1. Getting the Most of Antidepressants RVU 05-03-2014 Larry O. Sanders, MD Diplomate of the American Board of Psychiatry and Neurology

2. Goals Screening the Primary Care population for Mental Disease. First Line and Second Line Treatment of MDD. Evidence that more than Major Depression is Involved. When to Refer to Mental Health.

4. In US, Major Depression is a Common Medical Illness

5. Why Treat Depression? Disability Morbidity- Depression makes existing somatic conditions worse. (Inflammatory Factors) Mortality- Psychiatric patients die up to 20 years earlier than average. Most Common reason is Cardiovascular Disease! Second is Suicide.

6. Inflammatory Factors, 1 Major Depression Increases Inflammatory Factors, Worsening the Prognosis of Somatic Illness

7. Inflammatory Factors, 2 Somatic Illnesses Increase Inflammatory Factors, Worsening the Prognosis of Major Depression

8. Depression and Atherosclerotic Disease. Major Depression carries 4X Risk of developing a Myocardial Infarction! Anda 1993, Barefot, et. Al. 1996, Pratt 1996 MIs comorbid with MDD are 5X More likely to be Fatal. Anda 1993 16.5% Mortality Risk @ 6 months following Acute MI if also Depression vs 3% if not Depressed. Frasure-Smith 1993 Major Depression carries same Risk Factor for developing an MI, as Cigarette Smoking!

9. Major Depression 5 Symptoms, 2 Weeks, >50% each day Mood* Sleep Interest* Guilt or Hopelessness Energy Concentration Appetite Psychomotor Suicidal/Homocidal Ideation * Depressed Mood or Anhedonia must be present (pneumonic “Sige Caps”)

10. 10 Nature vs Nurture MDD is strongly genetic, with well over 100 genes involved. However, the largest risk for developing MDD as an adult is losing a parent before age 12. Many Environmental, Psychological and Sociological factors can effect it. 10

11. 11 Medical Disease can appear as Major Depressive Disorder Many Medical Diseases can appear as MDD. R/O: –Hypothyroidism –Anemia, both Microcytic and Macrocytic –Any inflammatory Disease –Hyperparathyroidism (even slightly elevated Ca++ may be important) –Various Vitamin deficiencies, including: D, B12, B6, Folate, etc. Vitamin D deficiency seems more common since the use of high SPF Sunscreens. 11

13. Other (Free) Scales PHQ 2 Screener ( Very brief. I don’t encourage its’ use). Zung Depression Rating Scale QIDS-SR Quick Inventory Depressive Symptomatology (Self Report) CUDOS Clinically Useful Depression Outcome Scale

14. Treat to Remission! Sub-Syndromal Depression = Relapse Months Well Judd 1998 7 months until Relapse! One or more Symptoms No Symptoms

15. Symptoms and Circuits Advocated by Stephen M. Stahl, MD

16. Circuit

17. When a Brain Circuit, when overstimulated or under-stimulated, it will produce certain symptoms. (adapted from Steven Stahl, MD)

18. Each Symptom, regardless of the disease, comes from the Same Circuit Malfunction! (adapted from Steven Stahl, MD)

19. Symptoms & Circuits By Knowing Which Symptom is related to which Circuit, and by Knowing How Each Medication Effects Each Circuit You can Logically Deduce Which Medication Will Best Treat Most Mental Conditions. (adapted from Steven Stahl, MD)

20. 3 Major Circuits Contributing to Mental Illness

21. Serotonin Circuits

22. Serotonin Norepinephrine Circuits

23. Serotonin NorepinephrineDopamine Circuits

24. Symptoms Associated with these Circuits

25. Symptoms associated with Serotonin Serotonin helps us “Cope”. If Serotonin is too Low: Irritable, Anxious, Easily Overwhelmed, Hopeless, Suicidal, “poor sense of Well-being” If Serotonin is too High: Serotonin Syndrome; Agitation, Fasciulations, Hyperthermia, Vital Sign Disturbance, leading to stupor, come then death. [Although pharmacists warn of this, neither I nor any Psychiatric Colleagues have ever seen this condition. So it appears to be very rare.]

26. Symptoms associated with Norepinephrine Norepinephrine is like “Adrenaline”. If Norepinephrine too Low: Anergy, Immediate Memory Impaired, Psychomotor Retardation. If Norepinephrine too High: Irritable, Agitation, Insomnia. (Similar Symptoms to Low Serotonin).

27. Symptoms associated with Dopamine Dopamine provides Interests/Desire, mentally. (Dopamine has other physical functions as well). If Dopamine too Low: Apathy, Dementia, Muscle If Dopamine too High: Hedonism, Psychosis, Mania

28. Mood* Emotion Cognitive Function Serotonin NorepinephrineDopamine Symptoms & Circuits

29. Mood* Emotion Cognitive Function Suicidal/Homicidal Frustration, “Sense of Well Being” Obsession, Sleep, Guilt or Hopelessness Serotonin NorepinephrineDopamine Symptoms & Circuits

30. Mood* Emotion Cognitive Function Suicidal/Homicidal Frustration, “Sense of Well Being” Obsession, Sleep, Guilt or Hopelessness Serotonin NorepinephrineDopamine Energy Alertness Psychomotor Working Memory Symptoms & Circuits

31. Mood* Emotion Cognitive Function Suicidal/Homicidal Frustration, “Sense of Well Being” Obsession, Sleep, Guilt or Hopelessness Serotonin NorepinephrineDopamine Desire Interest* Energy Alertness Psychomotor Working Memory Symptoms & Circuits

32. Mood* Emotion Cognitive Function Suicidal/Homicidal Frustration, “Sense of Well Being” Obsession, Sleep, Guilt or Hopelessness Serotonin NorepinephrineDopamine Irritability Anxiety Desire Interest* Energy Alertness Psychomotor Working Memory Symptoms & Circuits

33. Mood* Emotion Cognitive Function Concentration Motivation Suicidal/Homicidal Frustration, “Sense of Well Being” Obsession, Sleep, Guilt or Hopelessness Serotonin NorepinephrineDopamine Irritability Anxiety Desire Interest* Energy Alertness Psychomotor Working Memory Symptoms & Circuits

34. Mood* Emotion Cognitive Function Concentration Motivation Suicidal/Homicidal Frustration, “Sense of Well Being” Obsession, Sleep, Guilt or Hopelessness Serotonin NorepinephrineDopamine Irritability Anxiety Appetite Aggression Sex Desire Interest* Energy Alertness Psychomotor Working Memory Symptoms & Circuits Slaby and Tancradi 2002, Stahl 2004

35. Symptoms, Circuits & Medications

36. 5HT1a

37. Classes of Antidepressants SSRIs SNRIs, NaSSI SDRIs NDRIs (mechanism of Wellbutrin not fully understood) DRIs, DAgs NRIs – (not very effective). (MOAIs, not covered here, are powerful Antidepressants; but carry HTN risk with certain foods and/or meds and Serotonin Syndrome with SRIs.)

38. Suicidality vs Suicide An ironic fact about Antidepressant use is that Suicidality risk (thoughts, not death) increases transiently, BUT SUICIDE (DEATH) risk DECREASES in patients less than 24 y.o.! (expound)

39. Medications Effecting Primarily Serotonin

40. SSRIs “Multi Action” – ssri, 5HT1a, 1b, 3, & 7. Vortioxetine (Brintellix). “Dual Action” - SSRI & 5HT1a. Vilazadone (Viibryd). “Single Action” – SSRI. Escitalpram (Lexapro). Fluoxetine (Prozac). SSRI + bits of others. “Half Action” - Racemic mixture, half active. Cilatopram (Celexa).

41. “Multi Action”- Brintellix 5-20mg “Dual Action” - Viibryd 10-40mg “Single Action”- Lexapro 10-20mg Prozac 20mg “Half Action” - Celexa 40mg SSRI Mood* Emotion Cognitive Function Concentration Motivation Suicidal/Homicidal Frustration, “Sense of Well Being” Obsession, Sleep, Guilt or Hopelessness Serotonin Norepinephrine Dopamine Irritability Anxiety Appetite Aggression Sex Desire Interest* Energy Alertness Psychomotor Working Memory Larry O. Sanders, MD c 2002, 2014 Symptoms, Circuits & Medications -Trade Names

42. Medications effecting Both Serotonin and Norepinephrine

43. SNRIs Levomilnacipram (Fetzima) 1:2 S:N Duloxetine (Cymbalta) 9:1 S:N Desvenlafaxine (Pristiq) 15:1 S:N Venlafaxine(Effexor) 30:1 S:N At low dose is SSRI. At high dose SNRI. Strong W/D issues! {Paroxetine (Paxil) 20-40mg} Weight gain, Fatigue, Strong W/D issues!

44. “Multi Action”- Brintellix 5-20mg “Dual Action” - Viibryd 10-40mg “Single Action”- Lexapro 10-20mg Prozac 20mg “Half Action” - Celexa 40mg SSRI Mood* Emotion Cognitive Function Concentration Motivation Suicidal/Homicidal Frustration, “Sense of Well Being” Obsession, Sleep, Guilt or Hopelessness Serotonin Norepinephrine Dopamine Irritability Anxiety Appetite Aggression Sex Desire Interest* Energy Alertness Psychomotor Working Memory SNRI Fetzima 40-120mg Cymbalta 60mg Pristiq 50-100mg Effexor 75-375mg (Paxil) 20mg Larry O. Sanders, MD c 2002, 2014 Symptoms, Circuits & Medications -Trade Names

45. NaSSA Indirectly elevates Norepinephrine (Noradrenaline) and Serotonin Mirtazapine (Remeron) Sedating, increases appetite and weight gain.

46. “Multi Action”- Brintellix 5-20mg “Dual Action” - Viibryd 10-40mg “Single Action”- Lexapro 10-20mg Prozac 20mg “Half Action” - Celexa 40mg SSRI Mood* Emotion Cognitive Function Concentration Motivation Suicidal/Homicidal Frustration, “Sense of Well Being” Obsession, Sleep, Guilt or Hopelessness Serotonin Norepinephrine Dopamine Irritability Anxiety Appetite Aggression Sex Desire Interest* Energy Alertness Psychomotor Working Memory SNRI Fetzima 40-120mg Cymbalta 60mg Pristiq 50-100mg Effexor 75-375mg (Paxil) 20mg Larry O. Sanders, MD c 2002, 2014 Symptoms, Circuits & Medications -Trade Names Remeron 30-45mg (Indirect ^ S & N)

47. Medications Effecting Norepinephrine and Dopamine

48. NDRI Bupropion (Wellbutrin) 300-450mg IR. Not Well Tolerated. SR. Lasts 12 hours. XL. Lasts 24 hours.

49. Amphetamines Terminal Releasers and Reuptake Inhibitors of Norepinephrine and Dopamine

50. “Multi Action”- Brintellix 5-20mg “Dual Action” - Viibryd 10-40mg “Single Action”- Lexapro 10-20mg Prozac 20mg “Half Action” - Celexa 40mg SSRI Mood* Emotion Cognitive Function Concentration Motivation Suicidal/Homicidal Frustration, “Sense of Well Being” Obsession, Sleep, Guilt or Hopelessness Serotonin Norepinephrine Dopamine NRI NDRI Wellbutrin 300-450mg Amphetamines 10-30mg b.i.d. Irritability Anxiety Appetite Aggression Sex Desire Interest* Energy Alertness Psychomotor Working Memory SNRI Fetzima 40-120mg Cymbalta 60mg Pristiq 50-100mg Effexor 75-375mg (Paxil) 20mg Larry O. Sanders, MD c 2002, 2014 Symptoms, Circuits & Medications -Trade Names Remeron 30-45mg (Indirect ^ S & N)

51. Medication Effecting Serotonin and Dopamine

52. SDRIs Sertraline (Zoloft) Usual Dose range 50-200 mg/d One of the best tolerated, most effective AD.

53. “Multi Action”- Brintellix 5-20mg “Dual Action” - Viibryd 10-40mg “Single Action”- Lexapro 10-20mg Prozac 20mg “Half Action” - Celexa 40mg SSRI Mood* Emotion Cognitive Function Concentration Motivation Suicidal/Homicidal Frustration, “Sense of Well Being” Obsession, Sleep, Guilt or Hopelessness Serotonin Norepinephrine Dopamine NRI NDRI Wellbutrin 300-450mg Amphetamines 10-30mg b.i.d. Irritability Anxiety Appetite Aggression Sex Desire Interest* Energy Alertness Psychomotor Working Memory SDRI SNRI Fetzima 40-120mg Cymbalta 60mg Pristiq 50-100mg Effexor 75-375mg (Paxil) 20mg Zoloft 50-200mg Larry O. Sanders, MD c 2002, 2014 Symptoms, Circuits & Medications -Trade Names Remeron 30-45mg (Indirect ^ S & N)

54. Medications Effecting Primarily Dopamine

55. DRI & DAgs Methylphenidate (Ritalin) Dopamine Agonists: Pramipexole (Mirapex). Evidence based treatment. Avg dose 0.95 mg. Ropinirole (Requip).

56. “Multi Action”- Brintellix 5-20mg “Dual Action” - Viibryd 10-40mg “Single Action”- Lexapro 10-20mg Prozac 20mg “Half Action” - Celexa 40mg SSRI Mood* Emotion Cognitive Function Concentration Motivation Suicidal/Homicidal Frustration, “Sense of Well Being” Obsession, Sleep, Guilt or Hopelessness Serotonin Norepinephrine Dopamine NRI NDRI Wellbutrin 300-450mg Amphetamines 10-30mg b.i.d. DRI Ritalin 10-40mg bid Mirapex 0.25-1.5 mg HS Irritability Anxiety Appetite Aggression Sex Desire Interest* Energy Alertness Psychomotor Working Memory SDRI SNRI Fetzima 40-120mg Cymbalta 60mg Pristiq 50-100mg Effexor 75-375mg (Paxil) 20mg Zoloft 50-200mg Larry O. Sanders, MD c 2002, 2014 Symptoms, Circuits & Medications -Trade Names DAg Remeron 30-45mg (Indirect ^ S & N)

57. Medications Effecting Primarily Norepinephrine

58. NRIs Desiparamine Atomoxetine (Strattera) (Atomoxetine is a failed antidepressant approved for use in AD/HD. No NRI, other than the TCA Desipramine, has beat placebo).

59. “Multi Action”- Brintellix 5-20mg “Dual Action” - Viibryd 10-40mg “Single Action”- Lexapro 10-20mg Prozac 20mg “Half Action” - Celexa 40mg SSRI Mood* Emotion Cognitive Function Concentration Motivation Suicidal/Homicidal Frustration, “Sense of Well Being” Obsession, Sleep, Guilt or Hopelessness Serotonin Norepinephrine Dopamine NRI Desipramine Strattera NDRI Wellbutrin 300-450mg Amphetamines 10-30mg b.i.d. DRI Ritalin 10-40mg bid Mirapex 0.25-1.5 mg HS Irritability Anxiety Appetite Aggression Sex Desire Interest* Energy Alertness Psychomotor Working Memory SDRI SNRI Fetzima 40-120mg Cymbalta 60mg Pristiq 50-100mg Effexor 75-375mg (Paxil) 20mg Zoloft 50-200mg Larry O. Sanders, MD c 2002, 2014 Symptoms, Circuits & Medications -Trade Names DAg Remeron 30-45mg (Indirect ^ S & N)

60. “Multi Action”- Brintellix 5-20mg “Dual Action” - Viibryd 10-40mg “Single Action”- Lexapro 10-20mg Prozac 20mg “Half Action” - Celexa 40mg SSRI Mood* Emotion Cognitive Function Concentration Motivation Suicidal/Homicidal Frustration, “Sense of Well Being” Obsession, Sleep, Guilt or Hopelessness Serotonin Norepinephrine Dopamine NRI Desipramine Strattera NDRI Wellbutrin 300-450mg Amphetamines 10-30mg b.i.d. DRI Ritalin 10-40mg bid Mirapex 0.25-1.5 mg HS Irritability Anxiety Appetite Aggression Sex Desire Interest* Energy Alertness Psychomotor Working Memory SDRI SNRI Fetzima 40-120mg Cymbalta 60mg Pristiq 50-100mg Effexor 75-375mg (Paxil) 20mg Zoloft 50-200mg Larry O. Sanders, MD c 2002, 2014 Symptoms, Circuits & Medications -Trade Names DAg Remeron 30-45mg (Indirect ^ S & N)

61. “Multi Action”- Brintellix 5-20mg “Dual Action” - Viibryd 10-40mg “Single Action”- Lexapro 10-20mg Prozac 20mg “Half Action” - Celexa 40mg SSRI Mood* Emotion Cognitive Function Concentration Motivation Suicidal/Homicidal Frustration, “Sense of Well Being” Obsession, Sleep, Guilt or Hopelessness Serotonin Norepinephrine Dopamine NRI Desipramine Strattera NDRI Wellbutrin 300-450mg Amphetamines 10-30mg b.i.d. DRI Ritalin 10-40mg bid Mirapex 0.25-1.5 mg HS Irritability Anxiety Appetite Aggression Sex Desire Interest* Energy Alertness Psychomotor Working Memory SDRI SNRI Fetzima 40-120mg Cymbalta 60mg Pristiq 50-100mg Effexor 75-375mg (Paxil) 20mg Zoloft 50-200mg Larry O. Sanders, MD c 2002, 2014 Symptoms, Circuits & Medications -Trade Names DAg Remeron 30-45mg (Indirect ^ S & N)

62. “Multi Action”- Brintellix 5-20mg “Dual Action” - Viibryd 10-40mg “Single Action”- Lexapro 10-20mg Prozac 20mg “Half Action” - Celexa 40mg SSRI Mood* Emotion Cognitive Function Concentration Motivation Suicidal/Homicidal Frustration, “Sense of Well Being” Obsession, Sleep, Guilt or Hopelessness Serotonin Norepinephrine Dopamine NRI Desipramine Strattera NDRI Wellbutrin 300-450mg Amphetamines 10-30mg b.i.d. DRI Ritalin 10-40mg bid Mirapex 0.25-1.5 mg HS Irritability Anxiety Appetite Aggression Sex Desire Interest* Energy Alertness Psychomotor Working Memory SDRI SNRI Fetzima 40-120mg Cymbalta 60mg Pristiq 50-100mg Effexor 75-375mg (Paxil) 20mg Zoloft 50-200mg Larry O. Sanders, MD c 2002, 2014 Symptoms, Circuits & Medications -Trade Names DAg Remeron 30-45mg (Indirect ^ S & N)

63. “Multi Action”- Brintellix 5-20mg “Dual Action” - Viibryd 10-40mg “Single Action”- Lexapro 10-20mg Prozac 20mg “Half Action” - Celexa 40mg SSRI Mood* Emotion Cognitive Function Concentration Motivation Suicidal/Homicidal Frustration, “Sense of Well Being” Obsession, Sleep, Guilt or Hopelessness Serotonin Norepinephrine Dopamine NRI Desipramine Strattera NDRI Wellbutrin 300-450mg Amphetamines 10-30mg b.i.d. DRI Ritalin 10-40mg bid Mirapex 0.25-1.5 mg HS Irritability Anxiety Appetite Aggression Sex Desire Interest* Energy Alertness Psychomotor Working Memory SDRI SNRI Fetzima 40-120mg Cymbalta 60mg Pristiq 50-100mg Effexor 75-375mg (Paxil) 20mg Zoloft 50-200mg Larry O. Sanders, MD c 2002, 2014 Symptoms, Circuits & Medications -Trade Names DAg Remeron 30-45mg (Indirect ^ S & N)

64. “Multi Action”- Brintellix 5-20mg “Dual Action” - Viibryd 10-40mg “Single Action”- Lexapro 10-20mg Prozac 20mg “Half Action” - Celexa 40mg SSRI Mood* Emotion Cognitive Function Concentration Motivation Suicidal/Homicidal Frustration, “Sense of Well Being” Obsession, Sleep, Guilt or Hopelessness Serotonin Norepinephrine Dopamine NRI Desipramine Strattera NDRI Wellbutrin 300-450mg Amphetamines 10-30mg b.i.d. DRI Ritalin 10-40mg bid Mirapex 0.25-1.5 mg HS Irritability Anxiety Appetite Aggression Sex Desire Interest* Energy Alertness Psychomotor Working Memory SDRI SNRI Fetzima 40-120mg Cymbalta 60mg Pristiq 50-100mg Effexor 75-375mg (Paxil) 20mg Zoloft 50-200mg Larry O. Sanders, MD c 2002, 2014 Symptoms, Circuits & Medications -Trade Names DAg Remeron 30-45mg (Indirect ^ S & N)

65. “Multi Action”- Brintellix 5-20mg “Dual Action” - Viibryd 10-40mg “Single Action”- Lexapro 10-20mg Prozac 20mg “Half Action” - Celexa 40mg SSRI Mood* Emotion Cognitive Function Concentration Motivation Suicidal/Homicidal Frustration, “Sense of Well Being” Obsession, Sleep, Guilt or Hopelessness Serotonin Norepinephrine Dopamine NRI Desipramine Strattera NDRI Wellbutrin 300-450mg Amphetamines 10-30mg b.i.d. DRI Ritalin 10-40mg bid Mirapex 0.25-1.5 mg HS Irritability Anxiety Appetite Aggression Sex Desire Interest* Energy Alertness Psychomotor Working Memory SDRI SNRI Fetzima 40-120mg Cymbalta 60mg Pristiq 50-100mg Effexor 75-375mg (Paxil) 20mg Zoloft 50-200mg Larry O. Sanders, MD c 2002, 2014 Symptoms, Circuits & Medications -Trade Names DAg Remeron 30-45mg (Indirect ^ S & N)

66. Compliance “No Involvement, No Commitment” Month 1 40% of Patients are off meds. Month 2 60% of Patients are off meds. S/E-Weight Gain, Sexual Dysfunction, Emotional Blunting, Cognitive Dysfunction. Don’t Realize the Condition is Genetic. Confusion with Treatment vs Cure.

67. When 1st Line Fails in MDD Refer to Venn Diagram to Increase Dose, Change Meds or Augment. 5HT1a - Abilify, Seroquel, Viibryd. Lithium.

68. Don’t Underdose! If dose 50-200, PCP often give 50mg, maybe 75 mg. “You haven’t reached maximum dose until you have reached effect or intolerable side effects.”

69. Just When I Learned All of Life’s Answers, They Changed the Questions!

70. The Most Common Causes of Treatment Failure Non-Compliance. Comorbid Anxiety. Bipolar Depression. Most experts believe that 20-30% of all Depressed Patients have a Bipolar Disorder Comorid Substance Abuse Depression with Psychosis (47% risk of manifesting BP1 or BP11 with in 10 years).

71. When is more than MDD Involved? Anxiety Psychosis Mania Substance Abuse

72. Anxiety Anxiety Disorders are present in 20% PC Pts. Depression and Anxiety are HIGHLY Co-Morbid. If Depression present, 60% Chance of having Significant Anxiety Disorder AND vice versa. Untreated Anxiety consumes 6x more of your time & 6x more resources. Most Antidepressants Treat Anxiety Disorders, but it is Really Important to Know How to Select Proper Medication.

73. Types of Anxiety Disorders Generalized Anxiety Disorder (GAD) - Chronic Worry. Social Phobia (aka Social Anxiety) - Fear Social Judgement. Panic Disorder - Sudden, Intense Fear with Physical Symptoms. Post-traumatic Stress Disorder (PTSD) - symptoms delayed by > 1 month after trauma. Can be years. For every 1 soldier killed in action in Afganistan, 25 will die by suicide. Acute Stress Disorder - within 1 month of trauma. Obsessive-Compulsive Disorder (OCD) - Germs, Order, Counting, that they have Harmed to Others.

74. Anxiety Rating Scales GAD 7 - Rates GAD Zung Anxiety CUXOS YBOCS - for OCD

76. Treatment of Anxiety Disorders Antidepressants Serotonin Agents treat all. NE helps GAD, but may make Panic Worse. BZs Gabapentin

77. Be Certain It’s NOT Bipolar Depression! Experts agree that 30-40% of ALL Depressive Disorders have a component of Bipolar Disorder

78. Bipolar Mood States 53% 32% 9% 6% 50% 46% 1%2% Bipolar IBipolar II Adapted from Judd 2002 Judd 2003 (146 pts, 12.8 yrs)(86 pts, 13.4 yrs) % of Weeks 46% 50% 46%

80. MDQ Scoring

81. False Positives and False Negatives with MDQ

82. Treating Bipolar Disorder Treating Bipolar Disorder is often a Complex Challenge, much more difficult than treating Depression or Anxiety. “Every Bipolar is an “n of 1.” Must treat Current State and Prevent both Mania and Depression.

83. If Psychotic Depression Treat BOTH Psychosis and Mood. Psychotic Depression is a High Risk for having an underlying Bipolar Disorder

84. Non-Medical Treatments Individual Psychotherapies CBT, Supportive, Psychodynamic. Exercise Family Therapy Group Therapy

85. When to Refer Anytime you are uncomfortable. When Gravely Disabled, Imminently Suicidal or Homocidal (SEND TO ER!!!) Mania is present Psychosis present Anxiety doesn’t respond rapidly (Suicide Risk) When Substance Abuse present Therapy Needed or Helpful.

86. Epitaph of the Hypochondriac (or the Psych Patient)