- It’s common for most of Psychiatrists to feel lack of confidence and fear of what would happened during initial few months of independent practice… esp when we get tough/difficult cases esp with multiple diagnosis….
But if You know basics of interview esp establishing rapport and eliciting important diagnostic symptoms and basics of prescribing Psychiatric medicines, “You feel confident about Yourself only after starting to see responses to the medicines You prescribed”
- There is no need to feel that You r Young…
All depends on You feeling confident (ignore the insecurity) , becs it’s all depends how you talk to the patient and to the care takers.. and convincing (psychoeducating) about illness and about pattern of the therapy……
If You are confident, pt’s care takers don’t mind if You google or just have a look for reference once You start to prescribe medicines on spot ….
- Once diagnosis done, target the main illness or symptom…
and method of the prescribing:
Some Antipsychotics are to be given BD (as per half-life) e.g. Risperidone , Fluaxmine, Desvenlafaxine, Sodium valproate etc…
Some medicines to be prescribed only at night as they are significantly sedatives (Olanzapine, Amitriptiline etc)….
Some medicines should not be prescribed at night because they disturb sleep (except in combination with benzodiazepines) e.g : Fluvoxetine, Duloxetine, Escitalopram…
Some medicines depends on the dosage: e.g:
0.25 mg (or 0.125 mg) of Clonazepam is anxiolytic , but doesn’t cause sedation in a pt with Anxiety related disorders…
Quetiapine from 12.5 mg to 50 mg usually and sometimes 100 mg has only sedative effect but no antipsychotic effect (has to be something like 200 mg BD and beyond to get anti psychotic effects look for QT prolongation and EPS )
But most of our medicines has to be started from minimal doses and gradually increase every week or 10 days: e.g.
Fluoxetine 20 mg in an adult has no efficacy or effect (or minimal effect that too after minimum 20 days to 45 days of continuous intake)
Should be started as 1 (20mg) – 0 – 0 (not at night)
After 7 to 10 days as : 40 mg – 0 – 0 x wait for about 20 days for to get effects (fluoxetine & fluoxamine are best indicated for OCD and related illnesses)…
Till then we can get the symptoms subsidence by Clonazepam (0.25 mg 1 – 1 – 0) and Clonazepam or Etizolam (0.5 mg or 1 mg at night as SOS or to be advised that these benzodiazepines are to be tapered and stopped after few weeks & tell about its addictive potential if taken in same dosage regularly beyond 45 days or 2 months )
+/- Olanzapine 5 mg at night…
If patient has h/o consuming alcohol or other substances- may need higher doses of Benzodiazepines and if h/o cannabis use, he may need 10 mg of Olanzapine at night….
Here in this case:
History needs to elicited, if there is no OCD symptoms or depression or anxiety disorder as individual comorbid illness, there is no use of Fluoxetine & that too 20 mg least likely to have any significance & if it’s given at night, it has tendency to disturb sleep….
Need to elicit compliance of intake of Medicines: whether She taking daily or not (care takers should be asked to supervise)
20 mg Olanzapine is usually an optimum dosage to most of the patients (but has tendency to cause Metabolic syndrome…. so we use it initially then shift to less metabolic syndrome causing Antipsychotics like Risperidone , Amisupiride etc)
If patient is obese or having DM or Hypertension etc we can use Aripiorazole (start with 5 mg as morning dose and go on increasing [similarly Sertraline as morning only dose better in patients with Old patients of depressive disorder with smaller dosage of TCAs at night for short term and Gradually increase dose of Sertraline to 100 mg or 150 mg for longer time ]: (need to check weight during visits for most of our medicines even with Aripiprazole)
For an adult we can start with 2 mg of Risperidone at night or 1 mg BD and go on increase almost every 5 days…
Usually an adult needs 2 mg Trihexyphynidil (as 1 – 0 – 0 or 1 – 1 – 0 and never at night dose ) once we hit 6 mg or 8 mg per day, but for the safety we can star it by the time Risperidone reaches 4 mg per day…
We can give combination tablets (Risperidone 2 mg + THP 2 mg ) at morning and only Risperidone 2 mg or 3 mg as Night dose…. go on increasing it every 5 to 10 days upto maximum dosage like e.g. R 4mg +THP 2mg – 0 – R 4mg etc (if EPS present then one can add THP 2 mg as 0 – 1 – 0 )
Once patient has more than 50 to 70% improvements : start decreasing the Benzodiazepines doses and gradually keep on increasing the Antipsychotics or Mood stabilisers respectively etc….
Once patients reports of 70 to 90% improvements especially without any Benzodiazepines then keep the same dosage… and psycho educate “patient” and care takers for need of continuing same dosage (or slightly altered dosage by consultant) for 3 months to 2 years depending upon the “severity/frequency and kind” of illness or disorder
E.g. a pure OCD patient even if it is severe can be managed by 60mg or 80 mg of Fluoxetine alone and it should be continually taken for minimum 1 year before attempting to reduce 20 mg from 60mg or 80mg ….
And if a patient starts to get disturbing side effects beyond 60 mg Fluoxetine then one can add 5 mg of Olanzapine at night or 50 or 100 mg of Fluvoxamine or 250 to 500 mg of Sodium valproate depending upon other symptoms …. or can be given as Fluoxetine 60 mg – 20 mg – 0 x days
(e.g in case of Fluvoxamine prefered if patient is intolerant to Fluoxetine or if patient has Phobic disorders along with OCD or OC symptoms: 50mg – 0 – 50 mg or 0 – 0 – 100 mg for 10 days-> then 100 mg(or 50mg) – 0 – 100 mg then wait for 20 days to 30 days…. if persistent symptoms keep the Antipsychotics +/- benzodiazepine and increase Fluvoxamine to life 100 – 0 – 150 or 150 – 0 – 150 and wait for 20 days to 1 month and if patient is more than 80 to 90% improvements, then start tapering or stopping other drugs)
When a patient with multiple diagnosis maintaining well with multiple targeted Psychotropics, then one can start to tapper the drug (salt) of indication which is less clear or less troublesome…..
Most of the Antipsychotics (Not Antidepressants) and Benzodiazepines has broad spectrum action: it doesn’t mean that one can prescribe these in higher dosage for long term esp in patients with Depression, Anxiety disorders or RDD or BPAD….
also in contrast Mood stabiliser like Sodium valproate can be given as drug of choice not only Mania, Hypomania, Hyperthymia but also in Epilepsy disorders, Migraine, RDD (but Liver status should be checked) (so be careful while prescribing it and Chlordizapaxide in alcohol patients and IV Opioid Kali-peele ka patients )
For drug like Clozapine (usually kept as reserve Antipsychotic for Resistant Schizophrenia ), Blood DC esp Absolute Eosinophil count and Granulocyte count test should be ordered on regular basis or on any suspicion…..
I tried to tell few key treatment aspects…. rest depends on kind Illnesses , biology of patients, financial status of patients, severity of illnesses and compliance by patient etc…