Discussion of Chapter 10: Post- Disaster Psychotropic

Written by Iliana Garcia-Ortega and Stan Kutcher

Dr Maureen Irons Morgan Director, Mental Health and Substance Abuse, Ministry of Health, Jamaica. April 2012 Mental Health: a state of well-being — “A state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community” Mental Illness — A condition characterized by impairment of an individual’s normal cognitive, emotional or behavioural function Persons with mental illness post disaster — 1) Persons with pre-existing diagnosis of mental illness (high vulnerability) — 2)Persons developing mental illness in wake of disaster Mental Health Supports post disaster

— Mental health services — Professional help may be lacking, immediately following the disaster (psychiatrists, psychologists, physicians, nurses, counsellors) — Mental health services must have a disaster plan that includes ensuring monitoring of seriously ill (Schizophrenic register etc.),and maintaining access to services, including counselling and psychotherapy, inpatient and outpatient care

— duty rosters may be planned, sometimes police support may be necessary to ensure safe access

— Essential medications are part of disaster preparedness Essential Medication — Antidepressant – Amitryptiline, 25mg ; 75-300 mg/day — Uses – depression, disorders eg. PTSD, chronic pain, fibromyalgia — Side effects – dizziness or lightheadedness, drowsiness, confusion, constipation, difficulty urinating, dry mouth, — discontinuation syndrome with abrupt discontinuation – abrupt withdrawal after high dose, “flu-like” syndrome , likely due to cholinergic and adrenergic rebound Antipsychotic - Haloperidol — Injection- 5mg in 1 ml ampoule, or tablets 2mg, 5mg — Uses – acute and chronic psychoses, acute mania, agitation/ aggression , antiemetic, persistent hiccups, Huntington’s chorea and dementia associated with behavioural problems — Initial dosage- 0.5-3 mg /day — Dose range 3-20 mg — Half –life 12-36 hrs — Complications – Neuroleptic malignant syndrome, a life threatening adverse reaction to antipsychotic drug(muscle rigidity, fever, autonomic instability) Haloperidol — Precautions – use in extreme caution with Parkinson’s , movement disorders and . Also young men and children more at risk for extrapyramidal side effects — EPS- dystonias and dyskinesias.Dystonias include oligogyric crisis ,trismus, . Treat with IM or oral benztropine. Avoid by using prophylactic benztropine or biperidin — Other side effects – blurred vision, constipation, dryness of mouth, sedation, gain, abnormal lactation — Tardive dyskinesia-long term , elderly women more at risk, abnormal involuntary movements in tongue, lips and face Anxiolytic /hypnotic - Diazepam — Tablets – 2mg, 5mg — Injection 5mg per ml in 2 ml ampoule — Gel or rectal , 5mg per ml in 0.5 ml; 2ml and 4ml — Uses – Anxiety, insomnia (acute), alcohol withdrawal, depression with comorbid anxiety, disorder, seizures, neuroleptic induced akathisia, behavioural problems in patients with mania, psychosis, parkinsonism, muscle spasms, complications with hallucinogens or overdose of stimulants Diazepam — For control – adults 5mg IV, range 5-20 mg IV — Adolescents – 2.5 mg IV, range 2.5 mg-10 mg IV — Paediatric – 0.2 mg IV, range 0.2-5mg IV — Long term effects – tolerance, dependence, withdrawal syndrome. Dosage adjustment needed for elderly — Side effects – drowsiness, fatigue, sedation, confusion, anterograde amnesia (especially at higher doses) Antiparkinsonian - Biperiden — Injection 5mg (lactate) in 1 ml ampoule — Tablet 2 mg (hydrochloride) — Uses – Parkinson’s disease, extrapyramidal side effects — Initial dose 1 mg/day, range 2-12 mg/day, half-life 24 hrs often can be tapered and discontinued after several weeks without return of EPS — Side effects – constipation, dry mouth, tachycardia, confusion, urinary retention, blurred vision Antiepileptic - Phenobarbital — Injection 200 mg/ml — Oral liquid 15 mg/5ml, tablet 15 to 100mg — Uses – Generalized tonic-clonic, complex partial seizures, prevention of seizures related to operative or traumatic neurological events — Initial dose, child : up to 5 mg/kg daily (range – same) — Adolescent : 60-180 mg at night (range- same) — Adult : 1 mg/kg/day — Half-life 53-118 hrs Phenobarbital — Can be used in status epilepticus, when benzodiazepine has failed — Has addiction potential — Side effects – dry mouth, blurred vision, drowsiness, euphoria or disorientation, urinary retention, postural hypotension, constipation, agitation, disturbed behaviour Mood stabilizer – Lithium — Tablets or capsule, 300 mg — Uses – treatment of mania, bipolar depression, prophylaxis in bipolar disorder — Initial dose 300 mg twice daily — Dose range 600-1800 mg/day — Half-life 20-26 hrs (longer with impaired renal function and in the elderly) — Comments- Check serum lithium . Monitor renal and thyroid function. Maintain adequate fluid and sodium intake Lithium — Side effects- nausea, vomiting, diarrhea, dry mouth, weight gain, fatigue, dizziness, fine hand tremor, polyuria, polydipsia, hypothyroidism, cognitive blunting, psoriasis, acne, alopecia, edema, teratogen. — Toxicity: ataxia, vertigo,dysarthia, confusion, nystagmus