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Getting the Most of Antidepressants RVU 05-03-2014 Larry O. Sanders, MD Diplomate of the American Board of Psychiatry and Neurology Goals Screening the Primary Care population for Mental Disease. First Line and Second Line Treatment of MDD. Evidence that more than Major Depression is Involved. When to Refer to Mental Health. In US, Major Depression is a Common Medical Illness Why Treat Depression? Disability Morbidity- Depression makes existing somatic conditions worse. (Inflammatory Factors) Mortality- Psychiatric patients die up to 20 years earlier than average. Most Common reason is Cardiovascular Disease! Second is Suicide. Inflammatory Factors, 1 Major Depression Increases Inflammatory Factors, Worsening the Prognosis of Somatic Illness Inflammatory Factors, 2 Somatic Illnesses Increase Inflammatory Factors, Worsening the Prognosis of Major Depression Depression and Atherosclerotic Disease. • Major Depression carries 4X Risk of developing a Myocardial Infarction! Anda 1993, Barefot, et. Al. 1996, Pratt 1996 • MIs comorbid with MDD are 5X More likely to be Fatal. Anda 1993 • 16.5% Mortality Risk @ 6 months following Acute MI if also Depression vs 3% if not Depressed. Frasure-Smith 1993 • Major Depression carries same Risk Factor for developing an MI, as Cigarette Smoking! Major Depression 5 Symptoms, 2 Weeks, >50% each day (pneumonic “Sige Caps”) Mood* Sleep Interest* Guilt or Hopelessness Energy Concentration Appetite Psychomotor Suicidal/Homocidal Ideation * Depressed Mood or Anhedonia must be present Nature vs Nurture • MDD is strongly genetic, with well over 100 genes involved. • However, the largest risk for developing MDD as an adult is losing a parent before age 12. • Many Environmental, Psychological and Sociological factors can effect it. 10 Medical Disease can appear as Major Depressive Disorder • Many Medical Diseases can appear as MDD. R/O: –Hypothyroidism –Anemia, both Microcytic and Macrocytic –Any inflammatory Disease –Hyperparathyroidism (even slightly elevated Ca++ may be important) –Various Vitamin deficiencies, including: D, B12, B6, Folate, etc. • Vitamin D deficiency seems more common since the 11 use of high SPF Sunscreens. Other (Free) Scales • PHQ 2 Screener • ( Very brief. I don’t encourage its’ use). • Zung Depression Rating Scale • QIDS-SR • Quick Inventory Depressive Symptomatology (Self Report) • CUDOS • Clinically Useful Depression Outcome Scale Treat to Remission! Sub-Syndromal Depression = Relapse One or more Symptoms 7 months until Relapse! No Symptoms Months Well Judd 1998 Symptoms and Circuits Advocated by Stephen M. Stahl, MD Circuit When a Brain Circuit, when overstimulated or under-stimulated, it will produce certain symptoms. (adapted from Steven Stahl, MD) Each Symptom, regardless of the disease, comes from the Same Circuit Malfunction! (adapted from Steven Stahl, MD) Symptoms & Circuits By Knowing Which Symptom is related to which Circuit, and by Knowing How Each Medication Effects Each Circuit You can Logically Deduce Which Medication Will Best Treat Most Mental Conditions. (adapted from Steven Stahl, MD) 3 Major Circuits Contributing to Mental Illness Circuits Serotonin Circuits Serotonin Norepinephrine Circuits Serotonin Norepinephrine Dopamine Symptoms Associated with these Circuits Symptoms associated with Serotonin • Serotonin helps us “Cope”. • If Serotonin is too Low: Irritable, Anxious, Easily Overwhelmed, Hopeless, Suicidal, “poor sense of Well-being” • If Serotonin is too High: Serotonin Syndrome; Agitation, Fasciulations, Hyperthermia, Vital Sign Disturbance, leading to stupor, come then death. [Although pharmacists warn of this, neither I nor any Psychiatric Colleagues have ever seen this Symptoms associated with Norepinephrine • Norepinephrine is like “Adrenaline”. • If Norepinephrine too Low: Anergy, Immediate Memory Impaired, Psychomotor Retardation. • If Norepinephrine too High: Irritable, Agitation, Insomnia. (Similar Symptoms to Low Serotonin). Symptoms associated with Dopamine • Dopamine provides Interests/Desire, mentally. (Dopamine has other physical functions as well). • If Dopamine too Low: Apathy, Dementia, Muscle • If Dopamine too High: Hedonism, Psychosis, Mania Symptoms & Circuits Serotonin Mood* Emotion Cognitive Function Norepinephrine Dopamine Symptoms & Circuits Serotonin Suicidal/Homicidal Frustration, “Sense of Well Being” Obsession, Sleep, Guilt or Hopelessness Mood* Emotion Cognitive Function Norepinephrine Dopamine Symptoms & Circuits Serotonin Suicidal/Homicidal Frustration, “Sense of Well Being” Obsession, Sleep, Guilt or Hopelessness Mood* Emotion Cognitive Function Energy Alertness Psychomotor Working Memory Norepinephrine Dopamine Symptoms & Circuits Serotonin Suicidal/Homicidal Frustration, “Sense of Well Being” Obsession, Sleep, Guilt or Hopelessness Mood* Emotion Cognitive Function Energy Alertness Psychomotor Working Memory Norepinephrine Desire Interest* Dopamine Symptoms & Circuits Serotonin Suicidal/Homicidal Frustration, “Sense of Well Being” Obsession, Sleep, Guilt or Hopelessness Irritability Anxiety Mood* Emotion Cognitive Function Energy Alertness Psychomotor Working Memory Norepinephrine Desire Interest* Dopamine Symptoms & Circuits Serotonin Suicidal/Homicidal Frustration, “Sense of Well Being” Obsession, Sleep, Guilt or Hopelessness Irritability Anxiety Mood* Emotion Cognitive Function Energy Alertness Concentration Psychomotor Motivation Working Memory Norepinephrine Desire Interest* Dopamine Symptoms & Circuits Serotonin Suicidal/Homicidal Frustration, “Sense of Well Being” Obsession, Sleep, Guilt or Hopelessness Appetite Mood* Aggression Emotion Sex Energy Cognitive Function Alertness Desire Concentration Psychomotor Interest* Motivation Working Memory Irritability Anxiety Norepinephrine Dopamine Slaby and Tancradi 2002, Stahl 2004 Symptoms, Circuits & Medications 5HT1a 5HT1a Classes of Antidepressants • SSRIs • SNRIs, NaSSI • SDRIs • NDRIs (mechanism of Wellbutrin not fully understood) • DRIs, DAgs • NRIs – (not very effective). • (MOAIs, not covered here, are powerful Antidepressants; but carry HTN risk with certain foods and/or meds and Serotonin Syndrome with SRIs.) Suicidality vs Suicide • An ironic fact about Antidepressant use is that Suicidality risk (thoughts, not death) increases transiently, BUT SUICIDE (DEATH) risk DECREASES in patients less than 24 y.o.! (expound) Medications Effecting Primarily Serotonin SSRIs • • • • “Multi Action” – ssri, 5HT1a, 1b, 3, & 7. • Vortioxetine (Brintellix). “Dual Action” - SSRI & 5HT1a. • Vilazadone (Viibryd). “Single Action” – SSRI. • • Escitalpram (Lexapro). Fluoxetine (Prozac). SSRI + bits of others. “Half Action” - Racemic mixture, half active. • Cilatopram (Celexa). Symptoms, Circuits & Medications-Trade Names SSRI “Multi Action”- Brintellix 5-20mg “Dual Action” - Viibryd 10-40mg “Single Action”- Lexapro 10-20mg Prozac 20mg “Half Action” - Celexa 40mg Larry O. Sanders, MD c 2002, 2014 Serotonin Suicidal/Homicidal Frustration, “Sense of Well Being” Obsession, Sleep, Guilt or Hopelessness Appetite Mood* Aggression Emotion Sex Energy Cognitive Function Alertness Desire Concentration Psychomotor Interest* Motivation Working Memory Irritability Anxiety Norepinephrine Dopamine Medications effecting Both Serotonin and Norepinephrine SNRIs • Levomilnacipram (Fetzima) 1:2 S:N • Duloxetine (Cymbalta) 9:1 S:N • Desvenlafaxine (Pristiq) 15:1 S:N • Venlafaxine(Effexor) 30:1 S:N • At low dose is SSRI. At high dose SNRI. Strong W/D issues! • {Paroxetine (Paxil) 20-40mg} • Weight gain, Fatigue, Strong W/D issues! Symptoms, Circuits & Medications-Trade Names SSRI Fetzima 40-120mg Cymbalta 60mg Pristiq 50-100mg Effexor 75-375mg (Paxil) 20mg “Multi Action”- Brintellix 5-20mg “Dual Action” - Viibryd 10-40mg “Single Action”- Lexapro 10-20mg Prozac 20mg “Half Action” - Celexa 40mg Larry O. Sanders, MD c 2002, 2014 Serotonin Suicidal/Homicidal Frustration, “Sense of Well Being” Obsession, Sleep, Guilt or Hopelessness SNRI Appetite Mood* Aggression Emotion Sex Energy Cognitive Function Alertness Desire Concentration Psychomotor Interest* Motivation Working Memory Irritability Anxiety Norepinephrine Dopamine NaSSA Indirectly elevates Norepinephrine (Noradrenaline) and Serotonin • Mirtazapine (Remeron) • Sedating, increases appetite and weight gain. Symptoms, Circuits & Medications-Trade Names SSRI Fetzima 40-120mg Cymbalta 60mg Pristiq 50-100mg Effexor 75-375mg (Paxil) 20mg Remeron 30-45mg (Indirect ^ S & N) “Multi Action”- Brintellix 5-20mg “Dual Action” - Viibryd 10-40mg “Single Action”- Lexapro 10-20mg Prozac 20mg “Half Action” - Celexa 40mg Larry O. Sanders, MD c 2002, 2014 Serotonin Suicidal/Homicidal Frustration, “Sense of Well Being” Obsession, Sleep, Guilt or Hopelessness SNRI Appetite Mood* Aggression Emotion Sex Energy Cognitive Function Alertness Desire Concentration Psychomotor Interest* Motivation Working Memory Norepinephrine Irritability Anxiety Dopamine Medications Effecting Norepinephrine and Dopamine NDRI • Bupropion (Wellbutrin) 300-450mg • IR. Not Well Tolerated. • SR. Lasts 12 hours. • XL. Lasts 24 hours. Amphetamines • Terminal Releasers and • Reuptake Inhibitors of Norepinephrine and Dopamine Symptoms, Circuits & Medications-Trade Names SSRI Fetzima 40-120mg Cymbalta 60mg Pristiq 50-100mg Effexor 75-375mg (Paxil) 20mg Remeron 30-45mg (Indirect ^ S & N) Larry O. Sanders, MD c 2002, 2014 Serotonin Suicidal/Homicidal Frustration, “Sense of Well Being” Obsession, Sleep, Guilt or Hopelessness SNRI Appetite Mood* Aggression Emotion Sex Energy Cognitive Function Alertness Desire Concentration Psychomotor Interest* Motivation Working Memory Norepinephrine NRI “Multi Action”- Brintellix 5-20mg “Dual Action” - Viibryd 10-40mg “Single Action”- Lexapro 10-20mg Prozac 20mg “Half Action” - Celexa 40mg Irritability Anxiety NDRI Wellbutrin 300-450mg Amphetamines 10-30mg b.i.d. Dopamine Medication Effecting Serotonin and Dopamine SDRIs • Sertraline (Zoloft) • Usual Dose range 50-200 mg/d • One of the best tolerated, most effective AD. Symptoms, Circuits & Medications-Trade Names SSRI Fetzima 40-120mg Cymbalta 60mg Pristiq 50-100mg Effexor 75-375mg (Paxil) 20mg Remeron 30-45mg (Indirect ^ S & N) Larry O. Sanders, MD c 2002, 2014 Serotonin Suicidal/Homicidal Frustration, “Sense of Well Being” Obsession, Sleep, Guilt or Hopelessness SNRI SDRI Appetite Mood* Aggression Emotion Sex Energy Cognitive Function Alertness Desire Concentration Psychomotor Interest* Motivation Working Memory Norepinephrine NRI “Multi Action”- Brintellix 5-20mg “Dual Action” - Viibryd 10-40mg “Single Action”- Lexapro 10-20mg Prozac 20mg “Half Action” - Celexa 40mg Zoloft 50-200mg Irritability Anxiety NDRI Wellbutrin 300-450mg Amphetamines 10-30mg b.i.d. Dopamine Medications Effecting Primarily Dopamine DRI & DAgs • Methylphenidate (Ritalin) • Dopamine Agonists: • Pramipexole (Mirapex). • Evidence based treatment. Avg dose 0.95 mg. • Ropinirole (Requip). Symptoms, Circuits & Medications-Trade Names SSRI Fetzima 40-120mg Cymbalta 60mg Pristiq 50-100mg Effexor 75-375mg (Paxil) 20mg Remeron 30-45mg (Indirect ^ S & N) Larry O. Sanders, MD c 2002, 2014 Serotonin Suicidal/Homicidal Frustration, “Sense of Well Being” Obsession, Sleep, Guilt or Hopelessness SNRI SDRI Appetite Mood* Aggression Emotion Sex Energy Cognitive Function Alertness Desire Concentration Psychomotor Interest* Motivation Working Memory Norepinephrine NRI “Multi Action”- Brintellix 5-20mg “Dual Action” - Viibryd 10-40mg “Single Action”- Lexapro 10-20mg Prozac 20mg “Half Action” - Celexa 40mg Zoloft 50-200mg Irritability Anxiety NDRI Wellbutrin 300-450mg Amphetamines 10-30mg b.i.d. Dopamine Ritalin 10-40mg bid DRI Mirapex 0.25-1.5 mg DAg HS Medications Effecting Primarily Norepinephrine NRIs • Desiparamine • Atomoxetine (Strattera) • (Atomoxetine is a failed antidepressant approved for use in AD/HD. No NRI, other than the TCA Desipramine, has beat placebo). Symptoms, Circuits & Medications-Trade Names SSRI Fetzima 40-120mg Cymbalta 60mg Pristiq 50-100mg Effexor 75-375mg (Paxil) 20mg Larry O. Sanders, MD c 2002, 2014 Serotonin Suicidal/Homicidal Frustration, “Sense of Well Being” Obsession, Sleep, Guilt or Hopelessness SNRI Remeron 30-45mg (Indirect ^ S & N) Desipramine Strattera SDRI Appetite Mood* Aggression Emotion Sex Energy Cognitive Function Alertness Desire Concentration Psychomotor Interest* Motivation Working Memory Norepinephrine NRI “Multi Action”- Brintellix 5-20mg “Dual Action” - Viibryd 10-40mg “Single Action”- Lexapro 10-20mg Prozac 20mg “Half Action” - Celexa 40mg Zoloft 50-200mg Irritability Anxiety NDRI Wellbutrin 300-450mg Amphetamines 10-30mg b.i.d. Dopamine Ritalin 10-40mg bid DRI Mirapex 0.25-1.5 mg DAg HS Symptoms, Circuits & Medications-Trade Names SSRI Fetzima 40-120mg Cymbalta 60mg Pristiq 50-100mg Effexor 75-375mg (Paxil) 20mg Larry O. Sanders, MD c 2002, 2014 Serotonin Suicidal/Homicidal Frustration, “Sense of Well Being” Obsession, Sleep, Guilt or Hopelessness SNRI Remeron 30-45mg (Indirect ^ S & N) Desipramine Strattera SDRI Appetite Mood* Aggression Emotion Sex Energy Cognitive Function Alertness Desire Concentration Psychomotor Interest* Motivation Working Memory Norepinephrine NRI “Multi Action”- Brintellix 5-20mg “Dual Action” - Viibryd 10-40mg “Single Action”- Lexapro 10-20mg Prozac 20mg “Half Action” - Celexa 40mg Zoloft 50-200mg Irritability Anxiety NDRI Wellbutrin 300-450mg Amphetamines 10-30mg b.i.d. Dopamine Ritalin 10-40mg bid DRI Mirapex 0.25-1.5 mg DAg HS Symptoms, Circuits & Medications-Trade Names SSRI Fetzima 40-120mg Cymbalta 60mg Pristiq 50-100mg Effexor 75-375mg (Paxil) 20mg Larry O. Sanders, MD c 2002, 2014 Serotonin Suicidal/Homicidal Frustration, “Sense of Well Being” Obsession, Sleep, Guilt or Hopelessness SNRI Remeron 30-45mg (Indirect ^ S & N) Desipramine Strattera SDRI Appetite Mood* Aggression Emotion Sex Energy Cognitive Function Alertness Desire Concentration Psychomotor Interest* Motivation Working Memory Norepinephrine NRI “Multi Action”- Brintellix 5-20mg “Dual Action” - Viibryd 10-40mg “Single Action”- Lexapro 10-20mg Prozac 20mg “Half Action” - Celexa 40mg Zoloft 50-200mg Irritability Anxiety NDRI Wellbutrin 300-450mg Amphetamines 10-30mg b.i.d. Dopamine Ritalin 10-40mg bid DRI Mirapex 0.25-1.5 mg DAg HS Symptoms, Circuits & Medications-Trade Names SSRI Fetzima 40-120mg Cymbalta 60mg Pristiq 50-100mg Effexor 75-375mg (Paxil) 20mg Larry O. Sanders, MD c 2002, 2014 Serotonin Suicidal/Homicidal Frustration, “Sense of Well Being” Obsession, Sleep, Guilt or Hopelessness SNRI Remeron 30-45mg (Indirect ^ S & N) Desipramine Strattera SDRI Appetite Mood* Aggression Emotion Sex Energy Cognitive Function Alertness Desire Concentration Psychomotor Interest* Motivation Working Memory Norepinephrine NRI “Multi Action”- Brintellix 5-20mg “Dual Action” - Viibryd 10-40mg “Single Action”- Lexapro 10-20mg Prozac 20mg “Half Action” - Celexa 40mg Zoloft 50-200mg Irritability Anxiety NDRI Wellbutrin 300-450mg Amphetamines 10-30mg b.i.d. Dopamine Ritalin 10-40mg bid DRI Mirapex 0.25-1.5 mg DAg HS Symptoms, Circuits & Medications-Trade Names SSRI Fetzima 40-120mg Cymbalta 60mg Pristiq 50-100mg Effexor 75-375mg (Paxil) 20mg Larry O. Sanders, MD c 2002, 2014 Serotonin Suicidal/Homicidal Frustration, “Sense of Well Being” Obsession, Sleep, Guilt or Hopelessness SNRI Remeron 30-45mg (Indirect ^ S & N) Desipramine Strattera SDRI Appetite Mood* Aggression Emotion Sex Energy Cognitive Function Alertness Desire Concentration Psychomotor Interest* Motivation Working Memory Norepinephrine NRI “Multi Action”- Brintellix 5-20mg “Dual Action” - Viibryd 10-40mg “Single Action”- Lexapro 10-20mg Prozac 20mg “Half Action” - Celexa 40mg Zoloft 50-200mg Irritability Anxiety NDRI Wellbutrin 300-450mg Amphetamines 10-30mg b.i.d. Dopamine Ritalin 10-40mg bid DRI Mirapex 0.25-1.5 mg DAg HS Symptoms, Circuits & Medications-Trade Names SSRI Fetzima 40-120mg Cymbalta 60mg Pristiq 50-100mg Effexor 75-375mg (Paxil) 20mg Larry O. Sanders, MD c 2002, 2014 Serotonin Suicidal/Homicidal Frustration, “Sense of Well Being” Obsession, Sleep, Guilt or Hopelessness SNRI Remeron 30-45mg (Indirect ^ S & N) Desipramine Strattera SDRI Appetite Mood* Aggression Emotion Sex Energy Cognitive Function Alertness Desire Concentration Psychomotor Interest* Motivation Working Memory Norepinephrine NRI “Multi Action”- Brintellix 5-20mg “Dual Action” - Viibryd 10-40mg “Single Action”- Lexapro 10-20mg Prozac 20mg “Half Action” - Celexa 40mg Zoloft 50-200mg Irritability Anxiety NDRI Wellbutrin 300-450mg Amphetamines 10-30mg b.i.d. Dopamine Ritalin 10-40mg bid DRI Mirapex 0.25-1.5 mg DAg HS Symptoms, Circuits & Medications-Trade Names SSRI Fetzima 40-120mg Cymbalta 60mg Pristiq 50-100mg Effexor 75-375mg (Paxil) 20mg Larry O. Sanders, MD c 2002, 2014 Serotonin Suicidal/Homicidal Frustration, “Sense of Well Being” Obsession, Sleep, Guilt or Hopelessness SNRI Remeron 30-45mg (Indirect ^ S & N) Desipramine Strattera SDRI Appetite Mood* Aggression Emotion Sex Energy Cognitive Function Alertness Desire Concentration Psychomotor Interest* Motivation Working Memory Norepinephrine NRI “Multi Action”- Brintellix 5-20mg “Dual Action” - Viibryd 10-40mg “Single Action”- Lexapro 10-20mg Prozac 20mg “Half Action” - Celexa 40mg Zoloft 50-200mg Irritability Anxiety NDRI Wellbutrin 300-450mg Amphetamines 10-30mg b.i.d. Dopamine Ritalin 10-40mg bid DRI Mirapex 0.25-1.5 mg DAg HS Compliance “No Involvement, No Commitment” • Month 1 40% of Patients are off meds. • Month 2 60% of Patients are off meds. • S/E-Weight Gain, Sexual Dysfunction, Emotional Blunting, Cognitive Dysfunction. • Don’t Realize the Condition is Genetic. • Confusion with Treatment vs Cure. When 1st Line Fails in MDD • Refer to Venn Diagram to • Increase Dose, • Change Meds or • Augment. • 5HT1a - Abilify, Seroquel, Viibryd. • Lithium. Don’t Underdose! If dose 50-200, PCP often give 50mg, maybe 75 mg. “You haven’t reached maximum dose until you have reached effect or intolerable side effects.” Just When I Learned All of Life’s Answers, They Changed the Questions! The Most Common Causes of Treatment Failure • Non-Compliance. • Comorbid Anxiety. • Bipolar Depression. • Most experts believe that 20-30% of all Depressed Patients have a Bipolar Disorder • Comorid Substance Abuse • Depression with Psychosis (47% risk of manifesting BP1 or BP11 with in 10 years). When is more than MDD Involved? • Anxiety • Psychosis • Mania • Substance Abuse Anxiety • • • • • Anxiety Disorders are present in 20% PC Pts. Depression and Anxiety are HIGHLY Co-Morbid. If Depression present, 60% Chance of having Significant Anxiety Disorder AND vice versa. Untreated Anxiety consumes • • 6x more of your time & 6x more resources. Most Antidepressants Treat Anxiety Disorders, but it is Really Important to Know How to Select Proper Medication. Types of Anxiety Disorders • Generalized Anxiety Disorder (GAD) • Social Phobia (aka Social Anxiety) • Panic Disorder • Post-traumatic Stress Disorder (PTSD) - Chronic Worry. - Fear Social Judgement. - Sudden, Intense Fear with Physical Symptoms. - symptoms delayed by > 1 month after trauma. Can be years. For every 1 soldier killed in action in Afganistan, 25 will die by suicide. • Acute Stress Disorder • Obsessive-Compulsive Disorder (OCD) - within 1 month of trauma. - Germs, Order, Counting, that they have Harmed to Others. Anxiety Rating Scales • GAD 7 - Rates GAD • Zung Anxiety • CUXOS • YBOCS - for OCD Treatment of Anxiety Disorders • Antidepressants • Serotonin Agents treat all. • NE helps GAD, but may make Panic Worse. • BZs • Gabapentin Be Certain It’s NOT Bipolar Depression! Experts agree that 30-40% of ALL Depressive Disorders have a component of Bipolar Disorder Bipolar Mood States Bipolar I Bipolar II (146 pts, 12.8 yrs) (86 pts, 13.4 yrs) 1% 2% % of Weeks 6% 9% 32% 53% 50% 50% 46% 46% 46% 46% Adapted from Judd 2002 Judd 2003 MDQ Scoring False Positives and False Negatives with MDQ Treating Bipolar Disorder • Treating Bipolar Disorder is often a Complex Challenge, much more difficult than treating Depression or Anxiety. • “Every Bipolar is an “n of 1.” • Must treat Current State and • Prevent both Mania and Depression. If Psychotic Depression • Treat BOTH Psychosis and Mood. • Psychotic Depression is a High Risk for having an underlying Bipolar Disorder Non-Medical Treatments • Individual Psychotherapies • CBT, Supportive, Psychodynamic. • Exercise • Family Therapy • Group Therapy When to Refer • Anytime you are uncomfortable. • When Gravely Disabled, Imminently Suicidal or Homocidal (SEND TO ER!!!) • Mania is present • Psychosis present • Anxiety doesn’t respond rapidly (Suicide Risk) • When Substance Abuse present • Therapy Needed or Helpful. Epitaph of the Hypochondriac (or the Psych Patient)