The Psychiatric Assessment
The first visit to a psychiatrist may be somewhat uncomfortable. It is often difficult to open up to a complete stranger, even if that stranger is an expert in mental health who has been recommended by your family physician. At the first visit the psychiatrist will ask you to tell him or her what has been bothering you. Questions usually follow the pattern described in the link below. After the history is obtained, the psychiatrist will ask questions to assess your mental or emotional state.
In psychiatry there are 2 complimentary arms to treatment: Psychotherapy (or talk treatment) & Pharmacotherapy (treatment with medication). This section covers aspects of pharmacotherapy.
When it comes to choosing any medication an accurate diagnosis is very important for without the correct diagnosis it will be almost impossible to select the most appropriate medication.
Prescribing a medication follows a conversation between doctor and patient. The reason for the choice of the particular medication is explained together with a detailed discussion regarding dose, side-effects and expected response.
“STEPS” to take when choosing medication
The mnemonic “STEPS” guides selection of the most appropriate medication. (Preskorn SM. Journal of Clinical Psychiatry 1997:58(suppl6);3-8)
S: The drug must be SAFE (i.e. few interactions with other drugs, not dangerous in overdose, etc.)
T: The drug must be TOLERATED well (i.e. have few side-effects both in the short and long-term)
E: The drug must be EFFECTIVE (or else why use it?)
P: The drug must have a reasonable PRICE (especially if not covered by an insurance plan)
S: The drug must be SIMPLE TO USE (e.g. taken once daily, easy to reach the therapeutic dose))
Antidepressants
Antidepressants are believed to work by affecting the function of brain neurotransmitters, tiny chemical messengers carrying signals from one brain cell to the next.
Most antidepressants are equally effective and selection is based on side-effect profile and the physician’s experience with the medication. A popular type of antidepressant used today is a selective serotonin re-uptake inhibitor (SSRI). The original SSRI was fluoxetine with the trade name “Prozac”. Other SSRIs include citalopram (“Celexa”), escitalopram ("Cipralex”), paroxetine (“Paxil”), sertraline (“Zoloft”) and vortioxetine (“Trintellix”). SNRIs (serotonin-norepinephrine re-uptake inhibitors) are similar to SSRIs and include venlafaxine (“Effexor”), duloxetine (“Cymbalta”) and desvenlafaxine (“Pristiq”). Unlike SSRIs and SNRIs, the antidepressant bupropion (“wellbutrin”) affects transmission of dopamine and noradrenaline.
Although there are very many antidepressants on the market today, none of them (unfortunately) are more effective than Imipramine, the very first antidepressant. Imipramine was discovered accidently in 1956 by Dr. Roland Kuhn, in Switzerland, while searching for an effective treatment for schizophrenia.
Treatment Resistant Depression
Unfortunately, antidepressants often fail to relieve the feelings of depression afflicting the hopeless and suffering patient. When faced with the dilemma of non-response, the mnemonic OSCAR helps physicians to choose their next steps wisely.
O: Optimization (making certain that the diagnosis is correct, that the antidepressant dose is adequate, that the medication is being taken as prescribed, etc.)
S: Switching to a different antidepressant (a strategy not well supported by studies. Most antidepressants are equally effective)
C: Combining 2 antidepressants (like switching, this strategy is not well supported by research)
A: Augmentation (adding a non-antidepressant: e.g. Lithium, Aripiprazole, Brexpiprazole or Thyroid Hormone) to boost the efficacy of the initial antidepressant. (a strategy well supported by research)
R: Reviewing and/or Referring (carefully examining all previous steps taken and considering referral to an expert in mood disorders)
The mnemonic OSCAR, was first described in: “Pharmacological Treatment of Depression. Consulting with Dr. Oscar” (Berber, MJ. Canadian Family Physician 1999;45:2663-2668).
Side-Effects of SSRIs & SNRIs
When starting antidepressants, I recommend 50% of the usual therapeutic dose for the first week to reduce the risk of nausea & anxiety during initiation of treatment. After 7 days, dose should be increased to the recommended therapeutic dose. It usually takes 3 to 4 weeks to notice an improvement and the medication is taken every day. The most troublesome side-effects during long-term treatment are sexual problems which include loss of libido, delayed orgasm and erectile dysfunction. These side-effects can affect 40% of patients. The antidepressants bupropion (“Wellbutrin”) and mirtazapine (“Remeron”) have minimal or no sexual side-effects as these two agents lack direct effects on serotonin. Sexual side-effects can be measured using the Arizona Sexual Experience Scale (ASEX) available at the link below:
Antidepressant Withdrawal Syndrome
Withdrawal symptoms often occur when antidepressants are discontinued suddenly rather than tapered gradually. When the decision has been made to stop taking an antidepressant discuss the tapering with your health care provider.
The withdrawal symptoms are remembered by the mnemonic FINISH: [Berber MJ. Journal of Clinical Psychiatry 1998;59:255]
F: flu-like symptoms
I: imbalance or dizziness
N: nausea
I: insomnia
S: sensory feelings (pins & needles, feeling your brain is like "jelly", “brain zaps”)
H: hyper-agitation & headache
Switching Medications
Guidelines for switching antidepressants and antipsychotics were developed by psychiatrist Dr. Diane McIntosh and pharmacist Dr. Ric Procyshyn. Their website SwitchRx.com provides switching strategies as well as guidelines for managing side-effects.
Pregnancy & Lactation
The website Mother to Baby provides excellent guidance on the use of medications during pregnancy & lactation. The website mothertobaby.org is accessible at the link below
Benzodiazepines.
Benzodiazepines are a family of sedative medications. The best known are Lorazepam (ativan), Clonazepam (rivotril) and Alprazolam (xanax). Long-acting benzodiazepines (oxazepam and temazepam) remain in the blood system longer and are used as sleeping agents. Alprazolam (xanax) has the shortest half-life of all benzodiazepines and, as a result, has proved to be very difficult to discontinue. Xanax is best avoided. Although benzodiazepines are effective and fast-acting they do have disadvantages including addictive potential, tolerance and withdrawal effects. The link below compares the potency of several popular benzodiazepines.
Mood Stabilizers
The term “mood stabilizer” is difficult to define. Indeed, mood stability itself is ill-defined and poorly understood. Lithium is considered as the classic mood stabilizer. The anticonvulsant medications valproate (epival), lamotrigine (lamictal) and carbamazepine (tegretol) are also considered “mood-stabilizers” but they do not stabilize all aspects of mood. Certain second-generation antipsychotics [e.g quetiapine (seroquel), aripiprazole (abilify)] have been called “mood-stabilizers” but their role in stabilizing mood is less clear. It is a complicated issue best discussed with your mental health provider.
Treatment of Mania
Lithium is considered the “gold standard” treatment for acute mania. Adding an antipsychotic to lithium is associated with a 20 -25% increase in mania responses. However, combination therapy will produce more side effects such as weight gain, neurological effects and sedation.
Lithium
Lithium is a treatment of choice for preventing manic & depressive episodes in bipolar mood disorder. Lithium is also used to boost the effect of antidepressants. Lithium affects many neurotransmitter systems including the serotonin system. Lithium is excreted unchanged by the kidney and drugs that reduce renal clearance (see below) can cause lithium toxicity. Before starting any new medication, always check that it will not increase your lithium level. Symptoms of lithium toxicity include nausea and vomiting, abdominal pain, diarrhea, tremor , weakness and confusion.
Lithium (unless there is nausea) is best prescribed as a once daily nighttime dose. Nighttime dosing makes it easy to measure the lithium level which is checked 12 hours after the lithium dose. Studies show that once-daily dosing protects renal function (possibly because once-daily dosing results in periods when lithium level is low). Serum lithium level should be the lowest level compatible with absence of manic and depressive recurrences.
Starting & Monitoring Lithium Treatment
Before starting lithium treatment, every patient should undergo a baseline thyroid hormone evaluation (TSH), kidney function tests (creatinine & GFR), and serum calcium levels. The starting dose of Lithium is usually 300-900mg/day (lower doses in older patients). The level is checked after 5-7 days and dose altered accordingly. Lithium level is checked 1 week after each dose change until stable levels are achieved. Once the target dose is reached, recheck one week later. Thereafter, guidelines suggest checking the lithium level every 3 to 6 months. The Lithiumeter (below) suggests plasma levels for the various phases of illness.
Lithium Therapy Monitoring Recommendations
Lithium levels are measured 12 hours after taking the lithium medication. For example, if a patient takes lithium at 10PM, the blood test should take place as close to 10AM as possible. While patients are taking lithium, renal and thyroid function and serum calcium are also monitored. Review the recommended monitoring schedule at the link below. A baseline ECG is considered in patients over 40 years or if otherwise indicated. If the glomerular filtration rate (reflecting kidney function) is lower than 60ml/min/1.73m2, a kidney specialist should be consulted. Physicians can track laboratory results on the patient’s chart using the Lithium Monitoring Record.
Drug Interactions with Lithium
The following medications can significantly increase lithium levels by reducing its excretion by the kidneys:
ACE Inhibitors: Ramipril (‘Altace’), Quinapril (‘Accupril’), Enalapril (‘Vasotec’)
Analgesics (NSAIDs): Celecoxib (‘Celebrex’), Diclofenac (‘Voltaren’), Naproxen (‘Naprosyn’), Advil (ibuprofen), Aspirin
Diuretics: Thiazides
Lithium during Pregnancy
During pregnancy, especially during the 3rd. trimester, increased renal blood flow results in increased lithium excretion and lower lithium levels. To prevent relapse, during the last month of pregnancy, lithium levels should be checked every 1-2 weeks. At delivery, vascular volume decreases markedly and lithium levels increase dramatically. Lithium dose should be decreased by 25-50% in the week prior to expected delivery.
Epival (Valproate) Monitoring
Epival, a medication sometimes used to treat Bipolar Disorder, has a complex metabolism and may interact with other medications. Epival exists in a free (active) and protein bound state and the link between dose and blood level lacks clarity. Most physicians use the target concentration range established for the antiepileptic activity of the drug to guide dosing (Clinical Neuropharmacology 2006:29;350-60). When checking Epival levels, the blood test, as with lithium, is done 12 hours after the last Epival dose. If a patient is taking a morning dose of Epival, the morning dose is delayed until after the blood test is done. For prevention, a low dose is used initially and gradually increased, depending on clinical response, to a blood level in the 50-100 microg/ml range. This level is usually achieved at a daily dose around 1,500mg (Manic Depressive Illness by Goodwin & Jamison 1990).
Monitoring Physical Health of Patients taking Antipsychotic Medications
The Canadian Schizophrenia Guidelines suggest a monitoring schedule for patients taking antipsychotic medications (available at link below). The Swedish guidelines suggest additional tests including baseline measurement of prolactin & full blood count as well as baseline renal, liver and thyroid function tests & an electrocardiogram. (Nordic J Psychiatry 2011;64:294-302)
AKATHISIA is a potential side-effect of antipsychotic medication. Akathisia is a movement disorder characterized by a subjective feeling of inner restlessness accompanied by mental distress and an inability to sit still. Usually, the legs are most prominently affected. Those affected may fidget, rock back and forth, or pace, while some may just have an uneasy feeling in their body. The condition may be relieved by reducing the antipsychotic dose or by adding the medication, propranolol. Physicians sometimes use the scale below to measure the degree of any akathisia present.
Weight Gain
Weight gain is a side-effect of many medications, especially antipsychotics. From the moment a patient starts medication with potential for weight gain, monitoring and control of weight should begin. It is easier to prevent weight gain than to lose weight. By calculating your BMI (body mass index) you will learn if your weight is within the recommended range for optimum health. The link not only calculates your BMI but also offers many techniques to help you reach a healthy weight.
The Canadian Network for Mood & Anxiety Treatment produced a guide for patients and their families, written by patients and people with lived experience, to understand the different evidence-based treatments available for depression. The guide is available at the link below.