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PSYCHIATRY
Clerkship director: Heidi Combs, MD
Web site: http://depts.washington.edu/psyclerk/
REFERENCES & HELPFUL RESOURCES
1. Psychiatry 2008 ed, Hahn et al.
2. Handbook of Psychiatric Drugs, 2008 ed, Albers et al.
PSYCHIATRIC HISTORY
ID
Age, sex, marital status, referral source
CC
Reasons for seeing patient; typically a direct quote from the patient.
HPI
Current sxs (onset, duration), previous sxs and treatment, recent stressors, why
did patient present now
Psych Hx Previous and current psych dx, h/o tx (inpt, outpt), medication use, SI or attempt
Med Hx
Medical problems and medications
Substances Chem dependence tx, drug of choice, how much/often, since what age
Family Hx
Psych disorders, suicide or suicide attempts, alcohol or substance abuse
Social Hx
Income, education, relationships, children, who lives with patient, support,
alcohol use, drug use, occupation
Develop Hx Childhood relationships, family structure, developmental milestones
MENTAL STATUS EXAM (usually done at every visit with patient)
General appearance and behavior: grooming, hygiene, attitude, psychomotor activity
Speech: tone, fluency, quality, quantity, associations (e.g. pressured, poverty of speech)
Affect: external range of expression described in terms of quality, range, appropriateness
(e.g. flat, blunted, restricted, labile, full)
Mood: internal emotional tone of patient (e.g. dysphoric, euphoric, angry, anxious)
Thought processes: e.g. logical and linear, flight of ideas, loose associations, tangential,
perseveration, ideas of reference
Thought content: hallucinations, delusions, SI/HI (assess for intent and plan)
Cognitive evaluation: LOC, orientation, attention, memory, fund of knowledge, calculations,
abstractions
Insight: ability to understand current problems
Judgment: ability to make sound judgments
MINI-MENTAL STATE EXAM (to assess cognitive function)
Orientation
Points
What is the (year) (season) (date) (day) (month)?
Where are we: (country) (state) (town) (hospital) (floor)?
Registration
Name 3 object (apple, penny, chair) and then ask the patient
to repeat them; ask the patient to remember objects
Attention/Calculation
Serial 7s (stop after 5 answers) or spell “world” backwards
Recall
Ask for 3 objects the patient was asked to remember
Language
1
5
5
3
5
3
Name a pencil and watch
Repeat “No ifs, ands, or buts”
Follow 3-stage command “Take a paper in your right hand,
fold it in half, and put it on the floor”
Read and obey: CLOSE YOUR EYES
Write a sentence
Copy interlocking pentagons (below)
2
1
3
1
1
1
DSM-IV Multiaxial Assessment Diagnosis
Axis I
Psychiatric disorders
Axis II
Personality disorders and mental retardation
Axis III
General medical conditions
Axis IV
Psychosocial and environmental problems
Axis V
Global assessment of functioning (GAF)
The GAF is a numeric scale from 1-100 used by providers to subjectively rate the social,
occupational and psychological functioning of adults.
GAF scale
91-100
81-90
71-80
61-70
51-60
41-50
31-40
Superior functioning in a wide range of activities, life's problems never seem to
get out of hand, is sought out by others because of his or her many qualities.
No symptoms.
Absent or minimal symptoms, good functioning in all areas, interested and
involved in a wide range of activities, socially effective, generally satisfied with
life, no more than everyday problems or concerns.
If symptoms are present they are transient and expectable reactions to
psychosocial stresses; no more than slight impairment in social, occupational,
or school functioning.
Some mild symptoms OR some difficulty in social, occupational, or school
functioning, but generally functioning pretty well, has some meaningful
interpersonal relationships.
Moderate symptoms OR any moderate difficulty in social, occupational, or
school functioning.
Serious symptoms OR any serious impairment in social, occupational, or
school functioning.
Some impairment in reality testing or communication OR major impairment in
several areas, such as work or school, family relations, judgment, thinking, or
2
21-30
11-20
1-10
mood.
Behavior is considerably influenced by delusions or hallucinations OR serious
impairment in communications or judgment OR inability to function in all areas.
Some danger of hurting self or others OR occasionally fails to maintain minimal
personal hygiene OR gross impairment in communication.
Persistent danger of severely hurting self or others OR persistent inability to
maintain minimum personal hygiene OR serious suicidal act with clear
expectation of death.
SAMPLE NOTE
Psychiatric Inpatient Progress Note
Subjective: Direct quote from the patient and include complaints, sxs, meds side effects, life
events, and feelings
Objective:
Include observations from nursing staff, mental status exam, labs, current
meds
Assessment: Organized by problem w/ separate assessment for each; document
dangerousness to self or others; give reasons to support further hospitalization
including suicidality, homicidality, informed consent issues, monitoring meds
Plan:
Changes to current tx, future considerations, issues that require continued
monitoring
Diagnostic Pearls

Renenber that duration is a significant criterion (>2 weeks, < 6 mos, etc)

Remember that diagnosis of Axis I and II disorders may be deferred in settings
of substance abuse

Remember that decline in functioning is an important component of DSM-IV
disorders
PSYCHOTIC DISORDERS
Schizophrenia
•
Disorder characterized by apathy, avolition, affective blunting, hallucinations,
delusions, and misinterpretations of reality; characterized by alterations in thoughts,
perceptions, mood, and behavior
•
1% lifetime prevalence, onset usually teens to twenties (females have later onset)
•
Suicide rate 10-13%
DSM-IV Diagnostic Criteria
1.
2 or more of the following for at least one month: delusions, hallucinations,
disorganized speech, disorganized or catatonic behavior, negative symptoms
2.
Decline in social or occupational functioning
3.
Continuous signs of illness for at least 6 months with active symptoms for at
least one month
4.
Schizoaffective disorder and mood disorder with psychotic features are
excluded
5.
Symptoms are not due to general medical condition or substance abuse
6.
If there is h/o autistic disorder or developmental disorder, schizophrenia can
only be diagnosed with prominent delusions or hallucinations for at least one
month
Positive Symptoms: Characteristics not usually found in healthy people, but present here
3
1.
2.
3.
4.
Hallucinations, usually auditory or visual.
Delusions
Disorganized behavior
Thought disorder: loose associations, tangentiality, incoherent thoughts, ideas
of reference, etc.
Negative Symptoms: Characteristics usually found in healthy people, but absent here
1.
Poverty of speech (alogia) or poverty of thought content
2.
Anhedonia
3.
Flat affect
4.
Avolition
5.
Attention deficits
6.
Lack of social interest
Classification of Schizophrenia: significant because of its prognostic value
1.
Paranoid type: (best prognosis) characterized by preoccupation with delusions
or auditory hallucinations and do not have disorganized speech, behavior, or
inappropriate affect
2.
Disorganized type: (worst prognosis)prominent disorganized speech, behavior
and inappropriate affect
3.
Catatonic type: characterized by 2 or more of the following: immobility,
excessive motor activity, negativism or mutism, peculiar voluntary movements,
echolalia or echopraxia
4.
Undifferentiated type (moderate prognosis): not characterized by the other
types
5.
Residual type: continued negative sxs or 2+ attenuated positive sxs
Treatment of Schizophrenia
1.
Antipsychotic medications
2.
Psychosocial treatments
3.
Family therapy and individual supportive psychotherapy
4.
ECT - useful for catatonia or when prominent affective sxs are present
Schizoaffective Disorder
•
Illness meets criteria for schizophrenia and for a major depressive episode, manic
episode, or mixed episode
•
Must have delusions or hallucinations for 2 weeks without significant mood
symptoms
•
Mood symptoms must be present for a significant portion of the illness
•
Illness is not caused by substance use or medical condition
•
Lifetime prevalence < 1%
Classification of Schizoaffective disorder
1.
Bipolar type: dx when a manic or mixed episode occurs; major depression may
also occur
2.
Depressive type: dx if only depressive (no manic) episodes occur
Treatment of Schizoaffective Disorder
1.
Treat psychotic sxs w/ antipsychotic medications
2.
Treat depressive type w/ anti-depressant medications
3.
Treat bipolar type w/ mood stabilizers alone or in combination w/ antipsychotics
4.
ECT may be necessary for severe mood sx
Schizophreniform Disorder
4
Meets full criteria for schizophrenia, but duration of illness is between 1-6 months. Diagnosis
is deferred because is 30-50% of cases may resolve or differentiate into a different diagnostic
category.
Brief Psychotic Disorder (with or w/o marked stressors)
Hallucinations, delusions, disorganized behavior or speech for 1 day to 1 month.
Delusional Disorder
Non-bizarre delusions for at least 1 month; behavior/functioning not significantly impaired
MOOD DISORDERS
Major Depressive Episode
DSM-IV Diagnostic Criteria
1.
At least 5 of the following symptoms must be present for at least 2 weeks, and
anhedonia or depressed mood is required: anhedonia, depressed mood, weight
change, sleep
2.
Sleep disturbance, psychomotor retardation or agitation, fatigue or loss of
energy, feelings or guilt or worthlessness, difficulty concentrating, suicidal
ideation or thoughts of death
3.
Must be a change from prior functioning.
4.
Must cause social or occupational dysfunction
5.
Not caused by bereavement, medications, drugs, or medical condition
MDE symptom mnemonic: SIG E CAPS: Sleep, Interest, Guilt, Energy, Concentration,
Appetite, Psychomotor activity, Suicidal ideation.
Major Depressive Disorder
•
Suicide rate is 15%, 2:1 female to male ratio
DSM-IV Diagnostic Criteria
1.
History of one or more major depressive episodes
2.
No history of manic, hypomanic, or mixed episodes
Classification of MDD
1.
MDD w/ psychotic features: depression accompanied by hallucinations or
delusions, which may be mood congruent or incongruent
2.
MDD, chronic: full diagnostic criteria for MDD have been met for at least 2 yrs
3.
MDD w/ catatonic features: accompanied by at least two of the following –
immobility, excessive motor activity, negativism or mutism, peculiar voluntary
movements, echolalia or echopraxia
4.
MDD w/ melancholic features: depression w/ severe anhedonia and at least 3 of
the following—quality of mood distinctly depressed, mood worse in the AM,
early morning awakening, marked psychomotor slowing, significant weight loss,
excessive guilt
5.
MDD w/ atypical features: depression accompanied by mood reactivity and at
least 2 of the following—significant weight gain, hypersomnia, “heavy” feeling in
extremities, rejection sensitivity
6.
MDD w/ postpartum onset: onset within 4 weeks of parturition
7.
MDD w/ seasonal pattern: recurrent episodes of depression w/ pattern of onset
at the same time each year; full remissions occur at characteristic times of year;
over 2-yr period, at least 2 seasonal episodes w/ no nonseasonal episodes
5
Treatment of MDD
Anti-depressants, ECT, psychotherapy (CBT and insight-oriented psychotherapy)
Dysthymic Disorder: a more chronic, often less severe depressive disorder
•
6% lifetime prevalence w/ 3:1 female-to-male; onset usually in childhood/adolescence
DSM-IV Diagnostic Criteria
1.
Depressed mood for most of day, for more days that not, for at least 2 years
2.
Presence of at least 2 or more of the following—poor appetite/overeating,
insomnia/hypersomnia, low energy, low self-esteem, poor concentration,
hopelessness
3.
Never been w/o sxs for more than 2 months consecutively
st
4.
No MDE during 1 2 years
Treatment of Dysthmic Disorder
Anti-depressants, psychotherapy
Manic Episode
DSM-IV Diagnostic Criteria
1.
At least 1 week of abnormal, elevated, expansive, irritable mood (can be less
than one week if hospitalized)
a.
Must have 3 of the following during the period of mood change:
inflated self-esteem or grandiosity, decreased need for sleep,
pressured speech, flight of ideas, distractibility, increased goaldirected activity or psychomotor agitation, involvement
2.
Involvement in pleasurable activities (sex, spending money, gambling) with
potential for adverse consequences
3.
Does not meet criteria for mixed episode and not caused by medications,
medical conditions or substance use
Manix Sx mnemonic: DIG FAST: Distractibility, Insomnia, Grandiosity, Flight of Ideas,
Activity/Agitation, Speech, Thoughtlessness
Hypomanic Episode
DSM-IV Diagnostic Criteria
1.
At least 4 days of elevated, expansive or irritable mood
2.
At least 3 symptoms listed above for Manic episodes
3.
Noticeable to others, but does not require hospitalization, no psychotic features,
no marked social or occupational dysfunction
Lack of social and occupational dysfunction distinguishes hypomania from mania.
Mixed Mood Episode
DSM-IV Diagnostic Criteria
Meets criteria for both manic and depressive episode for at least 1 week
Bipolar I Disorder
•
0.5-1.5% lifetime prevalence; male-to-female ratio 1:1; suicide rate 10-15%
strong genetic component: 5-10% lifetime risk in first-degree relative
DSM-IV Diagnostic Criteria
1.
One or more manic or mixed episodes
2.
Commonly accompanied by one or more depressive episodes, but this is not
needed for the diagnosis
6
Classification of Bipolar I Disorder
1.
Describe current or most recent episode as either manic, hypomanic, mixed, or
depressive
2.
Most recent episode can be further classified—w/o psychotic features, w/
psychotic features, w/ catatonic features, w/ postpartum onset
3.
Rapid cycling: presence of at least 4 mood episodes within 1 year; must be sxfree for at least 2 months between episodes or must switch to an opposite
episode
Treatment of Bipolar I Disorder
Mood stabilizing medications, ECT, anti-depressants (use cautiously to avoid
precipitating manic episode), psychotherapy, antipsychotics if needed
Bipolar II Disorder
•
0.5% lifetime prevalence; more common in females than males; suicide rate 10-15%
DSM-IV Diagnostic Criteria
One or more depressive episodes and at least one hypomanic episode
Classification of Bipolar II Disorder
See bipolar I disorder
Treatment of Bipolar II Disorder
See bipolar I disorder
Cyclothymic Disorder
•
Chronic cyclical episodes of mild depression and hypomania
•
1% prevalence; onset between 15-25; 3:2 female-to-male ratio
DSM-IV Diagnostic Criteria
1.
Many periods of depression and hypomania, occurring for at least 2 years
2.
Depressive episodes do not reach severity of MDE
3.
Cannot be sx free for more than 2 months
Treatment of Cyclothymic Disorder
Mood stabilizing medications (Lithium); use anti-depressants cautiously to
avoid precipitating manic episode
7
ANXIETY DISORDERS
Generalized Anxiety Disorder
•
Most common anxiety disorder
•
5% lifetime prevalence; 2:1 female-to-male; onset during childhood or adolescence
•
30-50% also meet criteria for MDD
DSM-IV Diagnostic Criteria
1.
Excessive anxiety or worry present most days for at least 6 months revolving
around several life events
2.
Anxiety is difficult to control
3.
At least 3 of the following: restlessness, fatigability, difficulty concentrating,
irritability, muscle tension, sleep disturbance
4.
Anxiety does not revolve around fear of having a panic attack
5.
Causes significant distress or impairment in functioning
6.
Not caused by substance use, medical condition, or medication
Treatment of GAD
1.
First-line treatments include SSRI or venlafaxine. Buspirone and other antidepressants are also used
2.
Can use benzodiazepines as bridge therapy until anti-depressants start to work,
taper after several weeks, and avoid long-term BZD use due to potential for
dependence and tolerance
3.
Encourage patients to have healthy sleep habits and limit caffeine intake
4.
Psychotherapy (CBT w/ relaxation techniques, supportive or insight-oriented)
can also be helpful
Panic disorder
•
1.5-3.5% lifetime prevalence; 3:1 female-to-male ratio; onset in mid-20s
DSM-IV Diagnostic Criteria
Both 1 and 2 are required for the diagnosis
1.
a. Recurrent unexpected panic attacks, reaches peak in 10 minutes and
characterized by intense fear. 4 of the following should be present during
attack: palpitations, sweating, shaking, shortness of breath, feeling of choking,
chest pain, nausea, dizziness/light-headededness, derealization or
depersonalization, fear of losing control or going crazy, fear
a. Fear of dying, paresthesias, chills
b. Paresthesias
2.
Chills or hot flashes
3.
At least 1 month of fear of having additional attacks, worry about cause or
implication of attacks, or significant change in behavior due to panic attacks.
4.
Panic disorder can occur with or without agoraphobia. Agoraphobia = anxiety
and avoidance of places or situations where escape would be difficult or
embarrassing or help is not available.
Treatment of Panic Disorder
Cognitive behavioral therapy, medications including SSRIs or tricyclics. Benzodiazepines can
be used for short-term therapy.
8
Obsessive-Compulsive Disorder
•
2.5% lifetime prevalence; 1:1 female-to-male ratio; onset earlier in males
DSM-IV Diagnostic Criteria
1.
Either obsessions or compulsions are present
a.
Obsessions = recurrent, persistent thoughts, impulses, or images
experienced as intrusive and causing marked anxiety
b.
Compulsions = repetitive behaviors or acts that the person feels
driven to perform in response to obsessions
2.
Person recognizes that obsessions or compulsions are excessive or
unreasonable (children may not be able to recognize this)
3.
Obsessions or compulsions cause distress, occupy more than one hour per
day, and interfere with normal functioning
Treatment of OCD
Usually treated with medications: clomipramine, sertraline, paroxetine, fluoxetine,
citalopram, escitalopram, fluvoxamine. Behavior therapy can also be used.
Post-Traumatic Stress Disorder
•
8% lifetime prevalence (60% prevalence in combat soldiers and assault victims)
DSM-IV Diagnostic Criteria
1.
Occurs after traumatic event associated with intense fear or horror
2.
Persistent reexperiencing of event: nightmares, flashbacks.
3.
May have feelings of detachment, anhedonia, restricted affect, or avoidance of
thoughts/activities that may bring reminders of trauma (3 required)
4.
Patient has a general state of increased arousal after the traumatic event, which
may include poor concentration, hypervigilance, exaggerated startle response,
insomnia, or irritability (2 required)
5.
Symptoms have persisted for at least 1 month
6.
Symptoms cause significant distress or social or occupational dysfunction
Treatment of PTSD
Anti-depressants (SSRIs), Prazosin (pioneered at Seattle VA), psychotherapy,
behavior therapy, support groups, family therapy
COGNITIVE DISORDERS
Delirium
DSM-IV Diagnostic Criteria
1.
Disturbance of consciousness with reduced ability to focus, sustain, or shift
attention
2.
The change in cognition or perceptual disturbance isn’t due to dementia
3.
The disturbance develops over a short period of time (hrs to days) and
fluctuates during the course of the day
4.
There is clinical evidence that the disturbance is caused by a general medical
condition and/or substance use or withdrawal
Treatment of Delirium
1.
Treat the underlying condition
2.
Treat agitation w/ haldol, quetiapine, lorazepam, and a quiet environment w/
close observation
3.
Physical restraints may be needed to prevent injury to self or others
9
Dementia
•
Prevalence increases w/ age; Alzheimer’s is the most common (50-60%) followed by
vascular dementia (13%)
DSM-IV Diagnostic Criteria
1.
The development of multiple cognitive deficits manifested by:
•
Memory impairment
•
One or more of the following: aphasia (language disturbance),
apraxia (impaired ability to carry out purposeful movement),
agnosia (failure to recognize or identify objects), disturbance in
executive functioning (abstract thinking, planning and carrying out
tasks)
2.
The cognitive deficits cause significant social and occupational impairment and
represent a significant decline from a previous level of functioning
3.
The deficits are not the result of delirium
Classification of Dementia
Alzheimer’s
Vascular dementia
Dementia due to other general medical condition
AIDS-related dementia
Dementia caused by head trauma
Dementia caused by Parkinson’s disease
Dementia caused by Huntington’s disease
Dementia caused by Pick’s disease
Dementia caused by Creutzfeldt-Jakob disease
Lewy body dementia
Substance-induced persisting dementia
Treatment of Dementia
1.
Treat any underlying medical conditions
2.
Minimize CNS depressants and anti-cholinergic medications
3.
Treatment of AD:
a.
Mild: Cholinesterase inhibitors: donepezil, galantamine,
rivastigmine,(tacrine)
b.
Moderate: add NMDA antagonist memantine: may be
neuroprotective
c.
Vitamin E and selegiline may slow dementia
4.
Treatment of vascular dementia: HTN management, aspirin to reduce thrombus
formation
Axis II: Personality Disorders
•
15% of general population; many subtypes over-represented in medical
practices
Cluster A “Weird”
Paranoid
Pervasive distrust of others (4%)
Schizoid
Social detachment, restricted affect
Schizotypal Eccentric behavior, perceptual distortions, few close relationships (3%)
•
Schizoid and schizotypal have increased risk of developing schizophrenia and
st
are more likely to have 1 -degree relatives with schizophrenia
Cluster B “Wild”
Antisocial
Disregard for rules, violation of rights of others, behavior since age 15 (4%)
Borderline Unstable relationships, unstable self-image, poor impulse control, recurrent self10
harm behavior (6%)
Histrionic
Excessive emotionality and attention seeking
Narcissistic Grandiosity, lack of empathy, need for admiration
Cluster C “Worried”
Avoidant
Social inhibition, feelings of inadequacy
Dependent Needs to be cared for, submissive
OCPD
Preoccupation with perfectionism, orderliness, control (8%)
MOOD STABILIZERS / ANTIMANIC MEDICATIONS
Dosage
Notes
Start 500-750 mg bid-tid
50-125 µg/mL therapeutic level
Up to 500-4000 mg bid
Extended release form available
Hepatotoxicity
Avoid in pregnancy
Lithium carbonate
Start 300-600 mg bid-tid,
0.8-1.2 mEq/L therapeutic level
(Lithonate, Eskalith)
usu. 600-2400 mg/day
Monitor renal, thyroid function
Avoid in breastfeeding, OK in
pregnancy
Slow release available
Carbamazepine
400-1800 mg bid or qid
8-12 µg/mL therapeutic level
(Tegretol)
Risk of aplastic anemia
Valproic acid
Start 250 mg tid, up to
50-125 µg/mL therapeutic level
(Depakene)
500-3000 mg bid
Hepatotoxicity
Avoid in pregnancy
Gabapentin (Neurontin)
300-800 mg tid
Benign SE profile, used for
neuropathic pain
Lamotrigine (Lamictal)
100-400 mg
Stevens-Johnson syndrome
(mostly kids)
Tiagabine (Gabitril)
12 mg qd
Topiramate (Topamax)
Start 25-50 mg/day, up
Causes weight loss
to 400 mg qd
Drug
Divalproex sodium
(Depakote)
11
ANTIPSYCHOTIC MEDICATIONS
Drug
Dosage
Notes
Typical Antipsychotics: may lead to tardive dyskinesia and neuroleptic malignant syndrome
Chlorpromazine (Thorazine)
600-800mg
rarely used
Fluphenazine (Prolixin)
Start 0.5-10 mg/day to 20
Rarely used, Depot form
mg/day
available
Perphenazine (Trilafon)
Start 4-8 mg tid or 8-16 mg
Rarely used
bid-qid
Max 64 mg/d
Trifluoperazine (Stelazine)
Start 2-5 mg bid up to 30-40
Few EKG changes
mg/day
rarely used
Thioridazine (Mellaril)
600-800 mg
Rarely used
Mesoridazine (Serentil)
300-400 mg
rarely used
Haloperidol (Haldol)
Start 0.5-5 mg bid-tid
Depot form available
Atypical Antipsychotics: less TD and NMS risk
Clozapine (Clozaril)
Start 12.5 mg qd-bid to 300Risk of agranulocytosis, check
600 mg/day
WBC, danger of weight gain,
Max 900mg/day
lowers seizure threshold
Aripiprazole (Abilify)
Start 10-15 mg qd
IM, orally disintegrating forms
Max 30 mg qd
available. Mild side effect profile
Loxapine (Loxitane)
Start 10 mg bid to 75-100
Low potency, high risk of
mg/d
seizures, rarely used
Max 250 mg/day
Pimozide (Orap)
2-15 mg
May lead to EKG changes,
rarely used
Molindone (Moban)
Start 50-75 mg/day divided
Mid-potency, least likely to
tid-qid up to100 mg/day
cause seizures, rarely used
Max 225 mg/d
Thiothixene (Navane)
Start 2 mg tid to 30-40 mg/d
Ocular pigmentary changes,
Max 60 mg/d
rarely used
Risperidone (Risperdal)
Start 1 mg bid to 4-8 mg/day
Most popular rx in its class.
Max 16 mg/day
Depot (Consta), orally
disintegrating (M-tabs) forms
available, commonly used in
elderly, wt gain, ↑PRL.
Olanzapine (Zyprexa)
Start 5-10 mg qd, up to 5-20
Metabolic sx (wt gain,
mg/day
↑lipidemia) Also available in
orally disintegrating (Zydis) and
IM forms
Quetiapine (Seroquel)
Start 25 mg bid to 300-400
Significant sedation, hypoTN,
mg/day
↓ risk of EPS
Max 800 mg/day
Ziprasidone (Geodon)
Start 20 mg bid, up to 160
Least danger of weight gain
12
mg/day
Drug
Alprazolam (Xanax)
Chlordiazepoxide
(Librium)
Clonazepam (Klonopin)
Clorazepate (Tranxene)
Diazepam (Valium)
Halazepam (Paxipam)
Lorazepam (Ativan)
Oxazepam (Serax)
Buspirone (Buspar)
Venlafaxine (Effexor XR)
ANXIOLYTIC MEDICATIONS
Dosage
0.25-2 mg tid-qid
15-100 mg tid-qid for anxiety
0.25-2 mg bid-tid, max 4 mg/day
7.5-30 mg bid
2-15 mg bid-tid
20-80 mg bid
0.5-2 mg tid-qid
15-30 mg tid-qid
5 mg bid-tid up to 60 mg/day
37.5-75 mg/day
Max 225 mg/day
13
Notes
6-20 hr half-life
30-100 hr half-life
18-50 hr half-life
30-100 hr half-life
30-100 hr half-life
30-100 hr half-life
10-20 hr half-life
8-12 hr half-life
Well-tolerated, no tolerance or
dependence
ANTI-DEPRESSANTS
Drug
Fluoxetine (Prozac)
Dosage
10-20mg/d take in am, usual
dose 20-40 mg/day, max 80
mg/day
Fluvoxamine (Luvox)
50 mg qhs, up to 300 mg/day
Paroxetine (Paxil)
20 mg qhs, up to 80mg/day
Citalopram (Celexa)
Escitalopram (Lexapro)
20 mg/day initially, up to 60
mg/day
10-20 mg qd
Sertraline (Zoloft)
50 mg/day, up to 200 mg/day
Duloxetine (Cymbalta)
20 mg bid, up to 60 mg bid
Nefazodone (Serzone)
50-100 mg bid, up to 150-300
mg bid, up to 600 mg/day
37.5 mg/day initially, up to 150225 mg/day
Venlafaxine (Effexor)
Buproprion (Wellbutrin)
100 mg bid initially, increase to
100 mg tid
Used for smoking cessation
Trazodone (Desyrel)
Mirtazapine (Remeron)
Desipramine (Norpramin)
Protriptyline (Vivactil)
Nortriptyline
Amitriptyline (Elavil)
Clomipramine (Anafranil)
Imipramine (Tofranil)
Used for enuresis
Doxepin (Adapin, Sinequan)
50-100 mg qhs, up to 300-600
mg/day
15 mg qhs initially, up to 45
mg/day
25-50 mg qhs initially, up to 150300 mg/day
5 mg q am initially, up to 15-40
mg qd in bid dosing
25 mg qhs initially, up to 75-150
mg/day
25-50 mg qhs, up to 150-250 mg
/day
25-50 mg qhs initially, up to 150250 mg/day
75 mg qhs, up to 150-300
mg/day
25-50 mg/day initially up to 150300 mg/day
Notes
N&V, insomnia, sexual dysfunction, HA,
anxiety, anorexia, sedation (for all
SSRIs)
Longest half-life of SSRIs
Can be sedating
Hepatic enzyme inhibitor
Sedation, dry mouth, weight gain;
hepatic enzyme inhibitor
Minimal sedation. Does not interact with
hepatic enzymes
Minimal sedation. Does not interact with
hepatic enzymes
Minimal sedation. Does not interact with
hepatic enzymes
Nausea, anorexia, dry mouth, dizziness,
sexual dysfunction
Dry mouth, HA, somnolence, blurred
vision, postural hypotension
Can cause diastolic HTN, nausea,
insomnia, dry mouth, anxiety, HA,
sexual dysfunction
Agitation, dry mouth, insomnia, tremor,
anorexia. Caution in eating d/o. No
sexual SE. Ineffective for anxiety
relative to SSRIs.
Sedating, orthostatic
hypotension, rare priapism
↑ appetite, agranulocytosis
- Tricyclics: Danger of 3 Cs: Coma,
Convulsion, Cardiotoxicity.
- Anticholinergic SE are prominent (dry
mouth, blurred vision, constipation,
urinary retention)
- All are sedating with doxepin more
than others and protriptyline less than
others
-. Unsafe in OD
- Also causes orthostatic hypotension
(Adapted from Psychiatry, 2006, and Hahn, Reist, Albers and Tarason Pocket
Pharmacopoeia, 2003)
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