Rosen & Barkin's 5-Minute Emergency Medicine Consult (201 page)

• Ensure safety of patient and providers
  
• Understand local laws for involuntary commitment to hospital
  

• Safety: Assess risk of suicide, violence
  
• General medical evaluation
  
• Management:
  
  • 1-to-1 observation and suicide precautions when appropriate
    
  • Work up potential medical causes
    

• Psychological management:
  
  • Listen empathically to understand context and relevant stressors
    
  • Reassurance and education (e.g., depression is a treatable condition)
    
• Initiate medications:
  
  • Antidepressant medication may be initiated for some patients with clear diagnosis and established follow-up
    
  • Usually takes weeks for antidepressant medications to resolve major depression
    
  • Low-dose benzodiazepines or neuroleptics may be used for associated agitation, insomnia, or psychosis
    
• Choice of drug determined by:
  
  • Indications, efficacy
    
  • Side-effect profile and risks
    
  • Convenience, cost, availability
    
• Selective serotonin reuptake inhibitors (SSRIs: fluoxetine, paroxetine, sertraline, citalopram, escitalopram):
  
  • Well tolerated
    
  • Side effects may include:
    
    • Mild nausea
      
    • Headache
      
    • Anxiety, restlessness, insomnia
      
    • Somnolence
      
    • Sexual dysfunction
      
    • Weight gain
      
  • Minimal overdose risk
    
• Serotonin norepinephrine reuptake inhibitors (SNRIs: venlafaxine, duloxetine):
  
  • Well tolerated
    
  • May be helpful for some pain syndromes
    
  • Side effects similar to SSRIs
    
• Dopamine norepinephrine reuptake inhibitor (bupropion):
  
  • Agitation, insomnia
    
  • Tremor
    
  • Decreased seizure threshold
    
  • Well-tolerated; no sexual side effects
    
• Norepinephrine serotonin modulator (mirtazapine):
  
  • Weight gain
    
  • Sedation
    
  • Orthostasis
    
  • Constipation
    
• Tricyclic antidepressants (amitriptyline, imipramine, nortriptyline, clomipramine):
  
  • Anticholinergic effects
    
  • Weight gain
    
  • Postural hypotension
    
  • Sedation
    
  • Decreased seizure threshold
    
  • Cardiac risk; overdose can be fatal
    
  • Nortriptyline is best tolerated
    
• Monoamine oxidase inhibitors (phenelzine, tranylcypromine, selegiline transdermal):
  
  • Dietary and other medication restrictions to avoid hypertensive crisis
    
  • Dangerous in overdose
    

Medication dosage ranges are for adults.

Dose may be titrated over weeks as indicated.

• Amitriptyline: Initial 25–50 mg/d PO
  
• Bupropion: 75–400 mg/d PO
  
• Citalopram: 20–40 mg/d PO
  
• Desvenlafaxine: 50 mg/d PO
  
• Duloxetine: 30–120 mg/d PO
  
• Escitalopram: 10–20 mg/d PO
  
• Fluoxetine: 20–60 mg/d PO
  
• Imipramine: Initial 25–50 mg/d PO
  
• Mirtazapine: 15–45 mg/d PO
  
• Nortriptyline: Initial 25 mg/d PO
  
• Paroxetine: 20–40 mg/d PO
  
• Phenelzine: 15–90 mg/d PO
  
• Sertraline: 50–200 mg/d PO
  
• Tranylcypromine: 10–60 mg/d PO
  
• Venlafaxine: 75–300 mg/d PO
  

SSRIs, SNRIs, bupropion, mirtazapine

• Tricyclics and monoamine oxidase inhibitors
  
• Use with caution in geriatric or medically ill
  
• Consider ECT for severe or treatment-resistant depression, psychotic depression, or catatonia
  

• Older patients may require lower dose; pay careful attention to potential drug interactions
  
• Caution with orthostatic hypotension and cholinergic blockade
  

FDA “Black box” warning: Antidepressants may increase risk of suicidal thinking and behavior in some children, adolescents, or young adults with depression

In pregnant or breast-feeding women pay special attention to risks and benefits of medication treatments—consider consultation with a specialist in perinatal psychiatry

FOLLOW-UP

• Patient is suicidal or at high risk for suicide. See “Suicide, Risk Evaluation”
  
• Minimal or unreliable social supports
  
• Symptoms so severe that continual observation or nursing supportive care is required
  
• Psychotic features
  
• Civil commitment
  for psychiatric hospitalization is necessary if the patient is refusing treatment and is at risk to harm self or others
  

• Low suicide risk
  
• Adequate social support
  
• Close follow-up available
  

• Outpatient mental health appointments and/or partial (day) hospital for patients not admitted
  
• Insurance carrier may determine inpatient disposition and options for other levels of care
  
• Case management or social services in ED may be helpful for disposition issues
  
• Communicate and coordinate care with other providers including primary care
  

Follow-up depends on severity of illness and risk:

• If not admitted, patients with significant symptoms should follow up in 1–2 wk
  
• When medication is initiated, patient should be seen in follow-up in 1–2 wk
  
• More stable patients or those with minor symptoms may be seen with less urgency
  

• Patients with depression experience significant morbidity and may present a risk of self-harm
  
• Consider other conditions that mimic depression; also coexisting psychiatric and medical conditions, substance use
  
• Know hospitalization and involuntary commitment criteria in your area
  

• American Psychiatric Association. Practice guideline for the treatment of patients with major depressive disorder, third edition.
  Am J Psychiatry
  . 2010;167(suppl 10):1–152.
  
• Belmaker RH, Agam G. Major depressive disorder.
  N Engl J Med
  . 2008;358:55–68.
  
• Cassem NH. Mood disordered patients. In: Stern TA, Fricchione GL, Cassem NH, eds.
  MGH Handbook of General Hospital Psychiatry
  . 6th ed. St. Louis, MO: Mosby; 2010.
  
• Stewart DE. Clinical practice. Depression during pregnancy.
  N Engl J Med
  . 2011;365:1605–1611.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Bipolar Disorder
  
• Psychosis, Medical vs. Psychiatric
  
• Psychiatric Commitment
  
• Suicide, Risk Evaluation
  

CODES

• 296.20 Major depressive affective disorder, single episode, unspecified
  
• 296.24 Major depressive affective disorder, single episode, severe, specified as with psychotic behavior
  
• 296.30 Major depressive disorder, recurrent episode, unspecified degree
  

BASICS

• Dermatomyositis (DM) and polymyositis (PM) are systemic inflammatory myopathies, which represent the largest group of acquired and potentially treatable causes of skeletal muscle weakness
  
• Patients experience a marked progression of muscle weakness over weeks to months
  
• Can lead to respiratory insufficiency from respiratory muscle weakness
  
• Aspiration pneumonia can occur owing to a weak cough mechanism, pharyngeal muscle dysfunction, and esophageal dysmotility
  
• Cardiac manifestations include myocarditis, conduction defects, cardiomyopathy, and congestive heart failure (CHF)
  
• Arthralgias of the hands, wrists, knees, and shoulders
  
• Ocular muscles are not involved but facial muscle weakness may be seen in advanced cases
  

• The exact cause is unknown, although autoimmune mechanisms are thought to be largely responsible
  
• Incidence ∼1:100,000 with a female preponderance
  
• Association with HLA-B8 and HLA-DR3
  
• There may be an association between PM and certain viral, bacterial, and parasitic infections
  
• DM/PM occurs with collagen vascular disease about 20% of the time
  
• In DM, humoral immune mechanisms are implicated, resulting in a microangiopathy and muscle ischemia
  
• In PM, a mechanism of T-cell–mediated cytotoxicity is posited. CD8 T cells, along with macrophages surround and destroy healthy, non-necrotic muscle fibers that aberrantly express class I major histocompatibility complex (MHC) molecules
  
• Deposition of complement is the earliest and most specific lesion, followed by inflammation, ischemia, microinfarcts, necrosis, and destruction of the muscle fibers