Symptom-Focused Psychiatric Drug Therapy for Managed Care

S. Joseph

• Publisher: Taylor & Francis
• Year: 2018
• Print ISBN: 9781138324442
• eBook ISBN: 9780429834943
• Edition: 1
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Originally published in 1997, this title describes therapeutic applications of simple to complex combinations of medications to treat common psychiatric disorders among adults. Dr Joseph discusses practical, clinical guidelines that both the beginner and experienced practitioner will find useful. The 100 psychopharmacological cases presented in Part 2 illustrate the application of the diagnostic and treatment concepts described in Part 1. The cases are grouped into simple, moderately complex, and complex cases. The clinical cases, besides evoking a "hands-on" feeling which facilitates learning, can be used to compare your current treatment approach to that of an experienced and highly successful practicing psychiatrist.A vital addition to every psychiatrist's library, this guidebook is indispensable to those seeking a better understanding of patients' problems from a psychopharmacological perspective that is both practical and effective. Numerous and varied clinical presentations are reduced to treatable symptoms so that even physicians who lack experience with a specific medication or combination of medications will be able to use these interventions successfully. For each of the 100 clinical cases presented in the book, the clinical history, treatment course, medication doses, and treatment outcome are carefully detailed in a step-by-step analysis.Unique features of this book that will be useful to psychiatrists, primary care physicians, and all mental health clinicians include: its symptom-focused approach; its discussion of modern rational polypharmacy; specific dosing guidelines; office management of severe disorders; treatment of special patients, such as celebrities and other doctors; clinical cases; and sample answers to common questions asked by patients.Psychiatrists, psychiatric residents, psychotherapists, psychiatric nurses, and other physicians will find thorough and clear explanations of treatment strategies and their nuances in this volume. Physicians interested in learning balanced and rational use of various psychotropic medication combinations will find themselves turning to this book again and again as they strive to alleviate psychiatric symptoms in patients and exercise techniques that minimize or avoid inpatient psychiatric hospitalization.

PART I:
DIAGNOSTIC AND TREATMENT CONCEPTS

Chapter 1

Depression: Practical Diagnostic and Management Guidelines

DEPRESSION: GENERAL CONSIDERATIONS

Depressive symptoms, if interfering with one’s functioning, should be treated regardless of the cause. Treatment requires evaluation of the symptoms in terms of their characteristics, severity, duration, and etiology. Depression and other psychiatric syndromes can be related to a number of factors.

Case in point, most medical conditions can cause depression. Certain medical conditions such as hypothyroidism, cerebrovascular accident, and Parkinson’s disease frequently lead to depression. Other medical conditions such as chronic pain and diabetes can lead to increased frustration and stress, thereby precipitating depression. If the medical condition that is etiologically related to depression can be diagnosed and treated, depression is usually resolved. For example, thyroid supplements can reinstate euthyroid status and if hypothyroidism caused the depression, there should be resolution of depression with thyroid replacement. However, if a cerebrovascular accident causes depression, the treatment of depression must be symptomatic, using an antidepressant, since the cerebrovascular accident cannot be reversed.

There are many medical conditions that in varying degrees cause depression, or worsen depression. In many cases, treatment of the underlying medical problem may not lead to complete regression of the depressive symptoms. In some instances, medical treatment may cause the depression. Examples are cancer chemotherapy, some antihypertensives, and steroid treatment. In these latter cases, symptomatic treatment using antidepressants is usually necessary for optimal outcome.

In most cases, the chances are slim that an undiagnosed medical condition presents with depression, without other physical symptoms, signs, or complaints. For example, a brain tumor can present with depression; however, such a tumor frequently is accompanied by neurological symptoms or signs as well. The probability that a brain tumor will present with depression as the only symptom is remote except with frontal lobe tumors in rare cases. Nevertheless, there are probably cases reported where depression was the presenting symptom of a brain tumor. Does this necessitate obtaining a CT scan or MRI of the brain of every patient who presents with depression? The answer is an unequivocal no. However, physicians should be vigilant as to the existence of possible medical etiologies for various psychiatric symptoms by obtaining a thorough history, physical examination if indicated by the history, and laboratory studies, if needed, dictated by findings, if any, in the medical history, physical examination (if already done), and psychiatric symptoms. Endocrine, neurological, infectious, cardiovascular, rheumatological, gastrointestinal, reproductive, hematological, pulmonary and renal disorders, and nutritional deficiencies can cause or exacerbate depression. Hence underlying medical conditions, if amenable, should be treated for optimal psychiatric outcome. As mentioned earlier, in some cases diagnosis and treatment of the medical condition will correct the problem, but in most cases concomitant treatment of depression is necessary. Very frequently it is impossible to confirm whether or not a particular medical disorder is primary in causing depression. Any medical illness is a stress that can psychologically precipitate depression. Conversely, endogenous and reactive depression can stress the organ systems, causing physical symptoms, although the etiology is difficult to confirm and the precise mechanism is poorly understood.

It should be emphasized that as in other medical specialties, physical examination and laboratory studies should be guided by medical history. For example, if a patient complains of dizziness, vital signs including orthostatic blood pressure should be obtained. However, if a patient is seen in the office for depression with no medical complaints, a physical examination is usually not necessary. In a healthy patient with no medical complaints, the yield from routine physical examination and laboratory studies as they relate to the patient’s presenting psychiatric complaints is very low in an office practice context. However, the psychiatrist should not hesitate to conduct a focused physical examination and laboratory investigation if the patient’s history indicates the need because psychiatrists, by virtue of their primary medical training and qualification as physicians, are expected to continue to exercise basic medical judgment.

However, a thyroid profile is commonly obtained as part of the initial evaluation of patients with depression and anxiety. Even when thyroid abnormalities are discovered, treatment of the thyroid abnormality is frequently not sufficient to completely ameliorate the patients’ presenting psychiatric complaints and symptoms. Psychiatric intervention is eventually needed in most of these cases for optimal resolution of their psychiatric problems. However, identification and correction of the thyroid abnormality paves the way for improved response to psychiatric intervention. Therefore, routine thyroid screening using the widely available and fairly inexpensive thyroid stimulating hormone (TSH) level is justified, particularly in females and in the elderly, in whom thyroid abnormalities tend to be relatively more common.

In some of the psychiatric inpatient and outpatient programs, a wide variety of laboratory studies including EEG and brain CT/MRI scans are obtained as part of the routine admission workup, regardless of the presenting complaints and without regard to the cost involved. Some psychiatrists obtain computerized topographic mapping of the EEG, dexamethasone suppression test, etc., fairly routinely. These tests are costly, represent overutilization in most cases, and do not provide essential and valid clinical information in most cases.

This is not to imply that laboratory studies are not to be obtained. There are valid reasons to obtain laboratory studies in many circumstances:

– Medical history and physical exam may point to the need for specific tests.

– Various baseline laboratory studies are useful and necessary prior to starting different medications such as carbamazepine (Tegretol), valproic acid (Depakene, Depakote), lithium, disulfiram (Antabuse), etc. Mandatory baseline laboratory tests are required prior to clozapine (Clozaril) administration.

– Periodic blood level monitoring and other laboratory tests are necessary for proper patient management involving various medications as listed above, including clozapine, which requires a weekly WBC.

– The elderly and the medically ill tend to have occult physical problems which may dictate the need for a greater reliance on a variety of laboratory screening tests.

The appropriate function of a physician is to use discretion based on clinical judgment and the clinical needs of individual patients. If indeterminate testing involving a large battery of tests is conducted routinely without relevant clinical justification and without regard to individual needs, clinical judgment is supplanted, paving the way for inaccurate or invalid conclusions. A medical technician could very well supervise such a task. Laboratory testing or procedures without clinical indication suggest inappropriate utilization of services, invariably driving up the cost of mental health care. For the most part, patients admitted to medical wards are tested on a more focused basis, whereas for some reason, patients admitted to most psychiatric units are tested indiscriminately. This is true even for patients who are repeatedly admitted and whose diagnosis is not in question. This observation is based on the author’s experience of working in various inpatient psychiatric units in several major cities in the United States.

In addition to medical etiology, another important and common causative agent of depression is prescription medications, including antianxiety medication and antihypertensives. In many instances, substitution of medications is not possible, requiring treatment of depression using antidepressants. Most systemic medications listed in the Physicians’ Desk Reference (PDR) can cause depression and anxiety; hence, it is not always practical to avoid medications for which depression and anxiety are listed in the PDR as side effects.

It is a commonly held belief that propranolol (Inderal) causes depression. In the several cases the author can recall where a patient on a beta-blocker presented with depression, switching the patient to ACE inhibitors or calcium channel blockers did not resolve depression, and the eventual resolution necessitated antidepressant treatment.

Compared to prescription drugs, alcohol and street drugs are more important and more common precipitants of depression and anxiety. Since they are not medically needed, they are entirely avoidable. Abstention from their use could relieve some or all symptoms of depression. Many patients “self-treat” their psychiatric symptoms by abusing alcohol and illicit drugs. Primary psychiatric problems frequently found among alcohol and drug abusers are depression, anxiety, cyclothymia, hypomania, attention deficit disorders, various phobias, and chronic pain. However, if a primary psychiatric disorder, which the author’s experience suggests is present in most substance abusers, is not diagnosed and treated, the temptation and the drive to again “self-treat” with alcohol and illicit drugs will eventually resurface. Alcoholics and substance abusers should be strongly suspected of having an underlying treatable psychiatric disorder unless proven otherwise. Substance dependence is best seen as a symptom, not as a disease. This is why substance abuse treatment must not be limited to detoxification and rehabilitation treatment. A diligent search should be made to uncover probable underlying psychiatric disorders, so that appropriate psychiatric treatment can be initiated.

There is a tendency for polarized thinking among mental health professionals relating to psychiatric versus substance abuse disorders. At times, such thinking takes on concrete and fanatical proportions. For example, it is unfortunately common among substance abuse professionals to directly or subtly discourage patients from using prescription psychiatric medications. Usually this takes the form of devaluing the medication by labeling it “mind-altering,” or a “chemical,” or telling the patients that they are just substituting one drug for another. Over the years, I have seen many patients who have experienced relapses of their underlying psychiatric illnesses as a result of discontinuing psychotropic medications, as well as patients who have experienced relapses of their substance abuse, which could have been prevented by supporting the patients’ pharmacological treatment of primary or secondary psychiatric disorders. Since the substance abuse and mental health fields attract a heterogeneous group of professionals, such unfounded attitudes and ignorance are unfortunately likely to continue. Mental health and substance abuse problems are related problems requiring comprehensive...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Foreword: E. Michael Gutman
• Preface
• Acknowledgments
• Introduction
• PART I: DIAGNOSTIC AND TREATMENT CONCEPTS
• PART II: ONE HUNDRED TEACHING CLINICAL CASES
• Appendix A. Patient Assistance Programs
• Appendix B. Alphabetical Listing of Drugs by Generic Names, with U.S. Brand Names
• Appendix C. Alphabetical Listing of Drugs by U.S. Brand Names, with Generic Names
• Appendix D. Alphabetical Listing of Abbreviations
• Bibliography
• Index