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Behavioral Disorders and Psychotropic Medications. Tintinalli Chapters 288, 289, 290. Behavioral Disorders. Epidemiology Up to 1/3 of ER Population Most recognized prevalent ED psychiatric illnesses: Substance abuse Anxiety disorders Severe cognitive impairment Psychosis

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Behavioral DisordersandPsychotropic Medications

Tintinalli Chapters 288, 289, 290

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Behavioral Disorders

  • Epidemiology

    • Up to 1/3 of ER Population

    • Most recognized prevalent ED psychiatric illnesses:

      • Substance abuse

      • Anxiety disorders

      • Severe cognitive impairment

      • Psychosis

      • Antisocial personality disorder

      • Mood disorders

    • Schizophrenia overrepresented due to multiple visits

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Behavioral Disorders

  • Diagnosis

    • Most important, is the patient a threat to himself or others?

    • Treat the symptoms, then focus on the major complaint

    • Specific diagnosis is not essential

    • Need to be familiar with behavioral disorders to communicate effectively with other health care professionals

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Behavioral Disorders

  • Multiaxial Diagnostic System from DSM-IV TR – 2000

    • Axis I – Mental disorders

    • Axis II – Personality/Developmental disorders

    • Axis III – Medical disorders

    • Axis IV – Psychosocial and environmental disorders

    • Axis V – Global functioning

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Behavioral Disorders

  • Axis I Disorders – Psychiatric Syndromes

    • Delirium, dementia, cognitive disorders

    • Mental disorders due to medical condition

    • Substance induced disorders

    • Schizophrenia and other psychotic disorders

    • Mood, anxiety and somatoform disorders

    • Factitious, dissociative, eating and adjustment disorders

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Behavioral Disorders

  • Axis I Disorders

    • Dementia: pervasive disturbance of cognitive function with normal consciousness in several areas

    • Delirium: Disturbance in cognitive function with clouding of consciousness and decreased environmental awareness

      • Acute onset

      • Rapidly alternating in severity

      • Hallucinations common

    • Substance induced

      • Acute Intoxication – alcohol, amphetamines

      • Withdrawal - alcohol

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Behavioral Disorders

  • Axis I Disorders

    • Disorders due to Medical Condition

      • Thyroid, cancer, diabetes, HIV, etc…

      • Schizophrenia and other Psychotic Disorders

        • Deterioration in function characterized by

          • Hallucinations

          • Delusions

          • Disorganized speech

          • Disorganized behavior

          • Catatonic behavior

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Behavioral Disorders

Schizophrenia and other Psychotic Disorders

Negative Symptoms

  • Blunted affect

  • Emotional withdrawal

  • Lack of spontaneity

  • Anhedonia

  • Attention impairment

  • Persecutory, Grandiose, Bizarre –delusion types

  • Schizophreniform disorder – schizophrenia less than 6 months

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    Behavioral Disorders

    • Mood Disorders

      • Major Depression

        • Persistent depressed mood with loss of interest in usual activities for more than two weeks

        • Female > Male

        • IN SAD CAGES - Mnemonic

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    Behavioral Disorders

    • Axis I Disorders

      • Bipolar disorder

        • Onset 3rd to 4th decades

        • Mania cycling with major depression with periods of normal behavior

        • Depressive episodes more frequent than manic

        • Complications: substance abuse, marital and job problems, trauma, suicide – problems related to manic episodes

      • Dysthymic Disorder

        • Mild depression >2 years duration

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    Axis I Disorders

    Anxiety Disorders

    4-8% of population, may be higher in ED – perceived physical complaints

    Apprehension, fears and excessive worry with autonomic features


    Panic disorder

    Generalized anxiety disorder

    Phobic disorder

    Post-traumatic stress disorder

    Obsessive-compulsive disorder

    Behavioral Disorders

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    Behavioral Disorders

    • Axis I Disorders

      • Somatoform Disorder

        • Physical complaints or symptoms without any identifiable medical explanation

        • Conversion disorder-loss of function after psychological trauma

        • Somatization disorder-wide variety of complaints with no apparent medical cause - caution making this diagnosis in ED

        • Hypochondriasis - preoccupation with fear of serious illness despite appropriate medical evaluation

          • P.G. for those who have worked at Doctors, 156 visits last year

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    Behavioral Disorders

    • Axis I Disorders

      • Dissociative Disorder

        • Alteration in normal integration of identity and consciousness

        • Psychogenic amnesia-loss of memory for important personal details

        • Psychogenic fugue-loss of memory and assumption of new identity

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    Behavioral Disorders

    • Axis II Disorders – Personality Disorders

      • Lifelong pattern of behavior causing impairment in social or occupational functioning or causing considerable distress, unrelated to periods of illness

      • Most are unaware of their behavior and if become aware are unlikely to change

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    Behavioral Disorders

    • Axis II Disorders - Personality Disorders

      • Classifications – Table 288-3

        • Antisocial

        • Narcissistic

        • Paranoid

        • Obsessive-Compulsive

        • Dependent

        • Schizoid

        • Histrionic

        • Schizotypal

        • Borderline

        • Avoidant

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    Behavioral Disorders:Emergency Assessment

    • Psychiatric Emergencies

      • The acutely psychotic, suicidal or violent patient

      • Often present when lack of behavioral health resources - nights, weekends

      • ED Psychiatric Assessment

        • Is the patient stable or unstable?

        • Does the patient have a serious medical condition that is causing the abnormal behavior?

        • Is the cause psychiatric or functional?

        • Is psychiatric consultation necessary?

        • Should the patient be forcibly detained for evaluation?

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    Behavioral Disorders:Emergency Assessment

    • Safety

      • Violent patient – immediate restraint

      • Security and police are best trained

      • Violent or potentially violent should be disrobed and searched for weapons that can be used towards staff or the patient

      • Use non-threatening or non-judgmental tone – don’t make direct eye contact, submissive tone and posture

      • Allow room for escape – don’t let patient get between you and the door

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    Behavioral Disorders:Emergency Assessment

    • History

      • Change in behavior – confirmed by family if possible

      • Medical symptoms – rule out medical cause

      • Medical conditions

      • Medication history – prescription & OTC

      • Social history, alcohol, stressors – illicit drugs

      • Family history of psychiatric illnesses

      • Question family and friends

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    Behavioral Disorders:Emergency Assessment

    • Mental Status Examination

      • Psychiatric or medical disorder

      • MMSE – Table 289-1

        • Behavior

        • Affect

        • Language

        • Judgment

        • Orientation

        • Memory

        • Thought content

        • Perceptual abnormalities

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    Behavioral Disorders:Emergency Assessment

    • Physical Exam

      • Identify medical problems that may be causing behavior

      • Examine for evidence of trauma

      • Caution with

        • Abnormal mental status

        • Psychosis

        • Mental retardation

        • Elderly

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    Behavioral Disorders:Emergency Assessment

    • Laboratory

      • Urine toxicology

      • Urine pregnancy

      • Salicylate, APAP

      • Blood alcohol

      • ECG

      • Accucheck/Electrolytes

    • Consultation

      • Potential for suicidal or homicidal actions or psychotic

    • Don’t ignore abnormal vital signs

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    Behavioral Disorders:Emergency Assessment

    • Suicide

      • Major cause of death, especially the young

      • Suicide Characteristics (more common in suicide completers): older, male, lives alone or are physically ill

      • High risk psychiatric illnesses: Schizophrenia, substance abuse and major depression

      • Suicide attempts:

        • Drug overdose in large majority

        • Violent attempt (shooting, hanging, jumping) more likely to succeed and much more likely to try again if unsuccessful

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    Socially isolated

    Suicidal ideation

    Physical illness

    Social/Family structure loss

    Mental illness

    Suicidal attempts

    Repeated attempts

    Realistic plan

    Continuing thoughts of death

    Behavioral Disorders:Emergency Assessment

    • High Risk of Potential Suicide

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    Behavioral Disorders:Emergency Assessment

    • Disposition

      • Usually determined in conjunction with mental health professional

      • Criteria for discharge

        • Medically stable

        • Must not be intoxicated, delirious or demented

        • Treatment has been arranged

        • Precipitants to crisis have been addressed and reduced

        • Must not be imminently suicidal

        • Lethal means of self-harm removed

        • Agrees to return to ED if suicidal intent recurs

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    Behavioral Disorders:Emergency Assessment

    • Disposition

      • Criteria for Discharge

        • Physician believes patient will follow through with treatment plan

        • Caregivers and social supports (family) in agreement with discharge and treatment plan

      • If these cannot be assured, admission

      • Contracting for safety?

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    Psychotropic Meds

    • Be familiar with emergency indications, side effects, adverse reactions, and common interactions

    • 4 Classes

      • Antipsychotics

      • Anxiolytics

      • Antidepressants

      • Mood stabilizers, including anticonvulsants

    • Antipsychotics and anxiolytics have the most desired emergency utility

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    Antipsychotics (Neuroleptics)

    • These meds are symptom specific, not disease specific

    • They are useful for nearly all psychoses:

      • Primary (a result of psychiatric illness)

      • Secondary (substance induced or from general medical condition)

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    • In ED, most often used to control agitated or psychotic behavior that constitutes immediate danger to self or others

    • Contraindications – known allergy to the med or another drug in the same class

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    • Low potency antipsychotics (Thorazine) are rarely used due to significant hypotension side effect – rarely indicated in ED

    • High potency meds (Haldol) are safe even at high doses. They have few anticholinergic and alpha-blocking effects

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    • IV Haldol is not approved by FDA, but IV route has less extrapyramidal side effects than IM or oral routes, onset 10-20mins

    • Do not give Haldol to pts with

      • Parkinsons disease

      • Movement disorders

      • Anticholinergic toxicity

      • PCP toxicity

      • Pregnancy

    • Initial starting does 1-5 mg

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    • Max effective dose of Haldol is 10mg. Doses greater than 10mg only increases side effects and does not improve effectiveness or relief of symptoms

      • If need for increased relaxation add Ativan

    • Lower the initial dose in elderly, debilitated, brain injured, or those with AIDS

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    • To obtain rapid tranquilization, use Haldol with Ativan (2mg) effect.

    • Initial Haldol dose is usually 2-5 mg IM. May repeat in 30-45 minutes. Six doses max, in 24 hours.

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    Antipsychotics – Side Effects

    • Acute Distonia: Muscle spasms of the neck, face, and back

    • Most common side effect of antipsychotic meds

    • Less common: oculogyric crisis and laryngospasm

    • Diphenhydramine can also be used, 50-100 mg IV.

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    Antipsychotics – Side Effects

    • Akathisia: a sensation of motor restlessness with a subjective desire to move.

    • Can begin anytime after medication is started.

    • Worsened with increasing doses.

    • Treat with beta-blockers and lower the dose.

    • Cogentin and Benzodiazepines also effective

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    Antipsychotics – Side Effects

    • Parkinson Syndrome

      • Extrapyramidal Symptoms

        • Bradykinesia

        • Resting tremor

        • Cogwheel rigidity

        • Shuffling gait

        • Masked facies

        • Drooling

          • Often only one or two features are obvious

    • Usually begins in the first month of treatment.

    • Treat by lowering dosage and/or using anticholinergics

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    Antipsychotics – Side Effects

    • Anticholinergic Effects: range from mild sedation to delirium, dry mouth, blurred vision, urinary retention, constipation, and paralytic ileus.

    • Treat by stopping the antipsychotic and institute supportive measures as needed.

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    Antipsychotics – Side Effects

    • Cardiovascular Effects: Include QT prolongment, orthostatic hypotension, cardiovascular collapse

      • QT prolongation

      • Orthostatic hypotension

        • Neg. inotropic effect on heart and alpha adrengergic blockade.

      • Treat with IVFs and vasopressor support.

    • Almost exclusively seen with the low potency meds, although high doses of Haldol can cause torsades

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    Antipsychotics – Side Effects

    • Neuroleptic Malignant Syndrome: Idiosyncratic reaction manifested by rigidity, fever, autonomic instability (tachycardia, diaphoresis, and BP abnormalities) and a confusion state.

      • Flushing

      • Fever

      • High CPR in thousands

      • Leukocytosis ? LF shift

    • Mortality rate of 20%

    • Treat by stopping medication, IVFs, ICU support, and possibly dantrolene and valium

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    Atypical Antipsychotic Agents

    • Clozapine

      • Used in schizophrenia unresponsive to standard agents

      • Can cause: agranulocytosis, seizures, and respiratory depression

    • Risperdone

      • Probably safer than Clozapine

      • IM formulation for ED use

      • 2nd line agent

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    Atypical Antipsychotic Agents

    • Olanzapine

      • Similar to Risperdone

      • 2nd line agent

    • Ziprasidine

      • Profile similar to Risperdone

      • Waiting for studies to show effectiveness

      • Questionable ability to titrate

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    • Short term anxiolytic therapy may be helpful in the anxious, agitated patient during a crisis.

    • Useful in acute stressful situations unresponsive to reassurance.

    • Benzodiazepines are contraindicated in acute narrow-angle glaucoma.

    • Pregnancy is a relative contraindication.

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    • Rule out any serious underlying psychiatric illness, of which anxiety is a symptom.

    • Benzos are very effective anxiolytics with a high therapeutic index.

    • Non-benzos have much lower therapeutic indices and high addictive potential

      • Barbiturates

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    • With all Benzos, adjust dosage as necessary

      • Xanax

      • Ativan

      • Valium

      • Versed

      • Librium

    • Higher dosages may be needed in pts. with history of alcohol abuse or sedative use.

    • Decrease dose in those with hepatic disease or severe debilitation.

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    • Benzos potentiate other CNS depressants, so use with extreme caution with intoxicated pts.

    • Careful in pts with hypercarbia because they suppress hypoxic respiratory drive.

    • Caution with CO2 retainers (COPD)

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    Anxiolytics – Side Effects

    • Benzos side effects are usually mild

      • Drowsiness, decreased alertness, sedation and ataxia are the most common.

    • Decrease dose to treat.

    • If severe, give flumazenil 0.2mg IV over 15-30 seconds and then 0.2 to 0.4mg q 30-60 seconds up to 3mg total.

      • Careful of withdrawal symptoms

      • Go very slow – 0.2 increments

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    Anxiolytics – Side Effects

    • Don’t give flumazenil in chronic benzo use.

      • Can induce seizures.

    • Never prescribe more than week’s worth of benzos due to abuse potential.

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    • Previously Tricyclics, now called Hetero-cyclics (HCA’s).

    • Indications:

      • Major depression

      • Dysthymic disorder

      • Panic disorder

      • Agoraphobia

      • OCD

      • Enuresis

      • School phobia.

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    Antidepressants – Side Effects

    • HCA’s have low therapeutic indices. Most side effects are anticholinergic or cardiotoxic

      • Side effects can occur even at therapeutic doses.

    • Anticholinergic Effects: Most common, with other meds with anticholinergic effects: low potency antipsychotics, antiparkinsonian agents, and antihistamines

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    Antidepressants – Side Effects

    • Peripheral effects

      • Dry mouth

      • Metallic taste

      • Blurred vision

      • Constipation

      • Paralytic ileus

      • Urinary retention

      • Tachycardia

      • Exacerbation of narrow angle glaucoma

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    Antidepressants – Side Effects

    • Central effects

      • Sedation

      • Mydriasis

      • Agitation

      • Delirium

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    Antidepressants – Side Effects

    • Mild to moderate effects may be managed by dose reduction, changing to a med with fewer anticholinergic properties

      • Urecholine 10-25 mg tid.

    • Acute urinary retention:

      • Urecholine 2.5-5 mg SC.

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    Antidepressants – Side Effects

    • Cardiovascular Effects:

      • Non-specific T-wave changes

      • Prolonged QT interval

      • Varying degrees of AV block

      • Atrial and ventricular dysrhythmias.

    • Orthostatic hypotension especially significant in the elderly, due to alpha-adrenergic blockade.

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    Monoamine Oxidase Inhibitors

    • Therapeutic effects due to their ability to increase norepinephrine and serotonin in the CNS.

    • Indications:

      • Atypical severe depressive episodes, characterized by hyperphagia, hypersomnolence, reversed diurnal variation (symptoms worse at night), emotional lability, “leaden” paralysis (heavy arms or legs) and rejection hypersensitivity.

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    MAOIs – Side Effects

    • Fewer side effects than HCA’s.

    • Orthostatic hypotension, can be severe, usually responds to supportive therapy.

    • CNS irritability (agitation, motor restlessness, insomnia) managed by dose reduction or addition of benzodiazepine.

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    MAOIs – Side Effects

    • Autonomic side effects

      • Dry mouth

      • Constipation

      • Urinary retention

      • Delayed ejaculation

    • MAOIs block oxidative deamination of tyramine. May precipitate a hypertensive crisis when certain drugs or tyramine containing foods are ingested.

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    MAOIs – Side Effects

    • Tyramine containing foods:

      • beer

      • wine

      • aged cheese

      • chopped liver

      • sour cream

      • yogurt

      • pickled herring.

    • Symptoms include headache, HTN, cardiac dysrhythmias, restlessness, diaphoresis, mydriasis, and vomiting.

    • Phentolamine – antidote for malignant HTN

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    • Do not treat with beta blockers - may intensify vasoconstriction and worsen HTN.

    • Most patients recover completely within a few hours.

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    Selective Serotonin Reuptake Inhibitors

    • SSRIs are the most commonly prescribed anti-depressants

    • Indicated for treatment of major depressive episodes but also used for dysthymia and generalized anxiety disorders, panic disorders, and OCD.

    • Sertraline

    • Paroxetine

    • Flavoxamine

    • Citalopram

    • Escitalopram

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    • Favorable side effect profile and relative safety in overdose.

    • They have a high therapeutic index

    • Lack anticholinergic and cardiac effects like HCA’s.

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    SSRIs – Side Effects

    • Most common

      • HA

      • Dizziness

      • Sexual dysfunction

      • Nausea

      • Diarrhea

      • Insomnia

      • Agitation

    • Less common

      • Akathisia

      • Apathy syndrome

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    SSRIs – Side Effects

    • Discontinuation syndrome occurs especially with agents having shorter lives, Sertraline and Paroxetine

    • Typically presents several days after cessation:

      • Flu-like syndrome

      • Nausea

      • Vomiting

      • Fatigue

      • Myalgias

      • Vertigo

      • HA

      • Insomnia

      • Paresthesias

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    SSRIs – Side Effects

    • Treat by reinstating SSRI therapy and taper more gradually.

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    SSRIs – Serotonin Syndrome

    • Serotonin Syndrome: occurs when combining SSRIs with other serotonergic meds - MAOIs, HCAs, other SSRIs.

    • Syndrome presents as restlessness, tremor, myoclonus, hyperreflexia, seizures, and N/V/D.

    • Treat by stopping serotonergic agents and supportive care.

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    Mood Stabilizers

    • Lithium has been mainstay of bipolar treatment for years.

    • Anticonvulsants (Tegretol, Depakote, Lamictal, Topamax) are being used increasingly in management.

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    Mood Stabilizers - Lithium

    • Indicated for both acute mania and maintenance therapy in bipolar disorder.

    • Useful in some cases of major depression, and in some disorders characterized by episodic explosive outbursts or self-mutilation.

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    Lithium: Side Effects

    • Most serious side effects are due to toxic serum levels.

    • Mild side effects

      • GI distress

      • Dry mouth

      • Excessive thirst

      • Fine tremors

      • Mild polyuria

      • Peripheral edema

    • Most common during first few weeks of therapy and with therapeutic levels.

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    Lithium: Side Effects

    • Chronic side effects are unrelated to lithium levels and include

      • Polyuria

      • Nephrogenic diabetes insipidus

      • Benign diffuse goiter

      • Hypothyroidism

      • Skin rasher

      • Ulcerations

      • Psoriasis

      • Leukocytosis without left shift

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    Lithium: Toxicity

    • Severity of toxicity is related to the serum lithium level and duration of elevation.

    • Even in acute OD, symptoms may be delayed up to 48 hours.

    • Signs of toxicity include N/V, dysartheria , lethargy, and hand tremor.

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    Lithium: Toxicity

    • As toxicity worsens

      • Ataxia

      • Myasthenia

      • Incoordination

      • Hyperreflexia

      • Muscle fasiculations

      • Blurred vision

      • Scotoma

      • Coma

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    Lithium: Toxicity

    • Cardiovascular symptoms:

      • Nonspecific T-wave changes

      • Hypotension

      • AV conduction defects

      • Ventricular tachydysrhythmias

      • Vascular collapse.

    • Lithium toxicity may result in permanent neurologic impairment

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    • Work through different mechanisms to cause neuronal relaxation.

    • Used with rapid cycling, cyclothymic and mixed states of bipolar illness.

    • Other uses:

      • Impulsive aggression

      • Behavioral disturbances

      • Self-injurious behavior