Depression Symptoms Treatment
Archive for the ‘Disorders’ Category
November 9th, 2009 by admin
Acute Agitation and Aggression in Psychiatric Illnesses. Part 7. Treatment
Typical Antipsychotics: Strategies to treat agitation, aggression and psychosis have evolved since the introduction of chlorpromazine in 1952. During the 1970s and early 1980s the approach of "more is better" led to high acute doses given to produce a rapid remission of psychotic symptoms (e.g., haloperidol 100 mg as a starting dose or giving an antipsychotic dose every 15 to 30 minutes until asleep). This approach was known as rapid neuroleptization. Fortunately, pharmacists now know that remission of psychosis is not sped up by high initial doses. High doses possess a significant risk for extrapyramidal symptoms (EPS), especially acute dystonic reactions and neuroleptic malignant syndrome. The standard of care is to start with the long-term strategy in mind and give the lowest effective antipsychotic dose and allow time for a response. Acute agitation and aggression is best treated with short courses of antipsychotics or benzodiazepines after nondrug approaches have been tried. This approach is known as rapid tranquilization, which aims to control the agitated and potentially dangerous Read more [...]
November 9th, 2009 by admin
Acute Agitation and Aggression in Psychiatric Illnesses. Part 6. Treatment
Selection of Appropriate Pharmacotherapy
As previously stated, an important factor in selecting pharmacotherapy is knowing the underlying cause. For example, a patient with stimulant-induced psychosis may need to use antipsychotics only for a few days, while a patient with schizophrenia requires chronic antipsychotic treatment. Agitated dementia patients are often managed with nondrug means. If medication is warranted, they can be managed with high-potency typical anti-psychotic agents such as haloperidol rather than lower potency typical agents such as chlorpromazine, which could complicate matters by inducing an anticholinergic-induced delirium or dementia. Agitation associated with alcohol intoxication and withdrawal is managed by benzodiazepines due to their cross-tolerance with alcohol. Individuals with bipolar disorder are managed chronically with mood stabilizers such as lithium, divalproex sodium, carbamazepine or atypical antipsychotics such as olanzapine, but may require acute doses of benzodiazepines or antipsychotics to control behavior until the maintenance medications begin to produce Read more [...]
November 9th, 2009 by admin
Acute Agitation and Aggression in Psychiatric Illnesses. Part 5. Treatment
Treatment Goals The first goal is to ensure safety of the patient and those around him. Secondly, symptoms need to be reduced to such a degree that safety is no longer a problem and further medical and psychiatric assessments can be completed in order to identify potential causes. Subsequent interventions aim to prevent further aggression and to regain the patient's capacity for cooperation with treatment as soon as possible. Once the cause has been identified, appropriate treatment with accompanying goals specific to the underlying condition are implemented. Many pharmacologic interventions for acute agitation and aggression involve some post-dose sedation, which is not necessarily the primary goal. An optimal response would be a reduction in agitation or aggression but the patient remains alert, oriented, and able to participate with further assessment and treatment. Treatment Strategies Nonpharmacologic vs. Pharmacologic: The initial treatment choice is between using a medication or nondrug measures such as verbal interaction, seclusion, or restraint. The likely cause of the aggressive Read more [...]
Patient Evaluation
Once the safety of the patient and those around him is assured, a thorough evaluation is needed to identify contributing factors and to prevent further episodes. Medical, psychiatric and medication histories are core to an effective evaluation. Physicians, nurses, and pharmacists should participate using their particular expertise. Contributing factors may become clear after reviewing the patient's psychiatric history, especially if noncompliance, substance abuse, or psychosocial stressors coexist. A mental status exam identifying underlying symptoms, such as hallucinations or delusional thinking, will further guide treatment. Patients who develop agitation two to three weeks after starting antipsychotic treatment should be evaluated for akathisia as a potential underlying cause. When the cause is unknown, physical examinations and laboratory tests that identify common causes of aggression due to a general medical condition are undertaken (Table 3). The need for a specific test is based on the patient's presentation, physical findings, and medical history. The social context Read more [...]
CASE STUDY 1
KN is a 65-year-old woman admitted to a nursing home after her family can no longer care for her. She has Alzheimer's dementia and has become more difficult to manage over the past six months. She no longer takes care of her own grooming and hygiene and is pacing and trying door handles, attempting to get outside and go home. Today she started yelling at another patient and hit him with her lunch tray. The staff is trying to calm her, but she continues to yell and strike out at people.
CASE STUDY 2
JS is a 27-year-old male patient admitted to the psychiatric inpatient unit where you are the pharmacist. He is yelling at staff to leave him alone. He goes on to say that the CIA is looking for him and that the voice of the President is telling him to "stop the spies." He is dirty and unkempt in his appearance. He is starting to pace faster and faster up and down the halls and has refused oral medication. He is arguing with another patient on the unit whom he accuses of being a Russian spy. You know this patient as he has been admitted to the unit on several occasions for noncompliance Read more [...]
Agitation and aggression are common symptoms in inpatient psychiatric settings, geriatric medicine and emergency room care. For example, some 10% of patients admitted to psychiatric services with chronic psychiatric disorders exhibited violence toward others prior to admission. About half of patients with Alzheimer's disease have agitation or violent behavior and 24% have verbal outbursts. Between 10% and 30% of patients hospitalized on inpatient medical units commonly develop agitation as a complication of delirium. An expansive discussion on the management of delirium in the medically ill is beyond the scope of this paper and readers are referred to the American Psychiatric Association Practice Guidelines for the Treatment of Patients with Delirium. The purpose of this article is to provide a framework for pharmacists to describe and quantify agitation and aggression as they present in their patients, outline a logical basis for treatment selection and justification, and review follow-up strategies to minimize future problems.
Impact of Agitation and Aggression
The impact of agitation and Read more [...]
THE PHARMACIST'S ROLE IN PMDD
Premenstrual dysphoric disorder is a fairly recent discovery in women's health; yet, it currently costs the nation millions of dollars a year in direct and indirect costs.Most costs associated with PMDD patients are related to days missed from work or reduced work performance due to symptoms. Premenstrual dysphoric disorder symptoms result in a huge economic and health burden for our nation. To reduce the incidence of PMDD, it is crucial to understand the criteria and many different treatment options available.
When counseling a patient who may be suffering from PMDD, it is important to seek information. Table 6 provides a list of useful questions for the pharmacist to ask. The patient's complete medical and personal history should be carefully reviewed and assessed. It is important for the pharmacist to then make a decision to triage the patient to a physician or begin to work with the patient to institute an effective self-care program.
Table 6. Pharmacist Assessment to Individualize and Triage Therapy
General Questions
1.
Who is the patient? Is the Read more [...]
As the pathophysiology of PMS and PMDD suggests, symptoms are associated with the elevation and decline of sex hormones during ovulation. As symptoms are not found before menarche or after menopause, studies have focused on ovulation suppression to relieve these symptoms. If ovulation were suppressed, the rise and fall of these hormones would then be inhibited, resulting in a reduction or complete cessation of symptoms. Medical oophorectomy is the term used to describe using medications in the suppression of ovulation. GnRH agonists have been indicated to treat premenstrual dysphoric disorder and result in a hypoestrogenic state. Some GnRH agonists studied are leuprolide and buserelin, both found to be superior to placebo in reducing emotional and physical symptoms related to the menstrual cycle.
The disadvantages of using GnRH agonists include cost and negative side-effect profiles, being associated with menopausal symptoms, e.g., hot flashes, vaginal dryness, depression, headaches, and muscle aches. Also, long-term effects of these drugs may include osteoporosis or heart disease. GnRH agonists Read more [...]
Pharmacological Therapy for Emotional and Psychological Symptoms
Often, nonpharmacological interventions are insufficient for adequate menstrual relief for patients suffering from premenstrual dysphoric disorder. Dietary modifications that may then be recommended include daily calcium, magnesium, and L-tryptophan supplementation. These modifications have been clinically studied in premenstrual syndrome patients and are therefore assumed to be beneficial to the PMDD patient. Recommendations supported by controlled studies include 1,200 mg of calcium carbonate per day in divided doses, 50 to 100 mg of magnesium twice a day (up to 60 mg/day), 400 U of vitamin E per day, or 50 to 100 mg of vitamin B6 per day. Supplementation of L-tryptophan to reduce symptoms of PMDD has been indicated with limited data. The daily recommended amount of L-tryptophan is 6 g from the time of ovulation until day 3 of menses.
In addition to nutritional supplements, herbal products have also been studied to treat premenstrual dysphoric disorder. Dong quai is a coumarin derivative widely used in China for menstrual cramps Read more [...]
Once a patient meets the DSM-IV criteria and is diagnosed with premenstrual dysphoric disorder, therapy should be initiated. Consistent with many disorders and disease states, nonpharmacological therapy should be attempted initially. Nonpharmacological Therapy Nonpharmacological therapy consists of dietary modifications, moderate regular exercise, stress management, and supportive therapy. Dietary modifications include reduction in daily salt, caffeine, and alcohol intake. Although these modifications are not confirmed with substantial evidence, many patients have been found to benefit with these changes. Some studies also suggest smaller, more frequent meals with high carbohydrate content or complex carbohydrate drinks. Reducing chocolate consumption has been recommended, but no clinical link to alleviation of symptoms has been found. Moderate regular exercise has been shown to modify endorphin levels and improve mood during premenstrual dysphoric disorder. Clinical studies have not found any major correlation between exercise and improved mood, but epidemiological studies have validated Read more [...]