Panic Disorders Medication choice (see appendix on Commonly Prescribed

Drugs for dosage)

Caution
May initially exacerbate
symptoms.
1st line
Start at lower dose. Caution around
SSRI (such as Sertraline)
hyponatremia and GI Bleeds in the
Venlafaxine XR
elderly
Commence at a low dose
2nd line
Weight gain, sedation
Mirtazapine
Avoid benzodiazepines save
for acute crises

Examples of medication choice and dosage (1st line)

Comments Caution
Depression
Ideally SSRI such as Sertraline starting at 25mg or Citalopram 10mg
Mirtazapine starting at 7.5mg nocte
Less
interactions
May assist
sleep
Hyponatremia, bleeding
Sedation, constipation,
urinary retention
Anxiety
SSRI such as Sertraline starting at 25mg or Citalopram 10mg
Hyponatremia, bleeding
Acute mania or psychosis
Quetiapine starting at 12.5–25mg BD
Risperidone starting at 0.5mg
Aripiprazole starting at 5mg
Monitor for sedation and
postural hypotension.
Increased risk of stroke in
patients with dementia
Monitor for increased
prolactin. Increased risk
of stroke in patients with
dementia
Monitor for agitation
Agitation
Clonazepam starting at 0.5mg
Sedatives can worsen
confusion, and carry a
higher
risk of respiratory
depression
in the elderly
Insomnia
Zopiclone starting at 3.75mg
Trial not to exceed 4 weeks
Can worsen confusion
Examples of medication choice and dosage (1st line)
Comments Caution
Depression
Ideally SSRI such as Sertraline starting at 25mg or Citalopram 10mg
Mirtazapine starting at 7.5mg nocte
Less
interactions
May assist
sleep
Hyponatremia, bleeding
Sedation, constipation,
urinary retention
Anxiety
SSRI such as Sertraline starting at 25mg or Citalopram 10mg
Hyponatremia, bleeding
Acute mania or psychosis
Quetiapine starting at 12.5–25mg BD
Risperidone starting at 0.5mg
Aripiprazole starting at 5mg
Monitor for sedation and
postural hypotension.
Increased risk of stroke in
patients with dementia
Monitor for increased
prolactin. Increased risk
of stroke in patients with
dementia
Monitor for agitation
Agitation
Clonazepam starting at 0.5mg
Sedatives can worsen
confusion, and carry a
higher
risk of respiratory
depression
in the elderly
Insomnia
Zopiclone starting at 3.75mg
Trial not to exceed 4 weeks
Can worsen confusion
Medication choice in primary care
Comments Caution
1st line Dose required is higher Hyponatremia, GI
SSRI (ideally than for treatment of Bleeds in the elderly.
Fluoxetine, depression Monitor for
Paroxetine, If first SSRI is poorly emergence
Fluvoxamine, tolerated or there is an or worsening of
Sertraline, inadequate response, suicidal
Citalopram) review dose after 4–6 ideation
weeks; treat for 12
 months if effective.
Onset of effect may
take up to 12 weeks
ECG and blood
pressure measurement
if history of
2nd line cardiovascular disease.
Clomipramine Toxic in overdose so
limit prescription if
risk
of self‐harm
Examples of medication choice and dosage (1st line)
Comments Caution
Depression
Ideally SSRI such as
Sertraline starting at 25mg or Citalopram 10mg
Mirtazapine starting at 7.5mg nocte
Less
interactions
May assist
sleep
Hyponatremia, bleeding
Sedation, constipation,
urinary retention
Anxiety
SSRI such as
Sertraline starting at 25mg or Citalopram 10mg
Hyponatremia, bleeding
Acute mania or psychosis
Quetiapine starting at 12.5–25mg BD
Risperidone starting at 0.5mg
Aripiprazole starting at 5mg
Monitor for sedation and
postural hypotension.
Increased risk of stroke in
patients with dementia
Monitor for increased
prolactin. Increased risk
of stroke in patients with
dementia
Monitor for agitation
Agitation
Clonazepam starting at 0.5mg
Sedatives can worsen
confusion, and carry a
higher
risk of respiratory
depression
in the elderly
Insomnia
Zopiclone starting at
3.75mg
Trial not
to exceed 4
weeks
Can worsen confusion

Medication choice
Comments Caution
Hyponatremia, GI Bleeds in
1st line the
SSRI elderly
(escitalopram Paroxetine can cause initial
or sertraline) 10– increase in agitation and
12 Well tolerated also withdrawal effects on
week trial discontinuation.
SSRI (paroxetine Fluvoxamine has
or hepatic liver‐enzyme related
fluvoxamine) drug
interactions.
2nd line
SNRI
Monitor BP
(venlafaxine
modified release)
3rd line
Problematic interactions /
MAOI
strict
(moclobemide,
diet
phenelzine)
Antipsychotic choice
Medication choice Comments Caution
Prior to any
antipsychotic, every
patient should have an
ECG, weight and
height
check, and basic blood
‘Atypical’ or Side effects can
tests, including blood
‘second generation’ include weight
glucose. Monitor
antipsychotic gain, impaired
these
medications: glucose
annually
e.g. risperidone, tolerance,
With all
olanzapine, diabetes mellitus,
antipsychotics,
quetiapine, dry mouth,
‘neuroleptic malignant
aripiprazole, sedation, possible
syndrome’ can occur;
amisulpride, cardiac effects,
this is a rare adverse
ziprasidone, dizziness,
effect (pyrexia,
paliperidone impotence
confusion, muscle
rigidity, perspiration,
tachycardia) that
needs
hospital management
and can be fatal
‘Typical’ or ‘first Side effects can
generation’ include
 movement
antipsychotic problems (e.g.
medications: e.g. restlessness);
fluphenazine, metabolic,
flupentixol, cardiac,
haloperidol, or hormonal
zuclopenthixol, effects (e.g.
sulpiride, pimozide raised
prolactin)
nvestigations in suspected bipolar disorder:
• Full history, asking especially for previous episodes of mania or depression.
• Collateral history, from family or friends.
• Mental state examination, with particular emphasis on mood, suicidality,
features of psychosis, and insight.
• Drug testing, if indicated (e.g. for cocaine, cannabis, steroids).
• Physical investigations, if a physical cause is suspected (e.g. thyroid disease).
Treatment of mania in bipolar disorder:
• If the person is taking a mood-stabilising medication such as lithium,
check adherence, plasma level, and any other medication that might be
affecting it.
• If the person is taking an antidepressant on its own, consider stopping it
and offer an antipsychotic medication such as haloperidol, olanzapine,
quetiapine, or risperidone.
• If the person is not taking an antipsychotic or mood-stabiliser, offer an
antipsychotic.
• Further steps in treatment, if needed, will likely require specialist mental
health services input (e.g. further alternative antipsychotics or adding a
mood-stabiliser).
• When prescribing, take account of the person’s preferences, advance
statements, and relevant clinical factors (e.g. previous response,
side effects, physical comorbidity).
Treatment of depression in bipolar disorder:
• Psychological therapy for depression is very helpful in bipolar disorder,
especially in terms of avoiding triggering a manic episode.
• If a person develops moderate or severe bipolar depression and is not
taking medication for bipolar disorder, offer fluoxetine (antidepressant)
with olanzapine, or else quetiapine on its own. (If the person is already
on lithium, optimise lithium first)
• Further steps in treatment will likely require specialist mental health
services input
Partial Response to Antidepressant Treatment
1. Ensure the patient is adherent and has received a therapeutic trial (as defined in section D2
earlier) of
medication.
2. Patients can either be changed to a new antidepressant or receive adjunctive therapy. The 2016
CANMAT
guidelines have a helpful algorithm and tables (see References section).
3. An antidepressant with a different mechanism of action can be added (e.g., bupropion or
mirtazapine
to an SSRI or SNRI). Data are not strong for this practice. Use caution when combining agents to
avoid
potential serotonin syndrome with at-risk agents.
4. SGAs (or atypical antipsychotics) may be used as adjuncts to antidepressant therapy. Almost all
SGAs
have been used, but only aripiprazole, brexpiprazole, and quetiapine ER have received FDA
approval
for this indication. Evidence also supports the use of risperidone. Olanzapine in combination with
fluoxetine is also approved, but specifically for treatment-resistant depression.
Ketamine infusions are used off-label for depression and suicidality, particularly in patients who are
not
responsive or who are only partly responsive to antidepressants.
6. Other adjuncts include lithium, liothyronine, stimulants (including methylphenidate and
modafinil),
and buspirone.
N. Treatment-Resistant Depression
1. Has many definitions; usually defined as inadequate response to at least two antidepressants
2. FDA-approved treatment options
a. Olanzapine plus fluoxetine: Initial dosing is 6 mg/25 mg once daily; usual dosing is 6–18 mg/25–
50
mg daily.
b. Esketamine (intranasal; Spravato)
i. Approved for use in conjunction with an oral antidepressant
ii. Also approved for major depression with suicidality
iii. Mechanism of action: NMDA (N-methyl-d-aspartate) antagonist
iv. Onset for treating depression symptoms is within hours.
v. Dosing occurs in two phases: twice weekly during the induction phase, which lasts for 2
weeks, followed by the maintenance phase, in which dosing is weekly for 4 weeks and then
every 1–2 weeks thereafter.
vi. Carries black box warnings for sedation, dissociation, abuse and misuse (CIII), and suicidal
thoughts and behaviors
vii. Common adverse reactions: Increased blood pressure, dissociative reactions including
derealization and depersonalization, sedation, dizziness, anxiety, nausea, vomiting, and dysgeusia.
Long-term use or misuse of ketamine has also been associated with ulcerative or interstitial
cystitis. This has not been observed with esketamine in clinical trials but should be monitored.
viii. Only available through a REMS program in which patients must be enrolled. Only approved
pharmacies can dispense, and agent must be administered in a certified health care setting
where patients are observed for at least 2 hours after administration. During this time, mental
status and blood pressure must be monitored. Patients cannot drive until the following day.
Treatment-Resistant Depression
1. Has many definitions; usually defined as inadequate response to at least two antidepressants
2. FDA-approved treatment options
a. Olanzapine plus fluoxetine: Initial dosing is 6 mg/25 mg once daily;
usual dosing is 6–18 mg/25–50 mg daily.
b. Esketamine (intranasal; Spravato)
i. Approved for use in conjunction with an oral antidepressant
ii. Also approved for major depression with suicidality
iii. Mechanism of action: NMDA (N-methyl-d-aspartate) antagonist
iv. Onset for treating depression symptoms is within hours.
v. Dosing occurs in two phases: twice weekly during the induction phase, which lasts for 2
weeks, followed by the maintenance phase, in which dosing is weekly for 4 weeks and then
every 1–2 weeks thereafter.
vi. Carries black box warnings for sedation, dissociation, abuse and misuse (CIII), and suicidal
thoughts and behaviors
vii. Common adverse reactions: Increased blood pressure, dissociative reactions including
derealization and depersonalization, sedation, dizziness, anxiety, nausea, vomiting, and dysgeusia.
Long-term use or misuse of ketamine has also been associated with ulcerative or interstitial
cystitis. This has not been observed with esketamine in clinical trials but should be monitored.
viii. Only available through a REMS program in which patients must be enrolled. Only approved
pharmacies can dispense, and agent must be administered in a certified health care setting
where patients are observed for at least 2 hours after administration. During this time, mental
status and blood pressure must be monitored. Patients cannot drive until the following day.
Antidepressants (e.g. fluoxetine 60 mg daily) are sometimes used for
bulimia nervosa and binge eating disorder, but appear less effective
than psychological therapy, are not a substitute for psychological
therapy, and are usually prescribed by specialist services.
Medication choice
Comments Caution
Hyponatremia, GI Bleeds in
1st line the
SSRI elderly
(escitalopram Paroxetine can cause initial
or sertraline) 10– increase in agitation and
12 Well tolerated also withdrawal effects on
week trial discontinuation.
SSRI (paroxetine Fluvoxamine has
or hepatic liver‐enzyme related
fluvoxamine) drug
interactions.
2nd line
SNRI
Monitor BP
(venlafaxine
modified release)
3rd line
Problematic interactions /
MAOI
strict
(moclobemide,
diet
phenelzine)
Medication for relapse prevention and/or reduction of alcohol
consumption (all are specialist initiated or advised)
Comments Caution
Pregnancy / breast
Anticraving drug
feeding,
Acamprosate 666mg tds (bd if <
severe kidney disease,
60kg) for 6–12 months
severe liver disease
Anticraving and
relapse prevention
Start after detox 25mg Stop if drinking persists
Naltrexone
daily increasing to 4–6 weeks after starting
maintenance 50mg
daily for 6–12 months
Disulfiram Start > 24 hours after Provokes unpleasant
last alcoholic drink (and
Dose 200mg daily potentially severe)
reaction
if alcohol consumed
concomitantly
 Can cause flushing,
nausea, palpitations,
arrhythmias,
hypotension,
and collapse
18mg once daily with
Contraindicated in
monthly review for
severe
Nalmefene ongoing benefit and a
renal or severe hepatic
maximum treatment
impairment
duration of 1 year
Pharmacological treatment
Antipsychotics (note increased risk of stroke in patients with
dementia)
Drug Oral dose Adverse effects
Monitor for extra
pyramidal side
1st line
0.5–1mg BD effects
Haloperidol
and prolonged QT
interval
2.5–5mg per day
Monitor for
Olanzapine (do not exceed
sedation
20mg in 24 hours)
Monitor for
Oral 0.5mg BD
hypotension and
(do not exceed
Risperidone extrapyramidal
4mg
side
in 24 hours)
effects
Oral 12.5–50mg
Monitor for
BD
1st line sedation
(do not exceed
Quetiapine and postural
200mg in 24
hypotension
hours)

Benzodiazepines (note association with prolongation/

worsening of symptoms)
Lorazepam
(Avoid except for use
Oral 0.25–1mg Monitor for
in alcohol/sedative
every 2–4 hours as respiratory
withdrawal, Lewy
needed depression,
Body
(do not exceed over‐sedation,
Dementia, Parkinson’s
3mg and paradoxical
disease and
in 24 hours) excitement
Neuroleptic
Malignant Syndrome)

Drug treatments for behavioural problems in dementia (seek

specialist advice):
•  Mild agitation: trazodone, lorazepam, citalopram, sertraline.
•  Severe agitation or psychosis: quetiapine, risperidone, olanzapine, 
aripiprazole.
•  Depressive symptoms: citalopram, sertraline, mirtazapine.
Treatment of somatic symptom disorders:
•  Psychotherapy (including CBT, mindfulness, and/or psychodynamic 
psychotherapy).
•  Psychiatric Consultation Intervention.
•  Graded exercise.
•  Biofeedback.
•  Pharmacological treatment options for comorbid depression or anxiety 
include SSRIs (particularly anxiety disorders), SNRIs (particularly with 
predominant pain), tricyclic antidepressants, mirtazapine.
•  Self‐care.
Antidepressant choice
Comments Caution
Hyponatremia, GI
Bleeds in
1st line the elderly
SSRI (paroxetine, Monitor BP with
sertraline, or Well tolerated venlafaxine.
fluoxetine) May initially exacerbate
Venlafaxine XR anxiety symptoms. Start
at
lower dose
2nd line
Amitriptyline May assist sleep
Mirtazapine Effective for Toxic in overdose
Antipsychotics intrusive symptoms Weight gain, sedation
(risperidone, (flashbacks, Weight gain, sedation
olanzapine, nightmares)
quetiapine)

DSM-5 kategorija: Trauma i poremećaji povezani sa stresom

DSM-5 opisuje akutni stresni poremećaj kao razvoj specifičnog ponašanja straha koje traje od 3
dana do 1 mjeseca nakon traumatskog događaja. Ovi simptomi se uvijek javljaju nakon što je
pacijent doživio ili svjedočio smrti ili prijetnji smrću, ozbiljnoj ozljedi ili seksualnom napadu.
Primjeri traumatskih događaja iz DSM-5 uključuju fizički napad, fizičko zlostavljanje, pljačku,
aktivnu borbu, seksualno nasilje, prirodne katastrofe i ozbiljne nesreće. Akutni stresni poremećaj
također može proizaći iz slušanja o nasilnoj ili slučajnoj traumi voljene osobe ili opetovanog
izlaganja traumatskim događajima. Ishodi akutnog stresnog poremećaja najbolji su kada žrtva ima
pristup trenutnoj terapiji za upravljanje krizom. Kada krizna intervencija nije dostupna,terapija
prihvaćanja i predanosti učinkovita je terapijska intervencija.
Simptomi akutnog stresnog poremećaja:
Osobe s akutnim stresnim poremećajem doživljavaju nametljive misli ili sjećanja na traumatski
događaj. Česti su i uznemirujući snovi o traumi i opći poremećaji spavanja. Pacijent također može
doživjeti ljeskove ili uznemirenost kada je izložen okidačima traumatskog događaja. S druge strane,
pacijent može "blokirati" ili biti nesposoban zapamtiti dijelove ili cijeli traumatski događaj. Mnogi
pacijenti izbjegavaju vanjske podsjetnike, kao što su mjesta ili osobe povezane s traumatskim
događajem. Osim ovih nametljivih simptoma, pacijenti doživljavaju negativno raspoloženje. Mogu
se osjećati depresivno, tjeskobno, ljuto ili krivo i ne mogu se osjećati sretnima. Osim toga, pacijent
može imati nerealne osjećaje ili uvjerenja o događaju. Na primjer, vjerovanje da se avionska
nesreća mogla spriječiti da je pacijent učinio nešto drugačije. hiper budnost,česti su i problemi s
koncentracijom i pretjerana reakcija na prepad. Dodatno, DSM-5 objašnjava da se fizički simptomi,
kao što su glavobolja, vrtoglavica i osjetljivost na svjetlo ili zvuk, mogu pojaviti, čak i bez ozljeda.