Biological and somatic treatments (pharmacotherapy, ECT, TMS, other neuromodulation) and psychotherapy
Items combine practical prescribing rules with the indications and contraindications of ECT, TMS and the major psychotherapy models.
Core rules
- Antipsychotics: high potency (haloperidol, fluphenazine) means more EPS and less sedation; low potency (chlorpromazine) means more anticholinergic and orthostatic effects. Metabolic monitoring at baseline, twelve weeks and then periodically for weight, waist, glucose, lipids and blood pressure.
- QTc prolongation: greatest with thioridazine, pimozide, ziprasidone and intravenous haloperidol; correct potassium and magnesium before starting.
- Mood stabilizers: valproate is teratogenic (neural tube defects) and hepatotoxic; carbamazepine induces CYP3A4, causes hyponatremia and agranulocytosis; lamotrigine needs slow titration to prevent Stevens-Johnson syndrome.
- ECT indications: catatonia, psychotic depression, severe treatment-resistant depression, high suicide risk, refusal of food and fluid, NMS and pregnancy when medication is unsafe. Relative contraindications: raised intracranial pressure, recent myocardial infarction or stroke, uncontrolled hypertension, pheochromocytoma, retinal detachment. Cognitive effects are mainly retrograde amnesia. Courses are typically 6-12 sessions at two to three per week; seizures should last roughly 25-60 seconds.
- Anaesthetic points: avoid lidocaine (raises seizure threshold) and be cautious with lithium (prolonged seizures and neuromuscular blockade).
- TMS: left dorsolateral prefrontal 10 Hz protocol for depression; no anaesthesia; seizure is the main risk; contraindicated with metallic implants in the head.
- Psychotherapy: CBT for depression, anxiety and OCD; interpersonal therapy; exposure and response prevention for OCD; DBT for borderline personality disorder; family interventions reduce relapse when expressed emotion is high.
Worked example
A pregnant woman in the second trimester with psychotic depression refuses medication after a suicide attempt. ECT is the treatment of choice because it avoids fetal drug exposure, acts quickly and is effective in psychotic depression; anaesthetic agents are selected with obstetric input.
Traps
Combining lithium with ECT without caution; forgetting metabolic monitoring; using bilateral ECT as a first step for a mild episode; assuming TMS requires anaesthesia or that psychotherapy needs to precede medication in severe depression.