Psychiatric illness with depression

Widerlov, E., Wahlestedt, C., Hakanson, R. Ekman, R. (1986) Altered brain neuropeptide function in psychiatric illness - with special emphasis on NPY and CRF in major depression. Clin. Neuropharmacol. 9, 572-574. 

Medications that have been used as treatment for anxiety and depression in the postwithdrawal state include antidepressants, benzodia2epines and other anxiolytics, antipsychotics, and lithium. In general, the indications for use of these medications in alcoholic patients are similar to those for use in nonalcoholic patients with psychiatric illness. However, following careful differential diagnosis, the choice of medications should take into account the increased potential for adverse effects when the medications are prescribed to alcoholic patients. For example, adverse effects can result from pharmacodynamic interactions with medical disorders commonly present in alcoholic patients, as well as from pharmacokinetic interactions with medications prescribed to treat these disorders (Sullivan and O Connor 2004). 

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. 

First, you will learn about the human nervous system and how it works when it is healthy. This will include an introduction to the structure (anatomy) of the nervous system and the function (physiology) of the nervous system. Next, we ll describe the things that can go wrong. We ll look at how the system breaks down and malfunctions. Then we ll show you how these breakdowns can result in psychiatric illness. Finally, we ll introduce you to the medications used to treat psychiatric illness. You will learn where these medications work and our best guess of how they work. The presumed mechanism of action of many medications is just that, presumed. In contrast to antibiotics, in which we know quite a lot about the ways that they kill bacteria or stop them from reproducing and how these mechanisms ultimately effect a cure for an infectious disease, less is known about how psychotropic medicines work. Oh, we pretty well understand what psychotropic medicines do when they reach the nerve cell. For example, most of the antidepressants used today block the reuptake of serotonin at the nerve cell, but we re still not sure why blocking serotonin reuptake gradually improves mood in someone with depression. This will lead to a tour, if you will, of what happens to a medication from the time the pill is swallowed, until it exerts its therapeutic effect. 

Third is the presence of other psychiatric or medical disorders. This can help gnide antidepressant selection in several ways. In some cases, an antidepressant may be preferred becanse it can treat both disorders. For example, the extensive evidence that flnoxetine is an effective treatment for bnlimia nervosa makes it preferable for patients with depression and bnlimia. Similarly, the depressed Parkinson s disease patient whose nenrological illness results from a lack of dopamine in a particular area of the brain may have both her depression and her Parkinson s disease improved by bnpropion, which increases brain dopamine activity. In other cases, an antidepressant shonld be avoided if it worsens the other illness or interacts adversely with a medication needed to treat the other illness. For example, TCAs and MAOIs can complicate glncose control in diabetics and shonld not rontinely be used by depressed diabetics. (See Table 3.11.)... 

Historically, the treatment of alcohol use disorders with medication has focused on the management of withdrawal from the alcohol. In recent years, medication has also been used in an attempt to prevent relapse in alcohol-dependent patients. The treatment of alcohol withdrawal, known as detoxification, by definition uses replacement medications that, like alcohol, act on the GABA receptor. These medications (i.e., barbiturates and benzodiazepines) are cross-tolerant with alcohol and therefore are useful for detoxification. By contrast, a wide variety of theoretical approaches have been used to reduce the likelihood of relapse. This includes aversion therapy and anticraving therapies using reward substitutes and interference approaches. Finally, medications to treat comorbid psychiatric illness, in particular, depression, have also been used in attempts to reduce the likelihood of relapse. 

Insomnia Due to Another Psychiatric Illness. Insomnia is often a symptom of mood and anxiety disorders. Depression is classically associated with early-morning awakening of the melancholic type, whereas so-called atypical depression leads to hypersomnia. Anxiety commonly leads to problems falling asleep. These patterns are not invariable. One should therefore always perform a thorough assessment for anxiety or depression in patients complaining of insomnia. 

In this case, a more careful psychiatric and physical examination can be of help. Although there are admitted similarities to depression and the negative symptoms of schizophrenia, Parkinson s disease is also associated with a resting tremor, called cogwheel rigidity, and at times drooling. These other symptoms are not typically due to psychiatric illness. If these symptoms are present, one should investigate the possibility of a medication side effect or the presence of Parkinson s disease. 

Steroid psychosis Steroid psychosis is characterized by a delirious or toxic psychosis with clouded sensorium. Other symptoms may include euphoria, insomnia, mood swings, personality changes, and severe depression. The onset of symptoms usually occurs within 15 to 30 days. Predisposing factors include doses greater than prednisone 40 mg equivalent, female predominance, and, possibly, a family history of psychiatric illness. 

The field of antidepressant research was revolutionized in the late 1980s by the introduction of selective serotonin reuptake inhibitors (SSRIs), exemplified by fluoxetine (9). In addition to their antidepressant action, SSRIs have also proven effective for a broad range of psychiatric illnesses, and, more importantly, they demonstrated an improved tolerability profile as compared to TCAs and MAOIs due to their increased selectivity. On the other hand, SSRIs proved inferior to TCAs and MAOIs in their reduced antidepressant effects, slower onset of action, lower remission rates, and decreased ability to control the physical symptoms associated with depression. 

Several people found themselves in a difficult double bind. Intimacy demands honesty, yet questions of authenticity do not stop with disclosure of one s psychiatric history. Recall that people suffering from mental illnesses like depression remain deeply confused about whether... 

Structure is also essential in complex biological molecules. A lot of medicines used for psychiatric illnesses such as depression rely on their ability to interact with certain proteins in the brain. For instance, a class of antidepressants—medications that alleviate the symptoms of depression—act on proteins involved with the collection (reuptake) of the chemical serotonin, and they are known as selective serotonin reuptake inhibitors (SSRIs). This class of antidepressants includes Prozac and Zoloft. Earlier medications were also effective and are still sometimes used though they produce a number of side effects, such as dietary problems. Although an SSRI can also generate potentially dangerous side effects, psychiatrists tend to observe these effects less often. (Brain chemistry is the subject of chapter 3.)... 

GAD affects about 4 million Americans. It usually manifests after childhood and before a person reaches middle age. ft happens about twice as often in women as in men. Symptoms must persist for at least six months before a diagnosis of GAD may be made. In addition, GAD often occurs along with other psychiatric illnesses, such as depression or bipolar disorder, or with drug abuse, which probably leads to an underestimation of the amount of people affected by this disorder. There is some evidence that the disorder has a genetic component... 

Depression as an emotion is common and usually short-lived. As a symptom it can occur in most psychiatric disorders as well as other medical conditions, e.g. hypothyroidism, Parkinson s disease. As an illness, major depressive disorder (MDD), it is less common but, nevertheless, moderate to severe forms affect 5-10% of people in their lifetime and milder forms 20-30%. After a first episode, prophylaxis is required for at least 6 months and ideally 12 months to prevent relapse. This should usually be with the dose of antidepressant to which the patient initially responded. Those with recurrent episodes require prophylaxis over many years. 

Progressive inactivity, dissatisfaction with social life, and presence of medical and psychiatric illness can be most predictive of insomnia in old age [6, 7], In modern societies higher rates of insomnia are present in women, people who are less educated or unemployed, separated or divorced, the medically ill, and those with depression, anxiety, or substance abuse [8], In a number of studies, insomnia has been found to be correlated with frequent use of medical facilities [9-13], chronic health problems [13-18], perceived poor health [17], increased use of drugs [10,14], and specific medical conditions including respiratory diseases [19-21], hypertension [21], musculoskeletal and other painful disorders [19-24], heart diseases [19, 23], and prostate problems [19], On the other hand, chronic insomnia predisposes to the development of psychiatric disorders [25-27], Therefore, it is important to clearly establish whether co-morbidities are causative for, or simply co-exist with insomnia, in order to recommend the most appropriate treatment. This is why it is better to categorize insomnia as a disease rather than as a symptom [28],... 

The hypnogram of a patient with an underlying psychiatric illness may be characterized by a delay in sleep onset, the presence of residual muscular activity causing frequent awakenings, fragmented sleep, reduced REM and slow-wave sleep, and day-time drowsiness. Such disorders are generally not associated with a recent or transient event and the cause cannot usually be identified. Often such changes in the sleep architecture are associated with major psychiatric disorders such as depression, mania, psychosis or severe anxiety states. 

A 36-year-old woman with a history of psychiatric illness, including paranoid disorder, depression with panic episodes, and stress disorder, was found dead in bed. Caffeine, risperidone, and zolpidem were found in her urine. 

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