Depression Symptoms Treatment
Archive for the ‘Disorders’ Category
Dose versus Pharmacokinetics: Although use of a shorter acting benzodiazepine hypnotic will decrease the possibility of morning hangover, dose is of equal importance. All benzodiazepines given the night before can impair next-day performance. The longer half-life drugs produce more next-day performance impairment, but dose is the most important determinant. Use of shorter half-life drugs like triazolam may cause next-day impairment if doses of 0.5 mg are given, while doses of 0.125 and 0.25 mg greatly reduce next-day effects.
Rebound Insomnia and Memory Impairment: In the late 1980s and early 1990s, clinicians became aware that the benefits of a shorter half-life drug on next-day performance were countered by the increased risk of rebound insomnia and new memory impairment (anterograde amnesia) that was not commonly seen with the longer half-life drugs. These effects are also dose-related and can be minimized by use of the minimum effective dose consistent with appropriate clinician and patient expectations. Comparison of five benzodiazepine hypnotic agents found only the shorter half-life drugs Read more [...]
Antidepressant Drugs
Sedating antidepressants have been used to induce sleep in doses lower than those generally used for depression in an attempt to avoid the benzodiazepines’ liabilities of dependence, rebound insomnia, and withdrawal effects. Low-dose tricyclic antidepressants (TCAs), such as amitriptyline or doxepin, were once the most commonly used antidepressants for insomnia. Trazodone in doses of 50–200 mg at bedtime has more recently become the preferred antidepressant for insomnia. Trazodone’s hypnotic efficacy has not been directly compared to that of the benzodiazepines. It has been studied only in populations of depressed patients with insomnia, and usually the insomnia was secondary to SSRI use.Trazodone offers prominent sedation with little anticholinergic effect, but a slow onset and noticeable orthostatic hypotensive effect. There is no concern regarding dependence or withdrawal after as long as four months of use. Compared to TCAs, trazodone offers better safety in overdose. Priapism, a rare but serious adverse effect, can occur with daily doses of trazodone as low as 50–200 Read more [...]
Nonprescription Hypnotic Agents
Antihistamines: Most over-the-counter drug treatments for insomnia contain the antihistamines diphenhydramine, doxylamine or hydroxyzine. Individuals with insomnia report that these agents cause drowsiness and help them fall asleep. The most prominent disadvantage is the next-day “hang-over” effects of psychomotor impairment and anticholinergic side effects that can be intolerable. These agents are less effective for treating insomnia than are the benzodiazepines. Also, they typically are not effective for chronic insomnia because tolerance to the sleep-inducing effects often develops after one to two weeks of continuous use.
Melatonin: Melatonin is a naturally occurring hormone secreted by the pineal gland, which is located in the center of the brain. The pineal gland is connected to the retina via a nerve pathway that runs through the suprachiasmatic nucleus of the hypothalamus, the body’s circadian clock. The pineal gland produces melatonin (a byproduct of serotonin metabolism) only during the nocturnal phase of the circadian cycle and only in relative Read more [...]
Nonpharmacologic Treatment
Sleep experts universally recommend behavioral interventions, either alone or with adjunct medication, for the treatment of insomnia. When interventions such as keeping a regular sleep schedule; creating a dark, comfortable bedroom environment; and establishing a pre-bedtime ritual are effective, insomnia can be resolved without the expense of drugs or drug side effects. Specific interventions should be tailored to the type of sleep complaint. For example, eliminating alcohol for at least three to four hours before bedtime can alleviate fragmented sleep if alcohol is the cause. Avoiding exercise, heavy meals, or caffeine before bedtime can also benefit some patients. Light therapy is particularly beneficial for patients with circadian-rhythm sleep disorders, where an individual may delay sleep at night, then sleep in the next morning. Forcing the individual to awaken earlier, and exposing their face to 30–60 minutes of sunlight can “reset” the biologic clock so they naturally become sleepy earlier in the evening.
Mechanisms of Hypnotic Drugs
Benzodiazepines enhance Read more [...]
Physiology of Sleep
An understanding of normal sleep is essential in recognizing and effectively treating insomnia. Although individual sleep needs vary, between six and nine hours of total sleep are necessary to feel rested and refreshed and to have optimal daytime functioning. Polysomnography is not needed to evaluate typical insomnia in the clinical setting but provides valuable information on normal physiologic sleep.
Sleep is divided into five stages. REM (rapid eye movement) sleep and NREM (non-rapid eye movement) sleep, which is further divided into 4 stages. The usual time it takes to fall asleep is between 15 and 30 minutes. Stage 1 of NREM, also known as “relaxed wakefulness,” initiates sleep. Approximately 50% of total sleep time is spent in Stage 2, a relatively light sleep also known as alpha rapid-wave sleep. Hypnotic drugs typically increase time spent in Stage 2 sleep. Fifteen to twenty percent of total sleep time is spent in Stages 3 and 4, or delta sleep. Delta sleep is the deep, restorative sleep time during which immune function is fortified and growth hormone is secreted. Read more [...]
Newer agents with short duration of effect are changing the pharmacologic treatment of insomnia.
Insomnia negatively affects as many as 10% of the U.S. population, and its impact on medical illnesses, work productivity, and quality of life is only recently being fully appreciated. The need to effectively treat insomnia means pharmacists must understand the relative role of nonpharmacologic and pharmacologic treatment options. Drug treatment options continue to evolve, with benzodiazepine hypnotics being challenged by the newer nonbenzodiazepine drugs zolpidem and zaleplon. In addition, many patients are increasingly turning to alternative treatments such as melatonin.
Diagnosis and Epidemiology
Insomnia is diagnosed when an individual has measurable difficulty initiating or maintaining sleep. There are many causes of insomnia, including stress, environmental changes (new surroundings, temperature, and noise), medical and psychiatric illness, medications, and substance use or abuse.
Two Gallup surveys of representative samples of the adult U.S. population asking if respondents “ever had difficulty Read more [...]
Legal Considerations
By today's standards restraint and seclusion are to be used as safety measures, not as part of the treatment plan. According to the United States Health Care Financing Administration (HCFA), "A drug used as a restraint is a medication used to control behavior or to restrict the patient's freedom of movement and is not a standard treatment for the patient's medical or psychiatric condition."Documentation to demonstrate a clear need for medication or restraint given without a patient's permission is necessary to protect the patient from receiving punitive treatment and to protect the staff from accusations of excessive force or coercion.
Managing agitation and aggression in the elderly nursing home population has additional considerations because of the Omnibus Budget Reconciliation Act (OBRA) implemented in 1990 and updated in 1999.Overall, OBRA requires residents of long-term care facilities to be free from "unnecessary physical or chemical restraints imposed for discipline or convenience." An unnecessary drug is a drug given in an excessive dose, for an excessive duration, Read more [...]
November 9th, 2009 by admin
Acute Agitation and Aggression in Psychiatric Illnesses. Part 10. Treatment
Dosing and Choice of Dosage Form
Table 4 describes dosing schedules for benzodiazepine and antipsychotics used to treat agitation and aggression. Oral administration of any of the medications is preferred when the patient is cooperative, except in cases of acute risk of self-harm or danger to others. The agitated individual should first be given the opportunity to take their medication by mouth. Giving the patient a choice also offers a needed sense of empowerment and may improve future cooperation. However, if the patient is uncooperative, combative, or "cheeks" medication, then IM administration is used. IM dosing gives assurance that the dose was received, eliminating any problems with noncompliance. However, many patients may resist the injection, often aggressively, in cases of involuntarily medicating a patient.
Table 4. Medication Doses for Treating Acute Agitation and
Aggression in Adults
Druga
Onset
Oral dosingb,c
Acute IM dosingb,c
Lorazepam
30-60 min (oral)
15-30 min (IM)
1-4 mg
1-4 mg
Diazepam
30-60 min (oral)
2-10 mg
Not recommended for acute use
Risperidone
1 hour
1-4 Read more [...]
November 9th, 2009 by admin
Acute Agitation and Aggression in Psychiatric Illnesses. Part 9. Treatment
Atypical Antipsychotics vs. Typical Antipsychotics: Typical antipsychotics, particularly haloperidol, are still the most commonly used agents for treating agitation and aggression because of clinician comfort and experience with their use. Haloperidol is efficacious and can be given orally as a solution or tablet, IM or IV. Cardiovascular concerns are limited except in the critically ill population and with the IV route. However, the risk of dystonia makes haloperidol a less appealing option in some populations. There are now more data demonstrating the efficacy and safety of using atypical antipsychotics for the treatment of agitation and aggression. Olanzapine offers significant dosage form flexibility and is well tolerated in clinical trials to date, making it a reasonable choice, especially when olanzapine is also part of the long-term treatment plan. If oral olanzapine is initiated and supplemented with IM doses to treat acute symptoms, the patient should be monitored for orthostasis, especially until more clinical experience indicates whether there are any risks of using both dosage forms Read more [...]
November 9th, 2009 by admin
Acute Agitation and Aggression in Psychiatric Illnesses. Part 8. Treatment
Atypical Antipsychotics: Atypical antipsychotics have become a standard of care in schizophrenia and they are increasingly being used as mood stabilizers. Additionally, new dosage forms are making them more useful in acute agitation. The IM formulation of olanzapine is pending approval by the FDA and offers a rapid onset of action within 15 to 30 minutes; meanwhile the IM formulation of ziprasidone continues to be evaluated and may be marketed in the near future. Zyprexa Zydis (olanzapine) is an effervescent tablet that dissolves in seconds once coming into contact with saliva. While this route does not speed the onset of effect as the drug is not absorbed through the oral mucosa and requires swallowing of the tablet, it does provide a barrier to patients who may wish to "cheek" their medication. Risperidone is available as an oral solution and also provides a benefit in those patients where "cheeking" is of concern but it does not act significantly faster than the oral tablets.
Currier compared oral risperidone (2 mg) concentrate and oral lorazepam (2 mg) to IM haloperidol (5 mg) and IM lorazepam Read more [...]