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TreatmentDr Aseni Gammampila

http://www.nimh.nih.gov/brainbasics/index.html

Brain Basics

1. Antidepressants

2. Anxiolytics

3. Mood stabilizers

4. Antipsychotics

Medications for Psychiatric Diseases

Mainly to treat severe depression

Other treatable diseases◦ Obsessive-compulsive disorder ◦ Generalised anxiety disorder ◦ Post-traumatic stress disorder◦ Panic attacks◦ Chronic pain◦ Eating disorders

Antidepressants

Changes the levels of neurotransmitters

Neurotransmitters, such as serotonin and norepinephrine can improve mood and emotion (physiology is not well understood)

Used for symptomatic relief of depression

In complicated conditions used adjunct with other methods of treatment

Mechanism of Antidepressants

Mode of action is slow

Improvement of symptom may only be seen after 2-4 weeks of continuous treatment

Change treatment if symptom relief is not seen after 6 weeks of continuous use

Increased levels of neurotransmitters can also disrupt pain signals sent by nerves (use some antidepressants as a reliever of chronic pain)

Mechanism of Antidepressants

feeling sick dry mouth insomnia erectile dysfunction excessive sweating

◦ Side effects wear off with time

◦ A course of treatment usually lasts for six months

Side Effects

1. Tricyclic

2. MAOI (Monoamine oxidase inhibitors)

3. SSRI (Selective Serotonin Reuptake Inhibitors)

4. SNRI (Serotonin and Noradrenaline Reuptake Inhibitors)

5. NASSA (Noradrenaline and Specific Serotoninergic Antidepressants)

Types of Antidepressants

Antidepressant drugs’ mechanisms of action

The chemicals most involved in depression are thought to be Serotonin and Noradrenaline

50% and 65% get well after a minimum of 3 months treatment with antidepressant

Older type of antidepressants No longer recommended as first-line

treatment for depression Fatal in an overdose More unpleasant side effects than SSRIs and

SNRIs May be tried when SSRI and SNR fail (in

severe depression) Can be used in OCD and bipolar disorder

Tricyclic Antidepressants (TCAs)

amitriptyline (Tryptizol)(used also for chronic pain relief)

clomipramine (Anafranil) imipramine (Tofranil) lofepramine (Gamanil) nortriptyline (Allegron)

TCAs

Dry mouth A slight tremor Fast heartbeat Constipation Sleepiness Weight gain In older people,

confusion Dribbling urine faintness through low blood pressure falls

Not advisable in heart patients Dangerous in overdose

Side Effects of TCAs

Most widely prescribed antidepressants

Fewer side effects – less fatal

Fluoxetine is probably the best known SSRI (Prozac)

Other SSRIs include:◦ citalopram (Cipramil) ◦ paroxetine (Seroxat) ◦ sertraline (Lustral)

SSRI - Selective Serotonin Reuptake Inhibitors

feel sick and more anxious within the first 2 weeks

indigestion interfere with sexual function. rare episodes of aggression in younger or middle-aged people problems with urinating difficulty in remembering falls confusion hyponatraemia – in elderly

Side Effects of SSRIs

Similar to SSRIs

SNRIs include:◦ duloxetine (Cymbalta and Yentreve) ◦ venlafaxine (Efexor)

The side-effects are very similar to the SSRIs

Venlafaxine should not be used during heart diseases ( increase blood pressure)

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

1/3 of people who stop SSRIs and SNRIs have withdrawal symptoms which can last between 2 weeks and 2 months.◦ stomach upsets◦ flue like symptoms◦ anxiety◦ dizziness◦ vivid dreams or nightmares◦ sensations in the body that feel like electric

shocks

Serotonin syndrome is uncommon but potentially serious

levels of serotonin in your brain is too high

triggered by combined treatment of SSRI or SNRI or with another medication such as another antidepressant or St John’s Wort containing serotinin

Serotonin Syndrome

◦ confusion ◦ agitation ◦ muscle twitching ◦ sweating ◦ shivering ◦ diarrhoea ◦ Fever of 39.4°C (103°F) or above ◦ seizures (fits) ◦ irregular heartbeat (arrhythmia) ◦ unconsciousness

Symptoms of Serotonin Syndrome

Early antidepressant -First developed in the 1950s

Rarely prescribed now Wide range of side effects Only used when other types of antidepressants

are ineffective◦ Moclobemide (manerix) ◦ phenelzine (nardil)

With MAOI treatment certain foods and drinks with protein called tyramine should be avoided

Red wine and pickled fish Can cause a dangerous rise in blood pressure

Monoamine Oxidase Inhibitors (MAOIs)

Antidepressants may cause sleepiness and slow reactions

Taper off the dose than sudden stop If you have had two or more attacks of depression

then treatment should be continued for at least two years

Counselling is useful in mild depression Herbal remedies

◦ Hypericum ( st johns wort) Light

◦ Seasonal affective disorder (SAD) - a source of bright light which you have on for a certain time each day and which can make up for the lack of light in the winter.

Antidepressants

Dopamine is the main neurotransmitter affected by these medications.

Dopamine controls◦ Important, significant and interesting activities◦ Satisfaction◦ Motivation◦ Muscle control

Antipsychotics

Hallucinations

Delusions

Thought disorder

Extreme mood swings of manic depression/bipolar disorder

Overactive Dopamine

1. ‘Typical’ - the older drugs

2. ‘Atypical’ - the newer drugs

Types of Antipsychotics

first appeared in the mid-1950s

‘typical’ or 'first-generation' antipsychotics

block the action of dopamine

Older Antipsychotics

usually high doses stiffness and shakiness, like Parkinson’s disease slow thought process uncomfortable restlessness (akathisia) Sexual dysfunction if high therapeutic doses cause side effects

ancholinergics (Orphenadrine and Procyclidine) can be used to reduce the effects

long-term effect- tardive dyskinesia (TD) – continual movements of the mouth, tongue and jaw.

Side-Effects

Over the last 10 years

‘Atypical’ or ‘second-generation’ antipsychotics

Block dopamine

Also work on serotonin

Newer Antipsychotics

Sleepiness and slowness Weight gain Sexual dysfunction Increased chance of developing diabetes. In high doses, some have the same

Parkinsonian side-effects as the older medications

Long-term use can produce movements of the face (tardive dyskinesia) and, rarely, of the arms or legs.

Side-Effects

Newer◦ less likely to cause Parkinsonian side-effects

◦ less likely to produce tardive dyskinesia.

◦ more likely to produce weight gain

◦ more likely to produce diabetes

◦ more likely to give you sexual problems

◦ may help with “negative symptoms” in schizophrenic patients

Newer vs Older

Best antipsychotic medication Reduce suicidal feelings in people with

schizophrenia Minimal effect on the dopamine systems

which control movement Hardly causes any stiffness, shakiness or

slowness seen in other antipsychotics. May make increase drowsiness than older

antipsychotics

Clozapine

can affect your bone marrow, leading to a shortage of white cells – immediate discontinuation of medication ( followed with weekly blood tests for the first 6 months and 2 weekly blood tests)

Other side effects◦ weight gain◦ excessive salivation ◦ epileptic fits

usually only suggested after at least two other antipsychotics have been tried

Side-effects

Injection every 2-4 weeks

Difficult to change dose

Effects are known later

Difficult to monitor and control dose according to side effects

‘Depot’ Antipsychotics

Other ways of helping will usually be added to antipsychotic treatment rather than replacing it.

Cognitive behaviour therapy (CBT) Psychoeducation Family therapy

Benzodiazepines

Azapirones

Beta-Blockers

Anti-Anxiety Drugs

High-potency benzodiazepines combat anxiety

Benzodiazepines are potentially dangerous when used in combination with alcohol.

Effective for most anxiety disorders Overdoses can be serious, very rarely fatal

Benzodiazepines

Clonazepam (Klonopin®) - social phobia and GAD

Lorazepam (Ativan®) - panic disorder Alprazolam (Xanax®) - panic disorder and GAD. May experience withdrawal symptoms if

benzodiazepines are stopped abruptly ◦ Tapering off gradually is the best approach to stop

taking these drugs Benzodiazepines taken during pregnancy are

associated with birth defects (such as cleft palate)

Benzodiazepines

Buspirone (Buspar®) Newer anti-anxiety medication used to treat

GAD Act on serotonin receptors called 5-HT(1A). Works as well as a benzodiazepine for

treating generalized anxiety disorder. Takes several days to weeks for the drug to

be fully effective No withdrawal effects

Azapirones

Less pronounced side effects than benzodiazepines

Side effects◦ dizziness◦ headaches◦ drowsiness◦ nausea. ◦ must be taken consistently for at least 2 weeks to achieve an anti-

anxiety effect.

Buspirone should not be used with monoamine oxidase inhibitors (MAOIs)

Not addictive, despite long-term use

May be helpful for the patient whose anxiety disorder coexists with alcoholism or drug abuse

Azapirones

◦ propranolol (Inderal) ◦ atenolol (Tenormin)

block the nerves that stimulate a rapid heart rate

affect only the physiologic symptoms of anxiety- for social phobias and performance anxiety

Beta-Blockers

Lithium

Anticonvulsants

Atypical antipsychotics

Mood Stabilizers

Transcranial magnetic stimulation Deep brain stimulation

Electroconvulsive therapy (ECT)

Deep brain stimulation

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