Recommendations and Advice on the Use of Psychotropic Medications in the Hospital Setting

Sorting through and demystifying the toolkit of psychiatric medications available to hospital physicians, the Cleveland Clinic’s Leo Pozuelo, MD, presented a rational approach to effective inpatient use of the psychiatric armamentarium at the Society for Hospital Medicine’s 2013 annual conference, held May 17-19 at the National Harbor’s Gaylord Nelson Convention Center in Ft. Washington, MD. Pozuelo organized his discussion into medication classes, first discussing antidepressants and anxiolytics.

Pozuelo began with two key points about antidepressants: first, that all antidepressants, including older medications such as first-generation tricyclics and monoamine oxidase inhibitors, have approximately equivalent efficacy; and second, that antidepressants generally do not achieve efficacy until at least two to three weeks after onset of administration. Antidepressant choice is thus driven primarily by side effect profile, and hospitalists may consider bridge anxiolytic medications if antidepressant use is begun in the hospital.

Among older antidepressants, desyrel (Trazodone) is still often used for sleep because of its hypnotic effects at low doses; it has mixed serotonin effects, and is generally too intolerably sedating at doses therapeutic for depression. For inpatient initiation of an SSRI, Pozuelo recommends sertraline (Zoloft), citalopram (Celexa), or escitalopram (Lexapro), since these medications have fewer drug-drug interactions than paroxetine (Paxil) or fluoxetine (Prozac). Mirtazapine (Remeron) given at HS can be effective for sleep, and can help alleviate nausea via 5HT3 blockade. Venlafaxine (Effexor) and desvenlafaxine (Pristiq) inhibit both serotonin and norepinephrine, and are also relatively free of drug-drug interactions. Bupropion (Wellbutrin), a dopamine reuptake inhibitor, is not recommended for use with comorbid anxiety, though it has an excellent sexual side effect profile.

For cardiac patients requiring antidepressant use, both sertraline and citalopram are well studied SSRIs in this population and have a proven safety profile, as does bupropion. Mirtazapine may be considered, though weight gain can be a problem. For patients who have sustained a stroke, depression is common and can hinder rehabilitation. Anticholinergics, especially diphenhydramine (Benadryl), should be avoided, since their use can predispose to delirium. Stimulants, such as low doses of methylphenidate (Ritalin), can be a very useful adjunct in stroke patients who exhibit psychomotor slowing.

Pozuelo advocates for some role for benzodiazepines, especially for those patients whose inpatient stay provokes acute anxiety, or whose underlying anxiety may be newly discovered and treatment initiated during a hospital stay. Acknowledging that benzodiazepines carry some risk of abuse and dependence and are probably not a good long-term strategy, he feels that short term use can be both a humane and practical option in certain situations, as when bridging a patient until an SSRI becomes therapeutic.

Moving to the discussion of mood stabilizers and treatment of the bipolar patient, Pozuelo acknowledged that while lithium should be discontinued perioperatively to minimize risk of delirium, it is the keystone of mood stability for many patients, so should be re-initiated as soon as practical. For these patients or others whose medications may need to be discontinued for a time, consider a low dose of a sedating antipsychotic such as quetiapine (Seroquel) as adjunctive inpatient treatment. When restarting lamotrigine (Lamictal) after more than 7 days, clinicians should titrate the dose to minimize risk of Stevens-Johnson syndrome. Finally, protecting sleep is incredibly important for maintaining stability in individuals with bipolar disorder; in addition to nonpharmacologic sleep management, low doses of quetiapine or mirtazapine at bedtime may be helpful.

Among antipsychotics, haloperidol (Haldol) can have great utility not only for treatment of schizophrenia, but also in management of delirium. Although oral haloperidol can result in more extrapyramidal symptoms (EPS), there is less risk of QTc prolongation. The converse is true for IV haloperidol, whose administration requires telemetry monitoring. Haloperidol is not sedating, and low, frequent dosing can be effective in resolving delirium.

Atypical antipsychotics which are sedating and which may be useful for agitated or delirious patients include olanzapine (Zyprexa) and quetiapine. Perioperative management of the patient with schizophrenia should include behavioral and psychosocial interventions to provide reassurance and routine, as well as preservation of sleep to the greatest extent possible. The preoperative antipsychotic regime should be maintained if at all possible, and depot formulations of some antipsychotic may assist with bridging the perioperative period, given sufficient advance planning.