Clinical Psychiatry




Bipolar Disorder

Long-Term Treatment of Bipolar Disorder: Different Phases and the Problem of Non-Adherence

treatment non-adherence in bipolar disorder Outline:

  • Interactive animation: the different treatment phases of bipolar disorder
  • Treatment Non-Adherence: Its Importance and How to Avoid It
    • Extent of the problem
    • Definition
    • Complications
    • Types
    • Factors influencing non-adherence
    • Strategies to increase adherence

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Screening for Bipolar Disorder

bipolar disorder screening


  • Why is an accurate diagnosis important?
  • Why do we miss the diagnosis of bipolar disorder?
  • Interviewing challenges
  • Three aspects to consider in a bipolar disorder screening
  • Screening instruments:
    • Mood Disorder Questionnaire
    • Bipolar Spectrum Diagnostic Scale
  • PDF: The MoodCheck

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Bipolar Disorder in DSM-5: Highlights of Changes from DSM-IV-TR to DSM-5

Bipolar disorder concept


  • Increased activity was added to Criterion A for bipolar disorder
  • Mixed episode is now a specifier
  • Anxious distress is a new specifier
  • NOS was replaced by: other specified bipolar and related disorder and unspecified bipolar and related disorder
  • Antidepressant-induced mania can be now diagnosed as BD

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The Bipolar Disorder Concept: From Kraepelin to DSM-5

From Kraepelin (3)

This tutorial is a simplified review of the evolution of the bipolar disorder concept.

  • The “manic-depressive insanity” concept (Emil Kraepelin)
  • The unipolar vs bipolar distinction (Karl Leonhard)
  • From manic-depressive illness to bipolar subtypes (DSM-II to DSM-5)

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Critical Appraisal


Dr. Erick Turner: How to Read Papers in Psychiatry


Dr. Turner is Assistant Professor in the Department of Psychiatry at Oregon Health and Science University (OHSU) in Portland. He has previously held positions at the US Food & Drug Administration and the National Institute of Mental Health.

He is here to help us understand clinical research and to improve our critical appraisal skills. One of his research interests is publication bias, or reporting bias. We’ll learn why this concept is important to interpret the medical literature and understand the limitations of the papers we read.

 Part 1

  • Facts you may not know about FDA’s approval process
    • Current limitations
  • Off-label prescribing
    • How to approach off-label prescribing of old drugs vs. new drugs
  • Types of reporting bias
    • Study publication bias
    • Outcome reporting bias
    • Delayed publication bias
    • Type of paper bias
    • Place of publication bias
    • Multiple publication bias


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Part 2

  • Facts you may not know about FDA’s approval process
    • Current limitations
  • Off-label prescribing
    • How to approach off-label prescribing of old drugs vs. new drugs
  • Types of reporting bias

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Insomnia Pharmacotherapy: Off-Label Antidepressants and Antipsychotic


Off-label agents used for primary insomnia: evidence of efficacy and clinical aspects of antidepressants and second-generation antipsychotics.

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Insomnia Pharmacotherapy: Low-Dose Doxepin and Ramelteon

Diapositiva5Insomnia Pharmacotherapy: Low-Dose Doxepin and Ramelteon

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 Insomnia Pharmacotherapy: Non-Benzodiazepine Hypnotics (Z drugs)

Diapositiva11Non-benzodiazepine hypnotics: zolpidem, zaleplon and eszopiclone. Discussion of ther mechanism of action, indications,available formulations, pharmacokinetics, side effects and dosing.

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Insomnia Pharmacotherapy Part 1: Introduction and Benzodiazepines

Benzodiazepines (14)An introduction to the pharmacotherapy of insomnia. A general approach is presented, followed by the pharmacology of hypnotic benzodiazepines.

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 Assessing Insomnia Effectively

Diapositiva13This video discusses a practical approach to the assessment of insomnia


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Neuropsychopharmacology of Sleep: Integrating Neurobiology and Drug Treatment

Diapositiva34This is an integration between the different neurotransmitters that regulate sleep physiology and pharmacological interventions commonly used in clinical practice.



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Adult ADHD: Diagnosis and Clinical Features

Diapositiva13This video presents basic concepts regarding ADHD in adults . It is based mostly on DSM-5 criteria.

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Introduction to Drugs for the Treatment of ADHD

Diapositiva11This video discusses the role of the prefrontal cortex in ADHD and the mechanisms of action of amphetamines, methylphenidate, atomoxetine and alpha 2 agonists.

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Stimulants for ADHD: Summary of Formulations

ADHD formulationsThis presentation discusses clinical features of short, intermediate and long acting formulations of methylphenidate and amphetamines.

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 ADHD Pharmacotherapy: Side Effects


Diapositiva6This presentation discusses side effects associated with the use of ADHD medications.

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 ADHD Pharmacotherapy: Starting Treatment and Side Effects

Two videos discussing how to start drug treatment in ADHD and side effects monitoring.
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Generalized Anxiety Disorder


GAD Part 1: Diagnosis and Clinical Features

GADThis video presents basic concepts to diagnose generalized anxiety disorder in clinical practice. Based mostly on DSM V criteria.


  • Introduction
  • Epidemiology
  • Diagnosis: DSM V
  • Rating scales
  • Differential diagnosis

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GAD Part 2: Pharmacotherapy

GAD PharmacotherapyThis presentation is based on the latest international guidelines for the treatment of GAD.


  • First-line agents
  • Second-line agents
  • Adjunctive therapy
  • Treatment recommendations

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Obsessive-compulsive disorder


OCD Part 1: Diagnosis and Clinical Features

Obsessive Compulsive Disorder.pptxThis video presents the basic concepts to diagnose obsessive-compulsive disorder in clinical practice. It is based mostly on DSM V criteria.
Video outline:

    • DSM V criteria for OCD
    • Symptom clusters
    • Diagnostic issues
    • Epidemiology of OCD

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OCD Part 2: Pharmacotherapy of OCD

Pharmacotherapy of OCDThis video presents the basic concepts to treat obsessive-compulsive disorder in clinical practice.

  • General concepts on treatment response
  • The use of SSRIs and clomipramine for the treatment of OCD
  • Considerations on the initial treatment plan
  • Introduction to treatment resistance and augmentation

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Mood Stabilizers


Valproate Part 2: Side Effects, Pharmacokinetics, and Prescribing Information

Valproate part 2

Summary of side effects, warnings, pharmacokinetics and prescribing information.

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Valproate Part 1: Introduction and Indications

Diapositiva9This video is an introduction to valproate (valproic acid, divalproex sodium)

  • MOA: enhances GABAergic neurotransmission and affects intracellular signaling
  • FDA-approved for epilepsy, migraine and mania
  • Off-label use: maintenance treatment in BD, adjunctive in schizophrenia, impulsivity, and alcohol dependence

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Lithium Part 4: Practical Prescribing

4- Prescibing lithiumThis presentation focuses on how to prescribe lithium in clinical practice.

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Lithium Part 3: Side Effects

Diapositiva11This presentation summarizes the most common side effects associated with lithium therapy. Short-term and long-term side effects

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Lithium Part 2: Clinical Uses and Pharmacokinetics

Lithium Clinical Uses and PharmacokineticsLithium is efficacious for the treatment of manic and depressive episodes and as maintenance treatment, it also reduces suicidal behavior.

This presentation discusses the use of lithium for bipolar disorder and unipolar depression. It also summarizes the most important pharmacokinetic concepts.

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Lithium Part 1: Mechanism of Action

Lithium MOALithium has multiple levels of action, from macroscopic to microscopic levels. This presentation discusses:

      • Abnormalities found in brain structure of bipolar patients and changes in brain structure linked to lithium therapy.
      • Lithium modulation of  dopaminergic, glutamatergic and gabaergic neurotransmission.
      • Intracellular changes associated with lithium use.

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Dr. Joseph Goldberg: Side Effects of Mood Stabilizers

profilepic_lJoseph F. Goldberg, MD, is a clinical professor of psychiatry at the Icahn School of Medicine at Mount Sinai in New York City and director of the Affective Disorders Research Program at Silver Hill Hospital in New Canaan, Conn.

Part 1

  • An introduction to the tolerability profile of litihium, valproate, lamotrigine and carbamazepine
  • The effect of lithium on cognition
  • Why lithium is less frequently used nowadays
  • Tailored treatment for bipolar disorder: how to guide our choice of medications and how to address patients’ concerns about side effects

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Part 2

  • Valproate side effects: PCOS (background, expert’s opinion) and teratogenicity
  • Valproate monitoring
  • Evaluation and monitoring of patients on mood stabilizers: general tips and practical observations that might be useful to clinicians.

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Drug Summaries



Vilazodone is an antidepressant that combines SERT inhibition with 5-HT1A partial agonism. Currently it is approved only for major depressive disorder.

Regarding pharmacokinetics, it is metabolized mainly by CYP3A4. The tolerability profile is similar to SSRIs, some of the most common adverse effects are: diarrhea, nausea, headache, dizziness and insomnia.

Vilazodone has been promoted as a drug with low risk of antidepressant-induced sexual dysfunction, in this presentation we summarize the evidence for this.

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Mirtazapine: Pharmacological Aspects and Clinical Implications

mirtazapineMirtazapine is a noradrenergic and specific serotonergic antidepressant, it doesn’t have effects as monoamine reuptake inhibitor.
One significant feature is its effect as histamine 1 antagonist, as a consequence of this the drug can cause sedation and weight gain.

It is commonly used in the elderly population, in this group of patients insomnia and low weight might benefit from sedation and weight gain.  Mirtazapine has no significant drug-drug interactions, this makes it attractive for use in combination with other antidepressants as augmenting option.

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PAROXETINEDrug summaries of SSRIs: fluoxetine, fluvoxamine, sertraline, paroxetine, citalopram and escitalopram.


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Diapositiva19Drug summaries: Venlafaxine vs Desvenlafaxine, Duloxetine.

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bupropionBupropion is a norepinephrine dopamine reuptake inhibitor, or NDRI. It is approved as antidepressant as well as for smoking cessation.

Some characteristic aspects of its side effects profile include a lack of sexual side effects, compared to other antidepressants and an increased risk of seizures.

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Adverse Effects

Suicide Risk and Antidepressants Use

suicide riskIn 1990, case reports described patients who developed intense suicidal ideation during treatment with fluoxetine. In response to this, the manufacturer performed a meta analysis of 17 randomized trials and found no differences in suicidality with placebo.


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Antidepressant-Induced Sexual Dysfunction

This discusssion overviews normal sexual physiology and the mechanisms involved in antidepressant-induced sexual dysfunction. Antidepressants with lower risk of sexual dysfunction are also reviewed, along with management strategies for this important side effect (dose reduction, antidepressant switch, wait and watch and adding an antidote).

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Antidepressant Discontinuation Syndrome


Discontinuation symptoms can occur with all antidepressant classes. You will see many articles referring to SSRI discontinuation syndrome, this has to do with the fact that SSRIs are by far the most commonly prescribed antidepressant class.

Discontinuation symptoms include flu-like symptoms, insomnia, nausea, imbalance, sensory disturbances and hyperarousal. We can use the mnemonic FINISH to keep these symptoms in mind.

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Interactive Games


Educational Review Games: Vol 1


The following are educational activities to review some concepts related to antidepressant medications.

Topics include:  SSRI dosing, CYP2D6 inhibitors, Mirtazapine, Weight Gain and Sedation, Norepinephrine-dopamine reuptake inhibition

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Dr. Rajnish Mago Interview: Side Effects of Antidepressants

Mago_Rajnish-10_400x400Dr. Mago currently serves as Director of the Mood Disorders Program at the Thomas Jefferson University Hospital in Philadelphia, Pennsylvania. He is Associate Professor of Psychiatry at the Jefferson Medical College.

Part 1

Part 1 A – General Overview of Side Effects

      • Why side effects are “the other side of psychopharmacology”
      • The importance of side effects in treatment adherence
      • How to discuss side effects with our patients
      • Why are some patients more sensitive to side effects than others

Part 1 B

      • Excessive sweating

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Part 2

      • Orthostatic hypotension
      • Movement disorders
      • Nausea
      • Antidepressant-induced sexual dysfunction:
        • Three antidepressants that cause less side effects: bupropion, mirtazapine and moclobemide.
        • “Wait and watch” option
        • Drug holidays

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Dr. Derek Tracy: Reviewing Bupropion for Depression

Derek TracyDr. Tracy is a BRC research fellow and the neuromodulation lead at the Institute of Psychiatry, Psychology, and Neuroscience, King’s College London. Dr. Tracy also sits on the Editorial Board of the British Journal of Psychiatry.

His team published a review paper in Therapeutics Advances in Psychopharmacology titled “Bupropion: a systematic review and meta-analysis of effectiveness as an antidepressant”.

We discuss the following topics:

  • The effectiveness of bupropion as monotherapy and combination therapy, and how it compares to other antidepressants
  • The limitations of the literature reviewed
  • The importance of considering the possibility of insomnia and agitation when prescribing this drug
  • Symptom domains for which bupropion may be more effective and symptoms for which it may be less effective
  • The use of bupropion to avoid and treat antidepressant-induced sexual dysfunction
  • Specific clinical situations in which this drug is a good therapeutic option

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