BY Dr.

Wayan Westa, SpKJ(K) Dept Of Psychiatry Faculty of Medicine Udayana University/ Sanglah Hospital Denpasar

BIOLOGICAL THERAPY

THERAPY

DRUG THERAPY ELECTRO CONPULSIVE THERAPY SURGICAL THERAPY

PSYCHO THERAPY

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Benzodiazephine Receptor Agonists and Antagonists Dopamine Receptor Antagonists (Typical Anti Psychotic) Serotonin Dopamine Antagonists (Atypical Antipsychotic) Tricyclic and Tetracyclic Selective Serotonin Reuptake Inhibitor (SSRI) Selective Serotonin Norepinephrine Reuptake Inhibitors (SSNRI) Lithium

as sedative hypnotic, althrough other drugs can also be classified in this group Barbuturates Benzodiazepine enchane the activity of the GABA Receptor 1. Diazepam (Valium) 2. Lorazepam (Ativan) 3. Alprazolam (Xanax) 4. Estazolam (Esilgan) 5. Clorazepate (Tranxene) 6. Clobazam (Frizium) 7. Clonazepam (Riklona) 8. Etc Benzodiazepine are drugs of choice for management of acute anxiety and agitation

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Generalized anxiety disorders, adjusment disorders Mixed anxiety Depressive Disorders Panic Disorders and Social Phobia : Obsessive Compulsive Disorders Postraumatic Stress Disorders Insomnia Bipolar I Disorders (Mania) Akathisia Parkinson deseases

Anxiety, Irritability, Insomnia, Concentration Difficultis, Depression, Depersonalization, Increased Sensory Perception, Derealization. Fatigue, Headace, Muscle Twitching, Sweating, Dizzines, Nausea, When benzodiazepine are used for short periods 1 2 weeks Benzodiazepine Receptor Antagonist : Flumazenil used to overdosage of Benzodiazepine.

Treatment for : Schizophrenia and other psychotic disorders. Include : Chlorpromazine (Promactil), Thioridazine (Melleril) Haloperidol (Haldol) Trifluoperazine (Stelazine) Fluphenazine (Anatenzol). Also called typical antipsychosis A new class of antipsychotic agent : The Serotonin Dopamine Antagonist (SDAs) Also called : Atypical anti psychosis : Risperidon (Risperdal) Clozapine (Clozaril) Quetiapine (Seroquell) Olanzapine (Zyprexa) Ziprasidone, Aripifrazole (Abilify) which has fewer Neurological side effect

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Primary Psychotic Disorders Schizophrenia Bipolar Disorders Secondary Psychosis Organic Cause Severe Agitation and Violent Behavior Tourettes Disorders Other Psychiatric and Non Psychiatric Indication Anxiety Nausea Emesis Hiccups Proritus Ballismus

1. Non Neurological a. Cardiac effects prolong QT and PR Internal Suddent Death b. Orthostatic/postural hypotension c. Hematological effect : Leucopenia, agranulocytosis d. Periferal anticholinergic effect : dry mouth, nausea, vomiting, blurred vision, constipation urinary retention, mydriasis pupil e. Endocrine effect : galactorrhea, amenorrhea, impotence, inhibited Orgasm in women. Sexual adverse effects impotence treated with sildenafil (viagra) f. Weight gain g. Dermatological effect pigmentation in retina h. Cholestatic jaundice

2. Neurological effects : a. Parkinsonism Tremor, Rigidity treated with anticholinergic agents : Benztropine, (Cogentin) amantadine (Symmetrel) diphenhidramin (Benadryl) b. Acute Dystonia : torticolis spasmodic, oculogyric crisis c. Acute Akathisia Restlegsless syrodromes d. Tardive dyskinesia e. Neuroleptic Malignan Syndromes f. Epileptogenic effect g. Sedation

Tricyclic and Tetracyclic Antidepressants treatment for : 1. Major depressive Disorder 2. Mood disorder due to a general medical condition (secondary Depression) 3. Panic disorder with agoraphobia 4. Generalized anxiety disorder 5. Obsessive compulcive disorder 6. Post traumatic stress disorders 7. Eating disorder anorexia nervosa, bulimia nervosa 8. Pain disorder 9. Childhood Enuresis

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Psychiatric effect : Inducing Maniac episode Anticholinergic effect : dry mouth, constipation, blurred vision, urinary retention Sedation : effect anti histamin Autonomic effect : Ortostatic hypotension because an adrenergic blockade Cordiac effect : prolong QT internal, depressed ST, flattenal T Waves Neurological : myoclonic, ataxia, tremor Dermatological effect: Allergic, Exanthematous Rashes, agranulositosis Wight gain : because blockade of histamine 2 (H2). Impotence blockade dopamine receptor in tubero infundibular tract

First line agents for treatment of : Depression, Obsesive Compulsive Disorder, Panic Disorder. SSRIs included : Fluoxetin (Prozac), Sertraline (Zoloft), Paroxetine (Paxil), Fluvoxamine (Luvox), Citalopram (Celexa). Therapiute Indications 1. Depression 2. Suicide 3. Depression during pregnancy 4. Depression in the ederly and medically ill 5. Chronic depression 6. Depression in children 7. Anxiety disorders OCD, Panic, Social Phobia, PTSD, Bulimia, Anorexia, Obesity 8. Premenstrual dysphoric disorders 9. Premature ejaculation 10. Paraphilia comorbid with depression 11. Autistic Disorders 12. Attention deficit hyperactive Disorder 13. Chronic pain Syndromes 14. Psikosomatic Conditions

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Sexual disfunction inhibited Orgasm Gastrointestinal adverse effect nausea, dearhea, anorexia, vomiting Weight gain Headaches CNS adverse effect anxiety, insomnia, severe vivid dream, nightmare Anticholinergic effect : dry mouth, constipation. Extrapyramidal symptoms : tremor, akatisia Serotonin syndromes : tremor, dearhea, atoxia, myoclonus, hyperthermia, delirium, status epileticus, coma

Inhibiting degradation of biogenic amines : serotonine, dopamine, norapinephrine. But less frequently used because of the dietory precuations that must be followed to used avoid tyramine. Induced hypertensive crisis. MAOIs include : phenelzine (Nardil) isocarboxazid (Marplan) tranylcypromine (parnate), selegiline (Eldepryl) Therapuitic Indication 1. Depression characteristic by hypersomnia, hyperphagia, anxiety 2. Panic with Agoraphobia, Posttraumatic disorder, eating disorder, social phobia, pain disorder Precaution and Adverse Reaction 1. Orthostatic hypotensia 2. Insomnia 3. Weight gain 4. Oedem 5. Sexual disfunction 6. Tyramine induced hypertensive crisis 7. Withdrawal : mood desturbances, somatic symptom 8. Overdosis : Agitasi, hypertermia, coma Reversible Inhibitors Mono Amine Oxidase (RIMAs) Moclobemide (Aurorix)

Venlafaxine (Effexor) is an effective antidepressant drug that may have a faster onset of action than other antidepressant drugs when the dosage is increased rapidly. Venlafaxine is potent inhibitor of serotonin and norepinephrine and weak inhibitor of Dopamine reuptake Duloxetine (Cymbalta)

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Depressions with melancholic features Generalized anxiety disorder Obsessive compulsive disorder, Phobia, ADHD Chronic pain syndromes

Precaution and adverse Reactions The most cammon reaction are : nausea, somnolence, dry mouth, dizzines, nervousness, constipation, asthenia, anxiety, anorexia, blurred vision, abnormal ejaculation and orgasm