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

Cleveland Clinic Lerner College of Medicine

PRESERVING THE PASSION –

PRESERVING THE PROFESSION:

INNOVATIONS IN MEDICAL EDUCATION KATHLEEN FRANCO, M.D.