Psychiatric Treatments: Pharmacologic, Somatic, and Psychotherapeutic
Psychiatric treatments
Know mechanisms, adverse effects, monitoring, and evidence-based indications. SSRIs and SNRIs are first-line for many anxiety and depressive disorders; they can cause GI upset, sexual dysfunction, hyponatremia, and discontinuation syndrome, and serotonin syndrome is a medical emergency. Bupropion lowers seizure threshold; mirtazapine causes sedation and weight gain; trazodone is sedating; MAOIs require tyramine restriction and have dangerous interactions. Antipsychotics block dopamine D2; second-generation agents carry metabolic risk, and clozapine requires ANC monitoring because of agranulocytosis. Lithium requires renal, thyroid, and level monitoring; toxicity presents with tremor, ataxia, confusion, vomiting, and dehydration. ECT is highly effective for severe depression, catatonia, and psychosis; TMS is noninvasive for depression; ketamine and esketamine act rapidly but require monitoring. Psychotherapy modalities include CBT, DBT, psychodynamic, supportive, interpersonal, and family therapy. Match treatment to diagnosis, severity, prior response, and patient preference. Traps: missing serotonin syndrome or NMS; ignoring lithium dehydration; starting clozapine without ANC monitoring; combining MAOIs with serotonergic drugs; attributing all antipsychotic effects to D2 blockade; and assuming ECT causes permanent memory loss. Worked example: a patient on an SSRI develops agitation, clonus, hyperreflexia, and fever after adding a second serotonergic drug. Recognize serotonin syndrome, stop the agents, and provide supportive care. Rule of thumb: start low and go slow in older adults, and check interactions before adding any serotonergic agent.