SAMPLE CHAPTERSAMPLE CHAPTER · SAMPLE CHAPTER 6 Psychiatric Disorders T able 2: Drugs Used in the Management of Post-traumatic Stress Disorder Class Drug Dose Adverse Effects Drug

S A M P L E C H A P T E RS A M P L E C H A P T E R

SAMPLECHAPTER

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Chapter : Post-traumatic Stress Disorder 1

Psychiatric Disorders

ChapterPost-traumatic Stress DisorderR. P. Swinson, MD, FRCPsych, FRCPC

In the Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-5), post-traumatic stressdisorder (PTSD) is classified with other trauma- and stressor-related disorders that are diagnosed asoccurring due to exposure to a traumatic or stressful event.1 Other conditions in this classificationinclude reactive attachment disorder, acute stress disorder and adjustment disorders. Previously PTSDwas listed as an anxiety disorder.

PTSD is characterized by significant distress or impairment in functioning of at least 1 month's durationin response to a traumatic event described as exposure to actual or threatened death, serious injuryor sexual violence. Symptoms have been divided into 4 main categories and are included in Table 1.Children 6 years of age or younger with the disorder are now diagnosed using a separate set of criteria.

Goals of Therapy■ Eliminate or decrease symptoms of PTSD■ Eliminate or decrease PTSD-based disability■ Prevent recurrence■ Treat comorbid conditions

InvestigationsThe assessment for PTSD requires a detailed exploration of the nature and circumstances of thetraumatic event and its affect on the patient. It is important to be sensitive to the person's potentialinability to recall these details without becoming overwhelmed. It may take a number of sessions toallow for a complete understanding of the circumstances of the traumatic experience(s).■ Thorough history with attention to:

– nature of symptoms and onset– nature and extent of disability– presence of comorbid medical or psychiatric conditions (see Initial Management)

■ Criteria to assist in obtaining an accurate diagnosis (Table 1)■ Physical examination to exclude endocrine or cardiac disorders and to look for signs of substance use■ Laboratory tests:

– CBC, liver function tests, gamma-glutamyl transpeptidase (GGT; to screen for alcohol use),thyroid indices (supersensitive TSH), ECG

Note: Treat physical disorders of recent onset before making a definitive diagnosis of PTSD.

Therapeutic ChoicesAn illustration of the management of post-traumatic stress disorder is provided in Figure 1.

Compendium of Therapeutic Choices Copyright © Canadian Pharmacists Association. All rights reserved.


2 Psychiatric Disorders

Table 1: Diagnosis Criteria for PTSD1

Symptoms Examples

Repeated intrusion symptoms after thetraumatic event

Intrusive memories, distressing dreams, dissociative symptoms such as flashbacks,intense distress cued by aspects of the trauma

Avoidance Attempts to avoid memories, thoughts, feelings or external reminders associatedwith the triggering event

Negative cognition and mood A broad category that may include a distorted sense of blame of self or others,inability to recall aspects of the traumatic event, loss of interest in activities

Arousal Hypervigilance, sleep disturbances, self-destructive behaviour, irritability, verbalor physical aggression, recklessness

Figure 1: Management of Post-traumatic Stress Disorder

Abbreviations: CBT = cognitive behavioural therapy; PTSD = post-traumatic stress disorder; SNRI = serotonin-norepinephrine reuptake inhibitor;SSRI = selective serotonin reuptake inhibitor

Copyright © Canadian Pharmacists Association. All rights reserved. Compendium of Therapeutic Choices


Chapter : Post-traumatic Stress Disorder 3Initial ManagementMost people who experience trauma do not go on to develop either acute stress disorder or PTSD.In the first 4 weeks following a traumatic event, psychotherapy or pharmacotherapy, includingbenzodiazepines, should not be started. During this initial phase, help patients to understand that acuteresponses to trauma are common and often short term. Allow them to use their natural resilience andusual emotional supports to recover. Psychological debriefing, a short intervention delivered in groupsettings during the first 2 weeks following a traumatic event, may hamper natural recovery and is notusually recommended.2 There is little evidence to show that medication taken immediately after atraumatic event can prevent the onset of PTSD.3 In one small study, propranolol administered within afew hours of the trauma showed some promise.4 Newer agents are being investigated.5

For those individuals who are overwhelmed and have impaired functioning, psychotherapy ormedication may need to be instituted within the first 4 weeks following the traumatic event.

Treat comorbid mood disorders, especially depression, as the primary condition. It is important tomanage comorbid chronic pain and sleep disturbances in patients with PTSD. Patients with PTSD oftenattempt to self-treat and can have substance use disorders; referral to a specialized program may benecessary.

Nonpharmacologic ChoicesWhenever possible, trauma-focused psychotherapy is recommended before initiating pharmacotherapy.Several psychological approaches have been investigated in the treatment of PTSD and acute stressdisorder.

Cognitive behavioural therapy (CBT) that is initiated at least 1 month after the trauma occurs is veryeffective in reducing symptoms of PTSD.2 Evidence shows that therapies focused on the trauma, suchas trauma-focused CBT, eye movement desensitization and reprocessing therapy or stress management,are more effective than more general approaches.6 Support that does not deal with the trauma directly isno more effective than being on a waiting list.7

Pharmacologic ChoicesThe management of PTSD depends on the nature, severity and frequency of the trauma and requires amultimodal treatment program. Short-term treatment with medication may benefit patients who do nothave access to CBT. See Table 2 for a list of these drugs.

SSRI and SNRI antidepressants have been shown to reduce the severity of all the component symptomsof PTSD. Fluoxetine, paroxetine,8 sertraline9 and venlafaxine10 are first-line options. Otherantidepressants with evidence of efficacy include fluvoxamine,11 mirtazapine,12,13 moclobemide14and phenelzine15,16 and are considered second-line choices. Second-generation antipsychotics such asrisperidone and olanzapine may be effective in augmenting the effects of antidepressants in somepatients who do not respond to first-line PTSD treatment.17,18

Monotherapy with benzodiazepines is not recommended due to the effects on disinhibition and the highrates of substance use disorders in patients with PTSD.

Sleep disturbances are common in patients with PTSD. Although evidence from clinical trials islimited in this patient population, several PTSD practice guidelines support the use of trazodone19 inthe management of insomnia that has not responded to nonpharmacologic therapy (e.g., sleep hygiene)or treatment for comorbid conditions. Prazosin is an alpha1-adrenergic antagonist that reducessympathetic outflow in the brain. A systematic review based on a small but positive evidence base




concluded that prazosin is an important pharmacologic option in reducing the frequency and intensityof nightmares and improving sleep in patients with PTSD [Evidence: SORT B*].20

Choices during Pregnancy and BreastfeedingPTSD and PregnancyWomen who have encountered trauma during their lives may experience a worsening or relapse ofPTSD symptoms during pregnancy.

Many people with PTSD do not bring their distress to the attention of their caregivers. If possible,screen patients for the presence of PTSD or anxiety symptoms prior to conception. Screening canusefully be repeated during the pregnancy and particularly postpartum. It is imperative to screen for thepresence of mood symptoms and suicidality in a woman who is suffering from marked psychologicaldistress related to pregnancy and breastfeeding.

It may be necessary to refer women experiencing severe PTSD symptoms during pregnancy orpostpartum to a psychiatrist. Women's mental health programs are usually available in major centresand these programs customarily respond quickly to consultation requests.

Treatment for PTSD or other psychiatric disorders that are producing significant distress or interferingwith functioning can be offered to women before conception.

Management during PregnancyEvidence-based psychotherapies such as CBT can be administered without restriction throughoutpregnancy. There is good evidence to show that psychological treatments can have beneficial effectsfor more than half of the patients who remain with a treatment program. Therapies based in meditativeor relaxation techniques may be more acceptable to the patient than pharmacologic approaches.21

If PTSD symptoms are severe and producing significant impairment, medications can be appropriateand effective.22 SSRI/SNRI antidepressants are the mainstay of pharmacologic therapy for PTSDduring pregnancy.

SSRIs/SNRIs may cause agitation, sweating, nausea, gastrointestinal distress and weight gain. Therehave been reports of a slightly higher (but still low) risk of congenital abnormalities involving the heartor cleft lip/palate.23 Use of these drugs in the third trimester may be associated with neonatal withdrawalsymptoms such as tremors, increased muscle tone, feeding or digestive problems or respiratory distress.Whether benzodiazepines confer an increased risk of congenital malformations is controversial.

The use of SSRIs or SNRIs may be warranted in patients with severe symptoms that could affectfetal or maternal safety or health. In general, use the lowest effective dose for the shortest timenecessary. General principles for management of depression during pregnancy are applicable to themanagement of PTSD.24,25

PTSD and BreastfeedingIn the postpartum period, severe distress can impede the mother's sleep and erode her confidencein caring for her child.

As in pregnancy, nonpharmacologic options should be used whenever possible in the postpartumperiod, particularly in breastfeeding women. If drug therapy is necessary, consider paroxetine andsertraline, since both drugs appear in low concentrations in breast milk.26

* SORT (Strength of Recommendation Taxonomy) is a rating system (A, B or C) that addresses the quality of available evidence.For more information consult How to Use Compendium of Therapeutic Choices on page xxv.



Chapter : Post-traumatic Stress Disorder 5A discussion of general principles on the use of medications in these special populations can be foundin and . Other specialized reference sources are also provided in these appendices.

Therapeutic Tips■ Trauma-focused psychotherapy is recommended as first-line treatment for PTSD whenever possible.■ Assess a drug's effectiveness after a trial of an adequate dosage taken for an adequate length of time.■ If one antidepressant is not effective, switch to a second agent from the same or different drug class.■ If a second antidepressant is not effective, switch to an agent from a different drug class.■ Families of persons with PTSD can be significantly affected; refer spouses, children or other family

members to marital or family counselors when indicated.




6 Psychiatric DisordersTable2:

Drugs

Usedin

theManagem

ento

fPost-traum

aticStress

Disorder

Class

Drug

Dose

Adverse

Effects

DrugInteractions

Com

ments

Costa

Alpha

1-adrenergic

Antagon

ists

prazosin

Minipress,generics

Initial:1

mgQHSpo

Increase

by1–2mg

QHSpo

untileffective

dose

reached(range

3–15

mgQHSpo)

Orthostatic

hypotension

(particularlyfollowing

firstdose),dizziness.

Increasedriskoforthostatic

hypotensionwith

other

antihypertensives

orPDE-5

inhibitors(sildenafil,tadalafil,

vardenafil).

Asap-glyoproteininducer,

prazosinmay

reduce

the

efficacyof

dabigatranor

linagliptin,thoughinteractions

with

thesedrugshave

not

been

reportedclinically.

Usedtoimprovesleepand/or

reduce

nightmares

inpatients

with

PTS

D.

Current

orpast

useof

alpha 1-adrenergicantagonists

increasestheriskof

intraoperativefloppyiris

syndromeduringcataract

surgery;

discontinuing

the

drug

preoperativelydoes

not

eliminatetherisk.

Inform

the

ophthalmologistifprazosinhas

been

used

atanytim

epriorto

cataractsurgery.

$

Antipsychotics,

Second

-generatio

n

olanzapine

Zyprexa,

ZyprexaZydis,

generics

Initial:2

.5mgdaily

poTitrate

gradually

todesiredeffect,usually

2.5–5mgdaily

po.

May

need

toincrease

toamaximum

of10

mgperd

aypo.

Weightgain,dizziness,

sedation,anticholinergic

effects,

hepatic

aminotransferase

elevation,

orthostatic

hypotension,increased

riskof

diabetes

anddyslipidem

ia,

extrapyramidaleffects

(especially

akathisia).

Sedationwith

CNS

depressants;may

potentiate

antihypertensivedrug

effects;

inhibitors

ofCYP1A

2or

CYP2D

6such

asdiltiazem

,fluvoxamineor

paroxetine

may

increase

olanzapine

levels;inducersofCYP1A

2or

CYP3A

4such

asbarbiturates,

carbam

azepine,

phenytoin

orrifam

pinmay

decrease

olanzapine

levels.

Usedas

augm

entationtherapy

with

first-line

agentsinPTS

D.

Advisepatientsabout

antipsychotic-associated

body

temperaturedysregulation

andpreventionofheatstroke

(e.g.,hydration,sunprotection).

$-$$

risperidone

RisperdalPreparations,

generics

Initial:1

mgdaily

poTitrate

gradually

todesiredeffect,usually

1–2mgdaily

po.May

need

toincrease

toamaximum

of4mg

daily

po

Insomnia,

headaches,

weightgain,orthostatic

hypotension,

rhinitis,

anxiety,dose-related

hyperprolactinem

iaand

extrapyramidaleffects.

Additive

sedationwith

CNS

depressants;may

potentiate

antihypertensivedrug

effects;

inhibitors

ofCYP3A

4such

asclarithromycin,

erythrom

ycin,grapefruitjuice,

ketoconazoleor

prednisone)

may

increase

risperidone

levels;inducersofCYP3A

4such

ascarbam

azepine,

phenytoinor

rifam

pinmay

decrease

risperidonelevels.

Usedas

augm

entationtherapy

with

first-line

agentsinPTS

D.

Advisepatientsabout

antipsychotic-associated

body

temperaturedysregulation

andpreventionofheatstroke

(e.g.,hydration,sunprotection).

$




Class

Drug

Dose

Adverse

Effects

DrugInteractions

Com

ments

Costa

Mon

oamine

Oxidase

Inhibitors

phenelzine

Nardil

45-90mg/daypo

Insomnia,

dizziness,

orthostatic

hypotension,

edem

a,sexual

dysfunction.

Concurrentusewith

sympathom

imeticagents,

tyramineor

levodopa

may

resultinhypertensivecrisis;

donotuse

with

serotonergic

drugssuch

asSSRIs,S

NRIs,

TCAs,meperidine,tryptophan

(increasedriskofserotonin

syndrome).

Stringentd

ietary

restrictions

(tyramine-containing

foods)are

necessary.

$$$

Noradrenergic

andSp

ecific

Serotonergic

Antidepressants

mirtazapine

Rem

eron,Rem

eron

RD,generics

15-45mgQHSpo

Som

nolence,increased

appetite/weightg

ain,

dizziness.

Donotu

sewith

MAOIs;

additivesedationwith

other

CNSdepressantssuch

asalcohol,benzodiazepines;

substrate

ofCYP1A

2,2D

6and3A

4—cautionwith

inhibitorsor

inducersofthese

isoenzym

es.

$

Reversible

Inhibitors

ofMon

oamine

Oxidase-A

moclobemide

Manerix,

generics(RIMAs)

300–600mg/daypo

Nausea,insomnia.

Donotuse

with

meperidine,

TCAs,SSRIs.

Dietary

restrictions

arenot

requiredatusualdoses.

$

Selective

Serotonin

Reuptake

Inhibitors

fluvoxamine

Luvox,generics

150–300mg/daypo

Agitation(on

initiationof

therapy),

nausea,a

norgasmia,

anticholinergiceffects,

sedation,increasedrisk

ofGIbleeding.

Serotoninsyndromewith

MAOIs(hypertension,tremor,

agitation,

hypomania);

cautionwith

other

serotonergicdrugsincluding

amphetam

inederivatives,

dextromethorphan,

dihydroergotam

ine,linezolid,

lithium

,meperidine,

pentazocine,

selegiline,

St.John'swort,trazodone,

triptans,

tryptophan

(increasedriskofserotonin

syndrome);increased

risk

ofGIbleedingwith

NSAIDs,

antiplateletagents.

SSRIs

aresubstrates

andinhibitors

ofseveral

cytochromeP450

isoenzym

es.Thismay

result

indecreasedclearanceof

manydrugs(e.g.,clozapine,

methadone,mexiletine,

phenytoin,

pimozide,

May

take

2–3monthsto

achievemaximum

effect.

Discontinue

gradually.

$$

(cont'd)



Table2:

Drugs

Usedin

theManagem

ento

fPost-traum

aticStress

Disorder(

cont'd)

Class

Drug

Dose

Adverse

Effects

DrugInteractions

Com

ments

Costa

propafenone)

ordecreased

enzymaticconversion

ofa

prodrugto

itsactiveform

(e.g.,clopidogrel,codeine,

tamoxifen).

Avoidcombineduse

with

drugsassociated

with

prolongedQT c

interval/torsades

depointes,

such

asam

iodarone,

azithromycin,clarithrom

ycin,

domperidone,erythrom

ycin,

haloperidol,methadone,

pimozide,

quinine,

sotalol,

ziprasidone.

paroxetineimmediate-

release

Paxil,generics

Usual

dose:

20–40mg/daypo

Maximum

dose:

60mg/daypo

Agitation(on

initiationof

therapy),

nausea,a

norgasmia,



ofGIbleeding.

See

fluvoxamine.

May

take

2–3monthsfor

maximum

effect.

Discontinue

gradually.

$

paroxetinecontrolled-

release

PaxilCR

12.5–37.5mg/daypo

Agitation(on

initiationof

therapy),

nausea,a

norgasmia,



ofGIbleeding.

See

fluvoxamine.

May

take

2–3monthsfor

maximum

effect.

Discontinue

gradually.

$$$-

$$$$$

sertraline

Zoloft,generics

50–200

mg/daypo

Agitation(oninitiation

oftherapy),n

ausea,

anorgasm

ia,insom

nia,

diarrhea,increased

risk

ofGIbleeding.

See

fluvoxamine.

May

take

2–3monthsfor

maximum

effect.

Discontinue

gradually.

$





Class

Drug

Dose

Adverse

Effects

DrugInteractions

Com

ments

Costa

Serotonergic

Antidepressants

trazodone

generics

Initial:2

5–50

mgQHS

po May

increase

gradually

upto

100mgQHSpo

asneeded/tolerated

Drowsiness,orthostatic

hypotension,

nausea,

vomiting,headache,dry

mouth,priapism

(rare).

Toxicitymay

beincreased

byinhibitors

ofCYP3A

4such

asclarithromycin,

erythrom

ycin,grapefruitjuice,

ketoconazole).Effectiveness

may

bedecreasedby

inducersofCYP3A

4such

ascarbam

azepine,

phenytoin,

rifam

pin).

Form

anagem

entofinsom

nia.

NotaHealth

Canada-approved

indication.

$

Serotonin-

Norepinephrine

Reuptake

Inhibitors

venlafaxine

extended-release

EffexorX

R,generics

37.5–225

mg/daypo

Nausea,

insomnia,

dizziness,asthenia.

Donotuse

with

MAOIs.

Substrate

ofCYP2D

6and

CYP3A

4;cautionwith

inducersor

inhibitorsofthese

isoenzym

es.

May

take

2–3monthsfor

maximum

effect.

Discontinue

gradually.

Avoidin

severe

renal

dysfunction.

$

aCostof30-daysupply;includesdrug

costonly.

Dosageadjustmentm

aybe

requiredinrenalimpairm

ent;see.

Abbreviations:

MAOI=

monoamineoxidaseinhibitor;NSAID

=nonsteroidalanti-inflammatorydrug;P

TSD=post-traumaticstress

disorder;S

NRI=

serotonin-norepinephrinereuptake

inhibitor;SSRI=

selective

serotoninreuptake

inhibitor;TC

A=tricyclicantidepressant

Legend:

$<$25

$-$$

<$25–50

$$$25–50

$$$$50–75

$$$$

$75–100

$$$-$$$$$$50–125

$$$$$$100–125




Suggested Readings

Baldwin DS, Anderson IM, Nutt DJ et al. Evidence-based guidelines for the pharmacological treatmentof anxiety disorders: recommendations from the British Association for Psychopharmacology. JPsychopharmacol 2005;19(6):567-96.

Bandelow B, Sher L, Bunevicius R et al. Guidelines for the pharmacological treatment of anxietydisorders, obsessive-compulsive disorder and posttraumatic stress disorder in primary care. Int JPsych Clin Pract 2012;16(2):77-84.

Bisson JI, Roberts NP, Andrew M et al. Psychological therapies for post-traumatic stress disorder(PTSD) in adults. Cochrane Database Syst Rev 2013;12:CD003388.

Canadian Psychiatric Association. Clinical practice guidelines. Management of anxiety disorders.Can J Psychiatry 2006;51(8 Suppl 2):9S-91S.

Ravindran LN, Stein MB. The pharmacologic treatment of anxiety disorders: a review of progress. JClin Psych 2010;71(7):839-54.

References1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders: DSM-5. 5th ed. Washington (DC): American

Psychiatric Association; 2013.2. Kavan MG, Elsasser GN, Barone EJ. The physician's role in managing acute stress disorder. Am Fam Physician 2012;86(7):643-9.3. Bandelow B, Sher L, Bunevicius R et al. Guidelines for the pharmacological treatment of anxiety disorders, obsessive-compulsive disorder

and posttraumatic stress disorder in primary care. Int J Psych Clin Pract 2012;16(2):77-84.4. Pitman RK, Sanders KM, Zusman RM et al. Pilot study of secondary prevention of posttraumatic stress disorder with propranolol. Biol

Psychiatry 2002;51(2):189-92.5. Steckler T, Risbrough V. Pharmacological treatment of PTSD—established and new approaches. Neuropharmacology 2012;62(2):617-27.6. Canadian Psychiatric Association. Clinical practice guidelines. Management of anxiety disorders. Can J Psychiatry 2006;51(8 Suppl 2):9S-91S.7. Bisson JI, Roberts NP, Andrew M et al. Psychological therapies for post-traumatic stress disorder (PTSD) in adults. Cochrane Database

Syst Rev 2013;12:CD003388.8. Marshall RD, Beebe KL, Oldham M et al. Efficacy and safety of paroxetine treatment for chronic PTSD: a fixed-dose, placebo-controlled

study. Am J Psychiatry 2001;158(12):1982-8.9. Brady K, Pearlstein T, Asnis GM et al. Efficacy and safety of sertraline treatment of posttraumatic stress disorder: a randomized controlled

trial. JAMA 2000;283(14):1837-44.10. Seedat S, Stein DJ, Ziervogel C et al. Comparison of response to a selective serotonin reuptake inhibitor in children, adolescents, and adults

with posttraumatic stress disorder. J Child Adolesc Psychopharmacol 2002;12(1):37-46.11. Escalona R, Canive JM, Calais LA et al. Fluvoxamine treatment in veterans with combat-related post-traumatic stress disorder. Depress

Anxiety 2002;15(1):29-33.12. Connor KM, Davidson JR, Weisler RH et al. A pilot study of mirtazapine in post-traumatic stress disorder. Int Clin Psychopharmacol

1999;14(1):29-31.13. Davidson JR,Weisler RH, Butterfield MI et al. Mirtazapine vs. placebo in posttraumatic stress disorder: a pilot trial. Biol Psychiatry

2003;53(2):188-91.14. Neal LA, Shapland W, Fox C. An open trial of moclobemide in the treatment of post-traumatic stress disorder. Int Clin Psychopharmacol

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1991;179(6):366-70.17. Wang HR, Woo YS, Bahk WM. Atypical antipsychotics in the treatment of posttraumatic stress disorder. Clin Neuropharm 2013;36(6):216-22.18. Krystal JH, Rosenheck RA, Cramer JA et al. Adjunctive risperidone treatment for antidepressant-resistant symptoms of chronic military

service-related PTSD: a randomized trial. JAMA 2011;306(5):493-502.19. Bossini L, Casolaro I, Koukouna D et al. Off-label uses of trazodone: a review. Expert Opin Pharmacother 2012:13(12):1707-17.20. Kung S, Zelde E, Lapid MI. Treatment of nightmares with prazosin: a systematic review. Mayo Clin Proc 2012;87(9):890-900.21. Olatunji BO, Cisler JM, Deacon BJ. Efficacy of cognitive behavioral therapy for anxiety disorders: a review of meta-analytic findings.

Psychiatr Clin North Am 2010;33(3):557-77.22. ACOG Committee on Practice Bulletins—Obstetrics. ACOG Practice Bulletin: Clinical management guidelines for obstetrician-gynecologists

number 92, April 2008 (replaces practice bulletin number 87, November 2007). Use of psychiatric medications during pregnancy and lactation.Obstet Gynecol 2008;111(4):1001-20.

23. Tuccori M, Montagnani S, Testi A et al. Use of selective serotonin reuptake inhibitors during pregnancy and risk of major and cardiovascularmalformations: an update. Postgrad Med 2010;122(4):49-65.

24. Yonkers KA, Wisner KL, Stewart DE et al. The management of depression during pregnancy: a report from the American PsychiatricAssociation and the American College of Obstetricians and Gynecologists. Gen Hosp Psychiatry 2009;31(5):403-13.

25. Academy of Breastfeeding Medicine Protocol Committee. ABM clinical protocol #18: use of antidepressants in nursing mothers. BreastfeedMed 2008;3(1):44-52.

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SAMPLE CHAPTERSAMPLE CHAPTER · SAMPLE CHAPTER 6 Psychiatric Disorders T able 2: Drugs Used in the Management of Post-traumatic Stress Disorder Class Drug Dose Adverse Effects Drug