MEDICAL ALGORITHMS FOR

PSYCHIATRIC DISORDERS

CONTENTS
Diagnosis and Treatment of Post-traumatic Stress Disorder ............................... 2 Obsessive-compulsive Disorder (OCD).............................................................. 3 Pharmacotherapy of Panic Disorder ................................................................. 4 Anxiety Disorder ............................................................................................... 5 Unipolar Depression Management ..................................................................... 6 Tardative Dyskinesia Management ..................................................................... 7 ADHD Comorbid With Depressive Disorder ...................................................... 8 Acute Treatment of Mania ................................................................................. 9 Treatment of Chronic Major Depression ........................................................... 10 CTB for Depression ......................................................................................... 11 Schizophrenia Treatment ................................................................................. 12 Co-existing Symptoms of Schizophrenia in Acute Phase .................................. 13 Depression and Libido ..................................................................................... 14 Dopaminergic Pathways in Parkinsons Disease .............................................. 15 Dementia Management .................................................................................... 16 Bipolar Disorder Management .......................................................................... 17 Evaluation of Tremor ........................................................................................ 18 Depressive Symptoms Management ................................................................. 19 Diagnosis and Treatment of Premenstrual Dysphoric Disorder .......................... 20

Diagnosis and Treatment of Post-traumatic Stress Disorder

Sign and symptom

History of trauma?

Four or more symptoms positive on screening?

Yes Meets DSM-IV criteria for PTSD?

No

Yes Initiate treatment with an SSRI

No Provide support monitor patient and consider treating individual symptoms

Comorbid psychiatric illness?

Yes Treat comorbid substance abuse, mood disorder, or other anxiety dosrder; provide support and patient education; and consider referral for psychotherapy

No Monitor patient receiving SSRI, provide support and patient education, and consider referral for psychotherapy

DSM-IV criteria: Diagnostic and statistical manual of mental disorder, 4th edition.

Source: Am Fam Physician 2003;68:2401-08.

MEDICAL ALGORITHMS FOR

PSYCHIATRIC DISORDERS

Obsessive-compulsive Disorder (OCD)

Repetitive behaviors Dermatitis Depression Anxiety

Screen for OCD

Diagnose OCD by DSM-IV-TR

Serotonergic antidepressant

Referral for behavioral therapy

Titrate to recommended dose, minimum 10-weeks trial

Inadequate response

Change to another serotonergic antidepressant with adequate dose trial

Inadequate response

Referral to psychiatrist

Source: Prim Care Companion J Clin Psychiatry 2004;6(5):198.

Pharmacotherapy of Panic Disorder

Panic disorder

Short-term benzodiazepines only if needed

SSRI

If ineffective

Cognitive behavior therapy or Different SSRI or TCA, nefazodone or venlafaxine

If ineffective

Augmentation with TCA, benozodiazepine, buspirone, -blocker, bupropion, or valproate sodium or Benzodiazepine or MAOI

Cognitive behavior therapy

Source: Am Fam Physician 2002;66(8):1477-84.

MEDICAL ALGORITHMS FOR

PSYCHIATRIC DISORDERS

Anxiety Disorder
Stage 0

Diagnostic assessment and family consultation regarding treatment alternatives Nonmedication treatment alternatives

Any stage(s) can be skipped depending on the clinical picture.

Stage 1

Atomoxetine

Methylphenidate or amphetamine

ADHD and anxiety both improved Continuation No response of ADHD or anxiety

ADHD and anxiety both improved ADHD symptoms improve but not anxiety

No response of ADHD or anxiety

Stage 2 Methylphenidate or amphetamine

Atomoxetine

Add an SSRI

Maintenance

ADHD = Attention deficit hyperactivity disorder SSRI = Selective serotonin reuptake inhibitor

Source: Journal of the American Academy of Child and Adolescent Psychiatry 2006;45(6):642-57.

Unipolar Depression Management

Trial of an SSRI or SNRI

No response

Augment preferably with lithium, an atypical antipsychotic, (i.e., risperidone or olanzapine) modafinil, or triiodothyronine; other options include bupropion or mirtazapine (limited controlled data to date)

No response

Response

A trial of a TCA or MAOI

Maintain the patient on a combination of mirtazapine and nefazodone

No response

Augment with lithium, triiodothyronine and/or an atypical antipsychotic

No response

MAOI : Monoamine oxidase inhibitor SNRI : Serotonin norepinephrine reuptake inhibitor SSRI : Selective serolonin reuptake inhibitor TCA : Tricyclic antidepressant

Consider electroconvulsive therapy

Source: Current Psychiatry 2003 supplement p.No.22.

MEDICAL ALGORITHMS FOR

PSYCHIATRIC DISORDERS

Tardative Dyskinesia Management

Tardative Dyskinesia

Switch gradually to an atypical antipsychotic other than clozapine and discontinue anticholinergic

TD improved: maintain atypical antipsychotic

TD Persists
Switch to a second atypical antipsychotic other than clozapine TD improved: maintain atypical antipsychotic

TD Persists
TD worse or the same: switch to clozapine

Consider suppressive therapy with a classical agent in combination with an atypical agent (1st choice) or alone (2nd choice) or with tetrabenazine (3rd choice)

TD Persists

Choice A: add donepezil

Choice B: add melatonin

Choice C: add vitamin B or E

Choice D: add branched chain amino acids

Source: Can J Psychiatry 2005;50:703-695.

ADHD Comorbid With Depressive Disorder

Diagnostic Assessment and Family Consultation Regarding Treatment Alternatives

Stage 0

Any stage (S) can be skipped depending on the clinical picture

Non-Medication Treatment Alternatives

ADHD more severe

MDD more severe

Stage 1

Begin ADHD therapy - Stage 1

Begin Major Depressive Disorder (MDD) therapy - Stage 1

Both MDD and ADHD improve Continuation

ADHD improved, no response of depression

ADHD and/or depressive symptoms worsened

Depressive symptoms improve, no response of ADHD

Stage 2

Begin MDD therapy, add to ADHD treatment

Discontinue ADHD therapy begin MDD therapy

Begin ADHD therapy add to MDD treatment

ADHD = Attention Deficit Hyperactivity Disorder

Source: Journal of the American Academy of Child and Adolescent Psychiatry 2006;45(6):642-657.

MEDICAL ALGORITHMS FOR

PSYCHIATRIC DISORDERS

Acute Treatment of Mania

Acute Mania

Emphoric

Mixed/Dysphoric

Phychotic

Rapid Cycling, currently manic

Dvp Add Li or Cbz Add AAp Dvp + Li + Cbz

Li or Dvp

Dvp

Dvp or Li + AAp or CAp

add Bzd add AAp Dvp + Li change AAp Dvp + Li + Cbz Change Ap or add Bzd Dvp + Li Change Ap or combine AAp + CAp

*
Clz

*
Lmg

*
Gbp

offer ECT

*
offer ECT

Mild/moderate residual symptoms

Severe residual symptoms

offer ECT

*
Gbp or Tpr

Dvp + Li + Cbz or add Clz*

*
Tpr or T4 or calcium channel blocker

*
Gbp or Tpr

*
Clz or Gbp or Tpr

Legend AAp atypical antipsyhotic Ad Ap antidepressant antipsychotic

Dvp ECT Gbp Lmg Li T3 T4 Tpr

divalproex electroconvulsive therapy gabapentin lamotrigine lithium triiodothyronine L- thyroxine topiramate

Bzd benzodiazepine CAp conventional antipsychotic Cbz carbarnazepine Clz clozapine

* When adding second-line medications, discontinue 1 or more of the previous medications. Avoid combining carbarnazepine
and clozapine.
Source: Postgrad Med Special Report 2000:1-104.

Treatment of Chronic Major Depression

Stage1 Prescribe monotherapy SSRI, bupropion nefazodone, venlafaxine, mirtazapine or psychotherapy Remission achieved?

Yes
Continue therapy

Yes
Augment monotherapy with lithium, thyroid, or buspirone Remission achieved?

No Yes Partial response? No

Stage 2 Switch to different monotherapy SSRI, bupropion, nefazodone, venlafaxine, mirtazapine, or psychotherapy Remission achieved?

No Yes

Continue therapy

Yes
Augment monotherapy with lithium, thyroid, or buspirone Remission achieved?

No Partial response? No

Yes

No

Stage 3 Combine treatments antidepressant+ psychotherapy TCA+SSRI bupropion+SSRI nefazodone+SSRI bupropion+nefazodone antidepressant+antipsychotic Remission achieved?

Yes

Continue therapy

No
Stage 4 Consider electroconvulsive therapy Remission achieved?

Yes

No
Stage 5 Consider adding other drugs Mirtazapine+ bupropion anticonvulsants, antipsychotics Remission achieved?

Yes
Continue therapy

No
Consider novel treatments per psychiatrist Maintenance phase when indicated

Source: The Journal of Family Practice 2003;52:3:207.

MEDICAL ALGORITHMS FOR

PSYCHIATRIC DISORDERS

CBT for Depression

Patient meets DSM-IV criteria for unipolar major depression but does not have mania or psychosis

No Initiate management of bipolar of other disorder or refer patient for comanagement

Yes Depression is mild to moderate

No Depression is severe

Yes Discuss options and agree on treatment plan (pharmacotherapy, psychotherapy, or both)

Recommend pharmacotherapy and psychotherapy (e.g.,CBT); consider referral

Pharmacotherapy selected

No Suggest CBT or other psychotherapy

Yes Depression is in clinical remission

Yes Consider CBT, longer treatment, increase in dosing or change in medication Offer CBT to reduce relapse or improve response

CBT: cognitive behavior therapy DSM-IV criteria: Diagnostic and statistical manual of mental disorder, 4th edition.

Source: Am Fam Physician 2006;73:83-86, 93.

Schizophrenia Treatment
No History of Typical Antipsychotic Failure Olanzapine or Quetiapine or Risperidone (Any stage [s] can be skipped depending on the clinical picture) Use in any order Acute Exacerbation First presentation or not nonresponder to olanzapine, quetiapine or risperidone History of Typical Antipsychotic Failure Olanzapine or Quetiapine or Risperidone Use in any order

Stage 1

Nonresponse to one
Stage 2
Use Another

Nonresponse to one
Haloperidol Decanoate or Fluphenazine Decanoate

Noncompliance

Noncompliance

Use Another

Nonresponse to one

Nonresponse to two
Stage 3
Use the Third

Nonresponse
Use the Third

Nonresponse to two
Use the Third

Nonresponse to two

Nonresponse to three
Typical Antipsychotic

Nonresponse

Nonresponse to three
Typical Antipsychotic

Stage 4

Nonresponse

Stage 5a

Clozapine

Partial response
Clozapine + Augmenting Agent (typical or atypical antipsychotic, mood stabilizer, ECT, antidepressant)

Stage 5

Nonresponse

Nonresponse or clozapine refusal

Stage 6

Atypical+ Typical Combination of Atypicals, Typical or Atypical + ECT

Source: Am J health syst Pham 2003.

MEDICAL ALGORITHMS FOR

PSYCHIATRIC DISORDERS

Co-existing Symptoms of Schizophrenia in Acute Phase

Agitation/ Excitement Insomnia Depression Aggression/ Hostility

Add PO/IM Benzodiazepine PRN or PO/IM Antipsychotic drug PRN

Add Benzodiazepine PRN or Zolpidem PRN

Add: SSRI Venlafaxine Bupropion Mirtazapine

Add Typical Antipsychotic drugs first

No response

No response: (diagnosis ok, medical ok, substance abuse ok)

No response

Trazodone Add PO/IM Benzodiazepine PRN (See Note) or PO/IM Antipsychotic drug PRN Go to next stage of Antipsychotic Treatment Algorithm Add Valproate and/or increase dose of current drug

No response

Use other drug indicated

Source: Tima Physician Procedural Manual 2000;9(sect. 2-2).

Depression and Libido

Treat depression with SSRI. Discuss libido/sexual functioning with patient in context of depression, evaluation and treatment. Consider causative factors other than SSRI (relationship issues, etc.).

Has libido/sexual functioning improved/been maintened with treatment of depression

Improved/normal

No Improvement

Decreased: probable medication effect

Continue treatment with SSRI

Consider

Evaluate for comorbid illness (e.g., diabetes, endocrinopthy)

Substance abuse (alcohol, drugs)

Relationship issue (marital discord)

SSRI effect

Consider: Testosterone level Hormone replacement Other, as indicated by assessment

Substance abuse treatment

Marital/family counseling. as needed

Consider: Decreased dosage SSRI holidays Add bupropion SR,wellbutrin 150 mg in the morning Discontinue SSRI and change to: Bupropion SR, 150 mg twice daily or Nefazodone, 200 to 600 mg daily

Source: Am Fam Physician 2000;62:782-86.

MEDICAL ALGORITHMS FOR

PSYCHIATRIC DISORDERS

Dopaminergic Pathways in Parkinsons Disease

Dopaminergic neuron degeneration Dorsal (motor) dopaminergic striatal pathway degeneration

Ventral (non-motor) dopaminergic striatal pathway degeneration

Long-term dopaminergic treatment

Other factors?

Visual hallucinations Psychotic Symptoms

Motor symptoms

Source: J Neuropsychiatry Clin Neurosci 2006;18:149-57.

Dementia Management
Clinical suspicion of dementia History and physical examination

Mini-Mental State Examination (MMSE)

< 24

> 24

Assess for depression; consider using Geriatric Depression Scale or psychiatry consult.

Positive

Consider neuropsychologic testing or subspecialist evaluation (i.e., neurology, psychiatry, geriatric medicine).

Positive

Negative

Negative

Treat for depression; reassess in three to six months.

MMSE < 24

Work-up for reversible causes of dementia: laboratory testing (thyroid-stimulating hormone, B12); consider neurologic imaging

Reevaluate every six months

Normal MMSE and congnition normal

Abnomal

Alzheimers disease likely

Treat reversible cause

Recheck every three months

Reevaluate cognition

No change

Improved

Alzheimers disease likely

Recheck every three months

Source: Am Fam Physician 2005;71:1745-50.

MEDICAL ALGORITHMS FOR

PSYCHIATRIC DISORDERS

Bipolar Disorder Management

Euphoric Stage 1 Monotherapy*
Nonresponse: Try alternate monotherapy

Mixed VPA, ARP, RIS, ZIP 1b. OLZ or CBZ

Response Partial Response

Li, VPA, ARP, QTP, RIS, ZIP 1b. OLZ or CBZ

Response Partial Response

Nonresponse: Try alternate monotherapy

CONT

Stage 2 Two-Drug Combination*

Li, VPA, AAP Choose 2 ( not 2AAPs, not ARP or CLOZ)

Partial Response or Nonresponse

Response

CONT

Stage 3 Two-Drug Combination*

Li, VPA, AAPs, CBZ,OXC,TAP Choose 2 ( not 2 AAPs, not ARP or CLOZ)
Response Partial Response or Nonresponse

CONT

CONT= Continuatioan

Stage 4

ECT or Add CLOZ or Li + VPA or + AAP CBZ or OXC

*Use targeted adjunctive treatment as necessary before moving of next stage: Agitation/Aggression - clonidine, sedatives Insomia - hypnotics Anxiety - benizodazepines gabapentin

Li = lithium CBZ = carbamazepine LTG = lamotrigine OXC = oxcarbazepine TPM = topiramate VPA = valproate AAP = atypical antipsychotic ARP = aripiprazole CLOZ = olanzapine RIS = risperidone QTP = quetiapine ZIP = ziprasidone TAP = typical antipsychotic ECT = electronconvulsive therapy

Source: J Clin Psychiatry 2005;60:870-86.

Evaluation of Tremor
Postural Patient taking medications that may cause trernor Kinetic Task specific (handwriting,occupational)?

Resting Patient taking medications that may cause tremor?

Yes Yes Yes No

No

No

Possible durg Induced parkinsonism

Other signs of Parkinsons disease (rigidty bradykinesia Postural instability)? Possibledurg Induced tremor History of alcohol abuse? Task specific kinetic trernor Trial off medication
Yes No No

Intention trernor

Trial off drug

History of chronic alcoholism?

Yes

Classic Parkinsons disease Possible early Parkinsons disease

Possible alcohol withdrawal tremor

Other signs or symptoms of systemic disease? Alcohal tremor

Yes No

Yes

No

History of lithium toxicity?

Trial of dopaminergic agent

Monitor

Enhanced physiologic

Essential tremor

Yes

No

Test for hyperthyrcidism hypoglycerina, panic attack, benzodiazepine withdrawal

Trial of blocker, primicone [Mysoline]

Toxic tremor

MRVCT of head to rule out stroke, tumor, Multiple sclerosis

Source: American Family Physician 2003: 68(8).

Depressive Symptoms Management

Depressive Symptoms

Dysthymia

Major depression

Milder depression

Moderate severity and above

Consider

Alternatives to antidepressants for mildto-moderate severity

Educate, support problem solving and monitor

MEDICAL ALGORITHMS FOR

Antidepressant at proven effective dose

Consider

If no response, and with history or persistent

Partial response after four weeks Check: diagnosis compliance dosage social factors

Nonresponse to antidepressant after four weeks

Continue treatment for two more weeks (up to five more weeks in the elderly)

Action: ensure other physical/psychiatric conditions are treated address if necessary increase if necessary address if necessary

No response after four weeks adequate treatment or insufficient partial response after six weeks adequate treatment

Increase dose or switch to another class of antidepressant

PSYCHIATRIC DISORDERS

Failure to respond to second antidepressant

Refer to secondary care (where an augmenting agent or psychotherapy may be added, or treatment with an MAOI or ECT be given)

Source: Supplements Archive 2000;11: 23.

Diagnosis and Treatment of Premenstrual Dysphoric Disorder

Patients with suspected PMS/PMDD

Obtain history, conduct physical and mental status examinations

Presence of a physical or psychiatric disorder

Absence of a physical or comorbid psychiatric disorder

Treat that disorder

Confirm diagnoss using symptom checklist prospectively for two consecutive menstrual cycles and assess severity of symptoms

Mild to moderate severity and dysfunction (PMS)

Severe symptoms and dysfunction (PMDD)

Provide education and recommed lifestyle changes, nutritional, or nonnutritional interventions

Limited response

Consider lifestyle changes and SSRI (preferally during luteal phase only

Optimal response: Continue this approch

Optimal reponse contiune SSRI and lifesyle changes

Limited response

Consider another SSRI during luteal phase with lifestyle changes

Optimal reponse contiune intermittent use of SSRI during luteal phase with lifesyle changes

Limited response

Consider cogntive behavioral therapy or luteal phase specific low dose alprazolam and/or symptom focused therapy and lifestyle changes

Optimal reponse contiune alprazolam intermittently or the other therapies

Poor response
Consider GnRH agonist or danazol for two to three cycles
Source: Am Fam Physician 2002;66:1239-48.