Manejo perioperatorio de pacientes usuarios de antidepresivos / Perioperative management of patients using antidepressants

El uso de antidepresivos en el perioperatorio es muy frecuente, y la práctica clínica indica que los pacientes usuarios de antidepresivos que son sometidos a cirugía tienen un riesgo perioperatorio aumentado. No existen en la actualidad guías clínicas basadas en la evidencia que orienten el manejo de este tipo de pacientes, por lo que las recomendaciones se basan en las escasas revisiones sistemáticas y metaanálisis disponibles, reportes de casos y opinión de expertos, que en muchos casos resultan controversiales. La decisión de mantener o suspender la medicación antidepresiva implica considerar los riesgos tanto desde el punto de vista fisiológico (características generales del paciente, riesgos asociados al antidepresivo utilizado, la cirugía propiamente como tal, la interacción con fármacos frecuentemente utilizados en el perioperatorio, entre otros) como desde el punto de vista psiquiátrico (riesgo de síndrome de retirada, recaída de la enfermedad psiquiátrica, intentos suicidas), por lo que la decisión debe ser tomada idealmente de forma multidisciplinaria entre cirujanos, anestesiólogos y psiquiatras, con la idea de confeccionar un plan quirúrgico, anestésico y de manejo perioperatorio seguro para el paciente.

Antidepressant use in the perioperative is a common practice, and clinical evidence shows that surgical patients using antidepressants have an increased perioperative risk. There are not evidence-based guidelines for the perioperative management of these patients, and recommendations are based on few systematic reviews and meta-analysis, case reports and expert opinion, which in many cases are controversial. The decision to continue or discontinue the medication involves considering general patient characteristics, risks associated with the antidepressant used, type of surgery, interaction with drugs commonly used in the perioperative, risk of withdrawal symptoms, relapse of psychiatric disease and suicide risk, so decision should be made between surgeons, anesthesiologists and psychiatrists, in order to design a safe management plan for the patient who undergo surgery.

Awareness and confidence of family physicians in recognition and treatment of psychiatric disorders

OBJECTIVES: This paper aims to evaluate the competence and confidence of the primary care practitioner in the recognition, diagnosis and treatment of mental disorders.METHODOLOGY: A validated 13 point questionnaire which incorporated items from the DSM IV was given to the participants of the annual convention of the Philippine Academy of Family Physician held in Davao City Sept 8-10, 2000.RESULTS: Four hundred eighty five family physicians returned the self administered questionnaire. Fifty one percent (248/ 485) claimed they would immediately refer patients to the psychiatrist while 28% (137/ 485) would initiate treatment on their own. Fourteen percent (68/ 485) and 10.9% (53/ 485) of the respondents indicated that they were familiar with the DSM IV criteria for schizophrenia and depression respectively; however only 11.3 % (55/485)were confident in using the criteria for diagnosis. Fortytwo percent (204/485) described schizophrenic patients as being irritable and aggressive, 30% (146/485) believed that hallucinations were the hallmark symptom, while 18% (88/485) considered bizarre behavior as the most significant indicator of schizophrenia. For depression the subjective feeling of sadness and worthlessness was most indicative of depression for the respondents (63% or 305), while 21% or 102 considered low self esteem or unstable self image as one of the criteria for depression and 16% or 78 thought of diminished interest or pleasure in all activities as the more important symptom to look for when diagnosing depression. Tricyclic antidepressants were still the preferred drug by most family physicians in treating depression (72% or 340) while 62% (301/ 485) prescribed benzodiazepines and 51% (248/ 485) also used the newer selective serotonin reuptake inhibitors. Patients with schizophrenia would be given typical psychotropic drugs like chlorpromazine or haloperidol more commonly (88% or 427), while 46% (224/ 485) had begun to prescribe atypical antipsychotic medications.CONCLUSION:The family physician seems to be hesitant or unsure with their diagnosing or treating psychiatric patients though willing to administer psychotropic medications.

Severe Resistant Hypertension Induced by Carbamazepine in an Elderly Patient

We report a case of a 73-year-old patient with a 17 year-history of well-controlled primary hypertension with a single antihypertensive drug, which became uncontrolled since 9 months ago when he started on oral carbamazepine (CBZ) therapy for syringomyelia. On admission, the patient had a blood pressure of 200-215/95-104mmHg despite an antihypertensive combination therapy with five different drugs. Further investigations ruled out secondary hypertension such as primary aldosteronism, pheochromocytoma and renal artery stenosis. After the discontinuation of CBZ, the blood pressure profile became significantly improved. The rechallenge with CBZ aggravated his blood pressure profile. Therefore, we considered that resistant hypertension was induced by the oral CBZ therapy.

Effects of Various Tricyclic Antidepressants on Contractile Response of the Rat Vas Deferens to Electrical Stimulation of Hypogastric Nerve / 대한비뇨기과학회지

PURPOSE: To compare the inhibitory effects of various tricyclic antidepressants (TCAs) on contractile response of the rat vas deferens to electrical stimulation of hypogastric nerve. MATERIALS AND METHODS: A total of forty Spraque Dawley rats (weight 300-350gm) were divided into 8 groups (n=5 in each): doxepine, amitriptyline, trimipramine, desipramine, imipramine, clomipramine, protriptyline, and prazosin treated groups. Before (baseline pressure) and 20 minutes after intravenous injection of each agent (0.1-, 1-, 10-, and 20-fold of therapeutic doses for human in each agent), the hypogastric nerves, iden tified under operative microscope, were electrically stimulated with rectangular pulses of 0.5 mseconds duration, 10 Hz, and 10 V for 10 seconds. Dose of drug administered was gradually increased in order of 0.1- to 20-fold dose. RESULTS: All drugs tested in this study caused dose-dependent inhibition of the rat intravasal pressure induced by the electrical stimulation of hypogastric nerve. Inhibitory potency of each drug was doxepine (88.5% and 96.5% at 10- and 20-fold dose)> OR = amitriptyline (76.8% and 91.8%)>clomipramine (66.7% and 74.4%)> OR =imipramine (48.2% and 67.0%)=prazosin (45.6% and 63.5%)=trimipramine (52.7% and 65.4%)> OR =desi pramine (45.3% and 49.0%)> protriptyline (18.9% and 19.9%). CONCLUSIONS: Inhibitory effects of TCAs on contractile response of the rat vas deferens to electrical stimulation of hypogastric nerve would increase in proportion to their potency of alpha1-adrenoceptor blocking actions.

Regional differences in the levels of biogenic amines and their metabolites in rat brain after tricyclic antidepressant treatments

Changes in the levels of biogenic amines in different brain regions and the cerebrospinal fluid in rats were measured after acute or chronic treatment with tricyclic antidepressants. After single or 3 weeks' treatment with imipramine or desipramine, blocks of tissues were obtained from seven regions of the brain (frontal cortex, corpus striatum, hippocampus, thalamus, hypothalamus, substantia nigra and cerebellum) immediately after collection of the cerebrospinal fluid (CSF) from the cisterna magna. The concentrations of biogenic amines and their metabolites (norepinephrine, epinephrine, dopamine, 5-hydroxytryptamine (5-HT), dihydroxyphenylacetic acid (DOPAC), homovanillic acid (HVA), 5-hydroxyindoleacetic acid (5-HIAA)) in brain tissues and the CSF were measured using the high performance liquid chromatography-electrochemical detection system (HPLC-ECD). Treatment with desipramine or imipramine caused major alterations in the concentrations of central norepinephrine or 5-HT and its metabolite, respectively. Brain regional responses were variable according to the kind of tricyclic antidepressants and the duration of treatment. It is noteworthy that chronic treatment with both desipramine and imipramine caused altered hippocampal concentrations of norepinephrine and/or 5-HT and its metabolites. Striatal DOPAC concentrations were also changed after acute or chronic treatment with both drugs. These results suggest that tricyclic antidepressants altered neurotransmission according to the brain region, and the hippocampal norepinephrine and 5-HT and/or the striatal dopamine may have a significant role for the expression of antidepressant action of tricyclic antidepressants.