psychiatry algorithms part 1

8/6/2019 Psychiatry Algorithms Part 1

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MEDICAL ALGORITHMS FOR PSYCHIATRIC DISORDERS

CONTENTS

Diagnosis and Treatment of Post-traumatic Stress Disorder ............................... 2

Obsessive-compulsive Disorder (OCD).............................................................. 3

Pharmacotherapy of Panic Disorder ................................................................. 4

Anxiety Disorder ............................................................................................... 5

Unipolar Depression Management ..................................................................... 6

Tardative Dyskinesia Management..................................................................... 7

ADHD Comorbid With Depressive Disorder ...................................................... 8

Acute Treatment of Mania ................................................................................. 9

Treatment of Chronic Major Depression ...........................................................10

CTB for Depression ......................................................................................... 11

Schizophrenia Treatment ................................................................................. 12

Co-existing Symptoms of Schizophrenia in Acute Phase .................................. 13

Depression and Libido .....................................................................................14

Dopaminergic Pathways in Parkinsons Disease ..............................................15

Dementia Management ....................................................................................16

Bipolar Disorder Management ..........................................................................17

Evaluation of Tremor ........................................................................................ 18

Depressive Symptoms Management .................................................................19

Diagnosis and Treatment of Premenstrual Dysphoric Disorder.......................... 20


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Obsessive-compulsive Disorder (OCD)

Source: Prim Care Companion J Clin Psychiatry 2004;6(5):1

Repetitive behaviors Dermatitis Depression Anxiety

Screen for OCD

Diagnose OCD by DSM-IV-TR

Serotonergic antidepressant Referral for behavioral therapy

Titrate to recommended dose,

minimum 10-weeks trial

Inadequate response

Change to another

serotonergic antidepressant with adequate

dose trial

Inadequate response

Referral to psychiatrist


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Pharmacotherapy of Panic Disorder

Source: Am Fam Physician 2002;66(8):1477

Panic disorder

Short-term benzodiazepinesonly if needed

If ineffective

SSRI If ineffective

Cognitive behavior therapy

Augmentation with TCA,benozodiazepine, buspirone,

-blocker, bupropion, orvalproate sodium

or

Benzodiazepine or MAOI

Cognitive behavior therapy

or

Different SSRI

or

TCA, nefazodone orvenlafaxine


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Anxiety Disorder

Source: Journal of the American Academy of Child and Adolescent Psychiatry 2006;45(6):642

Any stage(s) can be skippeddepending on the clinical picture.

Diagnostic assessment andfamily consultation regarding

treatment alternatives

Stage 0

Stage 1

Stage 2

ADHD and anxiety

both improved

Methylphenidate

or amphetamineAtomoxetine

Nonmedication

treatment alternatives

Continuation

Methylphenidate

or amphetamine Atomoxetine Add an SSRI

Maintenance

No response of

ADHD or anxiety

ADHD and anxiety

both improved

ADHD symptoms

improve but not

anxietyNo response of

ADHD or anxiety

ADHD = Attention deficit hyperactivity disorde

SSRI = Selective serotonin reuptake inhibito


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Unipolar Depression Management

MAOI : Monoamine oxidase inhibitor

SNRI : Serotonin norepinephrine reuptake inhibito

SSRI : Selective serolonin reuptake inhibitor

TCA : Tricyclic antidepressant

Source: Current Psychiatry 2003 supplement p.No

No response

Maintain the patient on a

combination of mirtazapine

and nefazodone

A trial of a TCA orMAOI

Augment with

lithium,

triiodothyronine

and/or an

atypical

antipsychotic

Considerelectroconvulsivetherapy

Augment preferably with lithium, an

atypical antipsychotic, (i.e., risperidone

or olanzapine) modafinil, or

triiodothyronine; other options include

bupropion or mirtazapine (limited

controlled data to date)

No response Response

No response

No response

Trial of an SSRI or SNRI


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Tardative Dyskinesia Management

Source: Can J Psychiatry2005;50:703-6

Tardative Dyskinesia

Switch gradually to an

atypical antipsychotic other

than clozapine and

discontinue anticholinergic

Switch to a second atypical

antipsychotic other thanclozapine

TD worse or the same:

switch to clozapine

Consider suppressive therapy with a classicalagent in combination with an atypical agent

(1st choice) or alone (2nd choice) or with

tetrabenazine (3rd choice)

TD improved:

maintain

atypical

antipsychotic

TD improved:

maintainatypical

antipsychotic

Choice A:

add

donepezil

Choice B:

addmelatonin

Choice C:

addvitamin Bor E

Choice D:

add

branched chain

amino acids

TD Persists

TD Persists

TD Persists


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ADHD Comorbid With Depressive Disorder

Source: Journal of the American Academy of Child and Adolescent Psychiatry 2006;45(6):642-6

Non-Medication

Treatment Alternatives

Stage 1

Stage 2

Stage 0

Any stage (S) can be skipped

depending on the clinical picture

Begin Major Depressive Disorder

(MDD) therapy - Stage 1

Begin ADHD therapy

add to

MDD treatment

Discontinue ADHD

therapy begin

MDD therapy

Begin MDD

therapy, add to

ADHD treatment

ADHD improved,

no response of

depression

ADHD and/or

depressivesymptoms worsened

Continuation

Begin ADHD therapy - Stage 1

ADHD more severe MDD more severe

Both MDD and ADHD improve

Depressive

symptoms improve,no response of

ADHD

ADHD = Attention Deficit Hyperactivity Disorder

Diagnostic Assessment and

Family Consultation Regarding

Treatment Alternatives


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Acute Mania

Emphoric Mixed/Dysphoric Phychotic Rapid Cycling,currently manic

Li or Dvp Dvp Dvp or Li

+

AAp or CAp

Dvp

add AAp

Dvp + Li

change AAp

Dvp + Li + Cbz

Change Ap

or add Bzd

Dvp + Li

Change Ap

or combineAAp + CAp

offer ECT

Dvp + Li + Cbz

or add Clz*

Gbp or Tpr

add Bzd

Add AAp

Dvp + Li + Cbz

Clz

Lmg

Add Li or Cbz

*

*

Gbp

offer ECT

*

*

Tpr or T4 orcalcium channel

blocker

*

*

Mild/moderateresidual symptoms

Severeresidual symptoms

Gbp or Tpr

*

offer ECT

Clz or Gbpor Tpr

*

Legend Dvp divalproex

AAp atypical antipsyhotic ECT electroconvulsive therapy

Ad antidepressant Gbp gabapentin

Ap antipsychotic Lmg lamotrigine

Bzd benzodiazepine Li lithiumCAp conventional antipsychotic T3 triiodothyronine

Cbz carbarnazepine T4 L- thyroxine

Clz clozapine Tpr topiramate

* When adding second-line medications, discontinue 1 or more of the previous medications. Avoid combining carbarnazep

and clozapine.

Source: Postgrad Med Special Report 2000:1-1

Acute Treatment of Mania


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Patient meets DSM-IV criteria for unipolar major

depression but does not have mania or psychosis

Initiate management of bipolar

of other disorder or refer

patient for comanagement

Discuss options and agree on treatment plan

(pharmacotherapy, psychotherapy, or both)

Pharmacotherapy selected

Suggest CBT or other psychotherapy Depression is in clinical remission

Consider CBT, longer treatment, increase in

dosing or change in medication

Offer CBT to reduce relapse or

improve response

Depression is mild to moderate

Depression is severe

Yes

Yes

Yes

Yes

No

No

No

Recommend pharmacotherapy

and psychotherapy (e.g.,CBT);

consider referral

CBT for Depression

Source: Am Fam Physician2006;73:83-86,

CBT: cognitive behavior therapy

DSM-IV criteria: Diagnostic and statistical manual

of mental disorder, 4th edition.


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Olanzapine

or

Quetiapine

or

Risperidone

Use

Another

Use the

Third

Typical

Antipsychotic

Use

Another

Use the

Third

Typical

Antipsychotic

Use the

Third

Haloperidol Decanoate

or

Fluphenazine

Decanoate

Noncompliance Noncompliance

NonresponseNonresponseto two

Nonresponsto two

Stage 4

Stage 5a

Stage 3

Stage 5

Clozapine + Augmenting Agent

(typical or atypical antipsychotic,

mood stabilizer, ECT, antidepressant)

Atypical+ Typical

Combination of Atypicals,

Typical or Atypical + ECTStage 6

Clozapine

Stage 1

Stage 2

Nonresponseorclozapinerefusal

Nonresponse

Partial response

Nonresponse

Nonresponseto three

Nonresponse Nonresponsto three

Olanzapine

or

Quetiapine

or

Risperidone

Acute Exacerbation

First presentation or not

nonresponder to

olanzapine, quetiapine or

risperidone

(Any stage [s] can be skipped

depending on the clinical picture)

Use inany

order

Usein a

ord

History of Typical

Antipsychotic Failure

No History of Typical

Antipsychotic Failure

Nonresponseto one

Source: Am J health syst Pham20

Schizophrenia Treatment

Nonresponsto one

Nonresponse to one

Nonresponse to two

} }


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Source:Tima Physician Procedural Manual 2000;9(sect. 2

Co-existing Symptoms of Schizophrenia in Acute Phase

Agitation/Excitement

Add PO/IM

BenzodiazepinePRN

orPO/IM

Antipsychoticdrug PRN

Add PO/IMBenzodiazepine

PRN(See Note)

orPO/IM

Antipsychotic

drug PRN

Insomnia

AddBenzodiazepine

PRNor Zolpidem PRN

Trazodone

Depression

Add:

SSRI

VenlafaxineBupropionMirtazapine

Go to next stage ofAntipsychotic

TreatmentAlgorithm

No

response

No response:

(diagnosis ok,medical ok,

substance abuse ok)

Aggression/Hostility

Add Typical

Antipsychotic

drugs first

Add Valproateand/or

increase dose ofcurrent drug

Noresponse

Use other drug

indicated

No

response


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Source: Am Fam Physician2000;62:782

Treat depression with SSRI.

Discuss libido/sexual functioning with

patient in context of depression,

evaluation and treatment.

Consider causative factors other than

SSRI (relationship issues, etc.).

Has libido/sexual functioning improved/been

maintened with treatment of depression

Improved/normal No Improvement Decreased: probable

medication effect

Continue

treatment

with SSRI

Consider

Evaluate for comorbid

illness (e.g., diabetes,

endocrinopthy)

Substance abuse

(alcohol, drugs)

Relationship issue

(marital discord)

SSRI effect Consider:

Decreased dosage SSR

holidays Add bupropion

SR,wellbutrin 150 mg in

the morning

Discontinue SSRI and

change to:

Bupropion SR, 150 mg

twice daily

or

Nefazodone, 200 to 600

mg daily

Consider:

Testosterone level

Hormone replacement

Other, as indicated by

assessment

Substance abuse

treatment

Marital/family

counseling.

as needed

Depression and Libido


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Dopaminergic Pathways in Parkinsons Disease

Source: J Neuropsychiatry Clin Neurosci 2006;18:149

Ventral (non-motor)dopaminergic striatal

pathway degeneration

Dopaminergicneuron degeneration

Dorsal (motor)dopaminergic striatal

pathway degeneration

Visual hallucinations

Psychotic SymptomsMotor symptoms

Other factors?

Long-termdopaminergictreatment


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Clinical suspicion of dementia

History and physical examination

Mini-Mental State Examination (MMSE)

< 24 > 24

Assess for depression; consider using Geriatric

Depression Scale or psychiatry consult.

Positive Negative

Treat for

depression;reassess in

three to sixmonths.

MMSE < 24 Work-up for reversible causes of dementia:

laboratory testing (thyroid-stimulating hormone, B12

);consider neurologic imaging

Consider neuropsychologictesting or subspecialist evaluation

(i.e., neurology, psychiatry,geriatric medicine).

Reevaluateevery sixmonths

Abnomal

Treat reversible cause

Reevaluate cognition

No change Improved

Alzheimersdisease likely

Recheck everythree months

Recheck every

three months

Alzheimersdisease likely

MMSE andcongnition

normal

Normal

Positive

Negative

Dementia Management

Source: Am Fam Physician2005;71:1745


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Bipolar Disorder Management

Source: J Clin Psychiatry 2005;60:870

Li = lithiumCBZ = carbamazepine

LTG = lamotrigine

OXC = oxcarbazepine

TPM = topiramate

VPA = valproate

AAP = atypical antipsychotic

ARP = aripiprazole

CLOZ = olanzapine

RIS = risperidone

QTP = quetiapine

ZIP = ziprasidone

TAP = typical antipsychotic

ECT = electronconvulsive

therapy

*Use targeted adjunctive treatment as necessary before moving of next stage:

Agitation/Aggression - clonidine, sedatives

Insomia - hypnotics

Anxiety - benizodazepines gabapentin

VPA, ARP, RIS, ZIP

Euphoric Mixed

Nonresponse:

Try alternate

monotherapyResponseResponse

Nonresponse:

Try alternate

monotherapy

Monotherapy*

ResponseResponse

PartialPartial

Response

Partial Response or

Nonresponse

Response

Partial Response or

Nonresponse

Two-Drug Combination*

Two-Drug Combination*

CONT= Continuatioan

Stage 2

Stage 1 Li, VPA, ARP, QTP, RIS, ZIP

1b. OLZ or

CBZ

1b. OLZ or

CBZ

CONT

Li, VPA, AAP Choose

2 ( not 2AAPs,

not ARP or CLOZ)

Li, VPA, AAPs, CBZ,OXC,TAP Choose

2 ( not 2 AAPs, not ARP or CLOZ)

CONT

CONT

Stage 4

Stage 3

ECTor

Add CLOZ

or

Li + VPA or + AAP

CBZ or

OXC


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Kinetic

Taskspecific

(handwriting,occupational)?

Postural

Patientta

kingmedications

thatma

ycause

trernor

Resting

Patienttakingmedication

s

thatmaycause

tremor?

Possibledurg

Induced

parkinsonism

Other

signsof

Parkinsons

disease(rigidty

bra

dykinesia

Postural

instability)?

Possibledurg

Induced

tremor

Historyof

alcohol

abuse?

Taskspecific

kinetic

trernor

Yes

No

Yes

No

Yes

Trialoffdrug

Yes

No

Classic

Parkinsons

disease

Trialof

dopaminergic

agent

Possibleearly

Parkinsons

disease

Monitor

Trialoff

medication

Possiblealcohol

withdrawal

tremor

Othersignso

r

symptoms

of

systemicd

isease?

No

Yes E

nhanced

physiologic

No

Yes

Essential

tremor

Testforhyperthyrcidism

hypoglycerina,panic

attack,

benzodiazepine

withdrawal

Trialof

blocker,

primicone

[Mysoline]

History

ofchronic

alco

holism?

Alcohal

tremor

Toxic

tremor

Yes

H

istoryof

lithiumt

oxicity?

Inte

ntion

trernor

No

MRVCTof

headtorule

outstroke,

tumor,

Multiple

sclerosis

No

No

Yes

Eva

luationofTremor


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Dysthymia

Majordepression

Moderateseverityandabove

Consider

A

lternativesto

antidep

ressantsformild-

to-m

oderate

severity

Conside

r

Milderdepression

Educate,supportproblem

solving

and

monitor

Ifnoresponse,andwith

historyorpersistent

Antidepressan

tatproveneffectivedose

Partialresponse

after

fourweeks

Nonresponse

to

antidepressa

nt

afterfourweeks

Continuetreatmentfortw

omoreweeks

(uptofivemoreweeksintheelderly)

Noresponseafterfourwe

eks

adequatetreatmentorinsufficie

ntpartial

responseaftersixweeksadequate

treatment

Increasedos

eorswitchtoanother

classo

fantidepressant

Failure

to

respon

d

to

second

antidepressant

Refertosecondar

ycare(wherean

augmentingagentor

psychotherapymay

beadded,ortreatme

ntwithanMAOIor

ECTbe

given)

Check:

Action:

diagnosis

ensure

otherphysical/p

sychiatric

conditionsare

treated

compliance

addressifnecessary

dosage

increase

ifnecessary

socialfactors

addressifnecessary

Depressive

SymptomsManage

ment

DepressiveSymptoms


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Diagnosis and Treatment of Premenstrual Dysphoric Disorder

Patients with suspected PMS/PMDD

Obtain history, conduct physical and

mental status examinations

Presence of a physical or

psychiatric disorderAbsence of a physical or comorbid

psychiatric disorder

Confirm diagnoss using symptom

checklist prospectively for two

consecutive menstrual cycles and

assess severity of symptoms

Mild to moderate severity and

dysfunction (PMS)Severe symptoms anddysfunction (PMDD)

Provide education and

recommed lifestyle

changes, nutritional,

or nonnutritional

interventions

Optimal response:

Continue this approch

Consider lifestyle changes

and SSRI (preferally

during luteal phase only

Limitedresponse

Consider another SSRI during luteal

phase with lifestyle changes

Treat that disorder

Limited

response

Optimal reponse

contiune SSRI and

lifesyle changes

Limited response

Consider cogntive behavioral therapy or luteal phase specific low dosealprazolam and/or symptom focused therapy and lifestyle changes

Optimal reponse contiune intermittent use of SSRI during luteal

phase with lifesyle changes

Optimal reponse contiune alprazolam

intermittently or the other therapies

Consider GnRH agonist or

danazol for two to three cycles

Poor response

psychiatry algorithms part 1

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