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The one-page Psychopharmacology Algorithms sheet I refer to on a daily basis

Clinical experience

Making the same mistakes with increasing confidence over an impressive number of years

Evidence-based medicine

Perpetuating other people's mistakes instead of your own

-- A Skeptic's Medical Dictionary, by Michael O'Donnell

The use of evidence-based medicine (EBM) in psychiatry is controversial, and some have argued that EBM cannot be applied to psychiatry.

My observation is that physicians (psychiatrists included) tend not to follow EBM algorithms, which is most striking in treatment of bipolar depression. Nearly half of patients with bipolar disorder are prescribed antidepressants, despite a body of evidence that antidepressants in bipolar are more likely to be harmful than helpful. About 1 in 8 patients with bipolar disorder are treated with antidepressant monotherapy, which runs counter to all evidence-based guidelines.

I prepared a 1-page evidence-based treatment guideline sheet based primarily on Osser's Psychopharmacology Algorithms. Items that deviate from the formal algorithms are italicized.

1 page psychopharm algorithm
Download PDF • 107KB

As I update the sheet for personal use, the changes can be found on Google Drive.

Psychopharmacology algorithms for bipolar depression, evidence based medicine

Noteworthy observations:

  • Step one in treatment of a depressive episode is distinguishing bipolar vs unipolar depression.

  • A "severe melancholic" depressive episode (e.g., resulting in psychiatric hospitalization) is managed differently. Evidence-based first-line antidepressants for severe melancholic depression are venlafaxine (Effexor XR) and mirtazapine (Remeron).

  • The first-line treatment for classic mania (60% of cases) is lithium. For mixed mania (40% of cases), an antipsychotic is recommended.

  • Quetiapine (Seroquel) is among first-line treatments for bipolar mania, bipolar depression, and OCD comorbid with bipolar disorder.

  • Checking serum levels of antipsychotics can be useful.

  • For anxiety disorders, pregabalin (Lyrica) has more evidence than gabapentin (Neurontin).

  • Lavender extract (CalmAid brand) is evidence-based for generalized anxiety disorder.

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