Page �1 Vol 1, March 2016

Vol 1, March 2016

Forum for Psychiatry Resident is an educational website created by Dr Harvinder Singh and Dr Satinderpal Kaur, for the purpose of sharing and discussing comprehensive source of information regarding all aspects of Psychiatry and Neurology. This is our first newsletter dedicated to accomplishing this task in a newsletter format. The topics and questions posted in newsletter are high yield for ABPN and PRITE exam preparation.

Table of Contents:

Psychopharmcology: Skin Rashes with Mood Stabilizers Page 2

Addiction Psychiatry: Medications for Alcohol use disorder Page 3

Geriatric Psychiatry: Evaluation & Management of Driving Risk in Dementia Page 4

Journal Club: Dose Response Relationship of Selective Serotonin Reuptake Inhibitors in Major Depression Disorder.

Page 5

Question Series: For ABPN and PRITE Exam Preparation Page 6-7

NEWSLETTER

EDITORS

Harvinder Singh, MD

Satinderpal Kaur, MBBS

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Source: (1) Am J Clin Dermatol 2004;5:3-8.; (2) Br J Dermatol 1983; 109 (1);9-13.; (3) Epilepsia 1999; 40:985-991.; (4) N Engl J Med. 1994;331:1272-1285.

MEDICATIONS ASSOCIATED SKIN RASH

LITHIUM (1) Acne:Onset: first 6 months of treatment.Mechanism: Lithium included increase in circulating neutrophil chemotaxis, stimulating lysosomal enzyme release, and induce follicular hyperkeratosis.Common Presentation: monomorphic, papulopustular eruption of the trunk and extremities.Treatment: Antibiotics; Benzoyl Peroxide; Tretinoin. (Source: 1)

(2) Psoriasis:Onset: ranges from a few weeks to several months.Mechanism: Lithium induced decrease in cAMP & Inositol lowers intracellular calcium, resulting in lack of differentiation & increased proliferation of keratinocytes, enhanced chemotaxis and leukocytes phagocytic activity.Common Presentation: typical plaque type lesions affecting knees, elbows & scalp.Treatment: topical corticosteroids, topical retinoids, UV light. (Source: 2)

CARBAMAZEPINE & LAMOTRIGINE

(1) Morbiliform Rash: Benign and common.Onset: 2-8 weeks after initiation of medication.Risk: Higher dose; Rapid titration; lamotrigine and valproate coadministration.Presentation: Measles like appearance.Treatment: Disconinue medications (rash resolve 1-2 weeks after discontinuation); antihistamines. (Source: 3)

(2) Stevens-Johnson Syndrome: Rare dermatologic emergency.Onset: 1-3 weeks after initiation of medication.Presentation: small blisters on purpuric macules, producing target lesions. Associated with fever, sore throat, chills, and malaise and corneal scarring.Mechanism: immune-complex-mediated hypersensitivity reaction.Treatment: Discontinue medication; Supportive systemic steroids; infection control & associated skin care. (Source: 4)

PSYCHOPHARMACOLOGY: ✓Skin Rashes with Mood

Stabilizers

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Source: SAMHSA, HHS Publication No. (SMA) 15-4907

NALTREXONE ACAMPROSATE DISULFIRAM

MECHANISM OF ACTION

Blocks mu opioid receptors, which reduces reinforcing effects of alcohol with resultant decreased feelings of intoxication & less craving

Blocks glutaminergic NMDA receptors & activates 3-Amino butyric acid type A receptors

Blocks acetaldehyde dehydrogenase causing buildup of acetaldehyde with resultant nausea, flushing & tachycardia

CONTRA- INDICATIONS

- Long term opioid therapy or heroin use disorder- Hepatitis or liver failure(*check LFT monthly X 3months then Q3monthly)

- Severe renal impairment (Cr Cl < 30 mL/min)Note: dose adjustment needed in Cr Cl 30-50 mL/min.

- Concomitant use of alcohol or alcohol contining prep or Metronidazole.- Psychosis, coronary artery ds, severe myocardial disease.- Not recommended in: Seizure, Peripheral neuropathy, Cirrhosis with portal hypertension.

SIDE EFFECTS - well tolerated- Nausea (most common s/e), headache, anxiety, sedation

- well tolerated- transient diarrhea (most common s/e)

Disulfiram-Alcohol reaction, metallic taste, dermatitis, hepatotoxicity, peripheral neuropathy, psychosis, optic neuritis.

PREGNANCY FDA Category C FDA Category C FDA Category C

BREAST FEEDING

Transfer of naltrexone and 6ß-naltrexol into human milk has been reported with oral naltrexone.

not known whetheracamprosate is excreted in human milk

Do not give disulfiram to nursing mothers.

DRUG INTERACTIONS

Opioid medications no clinically relevant interactions

warfarin, isoniazid, metronidazole, phenytoin, any non prescription drug contining alcohol.

ADULT DOSE - 50 mg/day in single dose.- Patient should be opioid free for minimum of 7-10 days.- Naloxone challenge test should be employed in at risk patient.- Monitor LFTs

- 333 mg #2 (666 mg) TID- 333 mg # 1 daily for Cr Cl 30-50 mL/min.- Monitor Renal function

- 250 mg/day (max 500 mg/day)- Not to take Disulfiram for at least 12 hour after drinking alcohol- Alcohol-Disulfiram reaction can occur put 2 weeks after last dose

ADDICTION PSYCHIATRY ✓Medications for Alcohol

Use Disorder Treatment

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Source: 2010 American Academy of Neurology.

GERAITRIC PSYCHIATRY ✓Evaluation & Mgmt of

Driving Risk in Dementia

For patients with dementia, the Clinical Dementia Rating (CDR) scale is established as useful for identifying patients at increased risk for unsafe

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OBJECTIVE Previous meta analysis demonstrated flat dose response within therapeutic range of antidepressants and increased side effects at higher doses; but this meta analysis is limited by grouping all classes of antidepressants together. This present meta analysis is designed to find if higher doses of SSRIs are associated with improved outcome.

METHOD - PubMed searched for randomized placebo-controlled trials examining the efficacy of SSRIs for treating adults with major depressive disorder. - All medication doses were transformed into imipramine-equivalent doses. - longitudinal data were analyzed with a mixed-regression model. - Endpoint and tolerability analyses were analyzed using meta-regression and stratified subgroup analysis by predefined SSRI dose categories.

RESULTS - Included 4 studies= 10,039 participants- Higher doses of SSRIs were associated with greater therapeutic response- this association only flattens out at higher end of recommended dosing range (> 250 mg imipramine equivalents)- Greatest measured efficacy of SSRIs were in dosing range of 200-250 imipramine equivalents. - Higher doses of SSRIs were associated with an increased likelihood of dropouts due to side effects and and decreased likelihood of all-cause dropout.- Limitation: publication bias & strict inclusion criterias.

JOURNAL CLUB ✓Dose Response

Relationship of SSRIs

Systemic Review and Meta Analysis: Dose Response Relationship of Selective Serotonin Reuptake Inhibitors in Major Depression Disorder.

Am J Psychiatry 173:2. Feb 2016

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Question Series: ✓For ABPN and PRITE Exam

Preparation

(Q): Which of the following is a predictor of poor response to lithium prophylaxis?(a) Family history of bipolar disorder(b) Melancholic features during depressive episodes(c) Mixed episodes(d) Elated manic episodes

(Answer): (c) Mixed episode

PSYCHOLOGICAL PREDICTORS:

Predictors of a good response to lithium prophylaxis include:

Initial good response to lithium during the first 6-12 months of treatment (most reliable predictor of favourable response to lithium)Elated manic episodesPositive familial history of bipolar disorders (especially those known to be responsive to lithium)Absence of comorbid personality disordersBipolar type I disordersMelancholic features during depressive episodesMDI pattern in the illness course Early onset of lithium treatment.

PSYCHOLOGICAL PREDICTORS:

Predictors of a poor response to lithium prophylaxis include:

Mixed episodes (most reliable predictors of poor response to lithium)Rapid cycling bipolar disordersComorbid alcohol and/or drug abuseMood disorders with incongruent psychotic featuresEarly onset bipolar disorder before the age of 18Discontinuation of lithium treatmentHigh number of previous affective episodes in the illness course before lithium initiation and DMI pattern.

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(Q.1) Patient is a 74 year old male with history of parkinson’s disease is brought by family members for recent worsening of auditory hallucinations. He was evaluated for underlying medical causes and workup was negative. The non-pharmacological interventions were unsuccessful and symptoms are causing significant distress to him.

Which Antipsychotic is Preferred for Management of Psychosis in Elderly with Parkinson's Disease?

(a) Risperidone(b) Olanzapine(c) Quetiapine(d) Aripiprazole

(Q.2) A 26 year old male presented to outpatient clinic for evaluation of premature ejaculation. After evaluation and treatment discussion, patient agreed with plan of adding an antidepressant.

Which of the following antidepressant is most effective in treatment of premature ejaculation?

(a) Fluoxetine(b) Clomipramine(c) Paroxetine(d) Sertraline(e) Citalopram

BIOLOGICAL PREDICTORS: Predictors of a good response to lithium prophylaxis include:- High RBC/plasma-lithium ratio (one of the most controversial predictors of a favourable response to lithium in the literature) - Higher platelet serotonin-induced calcium mobilization- High rate of red blood cell membrane phospholipids, especially of phosphatidylcholine, and a phospholipid implicated in lithium intracellular transport. - Brain lithium concentrations above 0.2 mEq/L when measured by 7Li-MRS- Decreased cerebral intracellular pH and white matter hyper intensity at (31)P-MRS - High intensity of loudness dependence auditory-evoked potentials (LDAEP)

Predictors of a poor response to lithium prophylaxis include:- Epileptiform anomalies with diffuse theta waves on electroencephalography- Decreased cerebral phosphocreatine levels at (31)P-MRS

Source: Encephale. 2008 Sep;34(4):394-9.

Answers for above questions with explanations will be posted in next issue of newsletter.

Disclosures: No financial support. Please check the source references provided at each page for more information on post topics.

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