Psychiatric Conditions

Management of wandering mentally ill patient or a mentally ill patient with no family member or attendant

Mental Health Act, 1987 has provision for hospitalization of the mentally ill patients in mental hospitals. If one happens to come across a psychiatric patient wandering aimlessly or indulging in socially disorganized behaviour in a public place, one can approach the local police station. The incharge of the local police station under whose jurisdiction the place lies, has a duty under the Act to take the patient to the concerned Metropolitan Magistrate in Delhi (in metropolitan cities) or the Sub-Divisional Judicial Magistrate or Chief Judicial Magistrate or any Magistrate of first class (in other cities). The Magistrate can issue a reception order for admission of the patient to a mental hospital after getting him examined by a medical officer. Admission to mental hospital can also be made on the request of the patient, if the patient is willing to consent (voluntary admission) or on the request of family members, if they so desire (admission under special circumstances). Immediate medical management is as of an excited psychotic patient as given under schizophrenia (see section on schizophrenia).

Opiate Dependence Syndrome

1. Tab. Clonidine 10-20 mcg/kg/day in 3 divided doses. The dose is the adjusted to reduce withdrawal symptoms as much as possible without causing hypotension. The drug is usually withheld if a patient’s blood pressure drops below 90/60 mmHg. After stabilization on clonidine for 4-5 days (for short acting opioids like pethidine, morphine or heroin), the drug is tapered over 4-6 days. Clonidine assisted withdrawal is better carried out in inpatient settings where monitoring of the side effects like hypotension is possible. Some patients obtain very little symptomatic relief from clonidine as certain withdrawal features like pain and insomnia are not well controlled by the drug.
   Or
   Tab. Buprenorphine 0.6 to 1.2 mg/day PO divided in 3-4 doses. The dose is slowly built up to a maximum of 2-3 mg/day around 3 to 5 days of abstinence when the withdrawal from short acting opiates like heroin is likely to be at the peak. Once the patient is stable for 3-4 days, the drug is tapered off 20% per day. Tapering and stopping the drug is crucial as some patients, when not monitored properly and not helped by other modalities (psychosocial methods) of treatment, continue to take the drug indefinitely.
2. Hypnotics (e.g. Zolpidem, long acting benzodiazepines), NSAIDs, antidiarrhoeals, antiemetics are also used for a few days during acute withdrawal of opiates.
3. Dehydration and poor hygienic states need appropriate medical care.
4. Associated physical and mental disorders have to be managed simultaneously.

• Individual counselling, family support and encouraging the patient to join the self help groups are also important to help him maintain longterm abstinence. However opiate dependence is a highly relapsing disorder, and prolonged inpatient stay in settings that also provide rehabilitative inputs is usually beneficial.

Pharmacological (to be treated by a psychiatrist)

1. Tab. Naltrexone 50 mg/day PO is used to reduce craving and thereby to help patient maintain longterm abstinence (who have remained opioid free for at least 7-10 days. Baseline hepatic functions should be assessed, and to be monitored once a month while on naltrexone treatment. The drug is usually continued for a period of 6 months, however, it may have to be withdrawn in presence of significant liver disease (i.e. several fold increase in the serum levels of transaminases).

Patient education

• Patient should be told about nature of illness, course and treatment modalities available through individual sessions.

References

1. Manual of Psychiatric Emergencies. 2nd Edition, 1998 Little Brown & Co. Boston, pp 233-244.
2. Pocket Handbook of Clinical Psychiatry. 2nd Edition, 1996, B.I. Waverly Pvt. Ltd, New Delhi, pp 51-59.
3. American Psychiatric Association, Practice Guidelines for the Treatment of Psychiatric Disorders. Compendium 2000, American Psychiatric Association, Washington DC, 2000, pp 200-210.

Alcohol Dependence Syndrome

1. Inj. Thiamine 100 mg IM.
   Or
   Tab. Thiamine PO along with oral multivitamins and folate 1 mg.
2. Tab. Chlordiazepoxide 25 mg 3 times a day.
   Or
   Tab. Diazepam 5 mg 3 times a day.
   Once the patient is well sedated and stable, the dosage should be decreased 20% per day over a maximum period of two weeks. The patient should be monitored over this period for the appearance of the signs of delirium.

1. Inj. Thiamine 100 mg IV/IM for a period of a week.
2. Tab. Multivitamin along with folate also should be continued.
3. For young patients without any significant liver disease. Chlordiazepoxide 25 mg or Diazepam 10 mg (long acting benzodiazepines 3 times a day).
   For elderly patients or in presence of significant liver disease. Tab. Oxazepam 15 mg or Tab. Lorazepam 2 mg every 2 hour should be started.
   After the first day, long acting benzodiazepines may be given in four daily doses. The vital signs and withdrawal symptoms should be monitored 2-4 hourly. Once the patient is stable, the dose should be gradually tapered off (20% per day) over a period of 10 to 14 days.
4. Fluid and electrolyte disturbance should be corrected especially if there is vomiting or fever.
5. Seizures – Rum fits (appearing within 24 hours of abstinence) can be treated with Inj. Diazepam 10 mg or Inj. Lorazepam 2 mg IV stat especially when seizures are repeated. Prophylactic treatment is not recommended for true alcohol withdrawal fits.
6. Delirium tremens – The patient should be preferably treated in an intensive care unit.
   1. An intravenous line should be started immediately and Thiamine 100 mg IV should be administered. Thiamine along with multivitamin should be continued parenterally till normal diet is resumed.
   2. IV dextrose and saline should be given at a rate adequate to replace fluid losses and maintain blood pressure.
   3. Hyperthermia should be managed with cold sponge.
      Tab.Paracetamol 500 mg PO 4 times a day may be used in absence of any hepatic dysfunction.
   4. Diazepam 10 mg should be given slowly IV and should be repeated every 15-20 minutes till sedation is achieved.
   5. Physical restraint may be necessary if the patient is combative.
   6. Associated medical and surgical problems should be simultaneously investigated and treated appropriately.

Long term treatment (to be treated by a psychiatrist)

The goal of this treatment is to help the patient maintain long term abstinence.

Nonpharmacological

Individual counselling and family support should be planned along with pharmacotherapy. After remission the patient should be encouraged to join self help groups like Alcoholic Anonymous (AA).

Pharmacological

Tab. Disulfiram 250-500 mg a day may be used if the patient desires enforced sobriety and who have remained alcohol free for at least 7-10 days. Patients taking disulfiram develop an extremely unpleasant reaction on intake of even small amounts (e.g. 7 ml) of alcohol. The reaction occurs due to accumulation of acetaldehyde and includes flushing, headache, throbbing in head, dyspnoea, hyperventilation, tachycardia, hypotension, sweating and confusion.
In the event of disulfiram-ethanol reaction (DER). The diphenhydramine 50 mg IV is symptomatically helpful. Hypotension should be treated with IV saline. Vasopressors are required in case of shock. Respiratory distress improves with administration of oxygen. Hypokalaemia has been reported and should be corrected. Disulfiram should be continued for several months to establish a long term pattern of sobriety.
Or
Tab. Naltrexone 50 mg PO once daily.

Patient education

• Patient should be told about nature of illness, course and treatment modalities available through individual sessions.

References

1. Manual of Psychiatric Emergencies, 2nd Edition, 1998, Little Brown & Co. Boston, pp 245-254.
2. Pocket Handbook of Clinical Psychiatry, 2nd Edition, B.I. Waverly Pvt. Ltd, New Delhi 1996, pp 66-73.
3. American Psychiatric Association, Practice Guidelines for the Treatment of Psychiatric Disorders. Compendium 2000, American Psychiatric Association, Washington DC, 2000, pp 182-194.

Attention Deficit /Hyperactivity Disorder

• Tab. Methylphenidate 2.5-5 mg twice a day after meals at 8 AM and 12 noon; may be increased up to 10-15 mg/day (0.6-2.1 mg/kg/day), though maximum dose can be up to 60 mg/day, to be given under strict psychiatric supervision.

• Counselling; learning to anticipate the situations that allow behavioural problems to appear and plan ahead so as to minimize disruption.
• Encouraging parents to screen the peer relationships of the child so as to protect the vulnerable child.
• Recognizing the attention difficulties of the child and tailoring the work expectations by reducing the length and complexity of assignments.
• A coordinated effort both at home and school.
• Side effects include anorexia, headache, insomnia, weight loss, tachycardia, and growth suppression.

1. Synopsis of Psychiatry, 8th Edition, 1999, BI Waverly; New Delhi.
2. Attention Deficit Hyperactivity Disorder. In: Textbook of Postgraduate Psychiatry, JN Vyas & N Ahuja (eds), 2nd Edition, 1999, Jaypee Brothers: New Delhi.

Insomnia

• Treat the underlying cause. In both primary insomnia (where no cause is identifiable) and insomnia due to other causes management includes introducing good sleep hygiene and medications for short period if required

• Keep a regular time for going to bed and arising up. Avoid day time naps.
• Limit daily in-bed time to the usual amount present before the sleep disturbance.
• Avoid large meals near bedtime; eat at regular times daily. No stimulant medication or food beverages (caffeine, nicotine, alcohol, etc.) especially in the evenings.
• Mild to moderate physical exercise in the morning.
• Avoid evening stimulation: substitute radio or relaxed reading for television.
• Practice evening relaxation routines, such as progressive muscular relaxation or meditation.
• Maintain comfortable sleeping conditions

Pharmacological

Tab. Diazepam 5-10 mg or Tab. Nitrazepam 5-10 mg HS.
Or
Tab. Zopiclone 7.5-15 mg HS.
Or
Tab. Zolpidem 5-10 mg HS.

Precautions

• Medication to be given ½-1 hour before the usual time of going to bed.
• Medications should be prescribed at the lower dose for a period of 5-7 days.
• Benzodiazepines like diazepam and nitrazepam have risk of abuse potential if taken for more than 4-5 weeks.

Patient education

• Stress on basic principles of sleep hygiene as above.
• Zopiclone sometimes causes metallic taste.
• Patient to avoid exceeding the prescribed dose and should not take medicines beyond the prescribed period.
• Sometimes these drugs can lead to sedation during daytime. In such case reduce the dose to half and contact the doctor.
• Diazepam and nitrazepam carry risk of dependence.

References

Synopsis of Psychiatry, 8th Edition, 1999, BI Waverly; New Delhi.

Obsessive Compulsive Disorder

• Reassure the patient that though the disease being distressing and disabling, it is a treatable condition.
• The drug takes about 2 weeks for its therapeutic response to manifest.
• Side effects may appear before the onset of therapeutic response.

  Common side effects of Clomipramine are dry mouth, constipation, postural hypotension (giddiness), blurred vision, and sedation. Side effects of fluoxetine include gastrointestinal distress, nausea, headache, nervousness, anorexia, restlessness and sexual side effects. Patient usually adapts to these side effects with time.
• Advise the patient that treatment may continue for a long time. He/she should not leave drugs without medical advice.
• In case of any untoward effects of drugs, he/she must immediately get in touch with his clinician.
• Patient must continue all his regular activities as far as possible.
• Yoga, meditation, physical exercises are useful measures along with drug therapy.

1. Anxiety Disorders: Somatic Treatment. In: Comprehensive Textbook of Psychiatry B.J.Sadock & VI Sadock (eds), Vol. 1, 7th Edition, 2000, Lipincott Williams & Wilkins: Philedelphia, pp 1490-98.
2. A Review of Efficacy of Selective Serotonin Reuptake Inhibitors in 2000 Obsessive-Compulsive Disorder,1999, Journal of Clinical Psychiatry, pp 60, 101-105.

Social Phobia Or Social Anxiety Disorder

• Reassurance, encouragement, psychological support.
• Muscular relaxation exercises, meditation, yoga.
• Cognitive behaviour therapy (To be given by a psychiatrist).
• Social skill training (To be given by a psychiatrist).

• Don’t avoid the anxiety provoking situations. Try to face them.
• Take your medicines regularly as advised. Medicine helps in controlling the anxiety and building up the confidence.
• The symptoms can be treated effectively.

Anxiety Disorders: Somatic Treatment. In: Comprehensive Textbook of Psychiatry B.J.Sadock & VI Sadock (eds), Vol I, 7th Edition, 2000, Lipincott Williams & Wilkins: Philedelphia, pp 1490-98.

Panic Disorder

• Reassurance, encouragement, psychological support.
• Muscular relaxation exercises, meditation, yoga.
• Cognitive behaviour therapy (to be given by a psychiatrist).

• General reassurance about benign nature of symptoms and spontaneous recovery of individual attacks.
• Breathing exercises.

1. Anxiety Disorders: Somatic Treatment. In: Comprehensive Textbook of Psychiatry B.J.Sadock & VI Sadock (eds), Vol I, 7th Edition, 2000 , Lipincott Williams & Wilkins: Philedelphia, pp 1490-98.
2. American Psychiatric Association Practice Guideline for the Treatment of Patients with Panic Disorder. American Journal of Psychiatry 1998, 155 (5) Suppl.

Generalized Anxiety Disorder

• Counselling, reassurance, psychological support, encouragement.
• Relaxation exercises, meditation, yoga.

• Patient should be encouraged to bring out life style changes like mild exercise such as morning walk, keeping some time for leisure or entertainment.
• Patients should be informed about the abuse potential of the drug.

1. Anxiety Disorders: Somatic Treatment. In: Comprehensive Textbook of Psychiatry B.J.Sadock & VI Sadock (eds), Vol.1, 7th Edition, 2000, Lipincott Williams & Wilkins: Philedelphia, pp 1490-98.

Suicidal Patient

• Whether the patient often feels sad?
• Whether has lost all hopes in life?
• Thoughts that it is better to be dead than to face the constant miseries of life.
• Thoughts of causing death to self.
• Suicide plans.

• Patient should not be left alone and be kept under constant observation.
• Family should be explained the seriousness of the problem and actively included in management.
• Patient should be offered psychological support and reassurance and not criticized.
• No dangerous or potentially dangerous objects such as knife, blade, sharp edged objects, rope, medication supply, etc. be available in immediate vicinity of the patient.
• Specific treatment for depression, psychotic disorder or whatever may be the cause should immediately be started.

• Family should be advised to follow a supportive approach towards the patient and should not criticize.
• Suicidal attempt is indicative of distress and needs treatment of the causative illness.

Synopsis of Psychiatry, Kaplan HI, Sadock BJ (eds), 8th Edition, 1999, BI Waverly;New Delhi.

Mixed Anxiety Depression

• Psychological support, encouragement.
• Relaxation exercises, yoga, and meditation.

Pharmacological

Cap. Fluoxetine 20 mg/day, to be given in morning after breakfast. If no response after 4 weeks dose may be increased to 40 mg/day.
Or
Tab. Alprazolam 0.5-1.0 mg/day in 2-3 divided doses, if no response in 2 weeks may be increased to 2-3 mg/day.
(CAUTION: Alprazolam has risk of abuse potential if taken for more than 4-5 weeks)
Or
Tab. Buspirone 15 mg/day in 2-3 divided doses; if no response may be increased to 30 mg/day in 3 weeks time, Patient may be asked to come after one week initially. Later the follow up visits can be planned fortnightly or monthly, depending on response to treatment. Treatment may be continued up to a period of 6 months. If no response in 6 weeks, the patient should be referred to a psychiatrist.

Patient education

• It is a chronic though easily treatable illness, but treatment needs to be taken regularly for a long time.
• Do not stop treatment without consulting your doctor.
• The drugs are quite safe and do not cause any harmful side effects even if taken for a long time.

References

Synopsis of Psychiatry, Kaplan HI, Sadock BJ (eds), 8th Edition, 1999, BI Waverly; New Delhi.

Depression

• Counselling, reassurance, psychological support, encouragement.
• Cognitive therapy (to be given by a psychiatrist).

• Explain the nature of illness, consequences of untreated depression, suicidal risk, need for adequate doses for adequate duration, and other supportive measures.
• The therapeutic response takes time to appear but side effects may appear earlier. Common side effects of tricyclic antidepressants are dry mouth, constipation, postural hypotension (giddiness), blurred vision, sweating, palpitation, tremors, delayed micturition, sedation, etc.
• Common side effects of fluoxetine are agitation, headache, nausea or heartburn, tremors, changes in sexual performance, blurred vision, dry mouth, loss of appetite.
• Patient should be cautioned against increasing or decreasing the dose without medical advice.
• The drug may impair mental or physical abilities initially, avoid driving or operating machinery if you feel drowsy.
• One should avoid alcohol during treatment, as it may cause oversedation and dizziness.
• Patient should be advised not to stop drug suddenly as it may result in withdrawal symptoms.

1. American Psychiatric Association Practice Guideline for the Treatment of Patients with Major Depression. American Journal of Psychiatry 2000, 157 (4) Suppl.
2. Mood disorders: Treatment of Depression. In: Comprehensive Textbook of Psychiatry, B.J.Sadock & VI Sadock (eds), Vol I, 7th Edition, Lipincott Williams & Wilkins, Philedelphia, pp 1377-85.

Bipolar Affective Disorder

1. Inj. Haloperidol 5 mg IM Stat.
2. Inj. Promethazine chloride 25 mg IM stat. Injection can be repeated after 8 hours.

1. Tab. Haloperidol 5-10 mg/day in 2 divided doses.
   Or
   Tab. Chlorpromazine 300 mg/day in 3 divided doses.
   Or
   Tab. Trifluoperazine 15 mg/day in 3 divided doses.
   Or
   Tab. Risperidone 4 mg/day in 2 divided doses.
2. Tab. Trihexyphenidyl 2 mg once in morning and once in the afternoon.
3. Tab. Diazepam or Nitrazepam 5-10 mg at bedtime may be given in the initial period for sleep disturbance (usually for 10-15 days, to be tapered off thereafter).
   Improvement starts within one week. Treatment for the episode usually required for about 6 months. If the patient does not respond within one week, refer to a psychiatrist.

Current episode of depression
Line of treatment is similar to that as described under depression section.
Duration of treatment is relatively shorter than in major depression.Medications may be given for 2-3 months after the patient recovers from depression.

Prophylactic treatment
Tab. Lithium carbonate 900-1500 mg/day in 2-3 divided doses.
Or
Tab. Carbamazepine 600-1200 mg/day in 3 divided doses.
Or
Tab. Sodium valproate 600-1500 mg/day in 2-3 divided doses.
Note: Prophylactic treatment should only be given under psychiatric supervision. Prophylactic treatment may continue for a duration varying from 3 years to lifelong. Patients on lithium require regular blood levels monitoring. Liver function test should be performed once in 6 months in patients on carbamazepine and sodium valproate.

Patient education

• General guidelines about the illness and medications similar to that for schizophrenia.
• Emphasize about recurrent course of illness and not to get too much worried on recurrences.
• Relapses can be treated as successfully as the first episode.
• When on lithium, advice to take plenty of fluids especially during summer; not to restrict salt.
• If fever, vomiting or diarrhoea develops while on lithium, reduce the dose of lithium to half and contact the physician or the psychiatrist.

References

1. Synopsis of Psychiatry, Kaplan HI & Sadeek BJ (eds), 8th Edition, 1999, BI Waverly, New Delhi.
2. Psychiatric Drugs. Lieberman JA, Tasman A (eds), 2000, Harcourt Asia: WB Saunders, Singapore.

Schizophrenia And Acute Psychotic Disorder

1. Inj. Haloperidol 5 mg IM Stat.
2. Inj. Promethazine chloride 25 mg IM. The Injection can be repeated after 8 hours.

Oral medication can be started as soon as the patient is willing to accept orally. Oral therapy is given as below.

1. Tab. Haloperidol 5-10 mg/day in 2 divided doses.
   Or
   Tab. Chlorpromazine 300 mg/day in 3 divided doses.Or
   Tab. Trifluoperazine 15 mg/day in 3 divided doses.
   Or
   Tab. Risperidone 4 mg/day in 2 divided doses.
2. Tab. Trihexyphenidyl 2 mg once in morning and once in afternoon (attempts may be made to taper it off after 3 months).
3. Tab. Diazepam or Nitrazepam 5-10 mg at bedtime may be given in the initial period for sleep disturbance (usually for 10-15 days, to be tapered off thereafter).Improvement starts within one week. However, it may take few weeks to months for full response to come. If there is no improvement after one week, the patient should be referred to a psychiatrist.

Patient and family education

• Both the patient and the care givers to be educated that schizophrenia is a psychiatric illness, which can be effectively treated by medicines and needs long-term treatment, which may go on from one to many years in schizophrenia. Treatment for acute psychotic disorder is usually required only for 3-6 months.
• Provide psychological support to the family.
• Family not to criticize the patient and to be supportive.
• The medicine may cause mild to moderate side effects like sedation, slowness of movements, changes in facial expression and gait, rigidity, excessive salivation, dryness of mouth and constipation. Patient usually develops tolerance to these over few weeks. If the patient develops spasm of a part of body like neck or extremities or highgrade fever or alterations in sensorium, immediately contact the treating doctor or the psychiatrist.
• Treatment should not be stopped abruptly without the advice of the treating psychiatrist. Follow up is required weekly initially. Once the symptoms stabilize, frequency of follow-ups may be gradually reduced to once in fortnight to once in 1-3 months.

References

1. Expert Consensus Guideline Series Treatment of Schizophrenia 1999. The Journal of Clinical Psychiatry 60 Suppl 11.
2. Synopsis of Psychiatry, 8th Edition, 1999, BI Waverly, New Delhi.