Psychiatric Disorders

Definition of Depression

Feelings of depression may be described as feeling sad, blue, unhappy, miserable,

or down in the dumps .

Drug used in treament depression

Tricyclic Antidepression(TCAs)

Cardiotoxicity Orthostatic hypotension

Sedation Anticholinergic DURG

High High Moderate Moderate Imipramine

High Moderate High High Amitriptyline

Moderate Moderate Low Low Desipramine

Moderate Low Moderate Moderate Nortriptyline

Monoamine Oxidase Inhibitors

MAOIs block the enzyme responsible for the breakdown of certain neurotransmitters such as NE.

They are effective for atypical depression (sleeping too much ,increased appetite,weight gain )They should not be combined with other anti depressants.

CON

Switching aptient from anther anti depressant to MAOIs (wait 2week) except for fluoxetine 5-6week)

When swiching form MAOIs to anther anti depressant ,2week washout period ,EMSAM,it,is available in pach with (6mg/24h,9mg/24h,12mg/24h).

SELECTIVE SEROTONIN REUPTAKE INHIBITORS

(Characteristics of( SSRIs

ESCITALOPARM10

CITALOPRAM

FLUVOXAMIE

PAROXETINE

SERTR ALINE

FLUOXETINE CHARACTRISTIC

27-32hour

32hours 15hours 21hours 26hours 1-4days Hlif-life

no no no no no yes Active metabolite

10-20mg/

d

20-40mg/d

50-300mg/d

10-60mg/d

50-200mg/day

20-60mg/day

Usual dose

Note

Because these have potent serotonergic activity,combination with drug effecting serotonin can lead to serotonin syndrom (combination with MAOIs,dextromethorphan ,meperidine ,and other sympathomimetic) these can cause restlessness,tremor,diarrhea...etc

Treament -discontinuing the offending agent

Adverese Effects

GIT Complaints,insomnia,restlessness,headache,and sexual dysfunction(Bupropion&Nefazodone appear to be less likely to cause sexual dysfunction

Venlafaxine

Deual action (balanced NE&5-HT)At lower dose the effect on serotonin predominates,As dose increased the effect on Nebecomev moreSide effectAS SSRIS +mild HT

-TrazodoneSSRIS &Blocks 5-HT2A ,it dose not cause anticholinegic or cardiotoxic effects,cuase sedating effectNefazodone 5-TH2A antgonist ,block 5-

HT&NE,liver toxicity as side effectBupropion the parent drug block

dopamine reuptake ,whereas the metabolite block NE reuptake (This class called noradrenalin-dopamine reuptake inhibitors.

MirtazapineIncrease in NE&5-HT In the synapseSide effectSedation,weight gain.constipationDuloxetineMixed NE/Serotonin reuptake

blocker Side effect liver toxicity,increase of

B.P

Augmention Therapy

Augmention regimens include the following

-Lithium adding lithium help in the treament resisant depression

-Thyroid also adding help in the resistant depression T3 is effective more than T4 Buspiron

- Seconed generation antipsyotic

BIPOLAR DISORER

Amanic episode is characterized by at least 1 week of abnormal elevated mood,(irritability,decrease need for sleep,pleasure activities,poor attention)A-bipolar 1(presence of manic episodes +major depressiveB-bipolar11(presence of major depression +hypomanic episodes

ANTIPSYCHOTIC DRUGS

SchizophreniaPositive symptoms:

Thought disordersDelusions

-Hallucinations -Paranoia

Negative symptoms: -Amotivation

Social withdrawalFlat affectPoor speech

Two Class For Treatment of schizophrenia

1-Frist generation anti psychotic (FGAS)also called typical anti psychotic

-This class of agents older anti psychotic agents as chlorpromazine was first agents

2-Second generation anti psychotic (SGAS) also called Atypical anti psychotic

Anti psychotic agent for treatment of schizophrenia by chemical class

Degree of EPS Agent Class

+3 Fluphenazine First generation phenothiazine

+3 Trifluperazine

+2+/3 perphenazine

+1 Mesoridazine

+2 Chlorpromazine

+1 Thioridazine

+3 Haloperidol Butyrophenone Others

+3 Thiothixene

+1 Molindone

+2+/3 Loxapine

CONT

0 Clozapine Second generation anti pscychotics

atypical +1 Risperidone

0+/1 Olanzapine

0+/1 Quetiapine 0+/1 Ziprasidone

0+/1 Aripiprazole ? Paliperidone

by potency FGAS for treatment of Schizophrenia E.G))

EPS DecBP Sedation Anti cholinergi

Potency Dose meq(mg)

Agent

2 5 5 4 Low 100 Chlorpromazine

1 5 4 5 Low 100 Thioridazine

5 2 2 2 High 2 Fluphenazine

4 2 2 2 High 3-5 Thiothixene

5 1 2 1 High 2-3 Haloperidol

3 2 3 3 Int 10-15 Loxapine

3 2 2 2 Int 10 Perphenazine

Second generation –anti pscyhotic

These agents were developed to reduce EPS

Risk of dyskinsia is reduce-Ability to block 5-TH2

Metabolic adverse effects of SGAS

Comments Problem clozapine~olanzapine>risperidone~quetiapine>ziprasidone~aripiprazle watch body mass index ,diet&exercise ,change you med if need

Wight gain

Clozapine~olanzapine>riseridone ~quetiapine >ziprasidone~aripiprazole.may related to weight gain

Hyperglycemia or diabetes mellitus

clozapie~olanzapine>risperidone~quetiapine>ziprasidone ~aripiprazole .can (inc)total chlo,LDL ,triglyceride &(dec)heptic lipase pat should be diet and exercise

Lipid abnormalitie s

ANXIETY DISORDERS 1-Generalized anxiety characterized

by 6month or more worry2-Panic disorder sudden fear3-Obsessive-compulsive disorder 4-Posttraumatic disorder (Sertaline

first-line agent) 5-Social anxitey 6-Specific phobias(not treated with

medication)

OPTION FOR ANXIETY DISORDER 1-Benzodiazepine 2-Antidepressant 3-Buspiron 4-Miscellaneous agents A)B-blcker B)Monoamine oxide inhibitor C)antihistamine( e.g.) hydroxyzine D)Barbiturtes E)Antipsychotics

Half-liFes&potency of the most commonly prescribed Benzodiazepines.

DOSE(MG) HALF-LIFE(HOUR) AGENT

1 6-12 Alprazolam(xanax)

25 5-30(act.met) Chlordiazepoxide(librium)

10 20-100(act.met) Diazepam(valium)

1 10-18 Lorazepam(Ativan)

10 4-15 Oxazepam(serax)

INSOMNIA

• Insomnia is defined as inabilty to initiate or maintin sleep

TYPE OF INSOMNIA Transient,duration 2-3 days ,actue environmental

stress .Short term less 3weeks ,continued personal stress. Chronic more 3weeks,psychiatric illenss,medical

cause sleep disorder

AGENT TO TREAT INSOMNIA

1-Barbiturate (no longer indicated )

2-Non barbiturates e.g.(chloral hydrate)limited indication

3-Benzodiazepine4-Non-benzodiazepine

BENZODIAZEPINE

DURATION DRUG

SHORT TRIAZOLAM

intermediate Temazepam

intermediate Estazolam

long Flurazepam

long quazepam

SIDE EFFECT

1-Tolerance&physical dependence may occur after long periods

2-Residual daytime sedation3 -Rebound insomnia this

can occur when the drug is discontinued.

NON-BENZODIAZEPINE

1-Zolpidem(Ambien),has sedative&hypnotic effect ,lack of anticovulsant action,lack of muscle relaxant , lower risk of tolerance &withdrwalHalf life 1.5-4h ,avoide inrenal &hepatic ptns

2-over-the counter medication as antihistamine 3-non-benzodiazepine tcas

ALCOHOL -ABUSE

-Treament of actue alcohol withdrawalBenzodiazepine can eliminate many of

mamifestation of withrawal Loading dose diazepam ,is given in adose of 10-20 mgevery 1-2 hour until the symptoms of withrawal are alleviated.

Benzodiazepine in treament of actue alcohol

Comments Dose DrugGood for general use less problem with liver disease

1-2mg po /iv /im Lorazepam (ativan)

Use lower dose if liver disease may administer by slow iv

5-20mg po Diazepam(valium)

Long acting, be careful in case of liver disease

25-100mg po/iv Chlordiazepoxide (librium)

Nutritional considrtinsThiamine 100mg im to prevent Wernick-Korsakoff syndromeMagnesium, Electrolytes,Vitamins

-Fluid iv 5%dectrose soltuion with 0.5normal saline

-Hallucinations manage by benzodiazepine,and also seizures

-B-blocker help with vital signs &blood pressureALph –Agonists (e.g clonidine)this agents will help withdrawal symptoms.

Chronic therapy

Disulfiram thes drug blocks acetaldehyde dehydrogenase

-Naltrexone,it reduce alcohol craving-Acamprosate it ,s new drug also ,reduce

craving of alcohol.