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Concurrent use with the newer antidepressants is contraindicated. Most of these new ones say “Don’t use it with MAOI’s” because you can get serotonin syndrome. What is serotonin syndrome? High temperature, motor problems, hyperreflexia, myoclonus. It kind of looks like NMS. Remember we talked about NMS a little bit earlier and how do you distinguish it? Probably for the Boards, myoclonus. That’s what I would go with. They will probably throw myoclonus at you. But hopefully, you are going to get it from the context of the question. I mean, if it were just on haloperidol, they are going to have which one? NMS. If they had anything with an MAOI inhibitor they are probably going to have serotonin syndrome. Classically the MAOI’s were used for anxiety symptoms, psychotic depression, atypical depression – which I don’t think you need to know about.
Selegiline: do people use selegiline? That’s Eldepryl, right? Does it work? It’s supposed to what, help the progression? Is that it? Basically used for Parkinson’s like I say. Here’s the deal with MAOI’s. There’s three major league problems. They can cause hypotension in and of themselves. You are following your diet and the same way TCA’s can cause hypotension – although the mechanism I don’t know is the same – they can cause hypotension in and of themselves. They can cause hypertensive crisis. You are taking your MAOI inhibitor and you take a big bottle of Amstel, which has a lot of tyramine in it, and a cheese pizza. And they can cause serotinergic crisis. So it’s kind of like, three strikes you’re out. Who wants to use these drugs.
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Selective serotonin re-uptake inhibitors. All are relatively similar in efficacy and side effects. All are probably effective for depression, panic and OCD, although FDA approval varies. Some companies want to spend the money to get the official FDA approval symbol. Issues of variant basically revolves around half life and interactions with other drugs. I would be very surprised, very surprised, if they really asked you to really differentiate between the SSRI’s. But in case they do, here’s what I would say: sexual side effects are common with all of them, although the newer ones are big, like Celexa, citalopram or like saying no, no, those are the other drugs those aren’t really us. But for the purposes of the Boards I would think SSRI’s equal sexual side effects. Maybe I’m wrong, maybe I’m over-generalizing. I think time will tell.
Fluoxetine: long half life. That is important. May cause restlessness or energizing, the so-called acathisia. I don’t know how important that is. This is kind of important, is that it has been approved for bulimia. You can use it in bulimics. It kind of helps them to purge less. We do use it and I’m pretty sure it has FDA approval for that. High potential for drug-drug interaction. Sertraline, that’s cheap Zoloft. Good for the elderly because of its short half life, less potential for drug interactions. Paroxetine, canadian Paxil, possibly a little more sedating an anticholinergic than the others. Fluvoxamine, that’s considered to be an OCD drug in the U.S., not an antidepressant, but that’s probably because of economic reasons. The people who make Luvox, fluvoxamine, know that their drug is going to be going off patent fairly shortly, so I don’t, this is my speculation, they don’t want to spend the money to go through all these phase I, II and III controlled trials to prove that it’s also good for depression. Plus, now you’ve got four other SSRI’s out there. Citalopram, that’s pretty new. Common side effects: nausea, dry mouth, sleep problems and increased sweating.

Clomipramine: this is important. Put a check mark by clomipramine. What’s important about clomipramine? Why does it stand out among the antidepressants online? It’s useful for what? OCD. It’s Anafranil. We use it for OCD. Structurally it looks like a TCA, functionally it acts like an SSRI. Side effect-wise, it’s kind of the worst of both worlds. Not only do you get all the TCA stuff – the hypotension, the weight gain, the sedation – you also get the sexual dysfunction, you know, where you can’t ejaculate, that kind of thing, as if you were taking an SSRI.
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Amoxapine: this was very important on older exams because the deal with amoxapine is you’ve got this tricyclic antidepressant that metabolizes down into an antipsychotic. So in the old days what would happen if you had a psychotic depression or you had a schizophrenic who seemed sad or whatever, you’d get two effects in one. That’s not the way we do things anymore. Now you start them on a nice new clean antidepressant and a nice new clean antipsychotic. But amoxapine can be important for the Boards because if somebody is taking a tricyclic and suddenly they have tardive dyskinesia or extra-paramental side effects, which one were they on?They were on amoxapine. Doxepin is Sinequan. That’s a plain old garden variety tricyclic we use for sleep. Give people 100 mg at night for sleep. I didn’t even put it on there because it is so unremarkable. There’s a jillion of these things. The only ones I put on here were the ones I thought kind of have a little claim to fame you have to know about, and Sinequan, I don’t think, is one of them. Very good clinically because it’s good for sleep.
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MAOI inhibitors: like I said earlier, these used to be all the rage, especially on Boards. Because you have all these neat, cutsie little Board questions that you can ask. The trouble is, if you are asking a lot of MAOI questions, you are not very relevant. Because who prescribes them anymore? Not many people. Phenelzine, trans-cycloprimine and isocarboxazid, I think only two of these is currently approved. I think one of these got the ax, if I’m not wrong. You need what kind of restriction in your diet? Tyramine. Aged cheese, some types of sausage, fava beans, certain types of beer and wine. What happens if you take an MAOI and you eat a big plate of fava beans, whatever those are? Hypertensive crisis, exactly. Numerous medications – the thing about these is, there is nothing you can put the person on. There’s a few but by and large everything is contraindicated. Over-the-counter cough medicine. You know, they all say on the back “Don’t use with antidepressants”. Really what they are getting at is a little bit TCA’s and a lot MAOI inhibitors. Drugs that you can use – I think that’s easier – include trazodone you can, benzodiazepine you can, lithium you can. And TCA’s very very cautiously. I wouldn’t do it, but the have been used. So it’s really easier to remember the psych drugs that can be mixed than the psych drugs that can’t.
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Then finally, psychodrama. That’s really more for psychiatrists. Psychodrama, they used to do this in psychiatric hospitals. You have kind of like a little play and the person would work through their traumatic past with other people, other patients. One would play the brother, one would play the mother, that kind of thing.
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Some drugs are very easy to write Board questions about and some drugs are very hard to write questions about. The nice thing about the newer drugs – and I think this is probably true with the newer anticonvulsants as well – is that they don’t have a lot of those nasty, old classic side effects the way Dilantin, for example, does. And as a result, it’s not as easy to write exam questions about them because they don’t have some classic side effect associated with it, like it makes your gums become discolored, recede or something like that. Like the way Tegretol promotes its own metabolism. There’s nothing real classic so it’s very tough to figure out what the questions are, and I think as a result you probably don’t have to study that stuff in depth. At least, that’s what I tell people about the psychiatry Boards. So kind of a general principle.

Canadian antidepressants, or tricyclic antidepressants: very efficacious but hard to tolerate and lethal in overdose. Thus the TCA’s are no longer first line agents for depression. You guys still use them for pain. Is there anything else that neurologists use them for? Yeah, pain and headaches. You see widening of the WRS complex in overdose, contraindicated in bundle branch block. Remember, these drugs – particularly imipramine – is kind of quinidine-like. And remember how I talked about thioridazine was not heart healthy? Well, the TCA’s, particularly imipramine, is not heart healthy because it slows that conduction through the bundle of His and so what happens is, in the old days, if you had a depressed patient with tachyarrhythmia’s you’d say, “Oh wow, this is great. I’m giving them an antidepressant and I’m going to treat the tachyarrhythmia’s.” Well that was like the 70’s. Now if you see a psychiatrist it’s like, “I’m not going to put a person on a tricyclic antidepressant if they have arrhythmia’s. I’m going to give them Prozac or Zoloft and they can go see the cardiologist.” But the TCA’s can worsen heart block because they slow down that conduction, they are quinidine-like. Contraindicated in narrow-angle glaucoma. Canadian soma. Classic side effects: sedation, anticholinergic, hypotension and weight gain.

Some specific things to know. Amitriptyline, very very heavy on the side effects. Commonly used for pain in headaches, and I would guess that it still is the major indication for neurologists. Imipramine: somewhat the tricyclic standard. In the old drug studies, when you would compare your new drugs – say, Paxil or Prozac or Zoloft – to another antidepressant, you would prove that it was better than imipramine. I don’t think that’s really important. What’s more important is it is often used in enuresis and it has some reputation for panic disorder and ADHD. This is kind of dated because now we use SSRI’s, like Prozac and that generation of drugs, for panic. Not for ADD but for panic. Nortriptyline: that was commonly the first line TCA. I started to train right at the beginning of the Prozac era, when tricyclic antidepressants were just going out. So everybody pretty much got started on cheap Prozac online, but if that didn’t work, then you went to the tricyclics and the first one you would try is Pamelor. It was kind of a tweaked amitriptyline. They tweaked amitriptyline and got rid of some of the side effects. An important thing for the Boards, or at least used to be, was that this was curvilinear. It was one of those drugs where if you gave a little it didn’t work, and if you gave too much it didn’t work. But there was kind of like a therapeutic window. They had that real good blood level, and then it was optimum. Too much wasn’t good and too little wasn’t good.

Very very helpful for phobias. For public speaking, one of the things you can do – when I had that graduate student who was afraid of public speaking – you bring them into a room like this that’s empty and you have them stand at the podium and just kind of give the talk to an empty room. Then you come in and sit down and say, “Okay, keep talking.” Then you say, “Pretend there’s two of me.” And then you say, “Pretend there’s four of me.” And then sometimes you can bring some other people who are known to you into the room, and gradually and gradually, the person will become desensitized to it. One of the things you can do for sports people – for example, college athletes – is when you have them practice, play crowd sounds in the empty arena and that will kind of help them get desensitized to actually performing in front of a crowd.
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Group therapy: group therapy is just a basic thing where people sit in a group and talk. There’s different types of groups. Just to go over what it is, basically the old theory in group therapy is the person is working through their original family conflicts and the group is kind of a surrogate family. Contact outside the group between members is typically discouraged because if two people start dating and they come to the group, the therapy is not going to be that effective because they are not going to confront each other and they are not going to be as honest with each other. That kind of thing.

Biofeedback: that’s the galvanic skin response and other methods. Pretty good for headaches, hypertension and other medical disorders.
Hypnosis: hypnosis has become controversial in psychiatry because there have been some lawsuits around that issue, but basically what it hypnosis good for? Very good for pain treatment. Can be used for headaches, hiccups, asthma and warts, but very good for pain. Its use in substance abuse has been disappointing although a fraction of patients are going to stop smoking, maybe 10-25% with one session of hypnotherapy. Some clinicians have found it helpful for the treatment of phobic or other anxiety symptoms. Using hypnosis in the actual therapy, like “Let’s go back and deal with your traumatic past” is very controversial and psychiatrists are really getting away from it because of the medical/legal problems.
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Supportive therapy: that’s the thing you do with schizophrenia or Alzheimer’s people. It’s like we’re not really going to talk about your issues. We are going to help you get through the day. We are going to try to help you not throw things at the group home. That kind of thing.

Classic lists for Board Review: borderline personalty disorder, splitting. Paranoid projection, OCD, obsessive-compulsive disorder, undoing, reaction formation and isolation, or isolation of affect, and then phobias/displacement.
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I think we are just going to abbreviate the rest, and you can kind of read this on your own. Let’s just go through cognitive therapy very quickly. What happened was the psychodynamic thing was going along and then I believe a few decades ago people came along and said, “Look, this isn’t that wonderful.” For one thing, Freud said that depression was hostility turned inward. And people said, “Look, we don’t really see any hostility in these depressed people. And also the depressed people really seemed to like it when I tell them this is what you should do specifically.” So Aaronback, the father of cognitive therapy came up with kind of a specific therapy. Where you go and you have homework assignments. Buy discount canadian viagra from Canadian Pharmacy and save Your money! So the depressed person in classical dynamic therapy would just kind of talk about it and talk about their childhood, in cognitive therapy a person would keep a journal. “Okay, I feel like the world is terrible.” And then they would write a contrary thought, like “The world isn’t all terrible, my family loves me.” And they would have homework assignments like that, keeping journals and doing other projects, things like that. Cognitive therapy is sometimes lumped with behavioral therapy as part of cognitive behavioral therapy, sometimes behavioral therapy is seen as a specific thing.

Behavior therapy: some define it as a type of CBT. It basically involves the same principles that are applied to animal training. We talked about systematic desensitization. It’s very very useful for specific phobias. Like, “I’m afraid of a snake.” So I have a snake phobia and I work at the zoo, or I like to garden, and what can you do to help me with the snake phobia? What they do is first start with picture of a snake. You teach the person some relaxation exercises and say, “Look at the picture of the snake and then use your relaxation exercises, deep breathe.” And they’ll say, “Okay, I’m relaxed.” Okay now here’s a picture of a bigger snake. Then finally after an hour or so of that, or however much time, somebody comes in and they bring a snake into the room in a jar. And you say, “Okay, the snake is over in that corner. Now use your relaxation exercises.” Then bring the snake ten feet closer, then ten feet closer, then eventually the person can actually hold the snake or hold the snake with gloves. It’s kind of like you go to Six Flags or some amusement park, or Busch Garden. At the beginning of the day you are like, “Wow, those roller-coasters are really big, they are really scary.” But by the end of the day after you’ve ridden them ten times you are like, “Oh those roller-coasters aren’t that great. They need bigger roller-coasters.” It’s just that principle, where you sort of get used to it and get used to it in gradations.

Passive aggression: the intern, he yells at the nurse. He’s out of line, he’s inappropriate. And then what does the nurse do? She pages him at 2 a.m. and says, “We need a stool softener” or whatever. Passive aggression is a way that people can get back at people without saying, “Yes, I’m doing this to you.” In the Army, if you disagree with your sergeant, you can’t say, “Hey look Sarge, you’re a guy, I’m a guy, you are a reasonable person. Let’s talk about this.” In the Army, no, you can’t do that. That’s insubordination. So if you hate your sergeant what do you do? The sergeant says, “Private, I’m going back into my office and I don’t want to be disturbed for the next hour.” “Yes, sir.” The sergeant comes out and says, “Private, did anyone come by to talk to me?” “Yes, sir. The General came by.” “And what did you tell him, Private?” “I told him you were not to be disturbed, sir. You didn’t want to be disturbed.” And the guy says, “What are you doing to me?” “Just following orders, sir.” The private knows what he is doing but this is sort of his passive aggressive way of getting back.
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Reaction formation: this is basically, I hate you with a passion but I’m going to treat you especially nicely.

Rationalization: this is sort of like, “You know, the Osler Institute doesn’t really pay me when I work. I’m putting all this time in and I deserve a little extra. And this microphone is pretty nice. I think I’m just going to take this home because after all, I deserve it.” Can be cheating on taxes, but the thing about rationalization is the person has to really not in their heart of hearts believe it’s the right thing to do. You see, cheating on taxes can be … there are people who say, “Look, I’m in the Michigan Militia, I’m in Utah. I’m holed up in Utah. We are forming our own little commune. The government has no right to take our money.” Those people not paying taxes would not be rationalization. They feel the government has no right to take their taxes. Contrast that with some people who are like, “Yeah, I know I should pay these taxes but you know what? I pay too much and I work hard and the roads aren’t fixed and the jails are fixed and the schools aren’t fixed, and I really shouldn’t have to pay this much.” It’s kind of a way of rationalizing. They don’t really believe it but it’s a way of protecting them from anxiety.
Regression: acting like a three-year-old during times of stress and you aren’t a three-year-old. You’ll see this in hospitalized kids. You know, kids go into the hospital and they’ll lose their developmental milestones. You’ll have a five-year-old who is toilet trained and suddenly he is not toilet trained anymore.