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Mini Psychiatric Snapshots
for Internists
Kathleen Franco, M.D.
American College of Physians
October 10, 2013
Discontinuation Syndrome from
Antidepressants
• “Flu-like Symptoms” of nausea, vomiting,
diarrhea
• Dizziness, fever, sweating, chills
• Headache, malaise, lethargy
• Incoordination, insomnia, vivid dreams
• Myalgia, confusion, dyskinesias, parasthesias
• “Electric shocks” visual disturbances
• Anxiety aggitation, impulsivity, slowed thinking
• Aggression, hypomania, crying, irritability
Cause?
• Abrupt cessation of larger doses of psychiatric
medication or tapering too rapidly
• Common after prolonged use
• May frequently occur when trying to switch
from a medication which appears ineffective
How fast should you taper?
Variable: A. paroxetine 25% /week
B. fluoxetine generally self-tapers but
may need to wait for up to 5 weeks to
initiate another in the same class
Guideline:
• Shorter the halflife, the more slowly the taper
• SNRI eg venlafaxine 2-6 weeks;
desvenlafaxine increase period between doses
to q.o.d., q3d, etc.
When will discontinuation syndrome
occur?
1 – 7 Days after drastic dose reduction
Can last up to 3 weeks
Drug Classes Associated with
Discontinuation Syndrome • SSRI’s eg paroxetine, sertraline, citalopram
• Norepinephrine Dopamine Reuptake Inhibitor eg
burpropion (but not as frequently as SSRI’s)
• SNRI’s eg venlafaxine, duloxetine, desvenlafaxine
• Serotonin 2 Antagonists/Reuptake Inhibitors:
trazodone, nefazodone
• Noraderenergic/Specific Serotonergic:
mirtazepine
• Nonselective cyclics eg clomipramine, imipramine
• MAO-I’s usually not but rarely can (1-4 days)
can have palpitations, jerking, and hallucinations
Managing Discontinuation
Reinstate and more slowly taper
Try one dose of fluoxetine (10-20 mg)
for any SSRI or SNRI near end of taper
Ginger (nausea and disequilibrium)
Special Considerations for
Nonselective Cyclic Antidepressants
• Cholinergic, adrenergic, and serotonergic
Besides ginger, may need benztropine
0.5-4 mg prn or atropine 1-4m tid or qid
• Loxapine
• Anxiety may require benzodiazepine,
lorazepam or other
• Akasthisia – propranolol 10-20 mg tid
• Dyskinesia – clonazepam 0.5-2 mg
• Dystonia – benztropine 0.5-4 mg
After the last dose, how long to wait
before starting another?
Fluoxetine 5 weeks before MAO-I
MAO-I – 2 weeks before others
Other SSRI’s, SNRI’s, etc. very little
AS LONG AS NO SYMPTOMS OF
SEROTONIN SYNDROME
SUMMARY
1. When switching from one
antidepressant to another, consider
the half life and potential for
serotonin syndrome.
2. Patients should be coached about
symptoms to watch for and how to
slow taper if needed.
3. Slow titration up of new agent and
encourage patients to contact office
if they have unexpected symptoms.
Suicide
Prevalence
Hard to tell accidents or suicide – could be higher
Men 3.8 : Women 1
General Population/100,000
0.5 in 5 – 14 Y/O
10 in 15-24 yrs.
16 in 85+ Y/O
Risk Factors that Increase Need to
Hospitalize Suicide in family
Depression with suicide plan/intent and hopelessness
Unemployment; recent loss of love
Recent visit to physician or emergency care
Living alone (separated, divorced, single, etc.)
Serious physical illness, pain, dependence on others
Panic disorder (especially if depressed)
Previous attempts – especially if admitted to med-surg
floor
Suicide note
Age
Past Abuse – Physical or Emotional
Illnesses that have been associated
with increased suicide completion
Lung disease/COPD and others
HIV/AIDS
Peptic ulcer disease
Malignancy
Prostate disease
Neurological disorders (Huntington’s,
Alzheimer’s, Parkinson’s, etc.)
Visual impairment
Dialysis/end stage renal
Acute Stress
Psychiatric illness
Substance abuse
Medical illness
Family and social stressors
Super Imposed on Diathesis
Genetic predisposition
Early life experience
Chronic illness
Chronic substance abuse
Diet (cholesterol….)
Physician Suicide
All Physician Specialties – higher than
general population
Male and Female doctors nearly equal ,
although recently F>M
Women Physicians RR 5.7
Male Physicians RR 3.4
Be careful not to over or under identify
with any suicidal patients
Suicide Attempts
• 25 Times greater than completed suicides
• Sitter with training (one on one)
• When admitted to medical floor and if they
are impulsive and unpredictable, think like
a suicide
Sheets Windows and cords
Stairwells on blinds/drapes
Sharp objects Belts, shoelaces, ties
Pills Lighters
• Watch for agitation, medication needs,
observe going to the bathroom
How to Ask – Gentle Approach
Have you felt blue or discouraged lately?
How bad has it been?
Have you felt like it isn’t worth it or giving up?
Have you felt like throwing in the towel or
harming yourself?
When was the last time you felt that way?
Do you have access to what you’d need to do
that? (guns, rope)
Do you think things could get that bad you would
want to do that?
What kept you from doing that in the past?
What about now?
Listen for …“They’d be better off
without me.”
• Direct questions, frank discussions
• What happens once the family
taboo is gone?
• Watch out for automatic
antidepressant prescription Can become suicidal
• Palliative care – reassure pain
relief, spiritual needs
Lithium Reduces Risk for
Suicide
(but don’t get overly confident)
but remember it doesn’t mix well with
• Fluoxetine, fluvoxamine neurotoxicity
and seizures
• Sertraline, paroxetine -
Increased tremor and nausea
Increased risk for serotonergic effects
Medical Trainees
• Begin medical school with rates of
depression similar to non-medical
peers
• Overtime increase rates of depression
> peers
• Suicide rates of residents and medical
students > peers
Reaching out to colleague
• Same approach to questioning
• “Let’s get help, I’ll go with you.”
• Take it seriously
SUMMARY
1. Colleague risk is higher than general
population risk
2. Don’t be afraid to ask or extend a
helping hand
3. The benefit of doing this outweighs
the risk.
Alphabet Soup of Psychotherapies
CBT Cognitive Behavioral Therapy
• Efficacy = to and longer lasting than
medication (but slower)
• Depression, Panic Disorder,
Schizophrenia (adjunct) OCD,
Generalized Anxiety, etc.
• Distorted thinking increases
symptoms learn how to reframe more
objective interpretation
DBT Dialectic Behavioral Therapy
• Best for overwhelming emotion
• PTSD, Borderline Personality, some
bipolar patients, etc.
• Aspects of CBT and Mindfulness
training
Mindfulness
• Living in the moment, eliminating
distractive stimuli
• Examples: Deep breathing; visualize
flood of emotion flowing overhead and
far into the background
• Being offered in may hospitals for
physicians and nurses
ACT
Acceptance and commitment therapy
form of Clinical Behavioral Analysis
Uses acceptance and mindfulness
mixed with commitment and behavior –
The idea is to change strategies
Difference between CBT that tries to
teach people to reframe thoughts,
feelings or experiences, ACT teaches
individuals to “just notice” and accept
feelings
Increase psychological flexibility
REBT
Rational Emotive Behavior Therapy
A doesn’t cause C but rather B (Belief)
causes emotion
A. Something happens
B. You have a belief about it
C. Emotional reaction to
Therapist challenges/disputes irrational
belief
We continue to feel upset if we cling to
irrational beliefs
REBT
Goal to Change Irrational Beliefs. e.g.
1. I must do well and win approval
of others or else I am no good
2. Others must be considerate, fair,
kind, and behave the way I want
them to or they are no good,
punishable
3. I must get what I want and not get
what I don’t
Reality Therapy
“Choice Theory” – solve problems, rebuild
solutions considered a form of CBT
Focuses on the 3 R’s Realism
Responsibility
Right and wrong
Focuses on present life NOT past events
(Client) Person Centered
Treatment (Therapy or
Counseling)
Rogerian psychotherapy
Develop a sense of self; realize how
attitudes, feelings, and behavior are
negatively affected
Try to true positive potential
Therapist: non-judgemental, genuine
empathy
Clients find their own solutions to problems
Interpersonal Therapy
Time limited, patient regain control of
mood and functioning, treatment alliance
with patient
Stages: Engages, Understands, Affect,
Clear Rational
Treatment ritual and successful
experiences
EMDR Eye Movement Desensitization and
Reprocessing
Deals with trauma and disturbing memories
Recognized by Dept. of Defense and American
Psychiatric Association
Dual stimulation rapid bilateral eye movements,
tones or taps
Patient attends momentarily to past memories,
present triggers, and anticipated future
Work on event, situation, historic incidents
SUMMARY
CBT – Reframe distorted thoughts – We
make ourselves sick by the valence we
give our thoughts
Mindfulness – Focus on the moment,
eliminate distractions, reduce stress
DBT – Helps those who feel
overwhelmed frequently by intense
negative emotions