Treatment Algorithms and Guidelines

Foundations - Guiding Principles Pronto

• Purpose: Standardize care, ensure Evidence-Based Medicine (EBM), improve patient outcomes, provide medico-legal support.
• Key Sources: Indian Psychiatric Society (IPS), NICE, APA.
• Core Tenets:
  • Diagnosis precedes treatment.
  • Shared decision-making with patient.
  • Titration: "Start low, go slow."
  • Adequate trial: Minimum 4-6 weeks at therapeutic dose.
  • Prefer monotherapy; minimize polypharmacy.
  • Regularly monitor efficacy and Adverse Drug Reactions (ADRs).
  • Employ Measurement-Based Care (MBC).
  • Consider patient factors: age, pregnancy, comorbidities.

⭐ IPS guidelines are tailored for Indian population & resource settings, making them highly relevant for NEET PG.

Schizophrenia - Psychosis Pathway Pointers

• Initial Phase: Second-Generation Antipsychotics (SGAs) e.g., risperidone, olanzapine, aripiprazole, are first-line. Aim for 4-6 weeks trial.
• Non-response: Switch to another SGA or a First-Generation Antipsychotic (FGA).
• Treatment-Resistant Schizophrenia (TRS): Defined by failure of ≥2 antipsychotics (adequate dose/duration).
  • Clozapine is the drug of choice.
  • Requires strict Absolute Neutrophil Count (ANC) monitoring: weekly for first 18 weeks, then fortnightly up to 1 year, then monthly. 📌 ANC: "Always Needs Checking".
• Adherence: Long-Acting Injectables (LAIs) are crucial for poor adherence.
• Augmentation: Electroconvulsive Therapy (ECT), psychosocial support.

⭐ Clozapine is the only FDA-approved medication for reducing suicide risk in schizophrenic patients.

Mood Disorders - Mood Maze Maps

• MDD: Stepwise Approach

  • First-line: SSRIs/SNRIs (e.g., Escitalopram, Venlafaxine).
    • Adequate trial: 4-8 weeks at therapeutic dose.
  • Non/Partial Response:
    • Switch SSRI/SNRI or class.
    • Augment: Bupropion, Mirtazapine, AAPs (e.g., Aripiprazole), Lithium.
  • TRD:
    • ECT - most effective.
    • Ketamine/Esketamine.
    • VNS, TMS.

• Bipolar Disorder: Phase-Specific Tx

  • Mania/Hypomania:
    • Mood Stabilizers: Li (target: 0.6-1.2 $mEq/L$), Valproate, CBZ.
    • AAPs: Olanzapine, Risperidone, Quetiapine.
    • ⚠️ Avoid antidepressant (AD) monotherapy (risk of switch).
  • Bipolar Depression:
    • Mood Stabilizers: Lamotrigine (slow up), Li.
    • AAPs: Quetiapine, Lurasidone, Olanzapine-Fluoxetine Combination (OFC).
  • Maintenance:
    • Mood stabilizers (Li, Valproate, Lamotrigine).

  ⭐ Lithium is gold standard for long-term prophylaxis in bipolar disorder, reducing suicide risk.

Anxiety/OCD - Jittery Journey Guides

• First-line: SSRIs (e.g., Escitalopram, Fluvoxamine for OCD). Start low, go slow. Titrate to effective dose. Adequate trial: 8-12 weeks.
• Second-line: Switch SSRI, SNRI (e.g., Venlafaxine), or Clomipramine (TCA - esp. for OCD, up to 250 mg/day).
• Augmentation: Antipsychotics (e.g., low-dose Risperidone for OCD), Buspirone (GAD).
• Adjuncts: Benzodiazepines (short-term, ⚠️ dependence). CBT (ERP for OCD) crucial.

⭐ Higher doses of SSRIs are generally required for OCD (e.g., Fluoxetine up to 80 mg/day) compared to depression.

High‑Yield Points - ⚡ Biggest Takeaways

• SSRIs are first-line for Major Depressive Disorder (MDD); TCAs/MAOIs are later choices.
• Acute mania (Bipolar) often needs mood stabilizers (Lithium, Valproate) +/- antipsychotics.
• Schizophrenia is treated with antipsychotics; clozapine is crucial for Treatment-Resistant Schizophrenia (TRS).
• Anxiety disorders (GAD, Panic) usually start with SSRIs/SNRIs; benzodiazepines for short-term use.
• ADHD first-line treatment involves stimulants like Methylphenidate.
• Adherence to NICE/IPS guidelines is critical for standardized care and optimal outcomes.