Anxiety disorders bipolar disorder with

When is medication indicated in the treatment of psychiatric illness There is no short answer to this question. At one end of the continuum, patients with schizophrenia and other psychotic disorders, bipolar disorder, and severe major depressive disorder should always be considered candidates for pharmacotherapy, and neglecting to use medication, or at least discuss the use of medication with these patients, fails to adhere to the current standard of mental health care. Less severe depressive disorders, many anxiety disorders, and binge eating disorders can respond to psychotherapy and/or pharmacotherapy, and different therapies can target distinct symptom complexes in these situations. Finally, at the opposite end of the spectrum, adjustment disorders, specific phobias, or grief reactions should generally be treated with psychotherapy alone. 

Psychiatric medications do not currently play a prominent role in the treatment of cocaine-dependent patients (see Table 6.4). Although researchers have labored to find medications to treat cocaine addiction, there have not been any notable breakthroughs. As with other substance use disorders, the presence of a psychiatric disorder for which medication is indicated (i.e., depression, anxiety disorders, bipolar affective disorder, or schizophrenia) should prompt appropriate treatment. Similar to the presence of alcohol intoxication, deferring a diagnosis for a day or two in a new patient with no past history is often the more prudent course. 

In a retrospective chart review of 167 patients with a variety of anxiety disorders, excluding patients with evidence of current or previous mood disorder, manic episodes were recorded in five patients, a rate of 3% (20). While this might suggest a clear effect of SSRIs to induce mania, two of the patients were taking clomipramine, a tricyclic antidepressant, albeit a potent serotonin reuptake inhibitor. In addition, all the affected patients had additional diagnoses of histrionic or borderline personality disorder, known to be associated with mood instability. It is still therefore plausible that SSRIs cause mania only in patients with an underlying predisposition, although this may be more subtle than a personal or family history of bipolar illness. 

The primary uses for the SSRIs include MMD and bipolar depression (fluoxetine, paroxetine, sertraline, and citalopram), atypical depression (i.e., depressed patients with unusual symptoms, e.g., hypersomnia, weight gain, and interpersonal rejection sensitivity fluoxetine, paroxetine, sertraline, and citalopram), anxiety disorders, panic disorder (sertraline and paroxetine), dysthymia, premenstrual syndrome, postpartum depression, dysphoria, bulimia nervosa (fluoxetine), obesity, borderline personality disorder, obsessive-compulsive disorder (fluvoxamine, fluoxetine, paroxetine, and sertraline), alcoholism, rheumatic pain, and migraine headache. Among the SSRIs, there are more similarities than differences however, the differences between the SSRIs could be clinically significant. 

Rates of smoking among patients with bipolar disorders and anxiety disorders (e.g., posttraumatic stress disorder, panic disorder) are also higher than those in the general population (Lasser et al. 2000), but there has been htde smdy of the factors associated with motivation to quit smoking or of smoking cessation interventions in these patient groups. 

The mean age of onset of bipolar disorder is 20, although onset may occur in early childhood to the mid-40s.1 If the onset of symptoms occurs after 60 years of age, the condition is probably secondary to medical causes. Early onset of bipolar disorder is associated with greater comorbidities, more mood episodes, a greater proportion of days depressed, and greater lifetime risk of suicide attempts, compared to bipolar disorder with a later onset. Substance abuse and anxiety disorders are more common in patients with an early onset. Patients with bipolar disorder also have higher rates of suicidal thinking, suicidal attempts, and completed suicides. 

Bipolar I disorder affects men and women equally bipolar II seems to be more common in women. Rapid cycling and mixed mania occur more often in women. Individuals with bipolar disorder commonly have another psychiatric disease with 78% to 85% reporting another Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) diagnosis during their lifetime. The most common comorbid conditions include anxiety, substance abuse, and eating disorders.2... 

How can good pharmacotherapists be found First, check with experienced and respected colleagues, take note of which pharmacotherapists are referring patients to you, attend local educational meetings with psychiatrists, or, if there is a medical school nearby, attend the psychiatry department s grand rounds. Local patient advocacy and support groups, such as the Depression and Bipolar Support Alliance (DBSA), the National Alliance for the Mentally HI (NAMI), the American Foundation for Suicide Prevention (AFSP), and the Anxiety Disorders Association of America (ADAA), are valuable sources of information from the patient s perspective. 

In addition to treating insomnia, gabapentin has been used to treat epilepsy, anxiety disorders, and bipolar disorder. It is generally well tolerated with sedation and headaches being the only prominent side effects. Because gabapentin is excreted unchanged in urine, it does not require metabolism by the liver. It is therefore easily eliminated by elderly patients and those with liver disease, although it should be used with caution in those with poor renal (kidney) function. 

When all else fails, the patient may need to switch to another medication. Serotonin-boosting antidepressants are a reasonable alternative to benzodiazepines for patients with anxiety disorders. Likewise, there are several options for the bipolar patient who cannot tolerate GABAergic medications. 

Overall, the clinical picture of childhood MDD parallels the symptoms of adult MDD (Birmaher et ak, 1996b). There are some developmental differences, however. Symptoms of melancholia (e.g., lack of appetite, insomnia, lack of interest in anything), delusions, suicide attempts, especially high-lethality ones, are all less prevalent in young children and increase with age. In contrast, symptoms of anxiety, behavioral problems, and perhaps auditory and visual hallucinations seem to occur more frequently in children (AA-CAP, 1998 Birmaher et ah, 1996a). Also, it appears that the rate of onset of bipolar disorder is higher in... 

If relapse does occur, it should first be determined whether the patient was compliant with treatment. If the patient was not compliant, antidepressant medication should resume. If the patient was compliant and had been previously responding to the medication (without significant side effects), the existence of ongoing stressors (e.g., conflict, abuse) or comorbid medical or psychiatric disorders should be considered (anxiety disorder, ADHD, substance abuse, dysthymia, bipolar disorder, eating disorder). 

In four instances, the agency has invoked this rule at the time of approval of supplements for new indications for psychotropic drugs already approved for other psychiatric indications. It was noted in the approval letters for these supplements that, since the drugs in question would likely be used in children and/ or adolescents with the newly approved indications, the FDA required the sponsors of these products to conduct studies that would be pertinent to such use in the pediatric population. Since the products were ready for approval in adults, the FDA deferred the required pediatric studies to a future date. Alternatively, sponsors could make an argument for waiver of the requirement. The drug products and indications for which the FDA has required studies under the Pediatric Rule are as follows paroxetine for social anxiety disorder sertraline for post-traumatic stress disorder (PTSD) olanzapine for acute mania in bipolar disorder and fluoxetine in premenstrual dysphoric disorder (PMDD). 

---