Psychiatric treatment | Anatomy2Medicine
Psychiatric treatment

Psychiatric treatment

      • Moclobemide is antidepressant that is the reversible inhibitor of monoamine oxidase type A (RIMA)
      • The therapeutic index, which is a relative measure of a drug’s toxicity or safety, is defined as TD50/ED50
      • Adverse effects caused by blockade of muscarinic acetylcholine receptors
        • Blurred vision
        • Constipation
        • Delirium
      • Impaired ejaculation secondary to serotonergic drug use may be treated by Neostigmine
        • Neostigmine, 7.5 to 15 mg orally 30 minutes before sexual intercourse, may help alleviate impaired ejaculation, seconary to serotonergic drugs.
      • Patients with impaired erectile function secondary to use of serotonergic drugs may be helped by Sildenafil
      • Cyproheptadine is useful for treatment of inhibited male and female orgasm secondary to use of serotonergic agents:

 

  • Neuroleptic induced Parkinsonism”,

 

        • Characterized principally by the triad of resting tremor, rigidity and bradykinesia
        • Pathophysiology involves the blockade of D2 receptors in the caudate at the termination of the nigrostriatal dopamie neurons
        • Treatment involves reduction in dosage of the neuroleptics and administration of anticholinergic drugs.
        • The “Serotonin-Dopamine antagonists” are a recommended alternative to the dopamine receptor antagonists for patients with neuroleptic induced movement disorders.
      • Commonest side effect of neuroteptic drugs is Sedation

 

  • “Neuroleptic Malignant Syndrome” and “Tardive

 

Dyskinesia” are the side effects mainly associated

with antipsychotic medication. Antidepressant

has been incriminated in causation of these side effects is  Amoxapine.

 

  • Amoxapine has also got neuroleptic properties and thus may induce extrapyramidal side effects. Because of this neuroleptic activity, this is also useful in ‘Psychotic-Depression’.

 

 

Neuroleptic Malignant Syndrome

 

  • It is the combination of catatonic rigidity, stupor, unstable blood pressure, hyperthermia, profuse sweating, dyspnoea, and incontinence that occurs as a toxic reaction to use of potent neuroleptic (antipsychotic) agents in therapeutic doses.

 

    • The condition lasts 5-10 days after discontinuation of the drugs.
    • The mortality rate may be as high as 20%.
    • Bromocriptine, Dantrolene and sometimes Amantadine which possess direct dopamine receptor agonist effects, have been used to treat NMS if the usual treatment for hyperthermia is ineffective.
    • Haloperidol is associated with highest incidence of akathisia
    • “Novel (Atypical) Antipsychotics”

 

  • Novel antipsychotics are useful in treating pervasive developmental disorders.

 

      • Novel antipsychotics cause less EPS as compared to standard APDs
      • Epinephrine should not be used in treating hypotension induced by novel antipsychotics.
    • Drug of therapeutic benefit in schizophrenia is Fluphenazine

 

  • Long acting antipsychotics
  • Penfluridol
  • Fluphenazine
  • Flupenthixol decanoate

 

    • “Schizophrenia like features” may be caused by Amphetamine
    • Drug of choice for “Intractable Hiccoughs” is Chlorpromazine      
    • Most common side effect of clozapine is Agranulocytosis
    • Clozapine may cause Hypersalivation        

 

  • ” Medication-induced Postural Tremor”
  • Regular and rhythmic tremor of a frequency between 8-12 Hz

 

      • The lowest possible dosage of the psychotropic drug should be given at bedtime to minimize the amount of daytime tremor.
      • Beta-adrenergic receptor antagonists can be used to treat drug induced tremors.
      • Medication induced postural tremors decrease during periods of relaxation and sleep, and increase during periods of anger and increased tension.
    • Postural tremor may be caused by
      • Lithium carbonate
      • Valproate
      • Yohimbine

 

  • “Serotonin-Dopamine Antagonists
  • Risperidone
  • Clozapine
  • Sertindole

 

    • Chlorpromazine is an aliphatic phenothiazine which acts through D2-receptor antagonism.

 

  • “Atypical Antipsychotics”,

 

    • Less risk of neurological adverse effects
    • More effective in treating negative symptoms of schizophrenia
    • Lacking dopamine antagonism as primary mechanism of action
    • As compared to typical antipsychotics, atypical anti-psychotics cause less potent increase in prolactin secretion.

 

 

  • D2 receptor antagonist antipsychoics

 

      • There is a strong correlation between D2 receptor affinity and antipsychotic potency

 

  • The full antipsychotic effects of drugs may take weeks to develop

 

      • Decrease in plasma homovanillic acid concentra tions early in the course of treatment is correlated with a favourable clinical response
      • After long term administration of D2 antagonists, dopam-inergic neurons decrease their firing rates.
    • Nonpsychiatric indications of dopamine receptor/antagonists

 

  • Intractable hiccough
  • Chronic pain disorder
  • Pruritus
  • Dopamine receptor antagonists cause slowing and an increased synchronization of EEG, and thus decreasing the seizure threshold, i.e. more epileptogenic.
  • Treatment of neuroleptic induced movement disorder
  • Amantadine
  • Clonidine
  • Diphenhydramine

 

    • Amantadine, Bromocriptine and Levodopa possess direct dopamine receptor agonist effects, whereas haloperidol is a dopamine receptor antagonist.
    • “Pigmentary retinopathy (retinitis pigmentosa)” is a side   effect caused by chronic use of Thioridazine
    • “Cognitive enhancers”

 

  • Include Tacrine ,Dihydroergotoxin ,Donepezil

 

      • Cognitive enhancers work by inhibition of actyecho-linesterase, thereby reducing intrasynaptic cleavage adinactivation of acetylcholine, and thus potentiate choli-negic neurotransmission, and drugs with cholinergic antagonist activity, i.e. doxepin have opposite effect.
    • Indications for Beta-adrenergic receptor antagonists in psychiatric practice

 

  • Social phobia
  • Lithium induced postural tremor
  • Neuroleptic-induced acute akathisia
  • Anticholinergic drugs used to treat neuroleptic induced dystonia,
  • Amantadine
  • Procyclidine
  • Trihexyphenidyl

 

    • Adverse effects off anticho-linergic drugs

 

  • Delirium
  • Depression
  • Dementia
  • Anticholinergic drugs are used to treat dystonias

 

    • ‘Benzo-diazepines’

 

  • Benzodiazepines cannot be safely used in patients with sleep apnoea disorders

 

      • Benzodiazepines are useful as adjuvants in treating acute mania

 

  • Benzodiazepines are useful in treating antidepressant induced myoclonus

 

    • Food intake delay the rate of absorption of benzodiazepines
  • “Barbiturates”
    • Barbiturates suppress delta waves
    • Barbiturates suppress REM sleep
    • Barbiturates are excreted in breast milk
    • Barbiturates have a high suicide potential
  • Buspirone is an Anxiolytic
  • Alprazolam is benzodiazepines that also has antidepressant activity
  • indications for use of benzodiazepines
    • Akathisia
    • Bipolar-I disorder, as an adjuvant to lithium
    • Post traumatic stress disorder
  • Benzodiazepines are not prescribed for depressed, although they may be used as adjuvants,

e.g. for anxiety, panic.

 

  • Alprazolam – drug interactions

 

          • Alprazolam inhibits cytochrome P450 (CYP) enzyme CYP3A4,  thus it should not be administered concurrently with Nefazodone, Fluoxamine, Cisapride or grapefruit juice.
          • Alprazolam may be safely co-administered with Amitriptyline
        • Indications of bromocriptine,

 

  • Antipsychotic induced hyperprolactinemia
  • Neuroleptic malignant syndrome

 

          • Cocaine withdrawal
        • Bupropion belongs to serotonin-dopamine reuptake inhibitor (SDRI )class of antidepressants:
        • Antidepressants

 

  • Antidepressants can induce a manic episode

 

          • Antidepressants should not be prescribed for a long time in bipolar disorder
          • Antidepressants can precipitate a latent psychosis
          • SSRI’s cause not only mania, they can cause suicidal and homicidal feelings.
        • Adjuvant therapy in antidepressant nonresponders

 

  • Lithium
  • Liothyronine
  • L-Tryptophan

 

        • Loxapine is a dibenzoxapine, a dopamine receptor antagonist, used as an antipsychotic.
        • Bupropion is antidepressant that does not affect sexual functioning:
        • Fluoxetine
          • Nausea is common troublesome side effect of Fluoxetine
          • Antidepressant with proven efficacy in OCD is Fluoxetine
          • The antidepressant fluoxetine exerts its action by Selective serotonic reuptake inhibition

 

  • Trazodone

 

          • “Priapism” is a side effect associated with  use of Trazodone
          • Trazodone is a serotonin antagonist and reuptake inhibitor (SARI)
        • Therapeutic indications of Bupropion

 

  • Nicotine dependence
  • Childhood Attention Deficit / Hyperactive Disorder
  • Depression

 

        • Carbamazepine
          • Therapeutic indications of carbamazepine
            • Prophylaxis of both manic and depressive episodes in bipolar-I disorder
            • Impulse control disorders
            • Alcohol and benzodiazepine withdrawal

 

  • Carbamazepine is known to precipitate acute confu-sional state.
  • Therapeutic serum level for carbamazepine is 4-12 ng/ml

 

          • Drugs that produce decreased serum carbamazepine levels,

 

  • Phenobarbital
  • Phenytoin
  • Primidone

 

        • Carbamazepine induces the cytochrome P450 3A sub family and specifically the 3A3 and 3A4 isoforms (CYP3A3/4).
        • Coadministration with lithium, antipsychotic drugs, erythromycin, verapamil, nifedipine or diltiazem can precipitate carbamazepine induced CNS adverse effects.
        • Carbamazepine may decrease the blood levels of oral contraceptives, clonazepam, haloperidol, doxycycline and tricyclic drugs.
      • Therapeutic indications for clonidine,
        • Opioid withdrawal
        • Tourette’s disorder
        • Attention deficit / hyperactivity disorder
      • Clonidine is an Alpha 2- adrenergic agonist (presynaptic)which decreases release of neurotransmitters from presynaptic nerve terminals. This resets the sympathetic tone at a lower level and decreases arousal. It causes depression.
      • The drug of choice in weight reduction programme is Diethylpropion

 

        • Fenfluramine is anti-obesity drug is associated with fibrosis and thickening of heart values:

 

  • Drugs used to treat antipsychotic induced parkinsonism
  • Amantadine
  • Bromocriptine
  • Levodopa

 

        • Therapeutic indications of levodopa
          • Antipsychotic induced parkinsonism
          • Restless leg syndrome
          • Tardive dyskinesia

 

  • Lithium

 

      • Slow release preparations of lithium give plasma peak levels

 

  • within four hours

 

      • The risk of Ebstein’s anomaly in the foetus is more if lithium is taken in the 1st trimester of pregnancy

 

  • The therapeutic indications for lithium is Acute mania

 

      • Lithium toxicity affects Brain,Heart ,Kidney
      • Drugs used as maintenance treatment in Bipolar-I disorder,
        • Lithium
        • Valproate
        • Carbamazepine

 

  • Lithium induced tremors

 

      • has a frequency of 8-10 Hz
      • Reduced by dividing the daily dosage and by reducing caffeine intake.
      • Propranolol is effective in reducing tremor
    • Commonest early adverse effect of lithium therapy is polydipsia
      • The polydipsia results from the lithium’s antagonism of effects of anti-diuretic hormone; the net result of which is to decrease resorption of fluid from the distal tubules of the kidney.
    • The symptoms of lithium toxicity include
      • Tremors
      • Muscle weakness
      • Orthostatic hypotension
      • dryness of mouth.

 

    • Methadone is used in psychiatry primarily for maintenance phase of treatment of opioids/opiates addiction.
    • Venlafaxine belongs to Serotonin–norepinephrine reuptake inhibitors (SNRIs) group of antidepressants:
            • SNRIs

 

  • Venlafaxine
  • Milnacipran
  • Duloxetine
  • Sibutramine

 

        • Common indications for drug assisted interviews in modern psychiatric practice include
          • Un-informative or mute patients
          • Catatonia/supposed conversion disorder
          • To differentiate between schizophrenia and a depressive disorder
          • Narcotherapy (Narcoanalysis
            • used to facilitate gathering information during a psychiatric interview.
            • Sodium amobarbital and diazepam are commonly used drugs.
            • It helps by catharsis of repressed memory or thought which is brought to conscious awareness.
            • Sodium amobarbital has also been suggested as an adjuvant in supportive therapy.
            • Drug may be used to reinforce a therapeutic suggestion (for example, to stop smoking)

 

  • MAO inhibitors

 

          • Tranylcypromine ,Isocarboxazid and isomoxazin belongs to MAO-inhibitor class of drug.
          • Substances avoided in patients on MAO inhibitors
          • Beans, fava ,Bear-Wine ,Cabbage ,Beef ,Chicken liver, Fish ,Over-riped fruits, Chocolates, and Coffee
          • MAO inhibitor induced hypertensive crisis may be

reversed with Phentolamine

 

  • antidepressants are devoid of adverse effects on sexual functioning – Bupropion  ,Nefazodone , Mirtazapine

 

 

            • Therapeutic indications for Dextroamphetamine,

 

  • Attention deficit / hyperactivity disorder
  • Narcolepsy
  • Treatment resistant depression

 

          • Tricyclic antidepressants
            • Amitriptyline ,Nortriptyline ,Protriptyline are Tricyclic antidepressants
            • Maprotiline, Amoxapine and Mianserin are tetracyclic antidepressants.

 

  • Tricyclic antidepressants are contra-indicated in
  • Acute angle glaucoma
  • Gastric ulcer
  • Benign prostatic hypertrophy
  • Sodium valproate
  • Therapeutic serum levels of valproate is 50-100 ng/ml
  • The therapeutic effects of vatproate in bipolar disorder may be mediated by Activation of GABA receptors

 

            • Therapeutic indications for sodium valproate include

 

  • Absence seizures
  • Prophylaxis against migraine
  • Acute treatment of mania

 

            • Valproate may be used in short term treatment of bipolar type of schizoaffective disorder.
            • Alopecia is an adverse effect of treatment with Valproate .
              • Some clinicians recommend vitamin supplementations containing zinc and selenium as treatment of valproate associated hair loss.
          • Yohimbine
            • It is a Alpha 2-Pre and post synaptic adrenergic receptor antagonist on noradrenergic neurons

 

  • Stimulation of presynaptic oc2-adrenergic receptors result in a decrease in the release of neurotransmitters from the neuron; therefore, blockade of the receptors results in an increase in the release of neurotrans mitters.

 

 

 

  • “Mandrax”

 

        • it is a combination of Hypnotic and artihistaminic

 

  • “Mandrax” also known as mandrakes, is ‘methaqua- lone’

 

        • it the most commonly abused barbiturate like substance.

 

  • It is commonly used by young people under the belief that substance heightens the pleasure of sexual activity.

 

      • Abusers of methaqualone usually take one or two standard tablets (usually 300 mg/tablet) to obtain the desired effects
    • Phenobarbitone is associated with decreased attention

span:

      • Depression with seasonal pattern

 

  • Predominantly seen in women (80%)

 

        • Mean age of presentation is 40 years

 

  • The symptoms usually appear during winter and remit spontaneously in spring
  • The most common symptoms include depression, fatigue, hypersomia, hyperphagia, carbohydrate craving, irritability and interpersonal difficulty.

 

        • Light therapy is useful for Depression with seasonal pattern

 

  • Melatonin

 

        • Melatonin increases
          • Sleep time and sleep efficiency
          • Non rapid eye movement (N-REM) sleep 1
          • REM latency
        • Melatonin is a metabolite of serotonin produced only in
        • the pineal gland.

 

  • Melatonin is advocated for the management of Jet lag

 

      • When given in the morning, melatonin is said to cause

phase delays, which is the equivalent of travelling westward to a later time zone.

      • When given in the afternoon, melatonin causes phase advance, which is equivalent of travelling eastward to an earlier time zone.
    • Psychosurgery of choice in patients with severe and

treatment resistant OCD is Cingulotomy

 

 

  • Hallucinogens

 

        • Amphetamine
        • Lysergic acid diethylamide (LSD)
        • Mescaline
      • Amphetamine.
        • A colourless liquid that volatilizes slowly at room temperature.
        • Amphetamine sulfate is a synthetic, white, crystalline substance that acts as a CNS stimulant
        • used in narcolepsy and certain types of depression.
        • Large doses are toxic

 

  • prolonged use may cause drug dependence.

 

      • Lysergic Acid Diethylamide (LSD)
        • a derivative of an alkaloid in ergot

 

  • Cocaine Hydrochloride

 

        • A drug of abuse derived from shrub Erythroxylum coca, native to Bolivia and Peru,South America.
        • It produces only psychological dependence if used for extended period of time.
        • Street names for cocaine are: snow, coke, crack, lady, flake, gold dust,green gold, blow and toot.
        • It is used as topical anaesthetic for mucous membranes.

 

  • Mescaline.

 

      • A poisonous alkaloid

 

  • the active ingradient of the mescal cactus, that causes hallucinations, especially those involving colour and music.

 

      • “Crack”

 

  • it is a street name for Cocaine

 

        • Crack is street name for almost pure form of cocaine.
        • It is prepared from an aqueous solution of cocaine hydrochloride to which ammonia (with or without baking soda) has been added.

 

  • This causes the alkaline form of cocaine to be precipitated. Because crack is not destroyed by heating, it may be smoked.
  • “Free-Base”

 

        • it is a form of Cocaine
        • Freebase is a form for cocaine used by addicts.

 

  • It is prepared by alkalinizing the hydrochloride salt,extracting it with an organic solvent such as ether, and then heating the extract to 90°C.

 

        • The inhaled material is rapidly absorbed from the lung.
      • Cycloserine is anti-tuberculous drug is known to cause neuropsychiatric symptoms
      • Electro-convulsive therapy

 

  • Electro-convulsive therapy was pioneered by Ugo Cerletti and Lucio Bini
  • Indications for ECT,
  • Endogenous depression

 

      • Manic episode in bipolar-I disorder

 

  • Schizophrenia
  • Brief psychotic episode

 

      • Depressed pregnant woman
      • Depressed geriatric patients with medical illnesses
      • Severe depression with suicidal tendency in adolescents
      • Depression with suicidal tendencies

 

  • Medications are avoided in patients on ECT
  • Benzodiazepine

 

          • Benzodiazepines have anticonvulsant activity, so they may decrease the efficacy of ECTs

 

  • Lithium

 

          • Lithium can prolong seizure activity and increase post-ictal delirium

 

  • Reserpine

 

          • Reserpine may compromise respiratory and cardiovascular systems during ECTs.
        • “Burpropion” and Clozapine
          • they should also be withdrawn during ECTs as they are associated with the development of late appearing seizures.
        • Electroconvulsive therapy may cause Anterograde amnesia of short duration
        • Best indication for ECT will be Depression-agitated
        • ECT can cause Decrease in intra-ocular tension
        • Drugs used as premedications in patients on ECTs

 

  • Atropine
  • Succinylcholine
  • Methohexital

 

        • Muscarinic anticholinergic drugs in ECT
          • They are administered before ECTs to minimize oral and respiratory secretions, and to block bradycardia and asystoles, unless the resting heart rate is above 90 beats a minute.
          • The most commonly used drug is “atropine”, which can be administered 0.3 to 0.6 mg intramuscularly or sub-cutaneously 30 to 60 minutes before the anaesthetic or 0.4 to 1.0 mg intravenously 2-3 minutes before the anaesthetic.

 

  • Muscle Relaxants in ECT

 

          • succinyl-choline is administered to minimize the risk of bone fractures and other injuries resulting from motor activity during the seizures induced by ECTs.
          • Use of succinylcholine for ECTs reduces possibility of fractures

 

  • Administration of ECT requires general anaesthesia and oxygenation.

 

        • Methohexital, 0.75-1.0 mg/kg intravenously bolus is the most commonly used anaesthetic because of its short duration of action and lower association with post ictal arrhythmia.
        • Benzodiazepines are not used because thay may reduce the efficacy of ECTs as they have anti-convulsant activity.
      • Absolute contra-indication for ECT is/are Space occupying lesions of brain
      • Commonest side effect of modified ECT is/are Amnesia
      • What is modified ECT
        • The introduction of suxamethonium (succinylcholine), a safer synthetic alternative to curare, in 1951 led to the more widespread use of “modified” ECT.
        • A short-acting anesthetic was usually given in addition to the muscle relaxant in order to spare patients the terrifying feeling of suffocation that can be experienced with muscle relaxants

 

 

  • Contra-indications for ECT
  • Absolute contraindications:

 

          • Known pheochromocytoma

 

  • Relative contraindications:

 

        • increased intracranial pressure, ok if there is not a mass effect
        • Brain tumors, same recommendation as above
        • Recent stroke– ECT has been performed successfully
        • Cardiovascular conduction defects. Pacemaker is not a contraindication to ECT- AICD function can be deactivated and magnet should be available if needed
        • High-risk pregnancy– OB consult and fetal monitoring is recommended
            • Pregnancy is not a contraindication for ECT, unless pregnancy is high risk or complicated.

 

  • Aortic and cerebral aneurysms

 

      • Asthma/COPD- some suggest that you should discontinue theophyline because of its potential to cause status epileptics
    • Common adverse effects associated with ECTs are all, except:
      • Amnesia
      • Vertebral fractures
      • Confusion
    • Least memory disturbance is seen with Unilateral ECT
    • Amnesia caused by ECTs recovers within a few days to few weeks
    • Although memory impairment during a course of treatment with ECTs is almost the rule and, is seen in approx. 75% of patients. But almost all the patients are back to their cognitive baselines after 6 months.