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.
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