intern Med 2011;155:772) bAt lower doses, may be given as a single-dose QHS; otherwise should be divided BID or TID

 

Refractory depression: If no response in 4–10 wk, consider a different agent from the same or another class; confirm medication adherence, r/o organic causes, augment w/ CBT; treat comorbid SUD, personality d/o, or hx physical/sexual abuse (all ↑ refractoriness); if depression persists, refer to psychiatry; bupropion, mirtazapine, or 2nd-generation antipsychotics (quetiapine, aripiprazole, brexpiprazole) may augment the effectiveness of SSRIs

Relapse: Consider rechallenge of antidepressant that led to remission Indications for psych referral: Multidrug Rx, suicidality/thought d/o, depression refractory to 1st-line Rx, unclear dx, psychotic features, bipolar; pts may be reluctant to see psychiatrist/counselor, consider saying, “sx of depression are very common. I want to introduce you to a colleague whom I really like; I think you would like him/her, too, &

 

he/she could help.”

Exercise: In some trials results in ↓ in depressive sx (JAMA 2014;311:2432)

Special Populations (AFP 2010;82:926; 2011;84:1149; 2015;92:94; NEJM

2007;357:2269; 2011;365:1605)

Pregnancy: SSRIs, sometimes used in pregnancy, may modestly ↑ risk for birth defects; consider referral to perinatal psychiatry & for CBT; paroxetine is category D

Elderly: Some sx (poor concentration, energy) may be misinterpreted as dementia (see “Dementia”); start Rx (SSRIs) at very low doses & avoid TCAs if possible; ECT is an option for refractory sx (AFP 2004;69:2375; JAMA 2017;317:2114; NEJM 2014;371:1228); preferred

medications include citalopram, escitalopram, mirtazapine, sertraline, and venlafaxine

Geriatric depression screen: Extensively validated; depressive responses to at least 2/5 suggest dx: Are you basically satisfied w/ your life? Do you often get bored? Do you often feel helpless? Do you prefer to stay at home rather than going out & doing new things? Do you feel pretty worthless the way you are now? (J Am Geriatr Soc 2003;51:694)

Postpartum: 85% of ♀ experience transient postpartum blues w/ a peak incidence 4–5 d postdelivery; these should not affect function & remit by 2 wk; 5–15% of ♀ develop postpartum depression, likely due to lifestyle changes w/ childbirth (loss of sleep) (AFP 2016;93:852; JAMA 2006;296:2616); most SSRIs pass into milk and are thought to be safe in breastfeeding, although long-term studies lacking; sertraline is the most well-studied antidepressant in breast feeding (NEJM 2016;375:2177)

Patient information: AFP 1999;60:239; 2006;73:90; 2008;77:795;

2010;82:939; 2011;84:1155; JAMA 2008;299:2466; 2010;304:1736

 

 

EATING DISORDERS

Background (AFP 2015;91:46; Arch Gen Psych 2000;57:659; Int J Eat Dis 2002;31:151;

JAMA 1998;279:1992)

 

Classification of Eating Disorders (Mayo Clin Proc 2010;85:746; Curr Opin Psych 2013;26:532)

 

Anorexia nervosa (AN): ↓ food intake → significant ↓ wt w/severity mild (BMI ≥17), moderate   (BMI ≥16), severe (BMI ≥15), extreme (BMI <5); Intense fear of gaining wt; body image disturbance; Restrictive type: No binging/purging in past 3 mo; Binge eating/purging type: ⊕ binge eating or purging in past 3 mo; Lifetime prevalence: 0.9% in ♀; 0.3% in ♂; fatal in 8– 16% of pts

Bulimia nervosa (BN): Recurrent binging (consuming large amounts of food in a discrete time period w/sense of lack of control) followed by inappropriate compensatory behavior to prevent wt gain (e.g., purging, exercise, fasting, laxatives, diuretics) which occurs, on avg, ≥1×/wk for 3 mo; in contrast to anorexia, most pts are near-nl wt; lifetime prevalence 1.5% in ♀, 0.5% in ♂; 70% of pts in partial/full remission at mean f/u of ~12 y

Binge eating disorder: Episodic binge eating w/o purging, exercising or dietary behaviors to prevent wt gain; at least 3 of the following present: (1) Eating more rapidly than nl; (2) Eating until uncomfortably full; (3) Eating large amounts when not hungry; (4) Eating alone b/c of embarrassment of how much one is eating; (5) Feeling disgusted, depressed, or guilty from overeating; must occur ≥1×/wk for ≥3 mo; assoc w/ lack of control & distress over eating; lifetime prevalence: 3.5% in ♀; 2% in ♂

Avoidant/restrictive food intake disorder: Avoiding or restricting food intake, not related to distorted body image or general medical condition, leading to persistent failure to meet nutritional energy needs demonstrated by at least 1 of the following: (1) Clinically significant wt loss; (2) Nutritional deficiency; (3) Supplementary enteral feeding or oral supplements required; (4) Impaired psychosocial functioning

Pica: The following criteria must be met: (1) Repeated eating of nonfood, nonnutritional substances (e.g., chalk, clay, dirt) for at least 1 mo; (2) Eating behaviors are inappropriate to developmental level & outside of cultural/societal norms; (3) If it occurs in context of other mental disorder or general medical condition, it must have a severity warranting clinical attention; may be a manifestation of iron deficiency anemia

Rumination disorder: The following criteria must be met: (1) Repeated regurgitation of food, which may be rechewed/reswallowed/spit out for at least 1 mo; (2) Behavior not due to general medical condition (e.g., GERD); (3) Does not occur solely during course of other eating disorder; (4) If it occurs in context of other mental disorder or general medical condition, it must have a severity warranting clinical attention

Other specified feeding or eating disorder: Aberrant eating patterns & wt mgmt that cause significant distress/impairment but do not meeting above criteria

Differential diagnosis: IBD, celiac disease, achalasia, hyperthyroidism, Addison’s, hypopituitarism, DM1, cancer, HIV, TB, depression, SUD, medication effect

Evaluation (Ann Intern Med 2012;156:ITC4–1; JAMA 1999;282:1737; NEJM

1999;340:1092)

History: Wt & exercise hx, motivation for Δ, past response to Rx, s/sx of malnutrition (e.g., amenorrhea) (Ped Rev 2011;32:511); screen for comorbid psych d/o, e.g., anxiety (see “Anxiety Disorders”), OCD (see

 

“Obsessive Compulsive Disorders”), SUD (see “Substance Use Disorders”), depression (see “Depression”) & suicide (see “Suicide Assessment,” 17% prevalence of attempts in anorexia); FHx (↑ prevalence in pts w/ 1st-degree relative w/ alcoholism or eating d/o); social hx: hx dieting, sports w/ weight limits or where leanness emphasized (ballet, wrestling, running) or scoring is subjective (gymnastics, skating); OCP use

Body image: “What percent of the day are your thoughts occupied w/ food, eating, body size or shape? How often do you weigh yourself? Are you satisfied, dissatisfied, or distressed with your current body weight?”

Eating history: Ask about vomiting, spitting, use of laxatives, diuretics, diet pills, syrup of ipecac, or ruminating (regurgitating/rechewing); “Do you restrict calories or avoid certain foods?”

SCOFF questions: “Yes” to ≥2 or more questions = 100% Se & 87.5% Sp for diagnosis of an eating d/o (BMJ 1999;319:1467): (1) Do you make yourself Sick because you feel uncomfortably full? (2) Do you worry you have lost Control over how much you eat? (3) Have you recently lost more than One stone (14 lb) in a 3 mo period? (4) Do you believe yourself to be Fat when others say you are too thin? (5) Would you say that Food dominates your life?

Exam for anorexia nervosa: Gen: Emaciated, lack of ♀ fat distribution; VS: BMI, ↓ HR, hypothermia, HoTN; CV: MVP murmur; Ext: Ankle or pretibial edema; Derm: xerosis, hypercarotenemia, lanugo, thinning scalp hair

Exam for bulimia: HEENT: dental enamel erosion, enlarged parotid glands; Ext: Russell sign (callous over knuckles from purging) Workup: ECG (↑ QTc), Mg, Phos, Chem-12 (↓ K, metabolic alkalosis), CBC, TSH, CK (↑ if excessive exercise), U/A, amylase (↑ if purging,

lipase nl); labs can be nl even in anorexic pts w/ severe malnutrition (Clin Ter 2011;162:401); bone densitometry

Treatment (AFP 2008;77:187; Lancet 2005;365:79; NEJM 2003;349:875; 2005;353:1481;

2009;360:500)

Indication for hospitalization: HR <40, BP <90/60, sx hypoglycemia, K <3 mM, T <97°F, dehydration, orthostatic, CV abnormalities, wt <75%

 

expected, failure of outpt tx, rapid wt loss, requiring NG feeding, poor motivation/insight, abusive home environment, suicidal, serious comorbid psych conditions

General principles: Interdisciplinary care (psychiatrist, therapist, nutritionist, & PCP)

Goals: Attain & sustain nl BMI; stop abnl eating behaviors; replace cognitive distortions w/ capacity for emotional & behavioral self- regulation; improve coping skills

Anorexia: 1st-line tx is wt restoration w/ nutritional rehab + psychotherapy (AJP 2006;163:4); pt may safely gain 0.5–2 lb/wk outpt; meal plans start at 1500 cal/d, ↑ by 500 cal/d q3–4d PRN; vitamin supplementation; monitor for refeeding syndrome (potentially fatal shifts in fluids & electrolytes [↓ K, ↓ Phos, ↓ Mg]) in malnourished pts

Psychotherapy: CBT, family tx for younger pts (Maudsley—intensive outpt tx involving parents) (Br J Psych 2001;178:216; AJP 2006;163:4) Medical therapy: No FDA-approved meds (JAMA 2006;295:2605); treat comorbid psych d/o; some data suggest atypical antipsychotics (olanzapine) may target cognitive distortions, insomnia, & wt; zinc gluconate 100 mg/d & cyproheptadine 32 mg/d possibly helpful for more rapid wt restoration (Int J Eat Disord 1994;15:251; Clin Evid

2003;9:986)

Bulimia nervosa: CBT is best evidence-based form of psychotherapy (Int J Eat Disord 2007;40:95; Lancet 2010;375:583); Rx + psychotherapy better than either alone

Nutrition: Structured, consistent meals (e.g., 3 meals + 2 snacks/d) (Am J Psych 2006;163:4) Medical therapy: SSRIs 1st-line (fluoxetine 60 mg QD); 2nd-line tx is another SSRI (citalopram, fluvoxamine, & sertraline); 3rd-line tx, in order of preference: Topiramate, TCAs, trazodone, or MAOI; avoid bupropion due to ↑ seizure risk (Am J Psych 2006;163:4)

Binge eating: Psychotherapy more effective than behavioral wt loss therapy or pharmacotherapy (Am Psychol 2007;62:1999)

Psychotherapy: 1st-line; proven effective therapies include CBT, self-help CBT, interpersonal tx, & dialectical behavioral tx (Int J Eat Dis 2010;43:205) Medical therapy: Sertraline (50–200 mg/d) & fluvoxamine (50–300 mg/d) ↓ binge frequency (Am J Psych

 

1998;155:1756; 2000;157:1004); topiramate (50–600 mg/d) to ↓ sx (Am J Psych 2003;160:612; Arch Gen Psych 2003;60:1109)

Patient information: AFP 2003;67:311; 2008;77:196; 2008;78:223;

anad.org nationaleatingdisorders.org

 

 

INSOMNIA AND SLEEP DISORDERS

Background (AFP 2013;88:231; BMJ 2004;329:724; JAMA 2013;309:706; NEJM

2015;373:1437)

Insomnia: Difficulty initiating/maintaining sleep or early awakening → fatigue, daytime sleepiness, mood disturbance, impaired attention/concentration/memory, functional (occupational, academic, social) impairment. Occurs ≥ 3×/wk, is present for ≥3 mo, and occurs despite adequate opportunity for sleep

Epidemiology: Most common sleep disorder; ~30% of adults have sx, prevalence 10–15%; incidence ↑ w/ age, 2:1 ♀:♂

Ddx: Psych (anxiety, depression, mania/hypomania, adjustment disorders, PTSD), SUD, chronic pain, CHF, OSA (see “Obstructive Sleep Apnea”), COPD, asthma, hyperthyroidism, menopause, BPH, restless leg syndrome, meds (steroids, stimulants, levothyroxine, albuterol, BZD/EtOH withdrawal, caffeine, tobacco), high altitude

 

Forms of Insomnia (DSM–V)
Type	Clinical Features
Short- term	<3 mo duration, related to a stressor (Δ in bedroom setting, background noise/lighting), life events (work/school stress, divorce/relationship conflicts, bereavement), acute illness, drugs/substances, hospital admission → improves w/ adaptation or stressor resolution
Chronic	≥3 mo duration with sx of sleep initiation or maintenance occurring ≥3x/wk. Sx occur despite adequate opportunities and circumstances for sleep and lead to daytime consequences
Other	Difficulty w/sleep initiation or maintenance, do not meet above criteria

Narcolepsy: Chronic daytime somnolence & in some, cataplexy (transient muscle weakness triggered by emotion), hypnagogic

 

hallucinations (vivid visual or auditory phenomena likely reflecting intrusions of REM sleep into wakefulness), & sleep paralysis (transient inability to move after awakening)

Circadian sleep disorders: Shift work, jet lag (NEJM 2010;362:440) Nightmare disorder: Recurrent awakenings w/ recall of intensely disturbing dreams (usually provoking fear, anxiety, or other dysphoric emotions), w/ full alertness on awakening, & delayed return to sleep; assoc w/ anxiety, stress, other Y disorders

Evaluation (AFP 2007;76:517; 2015;92:1058; NEJM 2005;353:803)

History: Daytime somnolence, ↓ energy, impaired concentration or function in work/school/social interactions, depression, anxiety, irritability, HA; sleep log

Sleep history: Acute vs. chronic; bedtime (regularity & timing); quantity & quality of sleep, what wakes pt up; how long to fall asleep; timing of nocturnal & final awakening; daytime naps; pre- bedtime behavior (tobacco, EtOH, caffeine, vigorous activity); bedroom environment (light, noise, TV, use for nonsleep activities such as work, sex); stressors, snoring, restless legs, parasomnias (unusual sleep behavior)

Workup: Polysomnography (PSG or “overnight sleep study”) if concern for another sleep disorder (see “Obstructive Sleep Apnea”); multiple sleep latency testing for narcolepsy

Treatment (AFP 2017;96:29; Am J Med 2010;123:1087; Ann Int Med 2016;165:103;113;

JAMA 2017;317:762)

Insomnia: Sleep hygiene counseling: 1st-line tx along w/CBT (below); regular sleep schedule, do not remain in bed longer than 20 min if unable to sleep, avoid naps, sleep as long as needed to feel refreshed the next day but not more, preserve bedroom comfort (light, sound, & temperature), reserve the bed for sleep, exercise regularly but not close to bedtime, avoid mentally or emotionally challenging activities before bedtime, avoid caffeine/tobacco 4–6 h before bed (Sleep Med Rev 2003;7:215); treat comorbid conditions like polyuria/BPH and restless legs

Psychotherapy: CBT, relaxation techniques, sleep restriction Rx (limiting total time in bed to improve sleep efficiency) (AFP

 

2009;79:125; JAMA 2009;301:2005); Mindfulness also shown to be effective (JAMA Int Med 2015;175:494) Pharmacotherapy: Pts w/ difficulty in sleep onset may receive short-acting Rx (zolpidem, zaleplon, lorazepam, triazolam, ramelteon); pts w/ difficulty staying asleep should receive longer-acting Rx (zolpidem ER, eszopiclone, temazepam, estazolam, doxepin, suvorexant); counsel pt to use caution in driving, combination w/ sedating medications/EtOH, and document conversation; caution re: s/e profile of hypnotics and BZDs (see below)

 

Pharmacotherapy for Insomnia (Sleep Med Rev 2009;13:265; Ann Int Medicine 2016;165:103)
Type	Features
Benzodiazepines Risk of tolerance, dependence, impairment in attention, concentration, memory	Long-acting: Flurazepam, quazepam (↑ likelihood of daytime impairment); avoid diazepam 2/2 metabolite accumulation Intermediate-acting: Lorazepam, temazepam, estazolam Short-acting: Triazolam
Non-BZ Receptor	Zolpidem: Short-acting form most useful for sleep initiation; ER more effective for sleep maintenance; ↓ dose by 50% in elderly; max dose 5 mg in women (JAMA 2013;309:2203). SL form useful for middle of the night awakenings. Eszopiclone: Effective for sleep-onset & maintenance (AFP 2005;71:2359); Zaleplon: Effective for sleep initiation & nocturnal awakenings; ultra-short half-life
Agonists
Similar adverse effects as
BZs.
Sleep may be worse the 1st
night after
discontinuation.
Eszopiclone & zolpidem ER
eval in trials for up to 6
mo use; zaleplon for up
to 12 mo (Sleep
2007;30:959; 2008;31:79;
Sleep Med 2005;6:107)
Melatonin agonists	Melatonin (1–10 mg), several hours before bedtime; effective in circadian rhythm disorders (jet lag, shift work) Ramelteon (8 mg) ↓ sleep onset latency, ↑ sleep time. Approved in US but not Europe due to lack of efficacy; not DEA-controlled; fewest s/e among sedative-hypnotics, not habit forming
Ramelteon eval in clinical
trials for up to 6 mo use
(Sleep 2009;32:351)
Orexin receptor antagonists Suvorexant evaluated in clinical trial for 12 mo (Lancet Neurol 2014; 13:461)	Suvorexant (5–20 mg) 12-h half-life; most common s/e is sedation, may have rebound insomnia
Antidepressants Options in several classes, consider in pts	Trazodone: 25–50 mg QHS (can ↑ to 200 mg); limited published efficacy data but well tolerated, often used 1st-line Doxepin: 3–6 mg QHS; FDA approved for insomnia (AFP 2011;84:453);

 

w/comorbid depression (AFP 2011;84:1)	Mirtazapine: 7.5–15 mg QHS (AFP 1999;59:159)
Antipsychotics Consider where indicated for 1° mood or psychotic disorder	Often used off-label despite lack of RCT data Quetiapine: 12.5–100 mg QHS Olanzapine: 2.5–10 mg QHS
Antihistamines (Risk of oversedation the next day, anticholinergic s/e)	Diphenhydramine (25–50 mg), doxylamine (25 mg), hydroxyzine (25–50 mg)

Narcolepsy: Strategic daytime naps; modafinil (1° pharmacotherapy); methylphenidate or dextroamphetamine 2nd-line (limited by ↑ BP, ↑ risk SCD); venlafaxine & other SNRIs effective for REM suppression; counsel about driving

Nightmare disorder: CBT, desensitization, relaxation, image rehearsal (document nightmares, Δ narratives to be ⊕, rehearse rewritten dream); prazosin for PTSD-related nightmares

Jet lag: Melatonin, optimize light exposure, Δ sleep schedule in advance, short-acting sleep aids, hydration, use EtOH, caffeine judiciously; see “Travel Medicine”

Patient information: AFP 2007;76:527; 2009;79:131; JAMA

2012;307:2653; 2013;309:733

 

 

OBSESSIVE-COMPULSIVE DISORDER

Background (AFP 2009;80:239; Lancet 2009;374:491)

Obsessions: Recurrent thoughts, impulses (e.g., to harm someone for no reason) or images (e.g., violent scenes) that cause marked anxiety or distress, are experienced as intrusive, go beyond excessive worry about real-life problems, & are not related to another mental disorder Compulsions: Repetitive activities (e.g., hand-washing, ordering, checking) or mental acts (e.g., counting) in response to an obsession; acts aimed at preventing or reducing distress; pt usually recognizes as excessive or unreasonable (ego-dystonic)

Obsessions/compulsions are time-consuming (>1 h/d), cause marked distress or interfere w/ a person’s daily routine, occupation or social functioning, or lead to avoidance; may involve cleaning,

 

symmetry/order/counting, forbidden thoughts (i.e., sexual), harm to self/others, or hoarding

Hoarding: Now defined in DSM-5 as difficulty/distress in parting w/ possessions → distress, impairment, severely cluttered living spaces; typically treated w/ CBT (NEJM 2014;370:2023)

Epidemiology: Lifetime prevalence 2–3% in the general population; bimodal age of onset at 10 y & 21 y; mean age of onset: ~20 y; ♂:♀ 1:1; same incidence across cultural boundaries, monozygotic > dizygotic twins (Arch Gen Psychiatry 1988:45:1094)

 

Psychiatric Conditions Mistaken for OCD
Condition	Similar Sx	How to Distinguish
Anxiety	Worry	No rituals; OCD usually irrational
Bipolar	Manic delusions	Usually grandiose (ego-syntonic)
Body dysmorphic disorder	Preoccupation with bodily defect	Related to body alone
Depression	Ruminations	No rituals. Depressive ruminations often negative (guilt, regret)
Hypochondriasis	Fear of illness	Doesn’t arise from external stimuli (i.e., contamination), instead misinterpret regular body sx
OCPD	Hoarding, perfectionism, preoccupation w/ rules	Ego-syntonic, global traits not specific
Paraphilia	Intrusive sexual thoughts and urges	OCD obsessions are ego-dystonic
PTSD	Intrusive thoughts/images	Result of actual events (OCD anticipates future consequences)
Psychosis	Delusional beliefs	OCD pts realize delusions irrational

Evaluation and Prognosis (JAMA 2001;285:2121; NEJM 2004;350:259; 2014;371:646)

History: Screening questions: Do you have unwanted ideas, images, or impulses that seem silly, nasty, or horrible? Do you worry you might impulsively harm someone? Do you have to count things, wash your hands, or check things over and over? Do you worry a lot about

 

whether you have been immoral? Are there certain behaviors that you feel compelled to repeat? Evaluate for safety of pt and others around (does it affect home life and lead to danger, i.e., chemicals/physical illness/children at risk). Assess insight (i.e., does pt realize intrusive thoughts are not true)?

Natural history: 2/3rds of pts improve over a decade w/o tx, but full remission in only 20%; suicide attempts reported in 10% of pts (Arch Gen

Psych 1999;56:121)

Treatment (AFP 2015;92:896; Cochrane Database Syst Rev 2008:CD001765; JAMA

2017;317:1358; J Clin Psych 1999;60:101; J Clin Psychopharm 2002;22:309; 2014;28:403)

General principles: Treatment should be initiated by providers confident of dx and comfortable with Rx options; comanagement w/ psychiatry is typical; CBT is typically 1st-line for mild/moderate OCD in pts w/ good insight; Yale-Brown OCD Scale (Y-BOCS) can be useful in tracking sx; making goal quantifiable can be useful (i.e., < h/d spent performing behaviors)

 

Management of OCD (NEJM 2014;371:646)

Pharmacotherapy: Options include SSRI, SSRI + antipsychotic, clomipramine, SSRI + clomipramine. Efficacy: For SSRIs no difference in efficacy w/in class. Pts typically take longer to respond than for depression (i.e., 4–6 wk for initial response, 10–12 wk for max benefit). 25–40% of pts relapse if meds discontinued by taper after 1–2 y compared to 80% relapse rate for shorter Tx durations Dosing: Tx doses often 150% or more of typical max dose in depression, maximum tolerated dose usually most effective: Sertraline (50–300 mg), paroxetine (10–60 mg), fluoxetine (20–80 mg), fluvoxamine (50–300 mg); see “Psychotropic Medications” for specific properties & s/e. SSRIs & clomipramine lead to improvement in 40– 60% pts; on average, pts experience 20–40% ↓ in sx w/ meds alone, but best in combination w/ CBT. Antipsychotics: Consider if partial response w/ SSRI (risperidone has the most data)

Cognitive behavioral therapy: Exposure & response prevention (most effective behavioral intervention); graded exposure to anxiety-provoking stimuli; cognitive restructuring; pt & family psychoeducation; 13–20 weekly sessions = adequate trial. Used alone if milder sx or pt resistant to meds. 83% of pts responded to exposure-based CBT (>30% sx reduced); 76% show improved sx long-term. (J Consult Clin Psychol 1997;65:44) Internet-based CBT: ocdchallenge.com; managingyouranxiety.com; liveocdfree.com. App-based CBT (iTunes): Anxiety coach, icounselorOCD, OCD manager,

Surgery: Anterior cingulotomy, deep brain stimulation can be effective in refractory cases (Am J Psych 2002;159:269)

Relapse prevention: May be on meds indefinitely. If CBT completed, periodic sessions can be helpful to reinforce skills.

 

Patient information: JAMA 2011;305:1926; iocdf.org

 

 

PSYCHOTROPIC MEDICATIONS

 

Antidepressants (Ann Int Med 2016;165:ITC49)
	Class Characteristics	Drug and Notes (Doses in mg)
SSRI	Better tolerated, little risk in O/D S/e: Agitation, insomnia, sexual dysfunction, GI upset, wt gain; ↑ bleeding risk w/ ASA, NSAIDs; risk of serotonin syndrome in combination w/ certain drugs	Fluoxetine: More stimulating; long-acting metabolite mitigates w/d, missed doses; least amount of wt gain among SSRIs; ↑ drug–drug interactions (2D6 & 3A4 inhibitor); helpful for anxiety; SD: 10–20; TD: 20–40
		Paroxetine: Helpful for anxiety/OCD; withdrawal sx; more sedation, sexual dysfunction; ↑ orthostatic HoTN vs. other SSRIs; SD: 10–20; TD 20–40
		Citalopram: Helpful for anxiety; ↓ Na; risk of ↑ QTc; SD: 10–20; TD: 20–40
		Escitalopram: ↓ drug interactions; SD: 10; TD: 10–20
		Sertraline: More diarrhea; helpful in anxiety/OCD; stimulating; SD: 50; TD: 100– 200
SNRI	Well tolerated, helpful in chronic pain S/e: GI upset, withdrawal sx; stimulating; ? ↑ CV events; lethal in OD; ↑ drug interactions	Venlafaxine: ↑ doses may cause HTN; SD: 37.5 BID; TD: 75–300 BID or TID
		Duloxetine: S/e similar to venlafaxine w/ less e/o CV effects; contraindicated in liver disease; may worsen DM2; SD: 30 QHS; TD: 60–120
TCA	Similar efficacy to SSRIs but more s/e; anticholinergic, arrhythmogenic & possibly lethal in O/D; wt gain	Amitriptyline: Most sedating/anticholinergic; helpful in chronic pain/migraines; SD: 25–50; TD: 100–300
		Imipramine: Oldest TCA; SD: 25–50; TD: 100– 300
		Desipramine: Least sedating/anticholinergic SD: 25–50; TD: 100–300
		Doxepin: Mod sedating/anticholinergic SD: 25– 50; TD: 100–300
		Nortriptyline: Less sedating/anticholinergic;

 

		lower orthostatic HoTN compared to other TCAs; helpful in chronic pain/IBS; therapeutic at 50–150 ng/mL. Monitor BMP. SD: 25; TD: 50–150
MAOI	Can be effective in treatment resistant/atypical depression S/e: May be fatal in O/D, in drug combinations, or w/ tyrosine-rich food or drink; risk of hypertensive crisis and serotonin syndrome	Tranylcypromine: More stimulating than phenelzine, but less likely to ↑ wt; SD: 10 daily; TD 30-60 daily
		Phenelzine: Can rarely cause hepatotoxicity; SD: 15 daily; TD 60–90 daily
		Selegiline: Selective MAO-B inhibition at low doses; available as transdermal patch that does not require dietary restrictions at 6 dose; SD: 6 daily; TD 6–12 daily
Other Pharmacologic Agents (Drug & Notes)
Bupropion: Dopamine & noradrenergic reuptake inhibitor; fewer sexual s/e, not assoc w/ wt gain; stimulating; often used as an adjunct or for smoking cessation; ? helpful in ADHD; ↓ seizure threshold (little risk at low dose); contraindicated in eating disorders; may be fatal in O/D; SD: 50–75 mg BID; TD: 300–450 mg TID
Mirtazapine: Acts on norepinephrine, serotonin; ↓ drug–drug interactions; wt gain, sedation (useful in insomnia); less sedation, possible energy boost at doses 30 mg and above. Avoid EtOH, benzodiazepines. SD: 15 mg QHS; TD: 15–60 mg QHS
Trazodone: Serotonin antagonist & partial agonist; sedation, postural HoTN & priapism; SD: 25 mg; TD: 75–500 mg
Reactions Requiring Immediate Medical Attention (i.e., ED Referral)
Serotonin syndrome: From serotonergic agents alone or in combination: Fever, diarrhea, myoclonus, hyperreflexia, altered mental status, agitation (AFP 2010;81:1139)
Hypertensive crisis: From MAOIs combined with tyrosine-rich food or drink
Common Adverse Effects Requiring Outpatient Medical Attention
Antidepressant discontinuation syndrome: Dizziness, lightheadedness, insomnia, fatigue, anxiety/agitation, HA, flu-like sx, sensory disturbance (e.g., shock-like sensations); seen in up to 85% of pts; most common w/ paroxetine, venlafaxine; distinguished from depression relapse by presence of sensory disturbance, coincidence w/ tapering antidepressant, & resolution in 1–2 wk; Management: Pt education re: avoiding abrupt d/c of med; gradual taper (AFP 2007;74:449)

(Stahl’s Essential Psychopharmacology. 2014)

 

Antipsychotics (Drug & Notes, Doses in mg)
	Class Characteristics	Drug	Notes
First Generation		Haloperidol: Available in oral, IM, long- acting injectable formulations. Oral

 

	High potency: ↑ risk of EPS; less association with sedation, weight gain, anticholinergic activity	SD: 1–15 QD; TD: 1–40 QD
		Fluphenazine: Available in PO, IM, long-acting inj formulations. Oral SD: 12.5–25 QD; TD: 1-20 QD
		Pimozide: Oral formulation only. SD: 1– 2 mg/d in divided doses; TD: less than 10 mg/d
	Mid potency: Side effect profile more similar to high than low potency	Loxapine: Oral formulation only. SD: 20 mg/d in 2 doses; TD: 60–100 mg daily in 2–4 divided doses
		Perphenazine: Available in oral, IM formulations. Oral SD: 4–8 BID or TID; TD: 12–64 QD in divided doses
	Low potency: More sedating and anticholinergic effects; ↓ risk of EPS	Chlorpromazine: Available in oral, rectal, IM formulation. Oral TD: 50– 800 mg daily
		Thioridazine: Available in oral formulation only. SD: 50–100 mg TID; TD: 200-800 mg/day in divided doses
Second Generation	Aripiprazole: Available in oral, IM, long-acting injectable formulations. Can be used as augmentation to antidepressants. Oral SD: 2.5–5 QD; TD: 2.5–30 QD
	Risperidone: Available in oral, long-acting injectable formulations. Oral SD: 0.5–1 mg QD; TD: 0.5–8 mg QD
	Quetiapine: Oral formulation only. Oral SD: 25–50 mg daily; TD: 400–800 mg daily in 1–2 doses for psychosis, 300 mg daily for bipolar depression
	Ziprasidone: Available in oral, IM formulations. Oral SD: 20 mg BID; TD: 40– 200 mg QD in divided doses (with food) for psychosis, 80–160 mg QD for bipolar disorder
	Lurasidone: Available in oral formulation only. SD: 20–40 mg daily with food; TD: 40–80 mg/day for psychosis, 20–60 mg/day for bipolar depression
	Olanzapine: Available in oral, IM, long-acting injectable formulations (risk of delirium, requires 3-h monitoring postinjection). Oral SD: 5–10 mg QD; TD: 10–30 mg QD
	Clozapine: PO only. Indicated for treatment-resistant schizophrenia. May ↓ suicide. Therapeutic concentration 300–500 ng/mL. S/e include risk of agranulocytosis, seizure, myocarditis. Pts must be enrolled in clozapine registry w/ monitoring of CBC w/diff. Oral SD: 25 mg QD, increase by 25 mg QD. TD: 300–900 mg QD
Reactions Requiring Immediate Medical Attention (i.e., ED Referral)
Acute dystonic reaction: From antipsychotics; painful muscle spasms, posturing

 

Neuroleptic malignant syndrome: From antipsychotics; incidence up to 2.4% for typical antipsychotics (J Clin Psych 2004;65:464); fever, akinesia, muscular rigidity, altered mental status, autonomic dysfunction → rhabdomyolysis, DIC, respiratory, & CV failure

Clozapine agranulocytosis or myocarditis: Incidence 0.05–2% (Schizophr Bull 1995;21:579)

Common Adverse Effects Requiring Outpatient Medical Attention

Metabolic syndrome & antipsychotic use: ↑ insulin resistance, altered appetite from meds; incidence ↑ w/ olanzapine & clozapine, ↓ w/ aripiprazole & ziprasidone; Management: Measure at baseline & at f/u: waist circumference (annually), BP, fasting glucose (at 4–6 wk, then annual), fasting lipids (at 4–6 wk then q5y) (Diabetes Care 2004;27:596)

↑ QTc: May occur w/ any antipsychotic or antidepressant; incidence 8% in Ψ pts; ↑ w/ haloperidol, thioridazine, ziprasidone, citalopram; Management: ✓ ECG, K & Mg at initiation, w/ each dose escalation, & q6mo (Curr Drug Safety 2010;5:97)

(Stahl’s Essential Psychopharmacology. 2014)

 

Mood Stabilizers (Acta Psychiatr Scand Suppl 2009;439:27)
	Drug (labs)	Notes
Acute Mania	Lithium BMP, TSH, Ca (& PTH if abnl)	Therapeutic 0.6–1.2 mEq/L (12 h trough), 0.8–1.2 for mania. Takes 1–3 wk to work. May decrease suicide. S/e incl tremor, polyuria/dipsia, GI, wt. gain, acne. SD: 300 mg 1-2x daily, titrate to therapeutic range.
	Valproic acid CBC, LFTs, NH3	Therapeutic 50–125 µg/mL (12 h trough). May see effects within a few days. S/es sedation, GI, alopecia, wt gain PCOS. Rare hepatotoxicity, liver failure. SD: 15–20 mg/kg in 2 divided doses, titrate to therapeutic range.
	Carbamazepine BMP, LFTs q6– 12mo	Therapeutic 4–12 µg/mL. Takes a few weeks to work. S/e incl sedation, GI, blurred vision, benign leukopenia, rash. Rare aplastic anemia, agranulocytosis, SJS, SIADH, cardiac problems. SD: 200 mg BID, titrate to therapeutic range.
	2nd-generation antipsychotics	Risperidone and olanzapine most common agents used.
Bipolar Depression	Lamotrigine	S/e incl rash, sedation, blurred vision, insomnia, tremor, GI. Rare SJS, blood dyscrasias, aseptic meningitis. SD: 25 mg daily x 2 wk, increase to 50 mg/d wk 3, 100 mg/d wk 5, 200 mg/d wk 6; TD: 100–200 mg/d.
	Olanzapine + fluoxetine	SD: olanzapine 6 mg/fluoxetine 25 mg daily; TD: 6–12 mg olanzapine/25–50 mg fluoxetine.
Reactions Requiring Immediate Medical Attention (i.e., ED Referral)
Lithium toxicity: Level >1.2 mM → tremor, vomiting, diarrhea, confusion

 

Stevens–Johnson syndrome: 2/2 rapid dose ↑ of lamotrigine (incidence 0.1–0.8%) (Clin Neuropharmacol 2011;34:39)

Common Adverse Effects Requiring Outpatient Medical Attention

Hyponatremia: Any SSRI, AP, mood stabilizer may cause SIADH; ↑ risk w/ carbamazepine, oxcarbazepine, citalopram; Management: Baseline Na before starting med, q1–6 mo thereafter, r/o psychogenic polydipsia; see “Sodium Disorders”

Lithium-induced hypercalcemia: 4–6 fold ↑ incidence of hyperparathyroidism, up to 80% pts w/ some rise in Ca; Management: Stop lithium ± cinacalcet; see “Calcium Disorders”

Lithium-induced nephrogenic DI: ADH resistance in up to 40% of pts on chronic lithium; Management: Monitor for polyuria, water restriction test to establish dx; if DI present stop lithium if feasible in conjunction w/ psychiatrist; amiloride if lithium Rx necessary (NEJM 1985;312:408); see “Diabetes Insipidus”

(Stahl’s Essential Psychopharmacology. 2014)

 

Special Populations (AFP 2012;85:483)

Cardiovascular disease: Many meds interact w/ warfarin; significant cardiotoxicity w/ thioridazine, disulfiram; SSRIs are 1st-line for post-MI depression; Venlafaxine, bupropion may raise BP; hx arrhythmia/prolonged QTc: avoid ziprasidone, citalopram (Mayo Clin Proc 2012;87:1042); ↑ QTc potential for any antipsychotic/antidepressant; aripiprazole is only atypical antipsychotic not assoc w/ HLD

Liver disease: Most psychotropics metabolized by liver & are highly protein-bound; start w/ low doses, monitor closely, adjust gradually; BZDs of choice in liver disease: Oxazepam, lorazepam, temazepam (require only glucuronidation, not oxidative metab); paliperidone is not hepatically metabolized

Kidney disease: May → accumulation of drugs/active metabolites, start low, monitor closely, go slowly; lithium relatively contraindicated Women: PCOS common in pts treated w/ valproate before age 20; incidence of hypothyroidism w/ lithium higher in ♀

Elderly: Typical & atypical antipsychotics ↑ risk of death in older pts w/ dementia; BZD may have a paradoxical reaction, esp in the elderly Pregnancy: Paroxetine is category D; valproate, carbamazepine teratogenic; consider referral to perinatal psychiatry

Asian & South Asian Indians: Prior to carbamazepine Rx, HLA- B*1502 allele testing due to 5% incidence of Steven–Johnson

 

syndrome (Nature 2004;428:486)

 

Significant Drug–drug Interactions (Curr Psychiatry Rep 2012;14:376)
Psych Med	Interacting Agent & Effect	Management
BZD (CYP3A4)	Azole antifungals, clarithromycin, grapefruit ↑ levels	Consider ↓ of BZD dose by 50%
Antipsychotics (CYP1A2)	Smoking ↓ med levels, adjust dose w/ quitting or resuming smoking
Antipsychotics	↓ efficacy of oral hypoglycemics, statins	Dose adjustment
SSRIs	Triptans, MAOIs/TCAs, linezolid, meperidine, tramadol, ↑ risk of serotonin syndrome	Avoid combination if possible
Lithium	ACEIs, thiazides, furosemide, NSAIDs inhibit renal clearance, ↑ risk of lithium toxicity	Avoid combination, dose ↓
Carbamazepine/Valproic acid	Warfarin ↓ INR (CYP2C9)	Monitor INR, dosing
Lamotrigine/Valproic acid	VPA inhibits lamotrigine metabolism → ↑ plasma concentration → ↑ risk SJS	Dose and titration adjustment

 

 

POSTTRAUMATIC STRESS DISORDER

Background (Am J Med 2006;119:383; Occ Med (Lond) 2007;57:399; World Psychiatry

2014;13:265)

Definition: >1 mo of disturbances due to a traumatic event with sx of

(1) Re-experiencing event, (2) Avoidance of situations that recall the trauma, (3) Negative mood/thoughts due to the trauma, (4) Chronic hyperarousal

Traumatic event: Includes threat of death, serious injury, sexual violence; Experience may be direct, witnessed, or may have occurred for a close family member/friend Acute stress disorder (ASD): Same criteria as PTSD, though sx last only 3 d–1 m; ~50% develop PTSD, worsening thought due to stressors/additional traumatic events

Pathophysiology: Driven by changes in the amygdala and

 

hippocampus

Epidemiology: 10% ♀ and 5% ♂ exposed to trauma develop PTSD; lifetime prevalence is 6.8%; assoc w/ anxiety, mood, SUD, personality disorders, aggression, & overall disability

Risk factors: ↑ risk: ♀, young age, low socioeconomic status, low education, minority, interpersonal violence (kidnapping, physical/sexual assault), ↑ #/duration of trauma, ↑ perceived threat, ↑ peritraumatic emotion/dissociation, poor social support, ↑ life stress

Evaluation and Prognosis (JAMA 2015;314:501; NEJM 2017;376:2459)

History: Triggers to relive event (i.e., flashbacks), times of day, nightmares, response to triggers, avoidant behaviors; screen for depression and anxiety; impact of symptoms on functioning; sx of ↑ arousal (difficulty sleeping/concentrating, anger, arguments, violence, easy startling); physical sx (palpitations, nausea, etc.)

Evaluate for safety: Pts w/ PTSD 6× more likely to commit suicide

 

Primary Care PTSD Screen (Adapted from J Gen Int Med 2016;31:1206)

In your life have you had an experience that was so frightening/horrible/upsetting that in the past month you: Had nightmares/thought about the event even though you didn’t want to? Tried not to think about the event or went out of your way to avoid situations that reminded you of the event? Been consistently on guard, watchful, easily startled? Felt numb or detached from people, activities, or your surroundings? Felt guilty/unable to stop blaming yourself/others for the event/resulting problems?

Scoring: Yes: 1 pt, No: 0 pt. In veterans, score ≥ 3 95% sens, 85% specific.

Treatment (AFP 2013;88:827; Am J Psychiatry 2004;161:3; J Psychopharmacol

2014;28:403)

General principles: 3 approaches may be used alone or in combination, include psychotherapy, medications, education/support; Goals include (1) ↓ severity of sx, (2) better tolerate/manage distress,

(3) ↓ intrusive re-experiencing, (4) ↓ trauma-related avoidant behaviors, nightmares, sleep problems, (5) develop problem solving/emotional regulation skills, (6) educate about natural course of sx (worsen w/ re- exposure, perceptions of being unsafe, life stress, medication discontinuation)

 

Education and support: Helpful as early interventions ↓ sx after trauma; encouraging acutely traumatized persons to first rely on their inherent strengths, their existing support networks, and their own judgment may ↓ the need for further intervention

Psychotherapy: Speeds recovery and prevents PTSD when given 2–3 wk after trauma exposure

CBT: Desensitize to trauma-related triggers (e.g., exposure tx)

Eye movement desensitization & reprocessing (EMDR): Exposure-based therapy (brief, interrupted exposure to traumatic material) w/ eye movement, recall, tackling about memories; efficacy similar to CBT

Psychodynamic psychotherapy: Focuses on meaning of the trauma in developmental experience and relationships

Psychopharmacology:

SSRIs: Only sertraline (50–200 mg QD) and paroxetine (20–60 mg QD) FDA approved, all have empirical support; treats all PTSD symptom clusters (i.e., re-experiencing, avoidance/numbing), common comorbid disorders (depression, panic, OCD), and ↓ sx (SI, impulsive/aggressive behaviors); treatment of responders generally continues for at least 12 mo Other antidepressants: TCAs & MAOIs may ↓ sx; little evidence available for other antidepressant categories (e.g., venlafaxine, mirtazapine, bupropion) Benzodiazepines: May Tx anxiety and ↑ sleep, but do not address core symptoms of PTSD; worsening of sx with benzodiazepine discontinuation possible; may interfere with the cognitive processing needed for psychotherapeutic interventions to work

 

Medical Management of PTSD
Sx Cluster	1st-Line Treatment	2nd-Line Treatment
Re- experiencing	Prazosin: nightmares; start 1 mg QHS, ↑ as tolerated up to 10 mg QHS; some data for higher doses	Anticonvulsants: May improve sx related to re-experiencing; topiramate (most data) carbamazepine, divalproex, lamotrigine
Increased arousal	Propranolol 10 mg TID	2nd-generation antipsychotics may help if 1st-line ineffective, olanzapine and risperidone most studied

 

Treatment of nonresponders: Combine treatment modalities, augment antidepressant with olanzapine, risperidone or prazosin, refer to specialist.

Patient information: JAMA 2015;314:532

 

 

PSYCHOTIC DISORDERS

Background (AFP 2007;75:1821; 2014;90:775; 2015;91:856; NEJM 2003;349:1738)

Definition: Disturbance in perception of reality (hallucinations, delusions, thought disorganization)

Schizophrenia: Chronic/recurrent psychosis w/ impaired social/occupational functioning Schizoaffective disorder: Psychosis + mood disorder

Brief psychotic d/o: Psychosis in stressful situation; resolves w/ removal of stressor Postpartum psychosis: Typically presents 2 wk after childbirth in 0.1–0.2% postpartum ♀; assoc w/ ↑ risk of suicide, infanticide

DDx: 1° psychotic disorders: Schizophrenia; schizoaffective d/o; delusional d/o; Mood d/o: Bipolar or major depressive d/o w/ psychotic features; Personality d/o: Schizotypal personality d/o; Substance or medication-induced psychosis: Intoxication w/ or withdrawal from EtOH/illicits, steroids, pseudoephedrine, stimulants, anesthetics, hallucinogenics, bath salts, analgesics; Psychosis 2° to a medical condition: Delirium, dementia, CVA, CA, heavy metals, demyelinating dz, seizures, neuropsychiatric d/o (Wilson’s, Huntington’s, etc.), autoimmune, infections, endocrinopathies, nutritional deficiencies, metabolic d/o

Evaluation (Arch Gen Psychiatry 2005;62:247; Early Interv Psychiatry 2009;3:10; JAMA

2002;287:3249)

History: Mental status exam, MOCA, FHx of psychiatric problems, head trauma, screen for suicidality (lifetime risk of 4.8%) & homicidality

Positive symptoms: Hallucinations (auditory, visual, tactile, olfactory, gustatory); delusions, especially paranoid; disorganized speech and thought pattern Negative symptoms: Blunted or

 

flattened affect; anhedonia; alogia (poverty of speech); avolition; asociality or isolation; impaired self-care Cognitive symptoms: Impaired executive function, memory, attention

Screening questions: Do you ever hear voices you’re not sure other people can hear? Do you feel like your mind plays tricks on you?

Do you feel like people are trying to harm you or that there is a plot against you? Have you ever felt that people try to insert or control thoughts you have? Have you ever felt that the television, radio, or internet communicates special messages meant just for you?

Workup for 1st episode of psychosis: CBC, Chem-12, ESR, ANA, serum & urine tox, TSH, HIV, ceruloplasmin, folate, B₁₂, VDRL; brain MRI & EEG if clinically indicated

Treatment (Harv Rev Psychiatry 2007;15:189; Lancet 2013;382:951)

 

Comparative Risk of Side Effects of Antipsychotics (CNS Drugs 2007;21:911)
Drug	↑ QTc	Orthostasis	DM2	HLD/↑ wt	AC	EPS	Sedation
Aripiprazole	Low	Low	Low	Rare	Rare	Low	Low
Clozapine	Low	High	Med	High	High	Rare	High
Olanzapine	Low	Low	Med	High	Low	Low	Med
Quetiapine	Low	Low	Low	Medium	Low	Rare	Medium
Risperidone	Low	Med	Low	Medium	Rare	High	Low
Ziprasidone	Med	Low	Low	Rare	Rare	Low	Low
Medication	Considerations
Aripiprazole	Long half-life; ↑ risk of akathisia
Clozapine	Agranulocytosis, requires weekly ANC; used in refractory cases, not 1st-line
Olanzapine	↓ rate of discontinuation in chronic schizophrenia compared to other 2nd- generation antipsychotics
Quetiapine	Wide dosing range (≥200 mg likely for maintenance)
Risperidone	Hyperprolactinemia; ↑ risk of EPS at higher doses compared to other atypicals
Chlorpromazine, haloperidol, perphenazine: Risk of tardive dyskinesia; EPS common; hyperprolactinemia

AC, anticholinergic side effects; EPS, extrapyramidal side effects.

 

Medication selection: Choice guided by patient preference,

 

tolerability, and clinical situation (e.g., medical comorbidities, FHx, or psychopathological sx profile); no antipsychotic (1st or 2nd generation, including clozapine) clearly outperforms other antipsychotics in 1st- episode patients; American Psychiatric Association recommends 2nd- generation antipsychotics given potentially more tolerable side-effect profile

Initial antipsychotic: Choices could include risperidone, aripiprazole, quetiapine, or ziprasidone

General principles for antipsychotic prescribing: Start low, ↑ slowly until effective

Monitoring: Baseline & follow-up weight, BMI, waist circumference, lipids, and glucose Adverse effects: Extrapyramidal symptoms (dystonia, parkinsonism, akathisia); neuroleptic malignant syndrome; tardive dyskinesia; ↑ weight, HLD, DM2, ↑ QTc/TdP

Anticholinergic co-prescribing: Benztropine frequently given with 1st-generation antipsychotics to prevent dystonic reactions/EPS (but ↑ cognitive side effects)

Tardive dyskinesia: A potentially permanent & debilitating side effect; track involuntary movements using Abnormal Involuntary Movement Scores (AIMS) scale w/ all pts; can be reduced with slow dose decreases or using clozapine (Am J Psychiatry 1980;137:900)

 

Somatic Symptoms and Related Disorders

Background (Lancet 2006;367:452; JAMA 1997;278:673; 2009;302:550; NEJM

2001;345:1395)

Definition: Psychosocial & emotional problems manifest primarily through physical symptoms

Epidemiology: Disproportionately affects women, pts w/ low socioeconomic status, fewer years of education, & unemployed; common comorbidities include mood, anxiety, SUD, & personality disorders

Common complaints: Limb pain, insomnia/low energy, nausea/abdominal pain/distention. Up to 1/3rd of common symptoms seen in primary care do not have a disease-based explanation.

 

DSM-5 Diagnostic Criteria for Specific Disorders

Somatic symptom disorder: 1+ sx causing distress or psychosocial impairment; excessive thoughts, feelings or behaviors about sx as demonstrated by 1+ of the following: persistent thoughts about seriousness of sx, severe anxiety about sx or health, excessive time and energy devoted to sx; duration of 6+ mo.

Illness anxiety disorder: Mild or nonexistent somatic sx paired w/ preoccupation of having a serious, undiagnosed illness; anxiety about health & low threshold for alarm about health; excessive health behaviors or avoidance of activities thought to threaten health; not better explained by other mental disorders; duration of 6+ mo.

Conversion disorder: Sx/deficit affecting voluntary motor/sensory function (seizure, sensory loss, weakness/paralysis); often assoc w/ psychological conflict or stressor; not intentional; Predisposing factors: Prior med illness/psych dx, exposure to others w/ specific sx; Workup: Thorough investigation so that dx is confident; Ddx: Multiple sclerosis, myasthenia gravis, movement disorders, stroke, epilepsy, nerve entrapment

Psychological factors affecting other medical conditions: A general medical d/o must be present paired w/1+ of the following: behaviors/factors that increase health risks, exacerbate underlying pathophysiology, or affect course or treatment of medical condition

Factitious disorder: Intentionally feigning sx to assume the sick role, without obvious external benefits (e.g., financial gain or avoiding responsibilities)

Evaluation (AFP 2007;76:1333; 2015;93:49; Ann Int Med 2014;161:579)

History and exam: Diagnostic yield typically 70–80%; thorough evaluation of the following: relation of sx to pt emotions & social situation; hx physical/sexual abuse, domestic violence; substance use; past medical & psychiatric hx; hx of pattern of similar presentations; complete physical exam

Workup: Rating tools: Patient Health Questionnaire 15, Somatic Symptom Index, somatization subset of Symptom Checklist-90, Somatic Symptom Scale-8, Somatic Symptom Disorder-B Criteria Scale, Somatic Symptoms Experiences Questionnaire

Treatment (JAMA 2004;291:1464)

Share the dx: Explain which medical conditions are ruled out and reassure no evidence of life-threatening conditions

Validate patient complaints: Empathically acknowledge the patient’s experience; “It must be difficult to have recurrent pain,” or “Tell me more about how this is affecting you.”

Follow-up: Regular appts; avoid urgent appts, diagnostic tests, surgery unless indicated; communicate w/ involved specialists

Medications: Antidepressants are the mainstay of tx; TCAs for pain,

 

SSRIs for other somatic symptom disorders (J Psychosom Res 2004;56:455) Reattribution training: Short consultations aim to normalize pt interpretations of sx, modify beliefs about sx causes, & treat underlying depression (Psychosomatics 2002;43:394)

Behavioral/cognitive therapy: (Psychother Psychosom 2000;69:205) Relaxation: Yoga, meditation, diaphragmatic breathing, progressive muscle relaxation; Behavioral activation: ↑ pt engagement in pleasurable activities w/ aim to perform activities even when physical or emotional barriers exist; Cognitive restructuring: aims to alter ⊖ thinking and correct distortions, misperceptions, and misattributions of symptoms

 

 

SUICIDE RISK ASSESSMENT

Background (Mayo Clin Proc 2011;86:792; JAMA 2005;294:2064; 2013;309:2432; Am J Psych 2003;160:3)

Epidemiology: Account for >1% of all US deaths annually (10th leading cause of death, more than car accidents); PCPs write most antidepressant prescriptions & are the group most likely to see pts the month before suicide (Psychiatr Serv 2009;60:1167; Am J Psych 2002;159:909); 83% of people who commit suicide have had contact w/ a PCP w/in a year & up to 66% w/in a month of their death (Acta Psychiatr Scand 2000;102:126)

 

Warning Signs and Risk Factors for Suicide (JAMA 2000;283:2693)
Warning Signs	Transient, often modifiable: Talking, writing, or planning for suicide. Hopelessness, rage, anger, seeking revenge; impulsive or reckless actions, feeling trapped, ↑ EtOH/drug use, withdrawing from others, anxiety or agitation; Δ in sleep, mood. No purpose or reason for living
Modifiable Risk Factors	Psychiatric symptoms: Depression, psychosis (esp. command auditory hallucinations/paranoia), impulsivity, agitation, severe anxiety Substance use: Suicide mortality ↑6× in EtOH use d/o Living situation (living alone, homelessness, living in rural setting ↑ risk) Current stressful life events Medical problems + demoralization Posthospitalization transition
	Past/aborted suicide attempts — (↑ risk if recent) most consistent predictor of future and completed suicide attempts

 

 

 

 

Nonmodifiable Risk Factors

Past self-injurious behavior (include risk taking, unsafe sex, and reckless driving)

Family history of suicide

Multiple psychiatric diagnoses or history of abuse (esp depression, BPAD, EtOH/substance use, schizophrenia, personality disorders, anxiety disorders)

Demographics: ♂ complete suicide >3× more often, ♀ attempt suicide

>2× more often; White; older age (♂ >50, ♀ >60); single status (never married > widowed > separated > divorced > married)

 

Evaluation (AFP 2003;68:1814; 2006;74:1159; 2012;865:602)

History: Inquiring about suicide does not ↑ likelihood a pt will make an attempt; depression, EtOH, & SUD screening; suicidal thoughts/behaviors should be assessed in all pts w/ depression/hx depression, using a step-wise approach (J Clin Psychiatry 1998;59:58)

 

Step-Wise Evaluation of Suicide Risk

Thoughts of death or suicide: Passive vs. active, timing, frequency, precipitants, whether thoughts can be controlled/ignored, what will be accomplished with suicide (e.g., reunification w/ deceased loved one, ending pain, escaping shame, peace) Plan: Access to firearms, other means, specificity (place/time, plan details) Suicidal intent: Preparation or rehearsal, why not acted on thus far Past attempts: Timing, precipitants, intent, risk/rescue ratio, consequences, intoxication prior to attempt (20–25% who complete suicide are intoxicated) Other: Self-injurious behavior (frequency, severity, reason), presence of homicidality Sample questions: “Have you ever felt so down that you thought life wasn’t worth living?” “Do you think about hurting yourself? Do you have a plan?”

Management

General principles: Treat comorbid mental illness, including depression (see “Depression”), EtOH/SUD (see “Alcohol Use Disorders” and “Substance Use Disorders”), anxiety (see “Anxiety Disorders”)

 

SAFE-T Risk Assessment Model
	Low Risk	Moderate Risk	High Risk
Symptom	No specific plan or intent to commit suicide; no H/o suicide attempts.	Suicidal ideation + plan, but no intent or behavior	Serious thoughts of suicide; plan and/or intent; prominent agitation, impulsivity, psychosis; recent

 

			attempt
Rx	Outpatient f/u, remove obvious means of self-harm (i.e., firearms, large quantities of meds). Consider safety contract. Provide suicide hotline (1- 800-273-TALK).	Urgent referral to a psychiatrist vs. emergency department	Constant observation and monitoring until transfer for psych eval/hospitalization

Patient information: AFP 2006;74:1165; 2012;85:610; JAMA

2004;291:1158; 2005;293:2558