Y

* 14 * 14

Key: ^recognised indication; where numbers appear in the table, see notes below. Notes:

{I) Lithium augmentation may be used in depression (p. 375). Lithium is given in combination with a TCA, SSRI or novel antidepressant, usually when the symptoms have proved resistant to adequate trials of two or more antidepressants.

(2) Formerly, antidepressants were thought to be less effective in generalised anxiety disorder than in panic disorder. Evidence now suggests that the SSRI, paroxetine and the SNRI, venlafaxine are beneficial.

(3) Antipsychotics may be used short-term for management of severe anxiety, but only where other drug options have failed (due to adverse effect).

(4) Buspirone may be used in generalised anxiety disorder as an alternative to a benzodiazepine.

(5) SSRIs and MAOIs are effective in social phobia, p-adrenoceptor blockers may also be helpful, particularly in performance anxiety, combating tremor and other symptoms of autonomic overactivity.

(6) Serotonergic antidepressants, including the tricyclic clomipramine and the SSRIs are effective in the treatment of obsessive-compulsive disorder.

(7) Augmentation with classical or atypical antipsychotics may be attempted when obsessive-compulsive disorder is resistant to antidepressant treatment.

(8)TCAs (especially imipramine and amitriptyline) and SSRIs may be effective in post-traumatic stress disorder.

(9) Clomethiazole was an alternative to a benzodiazepine for alcohol withdrawal but is now rarely used due to concerns over respiratory depression and abuse potential.

(10) Drugs for alcohol dependence and withdrawal are discussed in Chapter 10.

(11) When a patient complaining of insomnia also has depression, a sedative antidepressant such as trazodone, nefazodone or mirtazapine should be considered. SSRIs do not provide direct sedation in such patients but may improve the quality of sleep over a longer period as mood improves.

(12) Fluoxetine is licenced in the UK for the treatment of bulimia nervosa.

(13) Acetylcholinesterase inhibitors provide transient improvement in cognitive and global functioning in mild to moderate dementia of Alzheimer's disease.They delay the onset of severe illness but cannot ultimately halt or change the course of the disease.

(14)The CNS stimulants methylphenidate and dexamfetamine are drugs of choice for attention deficit/hyperactivity disorder. Second line treatment options include clonidine and the antipsychotic agents risperidone, haloperidol and sulpiride.

It is plain that prescribers have a major responsibility here, both to warn patients and, in the case of those who need to drive for their work, to choose medicines having minimal liability to cause impairment. Patients who must drive when taking a drug of known risk (e.g. benzodiazepine) should be specially warned of times of peak impairment.

A patient who has an accident and who was not warned of drug hazard, whether orally or by labelling, may successfully sue the doctor in law. It is also necessary that patients be advised of the additive effect of alcohol with prescribed medicines.10 Car driving is a complex multifunction task that includes:11

• visual search and recognition

• information processing under variable demand

• decision-making and risk-taking

• sensorimotor control.

How the patient feels is not a reliable guide to recovery of skills and drivers may be more than usually accident prone without any subjective feeling of sedation or dysphoria: the fact that they feel OK does not mean that they are OK.

The criteria for safety in air-crew are more stringent than those for car drivers.

Resumption of car driving or other skilled activity after anaesthesia is a special case, and an extremely variable one, but where a sedative (e.g. i.v. benzodiazepine, opioid or neuroleptic), or any general anaesthetic has been used it seems reasonable not to drive for 24 h at least.

9 A dose-response relationship was found between benzodiazepine use and road-traffic accidents. Barbone F et al 1998 Lancet 352:1331-1336

10 Nordic countries require that medicines liable to impair ability to drive or to operate machinery be labelled with a red triangle on a white background. The scheme covers antidepressants, benzodiazepines, hypnotics, drugs for motion sickness and allergy, cerebral stimulants, antiepileptics and antihypertensive agents. In the UK there are some standard labels that pharmacists are recommended to apply, e.g. 'Warning. May cause drowsiness. If affected do not drive or operate machinery. Avoid alcoholic drink'. They are offered as 'a carefully considered balance between the unintelligibly short and the inconveniently long' (see BNF).

11 In: Willett R E et al (eds) 1983 Drugs, driving and traffic safety. WHO, Geneva.

The emphasis on psychomotor and physical aspects (injury) should not distract from the possibility that those who live by their intellect and imagination (politicians and even journalists may be included here) may suffer cognitive disability from thoughtless prescribing.

Summary

Table 19.9 summarises indications of the major groups of psychotropic drugs. Psychiatric illnesses are often associated with co-morbid conditions which may require treatment, e.g. schizophrenia may be associated with depression.

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