| ECT (electroconvulsive therapy) and efficacy in treating depression: | ECT, which causes a generalized CNS seizure, is effective in treating depression. ECT is probably most effective in management of severe depression and is especially helpful in managing
delusions and agitation accompanying depression in the elderly population. |
| Indications for ECT in management of depression: | Indications include circumstances in which medical conditions argue against antidepressant administration or when patients are refractory to such approaches. Furthermore, extreme suicidality represents another indication. ECT is also helpful in managing manic disorders and psychosis during pregnancy (when medications might be contraindicated). |
| Common side effects associated with ECT therapy: | Memory disturbance and headache are the most common side effects. Effects on memory are most likely related to number as well as frequency of ECT. Memory typically returns to pre-treatment levels in a few weeks, although some memory deficits may be permanent. Unilateral ECT is less likely to result in memory loss and bilateral ECT. |
| ECT contraindications: |
Elevated intracranial pressure is an important contraindication; however, cardiac disorders, bronchopulmonary pathology, aortic aneurysm and venous thrombosis represent relative contraindications. |
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Likelihood of serious ECT complications: | ˂ 1 per 1000 cases, with most complications referrable to the cardiovascular or respiratory system. |
| Drugs effective in treating either acute mania or hypomanic symptoms: | Lithium or valproic acid: several days of treatment may be required before results are evident. |
| Drugs which may be used adjunctively to lithium in treatment of acute mania or hypomanic conditions: | Atypical neuroleptics may be appropriate as either adjunctive treatment or as primary, monotherapy. Management of acute cases may also require adjunctive use of certain benzodiazepines such as clonazepam. |
| Lithium as a preventative for bipolar affective disease
recurrence: | Lithium reduces both frequency and severity of manic and depressive events in about 70% of patients. Factors that predispose to a positive response include a low episode frequency (no more than two per year in the absence of prescribed agents during intervals between attacks.
A factor that appears to limit effective episode prophylaxis initially is rapid cycling between manic and depressive events. In these individuals
exhibiting such rapid cycling, carbamazepine may be an effective alternative.. |
| Lithium in recurrent unipolar depression: | Lithium may be helpful in reducing the frequency of recurrent unipolar
disease, reducing nonspecific aggressive behavior and control syndromes. |
| Clinical laboratory and other assessments prior to initiation of lithium therapy: | In addition to the medical history and physical exam: the following laboratory assessments are appropriate: complete blood count (CBC), T4, TSH (thyroid-stimulating hormone), BUN levels (blood urea nitrogen), serum electrolytes, urinalysis,
and serum creatinine. In patients over 45 years of age or those with known
cardiac disease, an ECG (electrocardiogram) is appropriate. |
| Side effects associated with lithium treatment: | Mild G.I. symptoms which may be managed by taking lithium in divided doses with food. Additionally, fine tremors may occur which may be managed with the ß-adrenergic antagonist propranolol. Other effects include early and transient somnolence and minor muscle weakness. A moderate polyuria, associated with diminished renal response to antidiuretic hormone (ADH) and polydipsia secondary to increased plasma renin levels are commonly noted. Potassium administration may reduce this effect, which is also decreased with once-daily lithium dosing. Weight gain and a leukocytosis not related to infection are also frequently observed lithium-related effects. |
| Lithium side effects and the thyroid: | Goiter, hypothyroidism may occur. Concurrent administration of lithium and iodide or lithium and carbamazepine increases the likelihood of goitrogenic effects. |
| Long-term lithium treatment and extrapyramidal, CNS presentations: | Cogwheel rigidity and other extrapyramidal signs may be noted. Lithium-induced potentiation of Parkinsonian effects of haloperidol may also occur. Reduced memory and perceptual processing have been associated with long-term lithium treatment. |
| Lithium toxicity: | Notable toxicity occurs at blood lithium levels
˃ 2mEq/L. sodium and lithium compete for reabsorption at the same sites And proximal kidney tubules. Accordingly, sodium loss secondary to diuretic use, excessive sweating, or diarrhea, results in increased lithium levels. |
| Lithium toxicity: signs and symptoms | Vomiting and diarrhea are prominent. Other presentations include marked muscle weakness, confusion, dysarthria, vertigo, choreoanthetosis (a combination of chorea (irregular migrating contractions) and athetosis (twisting and writhing)), tremors and many others. |
| Management of patients who have taken very large amounts of lithium or patients with lithium blood concentrations greater than 2.5 mEq/L: | Management includes causing emesis and performing gastric lavage. urinary alkalinization may be useful since sodium bicarbonate reduces lithium proximal tubular reabsorption.. Acetazolamide exhibits the same action. Aminophylline increases lithium clearance by means of its diuretic action. Blood lithium levels
˃ 2.5 mEq/L, validated by CSF fluid lithium concentration assay, constitute a basis for hemodialysis. |
| Drug interactions and lithium: | Concurrent use of diuretics and lithium requires careful consideration of supervision.Thiazide-type diuretics increase lithium proximal tubular reabsorption, causing increased serum levels. A change in dosage is required to compensate for this action. A reduction in lithium dosage in this setting may be between 25%-40%, assuming 50 mg/day hydrochlorothiazide treatment. Serum lithium levels may also be increased if potassium-sparing category diuretics are being administered. These agents include amiloride, triamterene, and spirolactone. Loop diuretics do not appear to change serum lithium levels. Use of lithium and angiotensin-converting enzyme inhibitors (ace inhibitors) necessitate a 50%-75% decrease in lithium intake in order to obtain therapeutic lithium concentrations. |
| Valproic acid (divalproex) in management of mania: | Valproic acid is classified as an antiseizure drug with
a mechanism of action including effects on the GABA system. Valproic acid appears safer than lithium and is a first-line treatment for mania. In those patients susceptible to dehydration or malabsorption (groups including certain HIV/AIDS patients and other medically compromised patients), valproic acid administration represents an important alternative to lithium. |
| Drug-drug interactions involving valproic acid: | Elevation of valproate
levels may occur with concurrent aspirin use. By contrast, reduced valproic levels are associated with concurrent use of phenytoin or carbamazepine. Valproate administration may cause increased warfarin levels. |
| Principal side effects of valproic acid administration: |
Weight gain and GI symptoms. Valproic acid monitoring may require liver function test, CBC, glucose level determinations and weight assessment. Because of notable teratogenic activity of valproic acid, pregnancy must be ruled out as a possibility prior to starting treatment. |