Depression discontinuation

Desipramine and sertraline are efficacious for MS-related depression.15 If beta interferon treatment appears to be causing depression, discontinuation could be considered. 

Depression Observe patients who have a history of psychic depression. Discontinue the drug if the depression recurs to a serious degree. 

Monitoring Perform baseline and periodic leukocyte and differential counts and liver function studies. Fever or sore throat may signal serious neutrophil depression discontinue therapy if there is evidence of pathological neutropenia. 

For severe depression Discontinue treatment immediately and permanently obtain immediate psychiatric consultation... 

Moderate depression Decrease dose by 50%. If condition remains stable, continue reduced dosage. If symptoms improve and are stable for > 4 weeks, continue reduced dosage regimen or return to normal dose Severe depression Discontinue PEG-interferon a-2b permanently White blood cell count neutrophil count <750/mm or platelet count <80,000/mm Decrease dose by 50%... 

Like brines, alcohols were readily available and widely used as antifreeze Hquids in the early 1900s. Both methanol and ethanol offer exceUent heat transfer and efficient freeze point depression. However, the alcohols have the distinct disadvantage of their low boiling points. During the summer months when the engines operate hot, significant amounts of the alcohols are lost because of evaporation. These evaporative losses result in cosdy make-up requirements. Additionally, the alcohols have very low flash points and potentially flammable vapors. These safety concerns have, particularly in recent years, caused the use of alcohols to be completely discontinued for most heat-transfer systems. 

ETHAMBUTOL The nurse monitors for any changes in visual acuity and promptiy reports any visual changes to tlie primary health care provider. Vision changes are usually reversible if tlie drug is discontinued as soon as symptoms appear. The patient may need assistance with ambulation if visual disturbances occur. Psychic disturbances may occur. If die patient appears depressed, withdrawn, noncommunicative, or has otiier personality changes, the nurse must report the problem to the primary health care provider. 

Fyer AJ, Liebowitz MR, Gorman JM, et al Effects of clonidine on alprazolam discontinuation in panic patients a pilot study. J Clin Psychopharmacol 8 270—274,1988 Garvey MJ, Tollefson GD Prevalence of misuse of prescribed benzodiazepines in patients with primary anxiety disorder or major depression. Am J Psychiatry 143 1601-1603, 1986... 

Psychiatric adverse effects occur frequently and may include irritability, depression, and rarely, suicidal ideation. Individuals with a history of uncontrolled psychiatric disorders must weigh the risk versus benefit of treatment, as interferon may exacerbate or worsen the psychiatric condition. Patients who develop mild to moderate symptoms may require antidepressants or anxiolytics. Those with severe symptoms including suicidal ideation should have the treatment discontinued immediately.43... 

Depression is a common problem in patients with epilepsy, with approximately 30% having symptoms of major depression at some point.34 Patients with epilepsy should be routinely assessed for signs of depression, and treatment should be initiated if necessary. Certain AEDs may exacerbate depression, for example levetirac-etam and phenytoin. Other AEDs (e.g., lamotrigine, carba-mazepine, and oxcarbazepine) maybe useful in treating depression. Changes in mood can be precipitated by addition or discontinuation of an AED. If treatment for depression is necessary, caution should be exercised in choosing an agent that does not increase seizure frequency and does not interact with AEDs. 

Since early detection and intervention in schizophrenia is important for maximizing outcomes, treatment with antipsychotic medications should begin as soon as psychotic symptoms are recognized. Antipsychotic medications are the cornerstone of therapy for people with schizophrenia, and most patients are on lifelong therapy since non-adherence and discontinuation of antipsychotics are associated with high relapse rates. If other symptoms are present such as depression and anxiety, these symptoms should also be aggressively treated. Additionally, psychosocial treatments should be used concomitantly to improve patient outcomes. 

The initial dose of SSRI is similar to that used in depression. Patients should be titrated as tolerated to response. Many patients will require maximum recommended daily doses. Patients with comorbid panic disorder should be started on lower doses (Table 37-4). When discontinuing SSRIs, the dose should be tapered slowly to avoid withdrawal symptoms, with the possible exception of fluoxetine. Relapse rates may be as high as 50%, and patients should be monitored closely for several weeks.58 Side effects of SSRIs in SAD patients are similar to those seen in depression and most commonly include nausea, sexual dysfunction, somnolence, and sweating. 

Venlafaxine extended release, in doses of 75 to 225 mg/day, improves social anxiety, performance, and avoidance behavior with a reduction in disability.61 Treatment with venlafaxine results in response rates similar to those seen with paroxetine.60 Venlafaxine may be effective in SSRI non-responders.62 As with SSRIs, doses should be tapered slowly when discontinuing therapy. Tolerability is similar to that observed in depression trials with venlafaxine extended release. Common side effects are anorexia, dry mouth, nausea, insomnia, and sexual dysfunction. 

Benzodiazepines are used commonly in SAD however, there are limited data supporting their use. Clonazepam has been effective for social anxiety, fear, and phobic avoidance, and it reduced social and work disability during acute treatment.58 Long-term treatment is not desirable for many SAD patients owing to the risk of withdrawal and difficulty with discontinuation, cognitive side effects, and lack of effect on depressive symptoms. Benzodiazepines may be useful for acute relief of physiologic symptoms of anxiety when used concomitantly with antidepressants or psychotherapy. Benzodiazepines are contraindicated in SAD patients with alcohol or substance abuse or history of such. 

Common side effects noted include injection site reactions, weakness, dizziness, weight loss and flu-like symptoms, with depression being the most common reason for treatment discontinuation. ViraferonPeg is manufactured and marketed by Schering Plough. 

Adverse effects of /3-blockade include hypotension, heart failure, bradycardia, heart block, bronchospasm, altered glucose metabolism, fatigue, malaise, and depression. Abrupt withdrawal in patients with angina has been associated with increased severity and number of pain episodes and MI. Tapering of therapy over about 2 days should minimize the risk of withdrawal reactions if therapy is to be discontinued. 

BZ dependence is defined by the appearance of a predictable withdrawal syndrome (i.e., anxiety, insomnia, agitation, muscle tension, irritability, nausea, malaise, diaphoresis, nightmares, depression, hyperreflexia, tinnitus, delusions, hallucinations, and seizures) upon abrupt discontinuation. 

SSRIs are initiated at doses similar to those used for depression (see Table 68-13). If there is comorbid panic disorder, the SSRI dose should be started at one-fourth to one-half the usual starting dose of antidepressants. The dose should be tapered slowly during discontinuation to decrease the risk of relapse. 

The underlying cause of acute acidosis should be treated aggressively (e.g., administration of bronchodilators for bronchospasm or discontinuation of respiratory depressants such as narcotics and benzodiazepines). Bicarbonate administration is rarely necessary and is potentially harmful. 

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