3-17
wherein there is a prominent and illness of 2 or more weeks duration with
distinct period of signicant mood most of the symptoms and signs
elevation that impairs the affected described. Dysthmia–a longstanding
individual's social and occupational pattern of low mood more days than
functioning. Cyclothymia—periods not, for more than 2 years, but not as
of low mood alternating with periods severe as Major Depression. Adjustment
of elevated mood; distinct from Disorders—as the name indicates, there
“mood swings” in response to social is some difculty adjusting to a new
cues or irritability. Low or elevated stressor that results in functional
mood or the swings between interfere impairment. Of these listed, adjustment
with social or occupational functioning. disorders are the most common
conditions causing depressive
symptoms.
Always maintain a high index of suspicion for a physical or CNS injury to explain a change in mood!
Plan:
Treatment
Primary
- Ensure safety of the patient (suicide risk) through physical or chemical restraint, 1 on 1 watch or merely
increased supervision (as the situation dictates) until denitive care is available. - Mania: Manage the behavioral disturbance through benzodiazepines or neuroleptics.
a. Benzodiazepines (diazepam 5-10 mg po or IM or lorazepam 2 mg po, IM or IV)
b. Neuroleptics (haloperidol 2-5 mg IM or po or chlorpromazine 50-100 mg po or IM). Consider
diphenhydramine, 25-50 mg po or IM coincident with the neuroleptic.
c. If these fail to settle down an agitated patient, see the Psychiatric Restraint Procedure on CD-ROM.
If leather restraints are unavailable, consider physical restraint with sheets wrapped around patient
on litter. - Depression: Selective Serotonin Re-uptake Inhibitors (SSRIs) such as Prozac, Zoloft, and Paxil, are
mainstays of therapy, but take 1-2 weeks before becoming effective. In an uncomplicated patient without
other medical problems, starting an anti-depressant medicine like an SSRI sooner (rather than later) can be
very helpful. Starting dose is 1⁄2 the therapeutic dose:
STARTING DOSE THERAPEUTIC DOSE
Prozac (uoxetine) 10 mg 20 mg
Zoloft (sertraline) 50 mg 100 mg
Paxil (paroxetine) 10 mg 20 mg
- Refer to local civilian or military health authorities as soon as possible. (This may not be immediate.)
- Treat side effects that may emerge with use of SSRIs (nausea, loose stools and headache)
symptomatically. Evaluate other physical symptoms (severe headache, diarrhea) as a separate condition
and rule out distinct causes. - Implement weapons access restrictions.
- Educate commanders to provide time, opportunity, and conditions for sleep.
Patient Education
General: Get adequate rest. Go to bed and arise on same schedule daily. Avoid tobacco, alcohol, caffeine
in the evenings.
Medications: Take SSRIs with food. They may cause headache, diarrhea and nausea.
Follow-up Actions
Return evaluation: Follow frequently with scheduled and prn visits.
Evacuation/Consultation Criteria: Evacuate urgently, particularly if functionally impaired, suicidal or a