------------------------------------------------------------------------------- Psychiatry HP Note File (MASTER2.NDB) 05/10/99 ------------------------------------------------------------------------------- Ambien 5-10h = zolpidem interacts w/ GABA-BZ rcptr cmplx do not give w/ or aft meal b/o dec absorptn no inc in terminal 1/3d of nite as w oh hypnotics sl not b used > 7-10ds Antabuse Antabuse (disulfiram) 250 qhs get consent statement in VA *dg Antidepresant Augmentation use T3 (cytomel) not T4 (synthroid) TCA -> heterocyclic 20-50% rate TCA -> MAOI 65% TCA -> ECT 50-75% SSRI -> TCA 50-73% TCA + Li = 56.7% may take long t TCA + T3 58% few studies TCA + ssri approx 80% Antidepressant Discontinuation If D/Cing: Wait before starting: MAOI 2 wks Prozac 4 wks if MAOI; < if TCA but start low TCA 2-3 days Antidepressants ANTIDEPRESSANTS: (p. 198 Psy for HO) NEW: Dose: Antichol: Sedation: Prozac 20 qd 0-1 1 Wellbu 75-100 b-t 1 1 Trazo 50-100 t 1 3 TCAs: Dose: Antichol: Sedation: Amitrip 75-300 qd 5 5 Nortrip 25 t-q 3 1 Clomip 75-100 qd 5 5 Imipra 25-50 t-q 4 3 Desipr 25-150 qd 1 1 MAOIs: Dose/d: Antichol: Sedation: Nardil 45-90 1 1 Marplan 30-60 1 1 Parnate 20-60 1 0 Antipsychotics Potency Potency *dg chlorpromazine (Thorazine) 100:1 mg Hal thioridazine (Mellaril) 100 mesoridazine (Serentil) 50 fluphenazine (Prolixin) 1-2 trifluoperazine (Stelazine) 8 perphenazine (Trilafon) 10 thiothixene (Navane) 4 loxapine (Loxitane) 15 molindone (Moban) 15 haloperidol (Haldol) 1-2 pimozide (Orap) 1-2 clozapine (Clozaril) Anxiety Disorders 30% of GAD is heritable based on female:female twin study (Kendler 92) benzo rcptrs are not present evolutionarily b4 bony fish anx tt 2b accompaniment of vigilance cog behav tx sig >er than placebo (Gillis 93) Kagan 84: temperemental diff' seen h endure tr life hv hier prob of bg children of rents of panic attack Beck Depression Inventory dep mild = 18 +/- 10 mod = 25 +/- 10 severe 30 +/- 11 Benzos BENZODIAZEPINES: 1/2 life: Dose: Tranxene 50-'0 3.75-7.5 t Klonopin 25 .5 t Valium 20-50 2-10 bid Librium 24 5-25 t-q Xanax 12 hrs .25-.5 tid Ativan 8-20 .5-1 t Serax 5-15 1 -30 t-q Versed 2.5 15-30 hs Hypnodics: Dalmane 70-90 15-30 hs Restoril 8-25 Halcion 2-3 .25 hs Bipolar Disorder 1/2 relapse win 1 y of rcvry 50% will relapse in 5 mo can respond within 3 days to VPA only 41% hv gd 5 y f/u 65% respond to Depakote (v. 32% placebo) Pope, Bowden vpa ds better w/ mixed, rapid-cyclg, or Li failures rapid cycling only 15% will respond to Li (v 60% for non rapid cycling) so use anticonvulsants when augmenting use T4 (synthroid) v. T3 for depression Borderline mnemonic RABID Relationships, stormy Affective instability Boredom/emptiness Identity disturbance Damaging behavior => impulsvity Buspirone 5t ++ 20-30qd SE: dizziness, N, drowsiness, restlessness mech unk Caffeine coffee: drip = 110-150 mg percol: 64-124 decat 2-5 tea: 1" brew: 9-33 5" brew: 20-50 iced: 22-36 Mt Dew 54 Diet Coke 46 Vivarin 200 Excedrin 65 Celexa ad beg 20 mg qd inc to 40 as tolerated Chest Pain Algorithm Hx VS ECG O2 100% FM <-> 4-6 l NC NTG .3 SL x 3 if sys BP > 90 do NOT give procardia for reflex tach ABG call CCU resident NTP 2" q 6h, off MN-6am DC isordil while on NTP MSO4 10 mg Claritin loratadine 1 tab po qd (contains sudafed) clonodine (Catapres) .1 bid > inc .1 qd alpha antag, useful in detox *dg Clozaril 600 mg qd = avg; 900 max 12.5 hs, then 25, then 37.5 ch WBC 3x qwk @ 1st taper ativan SE: 1-2% drop in WBC, 3-5% seizures also: GI, orthostasis *dg Coma Tx Thiam/Glu/Narcan 1. Thiamine 100 mg iv accucheck 2. Glucose 25 mg iv 3. Narcan 4 mg iv pulse ox ? O2 ECG Constipation Lactulose 30 cc po qd Dulcolax 15 mg po prn, 10 mg rectally Docusate 100 mg po qd (aft 200 hs x 3) Soap Suds Enema Mg Citrate bottle *dg CVA distributions mot/sens: carotid aa contralat aphasia/apraxia if dom a/w amaurosis fugax <- retinal ischemia MCA contralat face/UE ACA contralat LE +/- akinetic mutism apathy oft spared b/o collat flow <- oh aas Vertebro basilar -> vertigo, ataxia dysphasia, diplopia L carotid <- dirly off aorta; R <- R subclavian aa Cylert = Pemoline se same as Ritalin + hepatotoxicity = 13 cases in whch children died or reqd liv tplant Database info id mar status lives w cc hpi past psych ho meds eff comp prior sui sa etoh last amt dwi bo cage sa last amt ivda hiv status fh med/surg hx PPD last tested all sh edu occ legal charges? mil hx branch rank job combat wia pow witness trauma mse app alert orient reg beh aff md tp tc del sh av rec cog serial 7s world vocab proverbs ij Mini Mental ori = 5 reg = 3 7s = 5 rec = 3 lang 2 = name pencil/watch 1 = rpt no ifs + buts 3 = take paper in R hand, fold in half, put on floor 1 = read: Close Your Eyes 1 = wri sent 1 = copy design ros heent gi pulm cv gyn breasts skin neuro gu sexu h/o blood tfusions hiv testing assess I-V plan bprs DBT Emotional Regulation acronymn PLEASE MASTER tx Phy illness bal Eating avoid mood-Alterg dgs bal Sleep get Exercise bld Mastery DBT Interpersonal Effectivenss Interpersonal Effectiveness: Describe Evaluate Assert wishes Reinforce Mindfully Appear confid Negotiate DBT Mindfulness What Skills Observing w/o labeling Describing w/o jdging Participating mindfully DBT Relationship Acronymn be Gentle act Interested Validate use Easy manner (humor) DBT Self Respect acronymn be Fair no Apologies Stick to values be Truthful Delirium Diff Dx WHHHHIMP Wernickes/Withdrawal HTN encephalop Hypox/Hypoglyc/Hypoperfusn of CNS Intracran hemorh Meningitis/enceph Poisons/meds *psy Delirium Diff Dx I WATCH DEATH Infx Withdrawal Acute metabol Trauma CNS pathology Hypoxia Deficiencies (B12, niacin, folate) Endocrinopathies Acute vascular (shock) Toxins/dgs Hvy metals (Pb, Mg, mercury) Delirium Protocol Hal 3 / Ati .5 IVP x 2 aft 20": 5 / 1 x 2 aft 20": 10 / 2 x 2 aft 20": 20 / 4 x 2 .. 40 / 6 x 2 .. keep doubling - *No limit* flush line if heparin used add Dilaudid .5 q 3 hrs if doesnt work *dg*psy Dementia, AIDS subcxical - triad: dykinesia dementia depression poor attentional set shifts slow processg reduced fluency impaired free recall prog loss of cog fxg mot d/o test: trailmaking eg 1A 2B 3C ... prev: 7% of Aids pts Dementia W/U causes of dementia: Alzheimers 65% vasc 15% other 20% Labs: ESR, CBC, STS, Thy, B12/folate, VDRL, Ca Mg UA CXR EEG (LP rarely) psych testing *psy Dependence Criteria ICCLP Intent: to tx a med dx Conseq: eg dysfx Control Legality Pttn of use Depression 5% of women get pp dep aft givg birth ECA: 8% anx do, 6% SA do, 4% dep, 2/3 untxed avail of tryptophan = rate-limitg step of 5HT synth decg tryptophan ld to relapse in dep givg tryptophan deficient diet to txed depd pt leads to profound relapse within hours MRI: focal white matter lsns; lk like ms caudate, putamen, thalamus decd in depd pts intermed bw parkinsons and nl Depression SIG: E CAPS Suicide, Interest, Guilt : = constipation Energy Conc App Psychomot Sleep 4 = prob 5 = dx if x 2 wks *psy Depression, Elderly 75-80% NT with or w/o IPT (interpersonal tx) 50% IPT only 20% placebo Depression AD Response Prredictors acute onset melancholia psymot ret obsessive compulsive pd < neuroticism married, gd rltnshp, gd sexual life children < comoribidity b comorbid pd, anx d/o, etd/sa may NOT matter in chronic dep introversn + social nervousness Depression Outcome Studies Pittsburgh Stdy of Maint Therapies in Recurrent Depression (1984-7) => 3 yr f/u period mean survival t to recurrence = 124 w on imipramine (p < .001) 131 w on imi + ptx (interpersonal, monthly) - hier surv rate tho (84% v 60%) 82 w on ptx alone (p = .052) 45 for placebo full v. 1/2 dose: 135 w v. 75 w before relapse Depression Relapse 80% relapse-free if imipramine over 3 y 20% relapse-free if interpersonal tx 0% relapse-free if placebo virtually all Depression & CV Dz 17% of those withihd hv dep dep incs mortality 3-4x dep a/w incd platelet activatn, reactivity, cardiac events ssris effective ad Detox - ativan/librium taper ativan 1-2 mg po q 4 h VS q 4 h 1 h b4 ea ativan dose *dg Dexamethasone Suppression Test Dex 1 mg po 2300 DST+ blood draws next d @ 8a, 3p, 10p 2d tube for dexamethasone lev DST+ = cortisol lev; nl = suppression Dexedrine = dextro-amphetamine beg: 5a, 5 @ noon, inc to 10, 10 sustained release tablet available Dilantin 100t loading: 10-15 mg/kg IV slowly or po: 400 mg, then 300 mg in 2h, then 300 mg in 2h. DOS commands format /f:720 or 1440 xcopy a: c: /s key-fake 0 13 0 "U" 0 @59 @59 = F1, @67 = F9, @58 = F10 [see DOS keys] DOS keys F1 27 59, F2 27 60, .. F9 27 67, F10 27 58 Shft+F1 27 84, Ctrl+F1 27 94, Alt+F1 27 104 Arrows: L 27 75, R..77, Up..72, Dn..80 Home 27 71, End 79 PgUp 73, PgDn 81 Ins 27 82, Del 27 83, Esc 27, Backspace 8, Return 13, Tab 9 Effexor = Venlafaxine 75 mg qd; inc 75 q 4ds if ndd like SSRI w anti NE reuptake action SEs like SSRI; also: HTN max: 375/d EPS Extrapyradimal Side Effects *psy*dg Parkinsonism - onset: 1-4 wks Acute Dystonic Reaction - 1-2 ds Akathisia - anytime Tremor/Rigidity/Akinesia - anytime Tardive Dyskinesia - mos-yrs rx: vit E Rx: Anticholinergics (artane, cogentin) emerg: benadryl 25 im, rpt 25" [p. 181 Psy for Hou] GAF: Global Assessment of Fxg 90 min, 80 tsient, 70 mild 60 mod sxs 50 serious sxs eg SI 40 impaired reality testg 30 behav influd by H/D 20 danger hurtg self/oths 10 persistent "" Genetics per twin stdys in Virginia: depression: 40% - 70% (latter if correct for error of measmt) bipolar: 70% schizophrenia 70% 50% concord for MZ twins note: hvg adoptive schiz relative has no effect height 98% alcoholism 71% - entirely fm genes, not env (not learned) 82.7% unaffed 8.3% prob drinkg 2.8% alcoholism w/o physio dep 6.2% " " w/ dep mhj - env influences use or no use - hi odds ratio tho for genes once y use for dep/abuse (virtly no env influ) Haldol (haloperidol) .5-5 bid to tid 10 po qd =100-200 decanoate q 4 wks; - takes 3 mos b4 steady state - very exp; use prolixin 1st beg @ 5 qd,  5 q 3 ds til cogwheeling maint: continue x 6 mos (2 yrs if > 3 exacerbations), then  50% gradually over mos; 25 mg/ .5 cc *dg HAM-D >= 18 = nc for entry into dg stdy < 8 = virtual cure HIV Rates 12/95: M F white 1/204 1/2000 black 1/44 1/135 Hispan 1/69 1/294 tot US infx: 630k-897k source: Natl Canc Institute, Science mag HIV Treatment begin w/ hiest doses tolerated bo risk of resis tx indic: prim infx or later (fallg cd4 count, preg, hi risk or sexual xposure cd4 < 500 or detectable plasma rna init tx sl b 2 nucleosides + a protease inhib any monotx regimenis unaccept azt = zidovudine - defective thymidine taken up by vir protease inhibitors -> buddg of noninfxous viral particles: idinavir - 800q8 = ideal dose; se=K stones so ++fluids ritonavir - ++effective, b ++tox esp hepatic saquinavir - --eff, --tox saq + rit => synergism -> halvg of dz progressn triple tx (zdv/idc/3TC) -> 80% of pts hv undetectable rna nelfinavir = newest dg 3TC -> >50% death rates in Eur trials non-nucleoside rvrse transcriptase inhibs + AZT -> 75% reductn in HIV detectability ZDV reduces tmissn rate by 67% in preg women unclear what terat effs Homicide Rates 15-24 y/o males #1: US: 34/100k (40/100k in gen pop) = 167/100k amng black males #2: Italy: 4/100k (6/100k in gen pop) Germany: 3/100k Japan: < 1/100k HTML Format file://c:/wri/dogs.doc Insulin Sliding Scale BS 0-199 give 0 200-249 2 u reg 250 299 4 300 349 6 350 399 8 >400 10 + call HO Internet Psychiatry Sites www.mhsource.com/disorders/index.html = links to materials on all disorders on the Web Klonopin (clonazepam) .5 tid > 20 qd max .5 mg klon = 1 mg Xanax = 5 mg valium *dg Life Expectancy 90% die of chronic illness life expectancy @ birth = 48 in 1900 - 50% of deaths were in children Lithium Therapeutic Levels .6-1.5 motrin will double Li level Major Depression Criteria 5 of following over 2 wks: - D mood - anhed - inc/dec wt, sleep, psychomot - fatigue - worthlessness/guilt - dec conc - sui thghts Manic Episode Criteria DSMIII-R Criteria Mood inc x 1 wk + 3/4 of: inc Self-esteem dec Sleep inc Speech +/- pressured FOI Distractibility inc Goal-oriented Activities Pleasurable actvty' -> Pain Mental Retardation IQ => rm: 70 = cutoff, then -15 mild 50-55 - 70 6th grade mod 35-40 - 50-55 1st grade severe 20-25 - 35-40 req const supervisn profound < 20-25 req const care Kaplan, 1026 Mental Status Exam Appearance A+Ox4 Reg/Recall Motor activity Speech - rate/tone LOA/FOI TC - H/D Mood/affect SI/HI Cognition Insight Judgement Migraine Tx Imitrex (sumatriptan) 25 mg im po qd prn ha Mini Mental Status Exam Mini Mental ori = 10 reg = 3 7s = 5 rec = 3 lang 2 = name pencil/watch 1 = rpt no ifs + buts 3 = take paper in R hand, fold in half, put on floor 1 = read: Close Your Eyes 1 = wri sent 1 = copy design Moban (molindone) 15:1 50-75 qd > 100 qd Naltrexone 50 qd for ETOH dep 50 qd or 100 q Mo, We, 150 q Fri naltrexone + coping skills traing grp did best for opioid dep: usu taken 3x qw 100/100/150 good for decg reincarceratn rates do not use until th person has bn detoxed else severe wd Navane (Thiothixene) 4:1; 5 bid > 20-30 qd Neuroleptic Malignant Syndrome Neuromalignant Syndrome autonom dysfx (T, HR, sweating) t course = 1-2 ds akinesia, slowing  stupor  coma labs: WBC, CPK (1000s), myoglobin death <- resp failu rx: stop antipsychotic bromocriptine, dantrolene Nicorette Gum 2 mg sig: chew 1 piece x 30" tid Nitropaste 2" q 6 h, off @ MN/DC isordil! *dg Nl Chem Values Ca 8.5-10.5 PO4 2-4 Mg 1.5-2.1 Cl 95-105 CO2 22-31 BUN 8-25 Cr .6-1.7 Glu 65-110 Nl WBC/diff values WBC 4.3-10.8 hct: 36-46 F, 41-53 M; plt: 150-400 Diff: 34-75% segs 0-8% bands 12-50% lymphocytes 3-15% monocytes 0- 5% eos 0- 3% basophils NTG .4 mg SL q 5" prn *dg OCD 1:1 m:f 39% of women hv onset a/w 1st childbirth caudate nuc smaller than controls tx: clomipramine to 250 qd -> 60% response prozac to 80 qd if tics, add Haldol Greist 90: behav tx -> 51% gt reductn, 30% mod reduction Striatal System Pathways: (cx -> striatum -> thalamus) input -> thal -> cx -> striatum) Sensorimot: through putamen Cognitive: """ caudate Affective/motivational tr nucleus accumbens Olanzapine 10h (Zyprexa) response in 1st week; can use 10 +/- 2.5, or 15 +/- 2.5 no benefit to hier good benefit against neg sxs + pos sxs SE: like clozaril, b w/o bone marrow ses SE: weight gain (sig), prolactin inc somnolence,dizziness, agitatn, asthenia, nervousness no acute dystonia, +akathisia in 1 trial (sig) some Parkinsonism* (not sig) no agranulocytosis mech: D2, 5HT2A antagonism selectively inhibs mesolimbic b not nigrostriatal dopaminergic sys acty, so no eps 1/2 life: 21-54h Opioid Dep detox: clonidine, naltrexone, benzo or maint: methadone or LAAM = Levo Alpha Acetyl Methadol or buprenorphine w/d fm hyperacty of locus ceruleus -> sxs Opioid Receptors Mu - respir dep Kappa - spinal anesthesia Delta - Orap (pimozide) 1:1 1-2 qd > 10 qd *dg Pain Rating Scale MADISON Multiplicity of complaints Authenticity - pt really wants Denial that emotional facs worsen pain Interpersonal probs Singularity "no one has pain like this" Only You can help me No change or nothing helps ea 0-4; if tot > 15 then psychogenic Panic Attacks < hour duration, 2x/wk freq common 2/3ds of pts w agoraph hv panic Prev: 2-5%, 1:2 male:female Kaplan 316 Paxil (paroxetine) 20-50 qhs (30-40 optimal) SE: N 27%, sedation 20%, HA 19%, sleep, diaphor, dizz, anxiety ( Zoloft > Prozac) *dg SSRI Prevalence of Psych D/O Prevalence of Psych D/o (based on Epi Catchment Area Study 84 Overall 33% prev of any mental d/o 22% if no ETOH/SA Anx 15% ETOH 13 Aff d/o 8% MDE 6% OCD 2% PTSD 1% in VN vets: 15% (see below) Primary Care & Mental Health 28% of pts hv mental illness 48% of mds t 3.6% of familys = 32% of physicians t Colyer Prolixin (fluphenazine) 1-2:1; 2.5-10 po qd Decanoate: 25 im q 2 wks - cheaper than hal - 25 mg/cc - 10 po qd = 12.5-25 mg q 2 wks *dg Prozac 20-40 mg qd beg slowly +  20 q 3ds > 40 not helpful xcept w OCD then  80 ** WAIT 4 WEEKS BEFORE STARTING MAOI, < TIME IF TCA, BUT START LOWER ** *dg SSRI PTSD Groups PTSD/spirituality Th 1-2:30 PTSD/family We 3-4:30 PTSD group Coberly PTSD mnemonic ERASE Event Reexperiencing - dreams/flashbacks/preoc Avoidance behaviors SE = sympathetic excess - hypervig/startle respone/anx duration: >= 1 mo; delayed onset if > 6 M aft trauma PTSD Stats NVVR: Prevalence = 15.2%/8.5% of all male/female vets who served in VN (v. 2.5%/1.1% of all era vets, 1.2%/0.3% age-matched civilian counterparts). Race & Education Asian w/ 1200 SAT has 5% chance of adm to Berkely black has 100% chance w/ same SAT 2.5k Asians w/ 4.0 avge were rej'd by Berkely in 89 17% of Berkeley's affirm actn entrants graduate v. 40% overall black, 65-75% overall w/Asian avge SAT diff w-b = 192 of 100k who took test in 1989 < 3k b scored > 599 in verbal or math only < 150 >699 verbal, < 400 >699 math b has 50% prob of adm to UVA; W = 25%; SAT diff = 240 pts w-b Berkely Office of Budget & Planng estimates <4% of stu body wl b black/His/Indian if merit alone were used Rapid Tranquilization Choinard 93: n = 16 manic -> clonaz 1-2 hal 5-10 q.5-1h => both sig dec manic sxs w/in 2h - b 1 hal pt had parkinsonism - no se fm bnzo REC: benzo pref to nnlep Wyant 90 n = 5 acutely agitated randome -> midazolam * Na amytal * *= dec mot acty better no se hal 10 im no rx diff bw grps Lazarus 89 hi loadg doses of nnlep hv NO benefit over mod doses rapid neuroleptization not recommended; RT ok Battaglia 97 n = 98 rand -> ati 2 hal 5 <= eps > hal alone hal + ati <= most rapid REC: combo rx Foster,S + Kessel,J 97 n = 37 dble blind -> ati 2 hal 5 q 30" x 4h NO DIFF IN OUTCOME REC: BNZOS PREFERABLE BC < SEs Remaron ad < sexu se than ssri Resume #2142674138 www.cweb.com/register = CareerWeb Risperidone 1 mg bid, then tid watch WBC Risperidone (Risperdal) 1b -> 3b; max = 6b beg @ 1b, 2b, 3b x 7d; 1 wk to reach steady state SE: saliv, EPS, orthostasis mech: 5HT2 + D2 blockade Ritalin 10a, 10 noon 1/2 life = 3h dose @ 1 mg/kg/dose, max = 2 m/k/d se: insom loss of appet, gi disturb, mild initial nervousness, intens of tics SAT Scores 1996: 1.1 million took test 508 = avge (recentered) Gender verbal math f 503 492 m 507 527 Race As 496 558 =1054 w 526 523 =1047 b 434 422 = 856 dif 92 101 = 193 per College Board Schizophrenia Algorithm hi pot NL avg 7 m/d x 4-6 w or low pot NL avg 350 m/d x 4-6w or Risperidone 6 m/d x 4-6w if no efficacy: inc dose x 4-6w if no efficacy decanoate or clozapine or augmentation strat if no efficacy consid ECT or investig protocol Serentil (mesoridazine) 50:1; 50 tid Serzone (nefazodone) 100 b x 1w, 150 b x 1w very lo sexu SEs ((1.5% impot), < 1% orgasmic dysfx Sexual dysfx anorgasmia: bethanechol 10 mg 1-2 po 1 h b4 intercourse Sleep circadian rhythm controlled by super chiasmic nucleus bdy Temp oscilation correlates w/ sleep Advd sleep phase = bed time later, get up later a/w yng Delayed sleep phase = fall to sleep earlier in evening + wake up earlier in am Stelazine (trifluoperazine) 8:1; 2-5 bid > 15-20 qd *dg Stimulants mg/d: avg max 1/2h peak/fades Dextro-amph Dexedrine 10-20 40 4-6h 2-3/4-5 MPH Ritalin 20-30 60-80 2-3h 1-2/3-5 Pemoline Cylert 50-75 110 7-8* 1-4/ 11-13 adult *children note: wt gain, insomnia will fade w/ tolerance SE: tics, psychosis, dependence gd as AD, b wears off in 2-4 wks Stress & Immunology David Spiegel 89 met br CA randomized into group tx v no tx mean survival for group tx = 36m v 10m lymphocyte mitogenesis, natu killer cs dramatically suppressed if animal shock immune sys activated by brief pulses of stress (sym stim) b depressed by anything longer or more severe Executive monkey studies - primates are hi responders,whch mns ty are more susc to push a lever to avoid a shock; executive (controlling monkies) died of duodenal ulcers pos feedback fm ea response will negate stress response <- 1. amt of behav respondg, 2. pos. fdback followg responses Substance Abuse of Americans: 90% use etoh 80% caff 25% nico 7% illicit drugs Alcohol dep: 30% prev amng 1st deg relatives 35% fraternal twins 70% of MZ twins Suicidality MOM SALAD Maj dep, Oth attempts, Male Substance abuse, Alcoholism, Loss, Age, Divorce *psy Suicide Rate Japan 17.2/100k US 12 /100k UK 7.5/100k Finland 27.3/100k source: Japans Health Ministry 6/98 Tachycardia vagal maneuvers verapamil 5 mg iv push slowly on monitor - or - dig .25 mg then agn in 1/2 hr then .125 mg/h not to exceed 1 mg *dg Tegretol Therapeutic Levels 8-12 Teratogenicity Li >> teg > vpa Therapeutic Index = ratio of drug nded to produce bad SE to dose needed to get therapeutic effect Thorazine (chlorpromazine) 100:1 SE: rashes,  sz thresh most *dg Thorazine (chlorpromazine) 1:100; 25 tid > 400 qd 100 mg = 1 mg haldol *dg Thyroid T4 T3U FTI 1.75-4.95 35-45% 1.0-2.3 Hyper ++ ++ ++ Hypo -- -- -- Preg ++ -- wnl TSH < 5 = wnl Tox Screen Info cocaine: benzoylecgnonine is active < 60 hours Trazodone Good as hypnotic;  serotonin spec SE: dangerous if PVC, priapism Trilafon (perphenazine) 10:1 8-16 bid-qid *dg Valproate (Depakote) vpa lev = 50-100 now fda approved for tx of mania se: liv failu 1/40k, all in children < 10 weight gain pancitis (rare) alopecia Viagra phosphodiesterase inhib 9/12 sc pts v 1/12 placebo pts had improvemt in erectile fxg 72.9% improvement @ 50 mg prior to intercourse se: ha, diarrhea, gi upset Violence 1960 1992 rate of violence/100k: 161 758 +371% black males 11 x more likely to b killed by gsw than whites No maj d/o: Maj Mental d/o: SA: SA+MDO: prev 2.1% 7.29% 21.01 22.82 OR - 3.94 13.67 16.79 homicide: 17% occur win family; males + females equal victim rate Hallucinations alone do not sig inc risk Risk Factors Male SES/IQ +/-black h/o abuse, h/o ***past violence  social support **ETOH/SA gang Dx: *Antisoc PD, **ETOH/SA, borderline/narc PD, PTSD, schizo, mania, dementia Personality:  empathy/remorse, impulsivity, para, entitlement Violence Factors Male SES/IQ +/-black h/o abuse, h/o ***past violence  social support **ETOH/SA gang Dx: *Antisoc PD, **ETOH/SA, borderline/ narc PD, PTSD, schizo, mania, dementia Personality:  empathy/remorse, impulsi vity, para, entitlement Violence & Reconciliation Stump tails (peaceful) raised w/ Rhesus (aggressive) -> Rhesus become as reconciliatory as Stump tails crowding -> > grooming and < aggression 60 mil ys ago hum/apes split w/ old world monkies 6 mil ys ago we split w/ chimpanzees/bonobos bonobos hv female dominance, sex used for reconciliation Wellbutrin 75 tid  100 tid; max = 200 tid +: no diarh, > stimg, no sex dysfx -:  seiz threshold, mult doses caution in bulemics b/o inc risk of sz Zoloft (sertraline) 50 mg qd  200 mg qd SE: N/V +/- diarh; CV SEs (palp, CP, BP; delayed ejacu in males; avoid in anxious or agitated pts. t1/2 = 66-80 hrs Avoid w/in 14d of MAOIs. *dg SSRI