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Prescribing Psychiatric Medications- A must know for all physicians

Feb 16 | 3:30 PM

Psychiatrists and primary care physicians frequently treat patients with comorbid mental health and chronic diseases. The inclusion of multiple providers into the patient care raises the opportunity for care continuity to be compromised. Join us for a live discussion with Dr. Himanshu Desai as he addresses the considerations a physician should undertake when treating comorbidities of a psychiatric patient.

[Music] hello welcome everyone uh i'm dr rucha i welcome you all on behalf of team metrics uh we are glad you all are here uh we have one interesting topic and session and one amazing uh professor of psychiatry with us here so sir uh dr himanshu desai uh welcome sir uh sir is consultant psychiatrist at fcg hospital ahmedabad uh and he will be talking about prescribing psychiatric medications which is like must you know for all the physicians uh even if we are on like in general opd there comes a point where we have to be very very precise about uh prescribing psychiatric medications it is nothing like otc so uh sir we'll be giving you a few tips and some things that we need to follow while prescribing good evening friends i am himanshu i'm doctor imagine a psychiatrist basically and today we'll be talking about prescribing psychiatric medications a must know for all physicians basically psychiatry is a subject which we have not read well we have just only we have done only one or two sorts not so psychiatry is just just we have just gone through psychiatry only word psychiatry we know we don't know much about psychiatric purpose as a subject because there was no exam for psychiatry only one or two short notes and you must have prepared repression or schizophrenia only two shorts not and must be you must be writing one topic on another topic so we are not fully aware with psychiatric medications per se so uh if we learn certain techniques of prescribing psychiatric medications and if you really concentrate then then maybe your practice will definitely flourish because because many of the patients of many of your patients like 30 to 40 percent of patients who are coming to us they are having some or another kind of psychiatric issues along with their medical problems so if we focus on really real psychetic symptomatology and if you treat them perfectly maybe half your practice will be very good then you will not be able to miss many things so basic psychedelic knowledge is very much important for general practitioners and for specialists also so my humble request is you just pick up the psychedelology you give them the right medications for right dose and for the right time of duration if you'll follow these three things maybe you will be able to do the best for psychiatric symptomology of all your patients so my request is just it's a one hour and maybe you'll learn what i've learned in three years so one hour would be sufficient which i am using in my everyday life so uh shall we go ahead with the slides please yes sure yeah and if you have any questions in between please feel free to write down in the comment section so then then it will have a very good discussion uh because offline is not available so we are meeting you through online offline works really nicely but even online should work well with all of us so prescribing psychiatric medication a must know for all physicians uh i'm working with gips cips is we are practicing practicing in a group setup and gips is our hospital we have a hospital also and we have opt setup also uh in this meeting there will be no lecture because we have what i've learned through all my career that when we are learning psychopharmacology full pharmacology and psychopathology then then we are not able to learn lot many things because they are they are out of my um my area so we will do basically case history prescription expert view and discussion and basically i've sent some of the fake patients to general practitioners with pure psychiatric complaints and what i have seen them they have been given this kind of pills so we all are treating psychetic patients but we are not sure what to give how much to give and for what duration to give so if you learn these three things maybe you'll be able to handle all psychic patients well uh there are few complaints which patients are always saying which people are usually complaining so here i'm i'm coming up with one patient there was a famous movie from zumu and this is the line from the movie zumuru there is there is a female 30 years of age she has a major complaint of sleep disturbance she has a weight loss she has a sadness of mood crying spells body ache she had disliking for many things she had lost interest her husband reported that patient is remaining alone and she was also complaining about death wish so these were the symptoms of this patient so my request is all of you to prescribe medication psychopharmacological medications to these patients you can write whatever molecule you like you can write whatever doses you want to give please write down on the comment sections maybe then we will have a better discussion about what you are what you will be prescribing this medication to this medic who's this lady and how we can help so luxurious saying that flocked in 25 milligram od i want only one tablet or many more tablet is writing uh uh that we should give uh acid from od patrill amitriplane uh acetyl from bd goodie milligram for 20 days yes alprazolam 0.5 milligram bd yes so first of all my request is to write down the diagnosis of this patient so so uh if you will see the comment section then then you'll listen so this is depression okay according to dsm five this is depression right how we diagnose patient because we follow dsm 5 or icd criterias so your diagnosis is depression depressor is very right so for depression to diagnose someone depression having depression we should follow certain criterias first criteria is sadness of mood second is decrease interest in pleasurable activities the activities which used to give pleasure in past the same activities are not giving pleasure at this moment so first criteria is sadness of boot second is lost interest in the activities which used to give laser in past third is sleep disturbance most of the time it is early morning kind kind of awakening kind of sleep disturbance then decrease appetite any atypical presentation sometimes there is increased appetite so most of the time decrease appetite and associated with weight loss right then decrease concentration sometimes with crying spells that hopelessness worthlessness life is not work then the last three days life is not worth living patient feels that it's better to die or suicidal ideation or suicidal attempt so out of nine criteria if patient is having at least four of at least five criteria for minimum 15 days of time and there should be social and occupational dysfunctions then we will consider this as a major depressive disorder major depressive disorder again i am repeating the criteria sadness of mood decreased interest in pleasurable activities sleep disturbance degrees appetite decreased concentration hopelessness worthlessness and death or suicide if out of nine if a person is having at least five criterias for minimum 15 days of duration then we'll consider this as a depression if if your girlfriend has left you and if you are feeling sad for 2-3 days then it is not considered considered as depression so definitely this patient is having depression right in general technology we are saying depression but according to we are writing major depressive disorder or major depression right so many of you have rightly said that it should it is a depression then what will be your prescription for this patient you should use either citrulline or acetyl pram or peroxide or phloxtape this all these three drugs three or four drugs are from the group of ssri this is serotonin specific reuptake inhibitor again i am saying that phloxtene you can start with 20 milligram one in the morning time if patient is not responding after one or two weeks then you should increase to 40 milligram you can go up to 60 to 80 milligram for mainly ocd type of patients but in general depression you should start with 20 milligram of flux tin you can go up to 60 to 80 milligram if you want to start centrally start with half tablet od then gradually increase to up to one tablet you can go up to you can go up to 150 to 200 milligram per day for certain alien for acetyl operon you can start with five milligram you can go up to 20 milligram because after 20 milligram it will not show much benefit even central in after 150 or 200 milligram it will not show much improvement perhaps in you can start with 12.5 milligram you can go up to 37.5 milligram you can select any of ssri whichever is comfortable to you almost all ssris have similar kind of side effect profile also they are relatively much safer for cardiac problem those patients having cardiac problem scenario would be a drug of choice uh there are certain choices also which we can which will discuss if time permits but for you if patient is having this kind of symptoms sleep disturbance weight loss sadness of mood crying spells body ache disliking loss of interest death wish then you should start with this kind of prescription along with that you can use any kind of benzodiazepine either chrono zipper you can start with point 25 milligram or alpha salon or even uh valium even diazepam would be okay even it is ola would be okay because all benzodiazepines are almost equal only there are some of the benzodiazepines are shorter acting mesoderm some some benzodiazepines are longer acting mesoderm speeds so clonazepam you can start with 0.25 milligram you can gradually if it depends on patient's requirement if some patients do not sleep well then we will have to aid you'll have to increase the dose of chronism so this would be an ideal prescription for these patients if you're non-psychiatrist if you learn these kind of prescriptions then almost all your patients should give very good reason but the most important thing is that you should you should counsel the patients patient that this medicine will take at least 15 to 20 days to be effective if you not counsel well and if you are prescribing for five days seven days then patient will not show any improvement so the most important part of this treatment is that you have to convince patient that the medicine will take at least 15 to 20 days to be effective before that it may not show it may not show any improvement so 15 to 20 days patient should wait if patient does not show improvement then you can increase the dose then you can go up to different doses for different molecules if patient is not responding then you can use you can add another group of medicines suppose this is ssri group of medications you can aid as an ri group of medications which are discussed in some another another time or some other slides so you can start with this kind of medications and patients should should show very good improvement previously before uh these medications were not available because because flux was one of the first ssri to come into the the the in the market before that we were using mainly dry cyclic antidepressants like imipramine may be amitriptyline but emu prominent was one of the gold standard um ninety percent which we were using immunobramin uh used to we used to start with 25 milligram or little less and we can go up to 225 milligram per day but there are certain side effects with sediment like postural hypotension dryness of mouth constipation and these side effects are sometimes so serious and so severe that patient patients were not ready to take these medications so after these newer medications we are not we have almost stopped using or we are not using uh amy pramin only in certain conditions where these patients this medications are not showing improvement we are using um immigrant or emitting kind of medications so this is about this slide so if such patient comes to you then my request is to start this kind of medications 28 years of age this is another patient which uses coming to your opd it's a female 28 years of patient uh she has the main complaint of body ache headache so it is pain everywhere she was complaining of giddiness lots of somatic complaints bodily complaints like burning pain all over the body burning pain is very common mainly in scalp consulted she has concerned many doctors she is coming she is coming up with a bunch of files she will say that she has the improvement for a few days only but again she will have the same complaints again and she's treated with a lot many medications like el prazolam dean is it kind of medications pronunciation she has been given all these predications but she has not shown any improvement so uh what is your call for this patient what is your diagnosis uh someone is saying with somatization disorder yes then any any more more diagnosis this time here okay then somatoform disorder yes then yes what will you give to this patient please write down your prescriptions also somebody symptom disorder bipolar no no this is not my problem this is not bipolar bipolar i'll show you bipolar ssri with cbt emitted between 25 milligram yes your answers please anxiety disorder munchausen syndrome no from five milligram okay yes your answers please depression psychosomatic to fuel with hyper deluxe state okay fellow flexing chloride epoxide cyclothymia emitter okay ct yes okay the diagnosis is depression with somatization uh mainly you need to give more uh norepinephrine that the medications which work on norepinephrine so snr a group of medications like nautiplane or despite the flexin or protradine or vendor vaccine or milaciprone or deluxe team any of the medications would be a good choice suppose uh if you ask me then my choice is not not rippling my choice would be either vandalaflexine or desvanelloflexin or even dulox team uh if you want to give use decimal vaccine then you can start with 25 milligram you can go up to 5200 milligram per day growth adding will be again a good choice which is again a tricyclic entity present thought high pin so you can start with 25 milligram or little less you can go up to 75 milligram or even 150 milligram also there are certain side effects with prothydis or or low type in uh so uh you can use well flexing also when reflection is is is my first choice basically a vendor effects you can start with 37.5 milligram in a lower dose when reflection works as as ssri only in higher dose it works as an snri but in low dose it definitely works as an as an ssri but you can start with 13.5 milligram od you can go up to up you can go up to you can start go up to 75 milligram even 150 milligram even 225 milligram but vanilla flexing is a commonest side effect is like a weight gain is very common with average reflexes and constipation is again a major side effect with wendell flexing milacipran uh had come into indian market with lots of expectations but it has not fulfilled the expectation of our of us we psychiatrists so villa cipro was really good molecule but it has not made much changes in the in the in the our basket but deluxe is again a good molecule uh patients with multiple somatic complaints ruloxin works nicely even it is useful for diabetic neuropathy direction is widely used by by for for diabetic neuropathy also so deluxe strain is a good molecule you can start with 20 20 milligram you can go up to 60 to 80 milligram dilox tea so uh you can use any of the molecule which has a more norepinephrogenic which works over more more epinephrogenic receptors so you can use any snri group of medications along with that you can use diazepam or laura zipam or any with with any benzodiazepine you're comfortable with so uh this basic molecule dashboard reflection or snri group of medications will take at least two to three weeks to be effective so till then this benzodiazepine will give a feeling of well-being to the patients so benzodiazepine in a low dose as per the need of the patients is very much required to give for this kind of population so whenever such patient comes if you use this molecule with proper counseling of the patients because many times you need to sit with the patients you need to listen them carefully you will not listen them carefully carefully they'll not feel satisfied so if you if you listen them carefully because they are having along with these symptoms there are there are many social social issues also which is going in in their family so you will not listen them well flood counts do proper counselling because all neurotic patients if you send them to a psychologist or if you sit with them if you if you give counselling stations to them then they are of a very good use so which helps in a therapeutic recovery of these patients sorry with that you can use benzodiazepine so this would be a good choice ect is really a very good thing when patient is suicidal we will ask patients to try with ect ecd is one of the fastest acting antidepressant ect is one of the fastest acting integrations in 1931 luciobini and other scientists they had invented ect but ect which we have we are showing in movies we are not giving in that way they are they are very badly depicted in the movie but is it is one of the more most kind of scientific method though the how effective how it works it is not known uh we are not sure how it works but it is one of the fastest acting antidepressants and it works surely usually we give alternate day uh usually most of the every time we give with proper anesthesia pentothal then muscle rejection we are using and patient in presence of anaesthetist we use specific machine and we are giving current to the patients for at least at least 15 10 to 15 seconds and there is a convergence like epileptic fit which is we usually request our and our anaesthetist to have this this this jerks for it is 50 to 20 seconds more around 30 seconds which is very much required to have better result five to six ecds they usually gives very good result usually the results are seen after third or four ecd usually i'm talking about usually and patients are showing fantastic result yet when a patient is not responding to any antidepressants we will suggest that patients should take um take acidity so acidity is again a very good choice uh for for depression when a patient is suicidal we usually give we usually uh request patient to uh we can try to convince the patient to take ect ecd is very badly depicted in the movie so patient has a lots of lots of questions uh for this recipe but you see it is one of the safest technique which we can help we can use to help our patients so treatment of depression is either antidepressants of any of um you can use group you can use tricellic antidepressants ssri snri you can use along with that sedatives anxiolytic ect and psychotherapy this is in general the protocol of treating patients with depression so whenever you are seeing such patients i would request you to start these medications without any any any any thought in your mind and most of your patients will respond well almost you are saving 60 to 70 percent will respond well if you will not use proper entity presence your patient will not respond if you'll use only clonazepam if you use only alprazolam your patient will not be better in their mood maybe they'll feel that they will have a good sleep but their mood will not improve so to have a proper improvement in mood you should use proper antidepressant for proper type of duration so when you are treating patients with medications and if you feel that you are not comfortable with these patients you should refer patients to a psychiatrist so when to refer to a psychiatrist if patient is harmful to self a patient is is harming himself him or herself is is then you should refer these patients to a psychiatrist if patient is suicidal then it will be much better if you refer a patient if patient is not responding to medications if you have tried one group another group and a patient is not showing improvement then it would be better to send this patient to a psychiatrist or if you feel that patient is showing side effects and you are finding it difficult to manage it would be better to set the pressures you want to see previous slide okay this is the treatment general treatment of depression is it fine so you can use any group of antidepressant medications triceratic ssri snr others you can use uh yes cycads definitely can do psychotherapy even even because we are also trained in doing psychotherapy during our training sessions even pure psychologists can also do psychotherapy but they should have at least proper understanding about this disease and what to do in this team cbt would be again a good choice cognitive behavior therapy would be again a good choice for depression and mainly wherever there is there are certain issues which is going in their mind then cbt would be again a good choice we can have a specific session for specific cbt which we can use how long treatment is to be given yes i am going to answer this thing basically if there is a first episode of depression then we should give treatment patient may show improvement within four to six weeks also within a one month or two one patient is showing very good improvement but at least we should continue this medications for first episode we should continue this medication for at least six months to nine months we should continue this medication for six months to nine months if it is a second episode then we should give this medication for at least two to three years if it is a more than third episode then sometime we request patients to conduce these medications for life long again i'm saying every the first episode of depression we should continue these medications for at least six months to nine months if it is a second episode we should continue this medications for at least two years if it is a more than third episode then we should continue this medications for lifelong if it's a chronic depression then maybe we can use a combination of these medications and we need to give this treatment for longer duration how to categorize the episode basically uh once a patient is showing a patient there is a baseline patient is going down that is depression and where prevention is coming back to a baseline and he or she is remaining on the baseline then we will consider that this episode is over and maybe a patient may have another episode after one year two years three three years then maybe it would be uh it would be another episode and we should see it accordingly this yes summit of form disorder has definitely criteria's uh i'll not go too into that detail uh i'll go with another slide because i have to call a lot many things what is the role of bleach heavy depression maybe i'll talk about the role of lithium depression we should not discontinue the treatment abruptly we should gradually reduce the medications and once specially stabilized one patient is they remain better with the medications then maybe we should omit these medications is a male 20 years of age he has his own business this is a heart s pain grammar's perspiration and he feels that there is attack kind of things he is feeling and which is lasting for 10 to 15 minutes only and goes to physician with complement of chest pain one to two times in a week all cardiac investigations like having many cities with him treadmill test is negative all branded wishes are within normal limit and he is not able to go outside because of fear he is not going uh out to see movies also he feels that this is very bad so what is your diagnosis anxiety disorder panic disorder jd yes many more please which medicine is gad yes please write it down panic anxiety phobia anxiety neurosis ssri panic attack yes please proper anxiety attack this is basically panic disorder as a part of anxiety disorder this is known as a panic disorder sudden episode of palpitation gabriel perspiration chest pain abdominal discomfort and the symptoms goes to expect within 10 to 20 minutes and patient is symptom-free within half an hour to one hour this is known as a panic episode if there is a more than three to four panic episode then this is known as a panic disorder again i'm telling you we all have gone through examination we have all gone through vivas and during viva what we were feeling when we were waiting outside gabra had perspiration palpitation shocking sensation we had to go for passing unit frequently there is abdominal discomfort butterflies in the stomach all these are anxiety symptoms but whenever there is there is such situation and we feel anxious it is okay but when we are relaxing if we have all these symptoms what we as we have seen before going to vaiwa if we have all these symptoms then it is known as a anxiety disorder or it is a panic episode certain episode is known as a panic panic episode but if you have all these symptoms then it is a part of generalized anxiety disorder if there were all the symptoms of anxiety palpitation perspiration gapra art then it is known as anxiety disorder generalized anxiety disorder or panic disorder what is the treatment you can use any of your ssris whichever is comfortable to you certainly peroxide essential problem you can start with low dose you can gradually escalate the dose of all the ss any ssri whichever you are comfortable along with that you can use clonazepam maybe around the clock maybe according to the patient's comfort you can start with 0.25 half tds or half bdd you can gradually increase up to more than more than the requirement you can go to half of one you can increase the dose according to your need or according to your patient is comfortable you can use beta blockers along with this uh for the patient's comfort you should definitely check blood pressures and and pulse rate before giving this thing so either prescription would be ssri along with benzodiazepine and relaxation therapy you can use bispheron would be again a good choice but be spiron it takes at least 10 to 15 days to be effective so you can you can start a bispiron 10 milligram bid but it will take at least 20 days 50 to 20 is to effective so clonazebum gives the fantastic fantastic result initially gradually circling or any ssri will take over so then gradually you can reduce the chronological dose because habit formation is very common with all benzodiazepine all benzodiazepine either william alpharazolem all benzodiazepine has a habit formation forming tech formation so gradually should withdraw the drug chlorazibum you should withdraw the truck meters up in is is an snri which usually we are not using for panic disorder or anxiety disorder metal zipping would be a good choice for depression when patient is not responding metabolism would will use metazoan has a very good potential it has a very good sleep producing potential so use whenever there is a sleep disturbance you'll use metabolism for depressive patients uh panic disorder is sudden episode of panic sudden episode of anxiety symptoms and anxiety symptoms venous goes off by its own within one to two hours patient is okay within one to two hours then it is on a panic episode while anxiety disorder patient may have a generalized anxiety for for many period for a long time then it is known as anxiety disorder these are difference between panic episode and generalized anxiety disorder so this would be prescription for a panic disorder or anxiety disorder also you can use the similar kind of prescription relaxation therapy we will usually ask patients to sit at a quiet place and he can have music which is a light music which you can use and gradually imagination of the of the things which which we are teaching them and they can use relaxation technique like all these kind of things they can they can they can evolve and which will help them to help to get the use when it's properly used whenever there is a palpitation is major symptoms when there is a gabriel is a major symptoms propanol would be a good choice you can start with 10 milligram tid or you can use the the control risk preparation 40 milligram would be a good thing guided imagery technique will be definitely helpful bio feedback music therapy anything would be a good thing guided imagery technique will be definitely helpful for such such patients if they will gradually get mastery over this guided imagery technique relaxation technique that will help them to be out of this this anxiety episodes shall we go to some other question the male 23 has to wash his hands five to ten times takes long time in bathing has to check the bits three to five times yes you're rightly diagnosed has to go two to three steps forward one step backward for any moment was very anxious and panels thought so what is the treatment then how will you treat them please write down the treatment reassurance will not work peroxide bispheron ssris please write down the molecule please write down the dose please write down the dose also because rose is very much important from in 40 milligram low doses high flocked in 40 milligram exposure therapy systemic decentralization low dose success rate block stain next pro 10 milligram flux in 20 million tds uh my request is to give foxton only single dose odors or if there is a more acidity then you can use 40 milligram or you know b.i.d dose but tds is not required because it has a long half-life it is a very good half-life flux 700 200 milligram okay anything else here is a prescription you can start with either chromopramine or phloxamine or phloxtene because for ocd there are only three or four drugs which is which is usually used so you can use any of this uh from this first ring fluoxetine or phloxamine or chlamy bramin if you want to start with phloxtene then you can start with 20 mm you can go to 40 milligrams 60 milligram you can go up to 120 milligram you should use either in a single dose or in a bit dose but usually we are usually giving frost in the morning rose because sometime by evening those it may produce sleep disturbance to the patient so usually fluxing should be given in a morning dose in market 10 milligram is available 20 milligram is available 40 milligram is available and 60 milligram is available flosting liquid is also available ocd is very commonly less which is seen in five to seven percentage of general population five to seven percent of the general population so it is a very widely seen but what we are seeing as a cycle is only maybe tip of iceberg there are plenty of people who are suffering from ocd but they are not going to a doctor many of us are having obsessive personality but if it is not producing disturbance to us and disturbance to the people around us then it is not a disease that it is not required to treat but when it produces tremendous anxiety to us when we are spending lots of time for obsession and compulsion then it is to be treated then it is to be treated right so the you can use any of this molecule either flux steam or fluxamine or chromium if one molecule is not sufficient then we should use another molecule or we should add another molecule if we are treating with only ssri then we can use chloramine from along with the ss7 usually my choice would be i would start with phloxtene because fluxten is little cheaper molecule than phloxamine so flux some flux tint i'll start with 20 milligram 40 milligram and gradually i'll beat up the dose up to 60 milligram or 100 or 80 to 120 milligram along with that i i'll use clonazepam because it produces it reduces anxiety of a patient and which helps our patients to be out of this problem if patient is not tolerating phloxtine because of acidity and headache is the most common side effect in flux acidity is most common side effects so usually we request patient to take frosting only after meal or only after breakfast you should not take frosting empty stomach along with that sometimes we have to use uh radiating kind of medications to prevent uh acidity if patient is not showing improvement then usually i i ate chlamypromine along with this trophy brahmin same time it is it is very notorious that for some of the patients because sometimes it produces lots of side effects like uh like constipation is very common with chromium dryness of mouth is very common with chronic brain sometimes sedation is very very common with formula weight gain is again very common with chromogramming so chromium pramin uh usually i keep it as a as a reserve molecule so uh i'll use flux stain if patient is not swinging improvement then maybe chromopriminality gradually i will build up the dose of chromium and foxtail and usually patient shows good improvement behavior therapy cognitive behavior therapy would be again a good choice a research says that only medications are only cbt rather if we combine both the things combination of medications and behavior therapy which gives better result than any any single uh therapeutic work uh phloxamine is again a good molecule uh usually i'll start with 50 milligram i can go up to 300 milligram of molecule so you can use either of these medications uh for children if we have quesadillas again very common common condition in children even five to seven years of child uh is suffering from ocd they are also having a repetitive repetitive behavior thought and behavior so uh in insects in children sutralin would be a good choice certainly you can start with 25 milligram half od gradually you can increase those saturn is fda approved uh antioxidant drugs for children so saturn would be again a good choice for adults also so if if and there is one thing you should you should keep in mind combination of phloxtene chromium priming which increases the blood level of each other and sometimes it produces seizure also so if you go very high to the flock stain and chromogramming sometimes patients show a patient may have caesar episode also so we should keep in mind and we should gradually reduce the dose of this molecule colonism is usually we are we are giving to uh chlorophyll we are usually giving a in a in these patients to reduce the the basic anxiety of a patient because sometimes anxiety is so tremendous that the patient has a lot of compulsion so we are giving chlorosome to reduce this anxiety sometimes we are using whispering also to reduce the anxiety but combination of medications and behavior therapy they are giving a very good zero uh in certain gi discomfort is is sometimes common so usually uh we ask all exercises to be given after meal uh they are giving better result shall you go ahead there is one patient in ocd you should give antidepressant like tricyclic or ssris in the anxiety clonazepam or bispheron and behavior therapy that would be a good choice for such patients this is another patient male 23 years recent change in behavior duration treatment for ocd you should give a little longer treatment than than depression patients usually we have to give patient treatment for at least six months one year two years is usually very common in ocd sometimes we have to give people for longer time also if patient is showing improvement then maybe we are reducing the dose again my palate male 20 is changing behavior fearfulness he feels that someone will kill me or kill us people are following him suspicious on wife bits are slip disturbance not ready to go for work body ache headache this is the complaint so your diagnosis is someone is saying that schizophrenia paranoia paranoid schizophrenia schizophrenia delusional disorder paranoid personality schizophrenia okay tell me how much duration should be there to diagnose schizophrenia if this boy is having disturbance since 10 days or 15 days can we call him as a schizophrenia okay six months okay 12 months psychosis okay six months three months division of persecution okay blips according to sort yes okay dsm for six months a quick psychosis six months okay very good according to dsm five that should be minimum uh for to diagnose someone as a schizophrenia patient should have delusion hallucination disorganized speech disorganized behavior and negative symptoms out of this five that should be at least minimum two for at least one month of active phase and there should be total six months of duration then we'll call him or she is having schizophrenia if it is an episode of 15 to 15 days then it is a brief psychotic disorder if it is more than one month then schizophrenia from disorder if more than six months of duration then it's just a schizophrenia right so this is uh there is no duration is not mentioned this is a psychosis of broad terminology which we are not using right now but for non-psychiatrists if you use psychosis word then it will be sufficient for a rest of the people to understand that what kind of symptoms the person is having person is having delusion delusion is false false but firm belief which is not shakeable even if you give evidence again i am repeating the definition it's a false but firm belief which is not shakeable even if you give evidence helices is a false perception in the absence of stimulus there is no one and if you are hearing voices there is no one if you are saying something then it is known as a visual hallucination if you are listening then it is known as auditory hallucination auditory hallucination and visualization is very common in psychosis persecuted delusion is very common with psychosis what will be the treatment what will be your treatment personality therapy no no no what medications you will give anti anxiety will not work here into psychotics yes but what antipsychotics can which those crisp product linzopine okay okay what those cutapine typical antipsychotic chronism two milligrams 172 milligram will be very low hello fried all those you should use respirator along with the triaxial with lorazepam or many benzodiazepine respiron would be again a newer antipsychotic you can start with two milligram you can go up to four milligram or six milligram if you do not want to use risperdon then you can use another molecule also so you can use antipsychotic either typical antipsychotic in the form of floprazine or heropedal or you can use atypical antipsychotic like olensopine like respiraton like uterpin like closer pain so there are there is a list but i'm not going to even you can use any browser also but you can use at least one antipsychotic either from typical antipsychotic or from atp antipsychotic along with that you can use either sedatives any sedatives which you are if of your choice tripopracin is older molecule like trinicam plus neocomplex lacam plus their older molecule and plus is coming always with trihexy fiddle so there is no side effect hemozygote has a good role but uh we are not using much in nowadays hemoside because there are better molecules are available teleport on was again a good molecule but it has not made heat to the indian market so we have we are not using telepath much right now we are more using respirator on olympian even atypical uh typical molecules like triflopros and hellopedal uh we can have another under the lecture on on schizophrenia and another psychotic kind of illness so here i am i'm running short with the time so you see it would be again a good choice duration in this case uh maybe maybe 15 days of duration so we can start with any of this molecule and patient should show very good result so there is the last question male 20 35 years of age two weeks of duration since first navratri saying i am something like god he has become more religious giving fast giving money to people sleep disturbance is talking more past history of similar episode before 10 years passes suicidal attempt details not available new york grandiose yes but in which condition mania okay bipolar mania mania yes salamat is a manic episode is a manic episode suddenly there is there is a there is a grandiosity a granule delusion of grandeur city and doing activities uh which which may be harmful he is talking more he feels that i am the boss i am the king so it is known as a manic episode sometime a patient of mania may have a depressive episode in his life or a manic episode so this is when whenever there is a manic episode and debris episode we call it as a bipolar disorder what will be the medication for this patient please write down the medication lithium okay what those tremolo low tremor doll you can use one of the mood stabilizer either divulge or lithium or ox karbazapine along with that you can use one antipsychotic either olens or pin or respirator or triploprazzin along with that you can use benzodiazepine like lorazepam or zolpidem kind of drugs you can use to give good sedation so why we should use one mood stabilizer either die wall product the blood level should be around 60 to 80 milligram mill equivalent per liter if you are using lithium then lithium should be around 800 milligram to 900 milligram the lithium level should be 0.6 to 1.2 milligram per liter so the basically whenever we are using this molecule we should use go ahead with blood level of this molecule either lithium or divert otherwise we will have a side effect of this molecule lithium is very common with having hypothyroidism and sometimes it produces renal disturbance also diagonal price is very common with producing uh hepatic toxicity and hair loss is very common with diabetics is is a valpic acid uh it's a divulge of of what we are using as a anti-trap so dive output is again a common molecule which you are we are giving to 500 total thousand milligram per day or 500 gram per day lithium we can start with 800 milligram you can use along with antipsychotic along with that yes levotogen can be used laboratory is very good drug for bipolar depression mainly combination of which psychiatric drug has to be avoided because we should we should avoid carbohydrate or oxycontin with mainly close up close up and we should avoid such kind of combination so this should be avoided oxygen carbazepine along with closure pin should be avoided usually um so this is bipolar mood disorder antipsychotic we should use along with that mood stabilizer i can either lithium wallpaper or carboxypin sedatives we should use and ect would be again a good choice for such patients hypomania is this such terminology is not there hypermania is again not there lithium safety levels 0.6 to 1.2 milli equivalent per liter per liter uh and the the this is lithium level uh there is either low phase high phase manic phase or depressive phase it's not a hyper or hypomania duration treatment we should continue uh for first episode medic manic episode we should give treatment for nine months to one year it is a second episode again two to three years it is a more than two to three episode we should use we should continue mood stabilizer for lifelong also dothar pin dao solupin is good truck for depression is concept yes lithium is safe provided you should regularly go ahead with serum tss level and serum creating level you should regularly use this thing previous slide okay there is the the order is not not okay you can use diver plate or lithium or uh ox carbohydrate then antipsychotic either olivine or respirator and benzodiazepine lorazepam enzo yes sometimes we have to give lithium for lifelong also [Music] what are citron what what to do what to be monitored sir for nothing it has to be monitored basically uh it's it's relatively safe follicle sometimes acidity is common sometimes this all ssrs are can produce uh sexual dysfunctions also sometimes there is a problem with the ejaculation also is very common with all uh ssris also soulfudem is safe in illegal patients it does not produce much problem also so zolapidum is safe those of those who will have been in in depression uh you can start with 25 millimeter 50 milligram you can go up to 75 milligram you can go up to 150 milligram also so it is much safer molecule but safer molecule but it has a side effect profile like like all tricyclic like constipation sometimes posterior hypertension is very common if psyched is not doing psychotherapy then maybe you you can you can go to a psychiatrist with wombs over you are comfortable you should go ahead if you are committed with psychiatrists you can he or she is doing psychotherapy then then also it is fine electronic disturbance is very common with ssri like it hyponatremia is very common with all all ssri even with with uh acetone problem so whenever we are prescribing acetone in elderly patients we should definitely be watchful about uh serum sodium level yes for chronic bone we can definitely use for a longer time for for manic episode for a kid manic episode we should use we should use antipsychotic mood stabilizer and sometimes he sees it would be very good choice for acute manic episode base drug dendroscopin anything any ssi would be good ssi would be good for for depression conversion rejection is again again a common condition uh psychotherapy counseling and and we need to go to the root cause of why a patient is having conversion what what is what is which is affecting to a patient and what is going in his or her mind would be if we'll go with proper counseling or psychotherapy that will give us a very good result bulgaria is the male 60 years he's a retired forget names forget the things he has kept becomitable on small issues why report that he doesn't like to go out so it's alzheimer's basically it is dementia alzheimer's is part of dementia almost 60 to 70 percent of dementias are alzheimer's dementia uh 20 to 30 percent are vascular dementia and rest of the rest of the dementia or a lot many of other kinds treatment would be either donopizil or mementine or with that you can use vitamin or all the things but we need to rule out first treatable call all cause of dementia yes we should reload all all strokes yes what are the psychiatric emergencies if there is a history of fever second post of day 11 talking seeing insects moving on the wall picking up bed sheets becomes irritable remove iv lines become normal in between so sometimes we have been called to see such patients yes it is delirium very well said it's a medical emergency treatment of underlying cause is required we are sometimes suggesting antipsychotic medications like hello pedal tablet would be a good choice and sometimes you type in would be again a good choice if patient is is in a long-term icu then we we i will request patients to go to uh i'll request the staff to take patients to into near sunlight because sometimes sunlight exposure is very much required for thing for such daily respection pseudo dementia is very delirium sorry anyway uh this is thank you from from me if you have any questions please i am here to discuss with questions uh we can have another session also for for discussion because uh there was yeah definitely it was amazing session and we loved especially the headings of all the slides it was really catchy and we could guess a lot of things and you explained beautifully so thank you so much so dr quireishi has asked uh sir which medication anti-anxiety pill can be used in patients with depression because propanol itself causes depression so should we avoid it beta blockers are known to produce depression but sometimes whenever there is a severe anxiety symptoms uh use of this molecule will be definitely of him right there is one interesting question post operative delirium we use haloperidol and laszo pam is that okay or do you recommend that that is perfectly hello produces time tested molecule but what those you are giving that is very much important sometimes we are because the tablets are coming into 0.5 milligram to 5 to 10 milligram so what losses you are using this is very much important some point five milligram may not work so you should gradually increase the dose sometimes half a pill of hello pedal would be of a good choice so it depends on the condition of the patient right thank you sir so for ptsd uh what's your advice uh on management same same you you'll use the same ssri along with benzodiazepine would be a good choice but basically in india we are not seeing much questions of ptsd which the the western british literatures are saying we are not seeing much questions of ptsd even after this this culture episode earthquake we have not seen much patience of proper ptsd but after earthquake we have seen patients having anxiety disorder but they will not have the similar symptoms like ptsd they will not remember the whole episode kind of things so we have seen many patients having anxiety after even after this corona even after this earthquake so we are seeing such questions of anxiety but ptsd is not common but even if there is a ptsd we should treat with the benzodiazepine with ssris and measures would be a good choice you're right on that note uh so there was one question going at the current rate of depression diagnosis in india and looking at the pandemic situation do you think india will be the uh capital of depression in the world if everyone is is facing those similar kind of problems basically so basically i wish that all of all of you should start picking up the depression and treating them because many of the patients are going not going to a psychiatrist they are not going to our doctors also or they are not treated well as having proper depression because we are afraid to send this patient to a psychiatrist we are afraid this patient to treat fully because sometimes the clinician feels that he should not give this treatment for longer duration and he'll say that the patient is they are recommending patients to go to a psychiatrist but patient is not going so my request to start treating them properly for the proper duration with proper doses of the treatment maybe you'll not need to send a patient to a psychiatrist that is what i wish everyone should start treating the depression because they pop that in general population 15 to 20 percent of people are having depression some or another time in their life subcopting yes identify them properly and treat them with proper wallet yeah thank you so much

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dr. Himanshu Desai

Dr. Himanshu Desai

Director at GIPS, Psychiatric clinic and Healthy Mind Hospital

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dr. Himanshu Desai

Dr. Himanshu Desai

Director at GIPS, Psychiatric clinic and Heal...

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