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Psychiatric Medications
Post-traumatic stress disorder (PTSD)
↑↑ role of psychological therapies with EMDR (eye movement desensitisation and reprocessing)
First line
SSRI: paroxetine
Second line
ANXIETY DISORDERS
TCA: amitryptiline
NASSA: mirtazapine
All patie
nts should be offered psychological interventions as a first line option or as an adjunct
Third line
to pharmacological therapy
MAOI: phenelzine
Se lf help materials
DEPRESSION
BT in groups or individually
Anxiety management therapy: combination of education, relaxation and graded exposure
Mild depression
Ps ychodynamic psychotherapy
Do not use antidepressants routinely
If patient
s present in an anxiety CRISIS they may require a short course of anxiolytic therapy to
Offer psychological interventions: self-help materials, CBT, or counselling
provide r apid response whilst longer-term treatment is being established
Consider medication if:
MAXIMUM OF 4 WEEKS’ ANXIOLYTIC THERAPY due to high risk of dependency
Past history of moderate/severe depression Be nzodiazepines: diazepam 2mg TDS, chlordiazepoxide 10mg TDS
Persistent subthreshold depressive symptoms (i.e. lasting over 2 years) Az apirones: buspirone 5mg BD/TDS
Mild depression persists after psychological interventions Sedative antihistamines: promethazine 25-50mg OD
Moderate to severe depression
Generalised anxiety disorder (GAD)
First line
Fir st line
SSRI: fluoxetine or citalopram
SSRI: fluoxetine, citalopram, paroxetine, or sertraline
Second line
SNRI: venlafaxine or duloxetine
NASSA: mirtazapine
SARI: trazodone
NARI: reboxetine or lofepramine
Se cond line
MAOI: moclobemide
Third line (severe depression)
Specialist
SNRI: venlafaxine or duloxetine
Clonidine (off-patent indication) TCA: clomipramine, imipramine or amitryptiline
Panic dis order
Refractory depression (failure to respond to 2 or more antidepressants)
First line
Consider PRN propranolol if attacks are infrequent/predictable
Combinations of antidepressants e.g. SSRI + NASSA, SNRI + NASSA SSRI: fluoxetine, citalopram or paroxetine
NARI: reboxetine or lofepramine
Augment therapy with lithium or atypical antipsychotics Se cond line
TCA: clomipramine or imipramine
Third line
BIPOLAR DISORDER
MAOI: phenelzine or moclobemide
Sp ecialist
Acute manic episode (manic symptoms lasting >1 week)
Clonidine (off-patent indication) First line
Phobic disorder
Atypical antipsychotics: olanzapine, risperidone or quetiapine
Fir st line
Second line
Consider PRN propranolol for situational anxiety or predominating physical symptoms
Augment antipsychotics with lithium, sodium valproate, carbamazepine or lamotrigine
SSRI: fluoxetine, citalopram or paroxetine
Acute depressive episode (depressive symptoms lasting >2 weeks)
Se cond line
Antidepressants are not used routinely in bipolar disorder, as they increase risk of rebound
TCA: clomipramine or imipramine
don’t prescribe them without antimanics Th ird line
First line
MAOI: phenelzine or moclobemide
Atypical antipsychotics: quetiapine, olanzapine in combination with fluoxetine
Obsessive compulsive disorder (OCD)
Antiepileptics: lamotrigine
First line
Long-term treatment (prevention of relapse through mood stabilisation)
SSRI: paroxetine
Again, antidepressants aren’t used routinely
Second line
First line
TCA: clomipramine
Third line
Second line
MAOI: phenelzine or moclobemide
Either replace or augment lithium therapy with other drugs Specialist
Antiepileptics: sodium valproate, carbamazepine or lamotrigine
Clonidine (off-patent indication) Atypical antipsychotics: quetiapine, olanzapine or aripiprazole
Atypical antipsychotics e.g. olanzapine Laura Jayne Watson 2011

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