treatment guidelines

1. start medications early

2. 1st-line: AAPs (except clozapine)

3. optimize; trial of 4-8wks at max tolerable dose

4. switch to different 1st-line agent, or augment

5. clozapine trial (or another 1st-line first)

• 6. augment
• - Li, anticonvulsants, ADs, benzos
• - ECT
• - AAP (last strategy)

6. oral typical neuroleptic ok if prev effective

7. consider depot

Combination medications + psychotherapy best

• 1st-line medications
• - all SSRIs
• - all SNRIs
• - bupropion
• - mirtazapine
• - moclobemide

• 1st-line psychotherapy
• - CBT
• - IPT

1. Start 1st-line medication

2. Optimize dose

3. Switch to other 1st-line medication

4. Augment with Li or AAP

5. Augment/combine with bupropion, mirtazapine, seroquel or cytomel

6. Add-on other agent or switch or consider 2nd-/3rd-line agents (TCAs, MAOIs, selegiline, trazodone)

Maintain at least 6-9 months after remission.

• At least 2 years to lifetime if risk of recurrence:
• - 3+ episodes
• - chronic episodes
• - psychotic episodes
• - severe episodes
• - harder to treat episodes
• - hx of relapse with AD discontinuation
• - older age
• - psychiatric/medical comorbidities
• - residual symptoms in current episode

PRN antipsychotic + benzodiazepines for agitation

• 1st-line medications:
• - Lithium
• - Epival
• - AAP
• - Li/DVP + AAP

Trial each step for 2 weeks at adequate medication dose before moving on.

1. Start 1st-line medication(s) and optimize

• 2. Switch to or combine with different 1st-line agent
• - Li/DVP -> switch/add AAP
• - AAP -> switch/add Li or DVP
• - combination Li/DVP + AAP -> switch one or both agents

3. Switch to or combine with different 1st-line agent

• 4. Switch to or add 2nd- or 3rd-line agents
• - Li + DVP
• - CBZ
• - ECT
• - Clozapine
• - Haldol
• - Asenapine
• - Paliperidone
• - Oxcarbamazepine
• - Tamoxifen

• 5. Try add-on or experimental agents
• - Tryptophan
• - Allopurinol
• - Amisupride

• 1st-line medications:
• - Lithium
• - Lamotrigine
• - Seroquel (IR/XR)
• - Li + DVP
• - Li/DVP + SSRI/bupropion
• - Olanzapine + SSRI

1. Start 1st-line treatment and optimize

• 2. Switch or add-on alternate 1st-line agent or consider 2nd-line agents
• - DVP monotx
• - Seroquel + SSRI
• - Li/DVP + lamotrigine
• - adjunc modafanil

3. Switch or add-on alternate 1st-line agent, or consider 2nd-line

• 4. Switch to or add-on 3rd-line agents, or novel agents
• - other mood stabilizers (CBZ, topiramate)
• - other ADs (venlafaxine, MAOIs, TCAs)
• - n-acetylcysteine
• - other combinations

• monotherapy:
• - mood stabilizer: Lithium, Lamotrigine, Epival
• - AAP: Olanzapine, Seroquel, Aripiprazole, Risperidone Consta

• combination:
• - Li/DVP + Seroquel
• - adjunctive Risperidone
• - adjunctive Ziprasidone

• 1st-line medications:
• - Quetiapine IR/XR

• 2nd-line medications:
• - Lithium
• - Lamotrigine
• - Epival
• - Li + DVP
• - Li/DVP/AAP + antidepressant

• 3rd-line medications:
• - Ziprasidone
• - antidepressant monotherapy

• Psychological:
• - CBT

• Medications:
• - all SSRIs
• - Venlafaxine
• - short-term benzodiazepine PRNs

• Psychotherapy:
• - CBT: exposure, cognitive restructuring, social skills training, relaxation

• Medications;
• - SSRIs (not fluoxetine or citalopram)
• - Venlafaxine
• - optimize dose and trial two 1st-line agents before switch to 2nd-line
• - 2nd-line: citalopram, gabapentin, pregabalin, phenelzine
• - 3rd-line: adjunc AD (fluoxetine, wellbutrin, remeron, clomipramine, moclobemide), mood stabilizers (epival, topiramate), AAP

• Psychotherapy:
• - Exposure-Response Prevention
• - CBT

• Medication algorithm:
• 1. 1st-line: SSRIs (not es/citalopram)
• 2. optimize (may need higher than usual doses)
• 3. switch to different 1st-line agent
• 4. consider augmentation with 2nd- or 3rd-line agent early if partial response
• 5. switch to Clomipramine
• 6. 2nd-line:
• - celexa, effexor, remeron
• - risperidone
• 7. trial combinations of 1st- and 2nd-line agents
• 8. add-on adjunctive 3rd-line agents:
• - IV Clomipramine
• - Seroquel, Olanzapine, Haldol, Phenelzine
• - Gabapentin, Topiramate
• 9. Continue medications 1-2y post-remission or lifetime

• Consider neurosurgical tx if no response:
• - anterior cingulotomy, anterior capsulotomy, subcaudate tractotomy, limbic leucotomy
• - DBS

• Psychotherapy:
• - CBT

• Medications:
• 1. 1st-line: Effexor, Paroxetine, Escitalopram, Sertraline
• 2. optimize; trial 8-12wks at adequate dose
• 3. switch to different 1st-line agent
• 4. 2nd-line: Bupropion, Imipramine, Buspirone, Pregabalin
• 5. switch or combine 1st- and 2nd-line agents
• 6. add-on 3rd-line as adjunct:
• - Risperidone, Olanzapine
• - Hydroxyzine
• - Remeron, Trazodone
• 7. continue tx at least 1y after remission

• Psychotherapy:
• - CBT
• - EMDR

• Medications:
• 1. 1st-line: fluoxetine, paroxetine, sertraline. venlafaxine
• 2. optimize, trial up to 8wks
• 3. switch to different 1st-line agent, OR
• 4. switch to or add 2nd-line:
• - fluvoxamine, mirtazapine, moclobemide, phenelzine
• - adjunctive risperidone or olanzapine
• 5. consider adjunctive 2nd- or 3rd-line agents early to preserve gains
• 6. 3rd-line adjuncts:
• - TCAs (monotx)
• - citalopram, trazodone, bupropion
• - CBZ, gabapentin, DVP, lamotrigine, topiramate
• -quetiapine
• - prazosin, clonidine (nightmares)
• 7. continue medications at least 1y if chronic PTSD

• Baseline studies:
• - CBC, lytes, BUN, Cr, TSH, glucose, bHCG
• - ECG
• - weight

• Monitor:
• - q1y: renal fn, TSH
• - weight
• - Li level: q3-6mo after 2 consec levels in therapeutic range (on stable dose)
• - target Li levels 0.8-1.1 mEq/L (0.4-0.7 for elderly)

• Baseline:
• - CBC, LFTs, bHCG
• - weight

• Monitor:
• - q1mo x6mo, then q6mo: CBC (plts), INR/PTT, LFTs,
• - weight and signs of PCOS
• - Epival level: q3-6mo after 2 consec levels in therapeutic range (on stable dose)
• - target Epival level 400-800 mmol/L

• Baseline:
• - CBC, diff, bHCG

• Monitor:
• - CBC at 1wk, 3 wk, then q1mo x6mo, then q6mo x2y, then q1y