Depression agitation and

The behavioral and emotional complications of dementia such as agitation, depression, and psychosis are often the most troublesome aspect of the illness. They can alienate the family members who are trying to provide care and often lead exhausted families to institutionalize these patients whom they would otherwise prefer to keep at home. 

Koukopoulos and Koukopoulos (1999) provided a remarkable discussion of varied manifestations of agitated depression and suggested that it should be viewed as a separate diagnostic entity called mixed depression. They warned about the risk of giving antidepressants to patients with agitated depressions ... 

The presence of other adverse drug reactions, often involving akathisia or stimulation along a continuum from irritability and agitation to agitated depression and mania, as well as indifference and apathy... 

Certainly, anxiety symptoms are seen in a very wide range of psychiatric disorders, including schizophrenia, mania, PTSD, agitated depressions, and severe personality disorders. It is important to keep in mind that anxiety symptoms do not necessarily signal a diagnosis of anxiety disorder. Almost without exception, however, when anxiety is associated with a more primary mental disorder, psychotropic medication treatment is aimed at the primary disorder. (Refer to appropriate chapters for descripfions of efiology and treatment.)... 

Acute benzene poisoning results in CNS depression and is characterized by an initial euphoria followed by staggered gait, stupor, coma, and convulsions. Exposure to approximately 4000 ppm benzene results in complete loss of consciousness. Insomnia, agitation, headache, nausea, and drowsiness may persist for weeks after exposure (126). Continued inhalation of benzene to the point of euphoria has caused irreversible encephalopathy with tremulousness, emotional lability, and diffuse cerebral atrophy (125). In deaths arising from acute exposure, respiratory tract infection, hypo- and hyperplasia of sternal bone marrow, congested kidneys, and cerebral edema have been found at autopsy. 

Although rare, benzodiazepine toxicity may occur from an overdose of the drug. Benzodiazepine toxicity causes sedation, respiratory depression, and coma. Flumazenil (Romazicon) is an antidote (antagonist) for benzodiazepine toxicity and acts to reverse die sedation, respiratory depression, and coma within 6 to 10 minutes after intravenous administration. The dosage is individualized based on the patient s response, widi most patients responding to doses of 0.6 to 1 mg. However, die drug s action is short, and additional doses may be needed. Adverse reactions of flumazenil include agitation, confusion, seizures, and in some cases, symptoms of benzodiazepine withdrawal. Adverse reactions of flumazenil related to the symptoms of benzodiazepine withdrawal are relieved by die administration of die benzodiazepine. 

The SSRIs are all chemically unrelated but their benefits and adverse effects are broadly similar. Their efficacy in depression is not superior to that of the TCAs but their side-effects (nausea, agitation, akathisia and sexual dysfunction), although sometimes problematic, are not life-threatening. They are also considerably safer... 

Differentiating between depression and dementia can be difficult, so symptoms of depression should be documented for several weeks prior to initiating therapy for the treatment of depression with AD. Citalopram and sertraline are recommended as first-line agents because of their efficacy in placebo-controlled trials.49 Indications for the use of antidepressants include depression characterized by poor appetite, insomnia, hopelessness, anhedonia, withdrawal, suicidal thoughts, and agitation. 

Pediatric patients should be observed closely for suicidality, worsened depression, agitation, irritability, and unusual changes in behavior, especially during the initial few months of therapy or at times of dosage changes. Furthermore, families and caregivers should be advised to monitor patients for such symptoms. 

Altretamine has shown activity in the treatment of ovarian and lung cancer. This orally administered drug has the dose-limiting side effects of anorexia, nausea, vomiting, diarrhea, and abdominal cramping. Other side effects include neuropathy, agitation, confusion, and depression. 

Implications of the prototypic classification method are that categories within the system will possess fuzzy boundaries. Individuals within a category will be somewhat heterogeneous and may not share any common features. In our depression example, a prototypic classification scheme may yield a diagnosis of depression in one patient who shows agitation, anhedonia, and suicidal ideation and the same diagnosis in another patient who shows sadness, fatigue, worthlessness, and decreased appetite. 

Trazodone (Desyrel). Trazodone was the first of the atypical antidepressants and was actually introduced prior to the SSRIs. It does not have the serious cardiac toxicity or anticholinergic side effects of the TCAs and was the most popular antidepressant until the arrival of the SSRIs. It is approved for the treatment of depression and is also commonly used in low doses to treat agitation in demented patients and insomnia. 

Nefazodone is approved for treatment of major depression and appears particularly effective iu treatiug depressed patieuts with agitation or anxiety. Its role in treating anxiety disorders is being studied. 

Before the arrival of the new antidepressants, the older tricyclic antidepressants were widely used to treat depression and agitation in demented patients. They have now largely been abandoned in these patients as their prominent anticholinergic effects tend to worsen dementia and the increased risk for cardiac toxicity can be especially dangerous in geriatric patients. 

Among these choices, bnspirone is preferred if the patient is also experiencing anxiety. If the patient is depressed and agitated, a SSRI should be tried first. Second line choices inclnde carbamazepine (Tegretol) or one of the atypical antipsychot-ics—ziprasidone (Geodon), risperidone (Risperdal), olanzapine (Zyprexa), quetiap-ine (Seroquel), or aripiprazole (Abilify) can be tried. If psychotic symptoms are present, one of the atypical antipsychotics should be tried first. 

Q83 Flumazenil is a specific agonist used in anaesthesia to reverse the CNS depressant effects. Flumazenil should not be administered quickly to avoid too-rapid wakening, which could result in agitation, anxiety and fear. 

Tranylcypromine ( rans-2-phenylcyclopropylamine, TCP, 8a) has close structural similarity to amphetamine (2-amino-1-phenylpropane) and is known as a nonhydrazine, nonselective, and irreversible inhibitor of both MAO A and B. It is also a potent reversible inhibitor of CAOs [36,37], Tranylcypromine has an important clinical use for treatment of certain depressive illnesses, particularly of nonendo-genous and atypical depressions and depressions associated with anxiety, agitation, phobias, and anergia [38-40], In combination with lithium, it is also applied for treatment of refractory depression [41], Recent reports also discussed MAO inhibitors as useful agents against neurodegenerative disorders such as Parkinson s or Alzheimer s diseases [42], Despite impressive clinical successes, clinical use of tranylcypromine and other MAO inhibitors is limited by various problems, including the cheese effect discussed in Section 1,... 

Some patients may experience jitteriness, restlessness, muscle tension, and disturbed sleep. These side effects typically occur early in treatment, before the antidepressant effect. All patients should be informed of the possibility of these side effects and be reassured that if they develop, they tend to be transient. In patients with preexisting anxiety, therapy should be started at low doses, with subsequent titration as tolerated. If overstimulation occurs with this approach, it will be less likely to be severe enough to result in nonadherence with therapy. The short-term use of a benzodiazepine also may help the patient cope with overstimulation in the early stages of treatment until tolerance to this side effect occurs. Despite these common transient stimulating effects, SSRIs are clearly effective in patients with anxiety or agitated depression. Similarly, insomnia that commonly occurs early in treatment may be tolerable if the patient is reassured that the side effect will be transient. Symptomatic, short-term treatment with a hypnotic at bedtime is reasonable. 

It is indicated in depression, illness accompanied by anxiety, agitation, restlessness and disturbances of sleep masked depression dysphoria and depression in alcoholics childhood bed wetting. It is also useful for prophylaxis of migraine. 

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