(Lexapro) (10-20 mg/day), are generally safe and better tolerated than other classes of antidepressants. SSRIs are considered to be Þrst-line pharmacologic therapy for depression. Headache and gastrointestinal (GI) disturbances, such as nausea and diarrhea, are the most common adverse effects. Giving the medication with food often helps prevent nausea, which is usually transient. Some SSRIs, namely sertraline, paroxetine, and citalopram, can be sedating. If sedating, the medication should be given at bedtime. In contrast, SSRIs like ßuoxetine and escitalopram, can be activating. If activating, the medication should be taken in the morning. SSRIs can also be associated with sexual dysfunction and, therefore, patients should be educated about this side effect prior to starting therapy [50].

Initial therapeutic effects of SSRIs may be seen in about 2-3 weeks, but optimal therapeutic effects may take up to 4-6 weeks. When SSRIs are abruptly discontinued, patients may experience headaches, GI upset, dizziness, lethargy, insomnia, nightmares, irritability, agitation, anxiety, dysphoria, confusion, and emotional instability (known as, discontinuation syndrome). So, taper the dose gradually over several weeks to help prevent such symptoms.

The TCAs doxepin (100 mg/day), amitriptyline (Elavil) (50-150 mg/day), desipramine (Norpramin) (100-200 mg/day), and clomipramine (Anafranil) (150250 mg/day) are all effective antidepressants but can be lethal in overdose. Therefore, if there is potential for suicidality, it is best to avoid TCAs or, at the very least, limit the quantity of TCAs dispensed per visit. Common side effects include sedation, weight gain, orthostatic hypotension, and anticholingeric effects (i.e. constipation, urinary hesitation, tachycardia, blurred vision, and dry mouth). TCAs can also cause cardiac conduction disturbance (i.e. prolongation of the QT interval), especially in elderly patients. So, consider checking an ECG at baseline and then periodically, especially when highdosages are used. Today, TCAs are rarely used as an antidepressant since they have more risks than SSRIs. When discontinuing TCAs, taper the dose gradually. Abrupt cessation of TCAs can cause withdrawal symptoms including nausea, vomiting, diarrhea headache, sleep disturbances, dizziness, malaise, hyperthermia, irritability, akathisia [51], [52].

MAOIs, such as phenelzine (Nardil) and translcypromine (Parnate), are virtually never used nowadays, since they have less favorable risk-to-beneÞt ratio as compared to the other treatment options as described above. However, they have been used in treating

depressed patients whose symptoms do not respond to the other antidepressants (also known as, refractory depression). MAOIs should be prescribed with caution because of the potentially dangerous side effects. Common side effects include orthostatic hypotension, drowsiness, weight gain, sexual dysfunction, dry mouth, and sleep dysfunction. MAOIs should not be used in combination with TCAs or SSRIs due to the risk of serotonin syndrome, a potentially life-threaten- ing adverse drug reaction. In addition, MAOIs have an increased risk of hypertensive crisis if taken with sympathomimetics or tyramine-rich foods, like wines and cheeses. Because of these serious risks, MAOIs are rarely used today and when prescribed are preferably used as monotherapy [44].

Electroconvulsive therapy (ECT) may be indicated if symptoms are unresponsive to pharmacotherapy, or if the patient cannot tolerate pharmacotherapy. ECT is considered to be a safe and effective form of treatment for depression. ECT can be used alone, or in combination with pharmacotherapy. About eight treatments are typically administered over a 2Ð3week period. But, patients often report signiÞcant improvement after the Þrst treatment. Because ECT can help rapidly reduce depressive symptoms, it may be useful in treating patients who are at risk of attempting suicide. The most common side effect is retrograde amnesia, which usually disappears within 6 months [44].

Summary: Conclusion

¥Mohs surgery can have tremendous psychological affects on patients. In the ideal situation, patients will experience the beneÞts of Mohs surgery, including a sense of relief that their cancer has been resected and improvements in quality of life. Unfortunately, however, the excision of the large, aggressive tumors on highly visible anatomical locations can result in surgical disÞgurement. Patients with surgical disÞgurement are at risk of developing secondary psychiatric disorders, including social phobia, generalized anxiety, and depression. It is, therefore, important that Mohs surgeons can appropriately diagnose and manage these debilitating, potentially liferuining psychiatric disorders.

47.5Conclusion

Many psychological issues may develop following treatment of skin cancer with Mohs surgery because of surgically induced disÞgurement. The basic diagnostic criteria and treatment modalities have been described in detail. The information provided here should serve as a useful tool in identifying and managing patients with psychological difÞculties secondary to disÞgurement. Mohs surgeons, however, should not be expected to treat patients with psychiatric problems on a regular basis. Whenever feasible, these patients should be referred to a board-certiÞed psychiatrist. If the patient refuses such a referral, as is frequently the case, the treating physician should not be discouraged. It may still be possible to obtain a consultation from a psychiatrist or other mental health professional if the referral is presented to the patient as an extra assistance above and beyond the continuing dermatological care, thereby allaying any patient fear of abandonment. Ultimately, it is our sincere hope this discussion helps the Mohs surgeon to more effectively handle the psychological problems that may arise in the clinical setting.

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