DOCSLIB.ORG

New Antidepressants and the Treatment of Depression Barry H

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
New Antidepressants and the Treatment of Depression Barry H Technology Review New Antidepressants and the Treatment of Depression Barry H. Guze, MD, and Michael Gitlin, MD Los Angeles, California Depression is a common and significant health problem antidepressant drugs, the new agents are generally safer associated with impairment in a patient’s ability to than traditional medications used to treat depression: function. The development of new antidepressant med­ they are well tolerated and, in case of overdose, less ications represents progress in its treatment. These new harmful than tricyclic antidepressants. agents work through the selective blockade of the re­ uptake of serotonin into the presynaptic neuron, thereby increasing the availability of this neurotrans­ Key words. Serotonin antagonists; antidepressants; de­ mitter at the synaptic cleft and enhancing its effective­ pression; antidepressive agents, tricyclic. ness. While no more effective than traditional tricyclic ( / Fam Pratt 1994; 38:49-57) Depression is a common condition.1 Among the nonin- probability of relapse include the severity of the initial stitutionalized elderly, the prevalence of clinically signif­ episode, the number of prior episodes, the response to icant depression is about 15%.2 With a lifetime preva­ prior treatment, and a history of chronic depression.10 lence of 6% and associated risks such as suicide, major Other important factors include comorbid conditions, depression is an important public health concern in the such as chronic medical conditions, and the degree of United States.3 In 1979 and still in 1989, suicide was the psychosocial perturbation. Because recurrence is so com­ fourth leading cause of death for white Americans.4 mon, early and aggressive treatment of depression has The economic impact of depression in the United been recommended.12 States has been estimated at more than $16 billion, only Depression is usually treated by primary care physi­ S2.1 billion of which is spent on diagnosis and treat­ cians. Major depression has been reported to be more ment.5’6 The balance is associated with lost productivity. common than hypertension in primary care practice,13 Major depression produces impairment in functioning and the presence of a psychiatric diagnosis is found in close in magnitude to that of chronic heart disease7 and 11% to 36% of patients in general practice.14 The recog­ exceeding that of many other chronic diseases. The risk nition of major psychiatric illness is poor, however, with of disability in minor depression is IV times that of 2 estimated rates for failure to detect depression ranging asymptomatic individuals; for major depression, it is 472 from 45% to 90%.15’16 In a study of nursing home times.8 patients, only 12.5% of major depression cases were The chronic nature of depression is exemplified by recognized and even fewer treated by staff physicians. An the high rate of recurrence among patients experiencing accurate differential diagnosis of mood disorder is the key an initial episode.9-11 Approximately 50% of patients to appropriate treatment. Diagnosis of a major depres­ who recover from an initial bout with depression will sive episode is appropriate when at least five of the have at least one subsequent episode during the follow­ symptoms listed in Table 1 are present nearly every day ing 2 years.11 The factors associated with a heightened for at least 2 weeks.17 One of these symptoms must be “depressed mood” or “loss of interest or pleasure in most Submitted, revised, September 8, 1993. or all activities.” from the Department o f Psychiatry and Biobehavioral Sciences, School o f Medicine, and Not all physicians are taking advantage of new de­ the Neuropsychiatric Institute and Hospital, University of California, Los Angeles. velopments in effective treatments to decrease the mor­ Requests for reprints should be addressed to Barry H. Guze, M D, UCLA NPI, 760 Westwood Plaza, Los Angeles, CA 90024. bidity and mortality associated with depression.18 Con- © 1994 Appleton & Lange ISSN 0094-3509 The Journal of Family Practice, Vol. 38, No. 1 (Jan), 1994 49 Guze and Gitlin New Antidepressants Table 2. Dosage and Administration of Three Selective Table 1. Symptoms of Depression__________ Serotonin Reuptake Inhibitors Depressed mood most of the day Range, Loss of interest or pleasure in most or all activities Usual Daily mg Comments Significant change in weight or appetite Medication Dosage, mg Insomnia or hypersomnia Paroxetine 20 10-50 N o active metabolites Psychomotor retardation or agitation Sertraline 50 50-200 No active metabolites Fatigue or loss of energy Fluoxetine 20 5-80 Active metabolite with Feelings of worthlessness or of excessive or inappropriate guilt long half-life Diminished ability to think or concentrate, or indecisiveness Recurrent thoughts of death, recurrent suicidal ideation, or suicide attempt ____________ _ Note: Diagnosis o f a major depressive episode is appropriate when a m inim um offive symptoms, one o f which is “depressed mood ” or “loss o f interest or pleasure in most or all antidepressants, and offer the same side-effect profile and activities,’’ are present nearly every day for at least 2 weeks. efficacy as tricyclic antidepressants.26 Selective serotonin reuptake inhibitors, the new an­ scientious long-term care, coupled with attention to tidepressant agents that recently have become available in patient compliance with treatment, can substantially re­ the United States, are no more effective than traditional duce the suicide rate among patients with mood disor­ agents, but their side-effect profiles often present impor­ ders. When proper recognition and pharmacologic treat­ tant clinical advantages, such as lower incidence of side ment of depression occurs, suicide rates can be effects compared with standard tricyclic and tetracyclic lowered,19'20 as exemplified by a two-session educational antidepressant drugs25 (Table 3). The mildness of their program on treating depression that was provided to side effects makes them particularly well suited for treat­ general practitioners on the Swedish island of Gotland. ing moderately depressed outpatients or the elderly.27 This program reduced the suicide rate by 71% as com­ The SSRIs also are used to treat conditions other than pared with the general rate in Sweden,21 suggesting that depression, including bulimia nervosa,28 personality dis­ increased recognition of depression and knowledge re­ orders,29 and obsessive-compulsive disorder.30 Treat­ garding its treatment can have an impact on mortality. ment of these conditions requires higher dosages than Depressive disorders can be divided into five cate­ the dosages to treat depression. gories: major depression, dysthymia, bipolar-disorder It has been estimated that 75% to 80% of patient depression, cyclothymia, and depressive disorder not taking tricyclic antidepressants receive subtherapeutic otherwise specified.17 Major depression itself can be fur­ doses because of the intolerable side effects associated ther subtyped into groups with and without psychotic with higher dosages.31 Thus, side effects may limit the features (delusions and hallucinations). Psychosis is clinical effectiveness of traditional antidepressant medica­ present in 10% to 25% of patients with major depres­ tions. In addition to subtherapeutic dosing, side effects sion.22 The presence of psychotic features often results in associated with tricyclic antidepressants often result in a different approach to treatment.23 Electroconvulsive long titration trials, premature discontinuation of ther therapy is thought by many to be the most effective apy, or lack of patient compliance, along with overdose treatment for this form of depression. The other ap­ fatalities.32 In clinical trials, twice as many patients have proach is the combination of a tricyclic antidepressant discontinued tricyclic antidepressants as have discontin­ and a neuroleptic.23 In most cases of depression, treat­ ued fluoxetine.32 ment with antidepressant medication alone is inadequate. Traditional tricyclic antidepressant side effects in- Choice of an Antidepressant Table 3. Common Side Effects of Selective Serotonin Pharmacotherapy is the most effective treatment for Reuptake Inhibitors (SSRIs) moderate to severe nonpsychotic depression,24 with tra­ Nausea ditional antidepressants being effective in approximately Somnolence 60% to 85% of patients.25 Current treatment options Weakness include traditional tricyclic antidepressants, monoamine Dizziness Insomnia oxidase inhibitors (MAOIs), tetracyclic antidepressants Sexual dysfunction (eg, maprotiline), and selective serotonin reuptake inhib­ Sweating iting (SSRI) antidepressants (Table 2). Tetracyclic com­ Tremor Decreased appetite pounds predominantly affect norepinephrine neurotrans­ Nervousness mission, are pharmacologically similar to the tricyclic Note: SSRIs may interact with AIAOIs to produce serotonin syndrome. 50 The Journal of Family Practice, Vol. 38, No. l(Jan), 199- yew Antidepressants Guze and Gidin dude orthostatic hypotension, alterations in cardiac con­ Selective Serotonin Reuptake duction, overdose fatality, dry mouth, constipation, Inhibitors blurred vision, urinary hesitancy, and memory impair­ ment,26 none of which are associated with SSBJs.25 Typ­ Paroxetine, sertraline, and fluoxetine are members of the ical side effects of the SSRIs include gastrointestinal SSRI group that are currently marketed in the United upset, such as nausea and diarrhea; restlessness or akathi- States. Fluvoxamine and citralopram are not currendy
Load more

Recommended publications
  • Efficacy of Treatments for Patients with Obsessive-Compulsive Disorder: a Systematic Review
    REVIEW Efficacy of treatments for patients with obsessive-compulsive disorder: A systematic review Yun-Jung Choi, PhD, RN, PMHNP (Lecturer) Keywords Abstract Systematic review; obsessive-compulsive disorder; efficacy of medication. Purpose: This systematic review examines the efficacy of pharmacological therapy for obsessive-compulsive disorder (OCD), addressing two major issues: Correspondence which treatment is most effective in treating the patient’s symptoms and which Yun-Jung Choi, PhD, RN, PMHNP, Red Cross is beneficial for maintaining remission. College of Nursing, 98 Saemoonan-Gil, Data sources: Seven databases were used to acquire articles. The key words Jongno-Gu, Seoul 110-102, Korea; used to search for the relative topics published from 1996 to 2007 were Tel: +82-2-3700-3676; fax: +82-2-3700-3400; ‘‘obsessive-compulsive disorder’’ and ‘‘Yale-Brown obsession-compulsion E-mail: [email protected] scale.’’ Based on the inclusion and exclusion criteria, 25 studies were selected Received: August 2007; from 57 potentially relevant studies. accepted: March 2008 Conclusions: The effects of treatment with clomipramine and selective sero- tonin reuptake inhibitors (SSRIs: fluvoxamine, sertraline, fluoxetine, citalo- doi:10.1111/j.1745-7599.2009.00408.x pram, and escitalopram) proved to be similar, except for the lower adherence rate in case of clomipramine because of its side effects. An adequate drug trial involves administering an effective daily dose for a minimum of 8 weeks. An augmentation strategy proven effective for individuals refractory to monother- apy with SSRI treatment alone is the use of atypical antipsychotics (risperidone, olanzapine, and quetiapine). Implications for practice: Administration of fluvoxamine or sertraline to patients for an adequate duration is recommended as the first-line prescription for OCD, and augmentation therapy with risperidone, olanzapine, or quetiapine is recommended for refractory OCD.
    [Show full text]
  • Drug Use Evaluation: Antipsychotic Utilization in Schizophrenia Patients
    © Copyright 2012 Oregon State University. All Rights Reserved Drug Use Research & Management Program Oregon State University, 500 Summer Street NE, E35 Salem, Oregon 97301-1079 Phone 503-947-5220 | Fax 503-947-1119 Drug Use Evaluation: Antipsychotic Utilization in Schizophrenia Patients Research Questions: 1. How many schizophrenia patients are prescribed recommended first-line second-generation treatments for schizophrenia? 2. How many schizophrenia patients switch to an injectable antipsychotic after stabilization on an oral antipsychotic? 3. How many schizophrenia patients are prescribed 2 or more concomitant antipsychotics? 4. Are claims for long-acting injectable antipsychotics primarily billed as pharmacy or physician administered claims? 5. Does adherence to antipsychotic therapy differ between patients with claims for different routes of administration (oral vs. long-acting injectable)? Conclusions: In total, 4663 schizophrenia patients met inclusion criteria, and approximately 14% of patients (n=685) were identified as treatment naïve without claims for antipsychotics in the year before their first antipsychotic prescription. Approximately 45% of patients identified as treatment naïve had a history of remote antipsychotic use, but it is unclear if antipsychotics were historically prescribed for schizophrenia. Oral second-generation antipsychotics which are recommended as first-line treatment in the MHCAG schizophrenia algorithm were prescribed as initial treatment in 37% of treatment naive patients and 28% of all schizophrenia patients. Recommended agents include risperidone, paliperidone, and aripiprazole. Utilization of parenteral antipsychotics was limited in patients with schizophrenia. Overall only 8% of patients switched from an oral to an injectable therapy within 6 months of their first claim. Approximately, 60% of all schizophrenia patients (n=2512) had claims for a single antipsychotic for at least 12 continuous weeks and may be eligible to transition to a long-acting injectable antipsychotic.
    [Show full text]
  • Sertraline and Venlafaxine-Induced Nocturnal Enuresis
    Case Report DOI: 10.5455/bcp.20140304091103 Sertraline and Venlafaxine-Induced Nocturnal Enuresis Inci Meltem Atay1, Gulin Ozdamar Unal2 ABS TRACT: Sertraline and venlafaxine-induced nocturnal enuresis Nocturnal enuresis is defined as the involuntary discharge of urine after the age of expected continence that occurs during sleep at night. Although there are a few reports in adults for nocturnal enuresis associated 1Assist. Prof., 2M.D., Suleyman Demirel University, School of Medicine, Department with serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs), the of Psychiatry, Isparta - Turkey mechanism or frequency of this side effect have not been identified yet. We report here a case of nocturnal Corresponding author: Dr. İnci Meltem Atay enuresis associated with both sertraline and venlafaxine in different major depressive episodes in an adult Süleyman Demirel Universitesi, Tıp Fakültesi, Psikiyatri Anabilim Dalı, Isparta - Türkiye patient that resolves after the discontinuation of the medications and continuation with escitalopram. To our E-ma il add ress: knowledge, in literature there have been no reports about nocturnal enuresis caused by those two agents in [email protected] the same patient. This case is discussed in detail for the recurrence of nocturnal enuresis, the importance of Date of submission: detailed assessment of even rare side effects and for their possible mechanisms. February 11, 2014 Date of acceptance: March 04, 2014 Keywords: nocturnal enuresis, venlafaxine, sertraline, depression Declaration of interest: I.M.A, G.O.U.: The authors reported no Klinik Psikofarmakoloji Bulteni - Bulletin of Clinical Psychopharmacology 2015;25(3):287-90 conflict of interest related to this article. INTRODUCTION side effect1-6.
    [Show full text]
  • Management of Major Depressive Disorder Clinical Practice Guidelines May 2014
    Federal Bureau of Prisons Management of Major Depressive Disorder Clinical Practice Guidelines May 2014 Table of Contents 1. Purpose ............................................................................................................................................. 1 2. Introduction ...................................................................................................................................... 1 Natural History ................................................................................................................................. 2 Special Considerations ...................................................................................................................... 2 3. Screening ........................................................................................................................................... 3 Screening Questions .......................................................................................................................... 3 Further Screening Methods................................................................................................................ 4 4. Diagnosis ........................................................................................................................................... 4 Depression: Three Levels of Severity ............................................................................................... 4 Clinical Interview and Documentation of Risk Assessment...............................................................
    [Show full text]
  • Haloperidol Injection, USP and 3) Treatment of Any Concomitant Serious Medical Problems for Which Specific Treatments Are Available
    drugs not essential to concurrent therapy, 2) intensive symptomatic treatment and medical monitoring, Haloperidol Injection, USP and 3) treatment of any concomitant serious medical problems for which specific treatments are available. (For Immediate Release) There is no general agreement about specific pharmacological treatment regimens for uncomplicated NMS. Rx only If a patient requires antipsychotic drug treatment after recovery from NMS, the potential reintroduction of drug therapy should be carefully considered. The patient should be carefully monitored, since recurrences WARNING of NMS have been reported. Increased Mortality in Elderly Patients with Dementia-Related Psychosis: Hyperpyrexia and heat stroke, not associated with the above symptom complex, have also been reported Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an in- with haloperidol. creased risk of death. Analyses of seventeen placebo-controlled trials (modal duration of 10 weeks), Usage in Pregnancy largely in patients taking atypical antipsychotic drugs, revealed a risk of death in drug-treated pa- Rodents given 2 to 20 times the usual maximum human dose of haloperidol by oral or parenteral routes tients of between 1.6 to 1.7 times the risk of death in placebo-treated patients. Over the course of showed an increase in incidence of resorption, reduced fertility, delayed delivery and pup mortality. No a typical 10-week controlled trial, the rate of death in drug-treated patients was about 4.5%, com- teratogenic effect has been reported in rats, rabbits or dogs at dosages within this range, but cleft palate pared to a rate of about 2.6% in the placebo group.
    [Show full text]
  • Rapid Tranquillisation of Violent Or Agitated Patients in a Psychiatric
    BRITISH JOURNAL OF PSYCHIATRY (2004), 185, 63^69 Rapid tranquillisation of violent or agitated patients Department of Psychiatry at the Christian Medical College, in Vellore in the southern in a psychiatric emergency setting Indian state of Tamil Nadu. The majority of patients presenting to the psychiatric emergency services of this 1800-bed teach- Pragmatic randomised trial of intramuscular lorazepam v. ing hospital were accompanied by family haloperidol plus promethazine members and were either brought directly, or were referred by general practitioners in the town or adjoining towns and villages JACOB ALEXANDER, PRATHAP THARYAN, CLIVE ADAMS, THOMAS JOHN, and from emergency services of this and CARINA MOL and JONCY PHILIP other hospitals. Background The pharmacological Violent or aggressive behaviour is a Patient selection management of violence in people with common reason for emergency psychiatric presentations, with assaultive behaviour Consecutive patients were assessed and psychiatric disordersis under-researched. seen in 3–10% of psychiatric patients were eligible for trial entry if the attending physician felt that intramuscular sedation Aims To compare interventions (Tardiff & Sweillam, 1982; Tardiff & Koenigsberg, 1985). A haloperidol– was clearly indicated because of agitation, commonly used for controlling agitation or promethazine mix is commonly used for aggression or violent behaviour, and if the violence in people with serious psychiatric rapid tranquillisation of agitated or violent physician did not feel that either
    [Show full text]
  • Geriatric Psychopharmacology: Anti-Depressants Amber Mackey, D.O
    Geriatric Psychopharmacology: Anti-depressants Amber Mackey, D.O. University of Reno School of Medicine Department of Psychiatry Chief Resident, PGY-4 Pharmacologic issues in the elderly More likely to experience drug induced adverse events Cardiac effects: Prolonged QTc, arrhythmias, sudden death Peripheral/central anticholinergic effects: constipation, delirium, urinary retention, delirium, and cognitive dysfunction Antihistaminergic effects: sedation Antiadrenergic effects: postural hypotension Other effects: Hyponatremia, bleeding, altered bone metabolism Pharmacokinetic Organ system Change consequence Circulatory system Decreased concentration Increased or decreased of plasma albumin and free concentration of drugs increased α1-acid in plasma glycoprotein Gastrointestinal Table tract 20-1 Decreased intestinal and Decreased rate of drug splanchnic blood flow absorption Kidney Decreased glomerular Decreased renal filtration rate clearance of active metabolites Liver Decreased liver size; Decreased hepatic decreased hepatic blood clearance flow; variable effects on cytochrome P450 isozyme activity Muscle Decreased lean body mass Altered volume of and increased adipose distribution of lipid-soluble tissue drugs, leading to increased elimination half-life Table 20-1, Physiological changes in elderly persons associated with altered pharmacokinetics, American Psychiatric Publishing Textbook of Geriatric Psychiatry, Fifth Edition, Chapter 20: Psychopharmacology. Other issues Illnesses that effect the elderly also play a role in diminishing
    [Show full text]
  • Compatibility of Cholecalciferol, Haloperidol, Imipramine Hydrochlo
    ORIGINAL ARTICLES Ortofarma – Quality Control Laboratories, Matias Barbosa, MG, Brazil Compatibility of cholecalciferol, haloperidol, imipramine hydrochlo- ride, levodopa/carbidopa, lorazepam, minocycline hydrochloride, tacro- limus monohydrate, terbinafine, tramadol hydrochloride and valsartan in SyrSpend® SF PH4 oral suspensions H. C. POLONINI, S. L. SILVA, C. N. CUNHA, M. A. F. BRANDÃO, A. O. FERREIRA Received October 21, 2015, accepted December 2, 2015 Ortofarma – Quality Control Laboratories, BR 040, n. 39, Empresarial Park Sul. 36120-000. Matias Barbosa – MG. Brazil [email protected] Pharmazie 71: 185–191 (2016) doi: 10.1691/ph.2016.5177 A challenge with compounding oral liquid formulations is the limited availability of data to support the physical, chemical and microbiological stability of the formulation. This poses a patient safety concern and a risk for medication errors. The objective of this study was to evaluate the compatibility of the following active pharma- ceutical ingredients (APIs) in 10 oral suspensions, using SyrSpend® SF PH4 (liquid) as the suspending vehicle: cholecalciferol 50,000 IU/mL, haloperidol 0.5 mg/mL, imipramine hydrochloride 5.0 mg/mL, levodopa/carbidopa 5.0/1.25 mg/mL, lorazepam 1.0 mg/mL, minocycline hydrochloride 10.0 mg/mL, tacrolimus monohydrate 1.0 mg/ mL, terbinafine 25.0 mg/mL, tramadol hydrochloride 10.0 mg/mL and valsartan 4.0 mg/mL. The suspensions were stored both refrigerated (2 - 8 °C) and at controlled room temperature (20 - 25 °C). This is the first stability study for these APIs in SyrSpend® SF PH4 (liquid). Further, the stability of haloperidol,iImipramine hydrochloride, minocycline, and valsartan in oral suspension has not been previously reported in the literature.
    [Show full text]
  • HALDOL Decanoate 50 (Haloperidol)
    HALDOL® Decanoate 50 (haloperidol) HALDOL® Decanoate 100 (haloperidol) For IM Injection Only WARNING Increased Mortality in Elderly Patients with Dementia-Related Psychosis Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Analyses of seventeen placebo-controlled trials (modal duration of 10 weeks), largely in patients taking atypical antipsychotic drugs, revealed a risk of death in drug-treated patients of between 1.6 to 1.7 times the risk of death in placebo-treated patients. Over the course of a typical 10-week controlled trial, the rate of death in drug-treated patients was about 4.5%, compared to a rate of about 2.6% in the placebo group. Although the causes of death were varied, most of the deaths appeared to be either cardiovascular (e.g., heart failure, sudden death) or infectious (e.g., pneumonia) in nature. Observational studies suggest that, similar to atypical antipsychotic drugs, treatment with conventional antipsychotic drugs may increase mortality. The extent to which the findings of increased mortality in observational studies may be attributed to the antipsychotic drug as opposed to some characteristic(s) of the patients is not clear. HALDOL Decanoate is not approved for the treatment of patients with dementia-related psychosis (see WARNINGS). DESCRIPTION Haloperidol decanoate is the decanoate ester of the butyrophenone, HALDOL (haloperidol). It has a markedly extended duration of effect. It is available in sesame oil in sterile form for intramuscular (IM) injection. The structural formula of haloperidol decanoate, 4-(4-chlorophenyl)-1-[4-(4-fluorophenyl)-4-oxobutyl]-4 piperidinyl decanoate, is: Haloperidol decanoate is almost insoluble in water (0.01 mg/mL), but is soluble in most organic solvents.
    [Show full text]
  • For More Than Half a Century, Haloperidol Has Been Used As a First
    Time to retire haloperidol? For emergency agitation, evidence suggests newer alternatives may be a better choice Joseph M. Pierre, MD or more than half a century, haloperidol has been used as a first- Health Sciences Clinical Professor Department of Psychiatry and line medication for psychiatric agitation constituting a “behav- Biobehavioral Sciences ioral emergency” when a patient cannot or will not take oral David Geffen School of Medicine at UCLA F medication. Today, haloperidol is most commonly administered as Los Angeles, California an IM injection along with an anticholinergic medication to minimize Disclosure The author reports no financial relationships with any extrapyramidal symptoms (EPS) and a benzodiazepine for additional companies whose products are mentioned in this article, sedation. The multiple-medication “cocktail” is often referred to by dou- or with manufacturers of competing products. ble-entendre nicknames, such as “B-52” or “5250” (ie, haloperidol, 5 mg; lorazepam, 2 mg; and diphenhydramine, 50 mg). In this article, I discuss whether haloperidol, a first-generation antipsychotic (FGA) medication developed in 1958, still deserves to be the IM “gold standard” for man- aging emergency psychiatric agitation. Earlier evidence of haloperidol’s efficacy The initial “discovery” of antipsychotic medications was made in 1951 based on the inadvertent observation that chlorpromazine had the potential to calm surgical patients with autonomic activation. This calm- ing effect, described as “désintéressment” (meaning a kind of “indiffer- ence to the world”),1 resulted in a new class of medications replacing barbiturates and bromides as go-to options to achieve “rapid tranquil- ization” of psychiatric agitation.2 Although the ability of antipsychotic medications to gradually reduce positive symptoms, such as delusions and hallucinations, has been attributed to dopamine (D2) antagonism, their more immediate sedating and anti-agitation effects are the result of broader effects as histamine (H1) and alpha-1 adrenergic antagonists.
    [Show full text]
  • HALDOL Brand of Haloperidol Injection
    HALDOL® brand of haloperidol injection (For Immediate Release) WARNING Increased Mortality in Elderly Patients with Dementia-Related Psychosis: Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Analyses of seventeen placebo-controlled trials (modal duration of 10 weeks), largely in patients taking atypical antipsychotic drugs, revealed a risk of death in drug-treated patients of between 1.6 to 1.7 times the risk of death in placebo-treated patients. Over the course of a typical 10 week controlled trial, the rate of death in drug-treated patients was about 4.5%, compared to a rate of about 2.6% in the placebo group. Although the causes of death were varied, most of the deaths appeared to be either cardiovascular (e.g., heart failure, sudden death) or infectious (e.g., pneumonia) in nature. Observational studies suggest that, similar to atypical antipsychotic drugs, treatment with conventional antipsychotic drugs may increase mortality. The extent to which the findings of increased mortality in observational studies may be attributed to the antipsychotic drug as opposed to some characteristic(s) of the patients is not clear. HALDOL Injection is not approved for the treatment of patients with dementia-related psychosis (see WARNINGS). DESCRIPTION Haloperidol is the first of the butyrophenone series of major antipsychotics. The chemical designation is 4-[4-(p-chlorophenyl)-4-hydroxypiperidino]­ 4’-fluorobutyrophenone and it has the following structural formula: HALDOL (haloperidol) is available as a sterile parenteral form for intramuscular injection. The injection provides 5 mg haloperidol (as the lactate) and lactic acid for pH adjustment between 3.0 – 3.6.
    [Show full text]
  • Mid Essex CCG 'Guidance for the Treatment of Depression in Adults'
    Guidance for the treatment of depression in adults MILD DEPRESSION - Medication is not first-line treatment or only treatment for depression Actively monitor symptoms, give life style advice, guided self- help or exercise MODERATE DEPRESSION Consider psychological intervention. This is accessed by referral or self-referral to Mid Essex IAPT (Improving Access to Psychological Therapies) and include Cognitive Behavioural Therapy (CBT) or Interpersonal Therapy (IPT) Ask about OTC/Herbal/St John’s Wort use – NO SSRI to be prescribed if already on St John’s Wort or stop St John’s Wort Consider referral to specialist care early if the patient has significant suicidal ideation, severe depression, depression in bipolar disorder. MODERATE to SEVERE DEPRESSION Discuss medication and treatment options with patient before prescribing, include side effects and risk of suicidal thoughts during onset of treatment. Consider patients co-morbidities when selecting antidepressant and ask about OTC/Herbal/St John’s Wort as described above. Refer to IAPT - Psychological therapies should be continued alongside medication. Ensure adequate duration of treatment has been tried before switching medication or increasing dose. CITALOPRAM 20mg daily or SERTRALINE 50mg daily Citalopram – consider Dose 10mg for 10days then Assess efficacy over 6-8 weeks. If effective see box 1 titration 20mg for 6-8 weeks Ineffective Sertraline – consider Poorly 25mg for 10days then tolerated 50mg for 6-8 weeks Increase to: Citalopram 30mg OD, Switch to fluoxetine or increase to 40mg after 6 line another SSRI or Mirtazapine. st weeks if required (MAX dose 1 Cross-taper when switching. Box 1. in elderly = 20mg) Increase to therapeutic dose.
    [Show full text]