Drugs used to Treat Antipsychotic-Induced Weight-Gain (Mnemonic)

The following mnemonic is for the drugs used to treat antipsychotic-induced weight gain. The list is not based on priority; however, metformin is the preferred choice, especially when there is comorbid polycystic ovary disease. Orlistat, with calorie restriction, is also an effective choice.

FORMAT-B

• Fluoxetine 
• Orlistat
• Reboxetine
• Metformin, methylcellulose, melatonin
• Topiramate
• Bupropion 

Summary of NICE Guidance for First-Episode Schizophrenia

> A complete assessment is mandatory before starting treatment

For people with first-episode psychosis offer:

●       oral antipsychotic medication with

●       psychological interventions (family intervention and individual CBT.)

Advise people who want to try psychological interventions alone that these therapies are more effective when delivered with antipsychotic medication.

If the person still wants to try psychological interventions alone:

1. offer family intervention and CBT
2. agree a time (1 month or less) to review treatment options, including introducing antipsychotic medication 
3.  continue to monitor symptoms, distress, impairment, and level of functioning (including education, training, and employment) regularly.

It is also mandatory to assess and monitor the physical health of the patients before commencing antipsychotics and during treatment.

Especially

1. Weight, BMI
2. Blood pressure and pulse
3. Serum lipids
4. Motor system and EPSEs
5. Blood glucose testing

And other baseline investigations

 

 

Pharmacological Treatment Algorithm for Treatment-Refractory Depression

These recommendations are based on the Maudsley Prescribing Guidelines 2018, according to which, depression is treatment refractory when it does not respond to sequential trials of three different antidepressants as recommended in their algorithms. 

In the first three steps below, we have enlisted the recommended pharmacological treatment options for an episode of depression. subsequently, we list the options for treatment-refractory depression. Maudsley Prescribing Guidelines focus on the pharmacological treatment options and algorithms, never nevertheless, they acknowledge the important role of non-pharmacological interventions in its treatment and recommend considering one of the appropriate options like cognitive behaviour therapy and/or behavioural activation and other factors identified as being responsible for resistance.

Step 1:

Recommend an SSRI or mirtazapine. monitor for signs and effects for 3- to 4 weeks. 

Step 2:

if no effects are appreciated, increase the dose, if appropriate (eg for escitalopram, sertraline etc) else, switch to another antidepressant (eg if the patient is on fluoxetine, where dose escalation does not produce any beneficial effects).  

Step 3:

Consider vortioxetine, agomelatine, or mirtazapine, if not already tried.

1. Vortioxetine
2. Agomelatine
3. Mirtazapine

Fourth line 

Augment with either lithium or low-dose quetiapine/aripiprazole, OR Combine mirtazapine (with SSRI or venlafaxine), bupropion (with SSRI), olanzapine (with fluoxetine)

(or first line for refractory depression):

Mnemonic: AV BLOQ

● Aripiprazole augmentation
● Venlafaxine (in combination with mirtazapine)
● Bupropion (+SSRI)
● Lithium augmentation
● Olanzapine and fluoxetine
● Quetiapine augmentation

Next

• Augment with anyone of an antipsychotic (risperidone), T3, buspirone, lamotrigine, OR
• Give Ketamine IV or intranasal esketamine, OR
• Start ECT, OR
• Give high-dose venlafaxine (above 200mg)

Treatment Guidelines for Panic Disorder

Drug of choice

SSRIs

Sertraline is recommended first-line per NICE Stepped Care Model

Second-line

MAOIs, Mirtazapine, Imipramine, Clomipramine, Venlafaxine

Experimental

Gabapentin, Inositol, Pindolol as augmentation

Psychotherapy     

CBT, Anxiety management

Treatment Guidelines for Generalized Anxiety Disorder

Psychotherapy     

Reassurance

Self-help and psychoeducation

à Pure self-help, guided self-help, group psychoeducation

Relaxation therapy

à applied relaxation, progressive muscle relaxation, deep breathing exercises

Cognitive behavior therapy

Exercise

Pharmacotherapies

Indications of pharmacotherapy

While on psychotherapy, short-term

Psychotherapy ineffective,

Psychotherapies not available

First-line       

Selective Serotonin Reuptake Inhibitors

àThese and SNRIs may initially exacerbate symptoms; a lower starting dose is often required.  Fluoxetine and sertraline are preferred options.  Sertraline is the most tolerable and cost effective, recommended as first choice by NICE. Fluoxetine is most effective choice.

Effexor (venlafaxine) SR up to 225 mg/day

Dulan/Duron (duloxetine) up to 60 mg/day

pregabalin 150–600 mg/day

Second-line choices           

Agoviz (agomelatine) 25 mg                2 x nocte

Agoviz (agomelatine) 25 mg                4 x nocte

Busron (buspirone) 5 mg                      1 x TDS

Steer (buspirone) 10 mg                       2 x TDS

Atarax (hydroxyzine) 25 mg                 1 x BD

Atarax (hydroxyzine) 25 mg                1+ 1 + 2

Qusel (quetiapine)  

Tofranil (imipramine)

Clomixet (clomipramine)

Ramargon (mirtazapine)

Beta-blockers for somatic symptoms, Vortioxetine 2.5–10 mg

Treatment of Guidelines for Psychotic Depression

Treatment of Guidelines for Psychotic Depression

First-line       

Tricyclic with olanzapine or quetiapine

Second choice        

SSRI/SNRI

Consider

Electroconvulsive therapy           

Treatment Options for Refractory Depression

Treatment of Refractory Depression

When depression does not improve with three sequential trials of antidepressants, we call it treatment-refractory depression. the following is the list of choices for treatment-refractory depression. 

First-line Treatment Options

1. Bupropion 400 mg/d + SSRI
2. Olanzapine + fluoxetine 25/50 mg/d
3. Venlafaxine + mirtazapine 30-45 mg/d
4. Add lithium, aim up to 1.0 mmol/L concentration. 
5. Add aripiprazole 2-20 mg/d
6. Add quetiapine 150-300 mg/d 

Second-line Choices

Ketamine-IV (0.5 mg/kg IV over 40 minutes),

  à rapidly effective, by the anesthetist

High-dose venlafaxine à 200 mg/d, 

 à NICE recommended, monitor BP

Electroconvulsive therapy

à effective, stigmatized

Add risperidone 0.5-3 mg/d,

 à weak evidence, hypotension

Add Triiodothyronine 20–50 μg/d,

à reasonable evidence, monitor TFTs

Lamotrigine, 100, 200, 400 mg/d,

à best tolerated, risk of rash

SSRI+ buspirone 60 mg/d,

à research-supported, dizziness at a high dose. 

Guidelines for the Pharmacotherapy of Major Depressive Disorder

I have summarised the following recommendations from the Maudsley prescribing guidelines in Psychiatry, 13th Ed.

Psychotherapies

Supportive psychotherapy, CBT, interpersonal therapy, marital/couple therapy, dynamic psychotherapy, behavioral activation

Depressive episode

Step-1

SRI/ Mirtazapine

à A generic SRI; use mirtazapine if sleep needed

Step-2

SSRI/non-SRI

  à Most evidence is for a switch to vortioxetine

Step 3

Mirtazapine, vortioxetine, agomelatine

 à if not already trialed

WHO 2012 Guidelines for the Treatment of Alcohol Withdrawal

WHO 2012 Guidelines to treat Alcohol Withdrawal

1. Clinicians should advise supported withdrawal in patients before beginning treatment.
2. The World Health Organization recommends benzodiazepines as front-line medication for the management of alcohol withdrawal. 
3. Long-acting benzodiazepines are superior to shorter-acting ones, except in cases of impaired hepatic metabolism. 
4. Clinicians should determine the dose and duration individually. 
5. The duration of benzodiazepine treatment should be 3 to 7 days.
6. Clinicians should not use antipsychotic medications as stand-alone medications for the management of alcohol withdrawal. 
7. Advise Benzodiazepines, and not anticonvulsants, following an alcohol withdrawal seizure.
8. Clinicians should dispense psychoactive medication in small doses.  
9. Patients at risk of severe withdrawal, or who have concurrent serious physical or psychiatric disorders, or who lack adequate support, should preferably remain in an inpatient setting. 
10. As part of withdrawal management, we should give all patients oral thiamine. 
11. Patients at high risk of Wernicke's Encephalopathy (malnourished, severe withdrawal) should be given 3 days of parental thiamine. 

WHO Alcohol Withdrawal Treatment Guidelines

What interventions are safe and effective for the management of alcohol withdrawal, including treatment for alcohol withdrawal seizures and prevention and treatment for acute Wernicke's encephalopathy?

Alcohol withdrawal can be uncomfortable and occasionally life-threatening. Pharmacological management of alcohol withdrawal is an essential component of alcohol dependence. Benzodiazepines (BZDs), non-sedating anticonvulsants, and antipsychotics are commonly used in the treatment of alcohol withdrawal. 

Given that they are all potentially toxic medications, what is the evidence that the benefits of their use justify the risks? Which is more effective?

Below, I summarize the WHO 2012 Guidelines to treat Alcohol Withdrawal that explains the answers to these questions. 

NICE Stepped Care Model for Obsessive-compulsive Disorder (OCD)

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