Chapter psychopharmacology in psychiatry

Introduction to psychopharmacology course

1. ጅማዩኒቨርሲቲwww.ju.edu.et
Chapter four
psychiatric drugs

2. ጅማዩኒቨርሲቲwww.ju.edu.et
psychiatric drugs
Whatarepsychiatricmedications?
•Psychiatricmedicationstreatmentaldisorders.
•Sometimescalledpsychotropicorpsychotherapeutic
medications,theyhavechangedthelivesofpeoplewith
mentaldisordersforthebetter.
•Manypeoplewithmentaldisorderslivefulfillingliveswiththe
helpofthesemedications.Withoutthem,peoplewithmental
disordersmightsufferseriousanddisablingsymptoms.

3. ጅማዩኒቨርሲቲwww.ju.edu.et
Howaremedicationsusedtotreatmentaldisorders?
•Medicationstreatthesymptomsofmentaldisorders.
Theycannotcurethedisorder,buttheymakepeople
feelbettersotheycanfunction.
•Medicationsworkdifferentlyfordifferentpeople.Some
peoplegetgreatresultsfrommedicationsandonlyneed
themforashorttime

4. ጅማዩኒቨርሲቲwww.ju.edu.et Anti-anxiety drugs (Anxiolytics)
•Anxietyisanormal,inevitablepartofeverydaylife.
•Inmanysituationsitisappropriatetoreactwithanxiety-itis
anaturallyhealthycopingreactiontoathreateningor
dangeroussituation.
•Anxietycanbecomeaprobleminsituationswherethereisno
realthreat,orwhenanxietycontinueslongafterathreathas
passed.

5. ጅማዩኒቨርሲቲwww.ju.edu.et Anti-anxiety drugs (Anxiolytics)
•Anxietyoccurinallpeopleregardlessofculture,race,age,
religion,gender,levelofeducationoreconomicbackground.
•Characterizedby
excessivefearand/orinappropriatefeelingsofnervousness
verygeneral(appliedtonearlyallaspectsoflife)
veryfocusedonaparticularsituation.
•Oftenchronicanddisabling

6. Clinical features
Psychological
□Inability to relax
□Nervousness, irritability
□Excessive worry
□Disturbance of concentration
□Panic
□Feelings of unreality
□Fear of losing control
□Fear of going crazy
□Fear of dying
6

7. Clinical features
Autonomic/Somatic Symptoms
□Chest pain
□Choking sensation
□Diarrhea
□Diaphoresis
□Dyspnea
□Fatigue
□Flushing
□Headache
.
□Hyperventilation
□Muscle tension
□Nausea
□Palpitations
□Parenthesis
□Tachycardia
□dizziness
□Vomiting
7

8. 8
Anxiety Disorders
□Six disorders:
Generalized anxiety disorder (GAD)
Phobias
Panic disorder
Obsessive-compulsive disorder (OCD)
Acute stress disorder
Posttraumatic stress disorder (PTSD)

9. Classification of Anxiolytics and hypnotics
Hypnotic—Adrugthatproducesdrowsinessand
facilitatestheonsetandmaintenanceofsleep.
Sedative—Adrugthatdecreasesactivityandcalmthe
recipient.
Anxiolyticdrug—Adrugthatdecreasesfeelingsof
anxietyorpanic
Groupofdrugsare:
Benzodiazepines
5HTIAreceptoragents
Barbiturates
B-adrenoreceptorantagonists
Miscellaneousagents

10. Benzodiazepines
They are a group of medications which have been used
since the 1960s to treat:
Anxiety
Epileptic seizures
Mania
Alcohol withdrawal sleeping problems
Based on their duration of action roughly divided into :
□short acting (e.g. flurazepam, triazolam),
□medium acting (e.g. alprazepam, lorazepam) and
□long acting compounds (e.g.
diazepam,chlordiazepoxide, clonazepam).

11. Mode of action
Benzodiazepines act on GABA receptors which mediates fast
inhibitory response produced by activity in GABA-ergic
neurons.
Are not effective in the absence of endogenous GABA.
There are three subtypes of benzodiazepine receptors:
(i) Omega-1 mediates hypnotic effect of drug
(ii) Omega-2 mediates anxiolytic effect of drug
(iii) Omega-3 mediates relaxant effect of drug

12. Pharmacologic effect on CNS
□Reduction of anxiety and aggression
□Induction of sleep
□Reduction of muscle tone
□Anti-convulsant effect( treatment of epilepsy and bipolar
disorder)

13. Pharmacologic effect on CNS
Indications
□Treatment of anxiety, Diazepam 5 mg twice daily
□Treatment of insomnia, Temazepam 7.5 –30 mg at
bed time
□Treatment of epilepsy
□Treatment of muscle spasms ( contraction)
□Treatment of ethanol withdrawal syndrome
(Benzodiazepines are also used for alcohol
withdrawal patients.)

14. Adverse effect of benzodiazepines
□Drowsiness( sleepiness)
□Confusion
□Amnesia (anterograde)
□Impaired coordination (motor skill)
□Tolerance and dependence

15. Adverse effect of benzodiazepines
Advantages of benzodiazepines:
(i)Milderside-effects-includinglessriskofrespiratory
depression.
(ii)Lessseverephysicaldependence.
(iii)Lessdangerousinoverdosage.
(iv)Lesslikelytointeractwithotherdrugs-asinduction
ofhepaticmicrosomalenzymesdoesnotoccurtothe
sameextent.

16. Barbiturates
Barbiturates have historically played an important role
in the treatment of a variety of CNS disorders
including;
□Anxiety disorders
□Sleep disorders
□Seizure disorder-Pheno-barbital ( long acting)
□Muscle spasm and anesthesia-Thiopental (short
acting)

17. Barbiturates
mostoftheiruseinclinicalpracticearereplacedby
benzodiazepinesbuttheyarestillinuseincertainclinical
situationseg.Seizuredisorder(Pheno-barbital),and
anesthesia(Thiopental).
Theiruseinoutpatientshasbeenmoreorlesseliminated
duetothenarrowmarginofsafety,andriskofsuicidein
overdose.

18. Adverse effects
□High toxic in acute over dose (respiratory and
cardiovascular depression)
□Drowsiness, incoherence, slurped speech.
□High degree of tolerance and dependence
□Withdrawal effects from barbiturates are more rapid and
severe.
Most symptoms resemble those of benzodiazepines.
Benzodiazepines and barbiturates should be given to the
patient for short period of time

19. B-adrenoreceptorantagonists (e.g. propronol)
These are used to treat some forms of anxiety, particularly
where physical symptoms such as sweating, tremor and
tachycardia, are troublesome.
Use by actors, musicians, politicians etc. to reduce
symptom of stage fright. Have little effect on subjective
feelings of anxiety.
Adverse effects
Contraindicated in patients with,
□Asthma
□Obstructive air ways disease
□Heart failure
□Second or third degree heart block.

20. Anti-psychoticdrugs(neuroleptics,major
tranquillizers)
Antipsychoticmedicationreferstotheuseofagroupof
psychoactivedrugsthatismainlyusedtotreatpatients
sufferingfrompsychoses,mostoftenschizophreniabut
alsomaniaanddisorders.

21. Schizophrenia -Clinical picture
Positive symptoms
Delusions–persecutory, religious, somatic,
sexual, bizarre
Hallucination–auditory, visual
Disorganized speech–derailment,
tangentially, circumstantiality, perseveration,
etc.
Disorganized or catatonic motor behavior–
stupor, mannerism, posturing, echopraxia, etc.
Incongruity of affect-smile, giggle for no
reason

22. Schizophrenia -Clinical picture cont’d
Negative symptoms
Alogia –poverty of speech –amount, content
Affective flattening
Anhedonia–inability to experience pleasure
Asociality–few social contact
Avoliton/Apathy–lack of energy, decreased
motivation
Attentional impairment -absentminded

23. Schizophrenia -Clinical picture cont’d
Social and occupational deterioration
Work inhibition
Poor interpersonal relationship, social
withdrawal
Poor self care –unkempt, bizarre
clothing
Decreased level of achievement –
academic etc.
Breaking social rules –stand manner,
obscenities, collecting garbage

24. Typical or first generation anti-
psychotics
Thesefirstappearedinthemid-1950s.Theseolder
drugsareoftencalled‘typical’or'first-generation'
antipsychotics.Theyallblocktheactionof
dopamine,somemorestronglythanothers.
□Chlorpromazine Thioridiazine
□Haloperidol Flupeenthixol
□Fluphenazine.

25. Typical or first generation anti-
psychotics
Side-effects include:
□stiffness and shakiness, like Parkinson’s disease
□feeling sluggish and slow in your thinking
□uncomfortable restlessness (akathisia)
□Problems with your sex life.

26. Parkinsonism
□Parkinsonism is a clinical syndrome that comprises four
main features:
□bradykinesia (a slowness and poverty of movement),
□muscular rigidity (increased resistance of muscles to
passive movement),
□resting tremor, which usually disappears during
voluntary movement, and
□abnormalities in posture and way of walking.

27. Atypical anti-psychotics
□They still block dopamine, but much less so than the older
drugs
□Clozapine Sulpiride
□Risperidom Olanzapine
Compared to the older drugs they seem:
□less likely to cause Parkinsonian side-effects
□Less likely to produce tardive dyskinesia.(involuntary muscle
movement)
□more likely to produce weight gain
□more likely to produce diabetes
□More likely to give you sexual problems.

28. Depot’ antipsychotics
The word ‘depot’ means that the medication is given not
as tablets, but as an injection every 2 to 4 weeks
Long acting depot injections administered intramuscularly
as an oil injection and slowly released in to the blood
stream. The effects are generally the same as medications
taken by mouth.
Advantages
□Rapid initiation of effect
□For ensuring better patient compliance
□For controlling aggressive patients

29. Depot’ antipsychotics
Disadvantages
□MaygiverisetohigherincidenceofEPSE
□Ittakesalongtimetoknowtheeffectofchangingthe
dose.
□Ifaparticulardoseisgivingyouside-effects,loweringit
maymakelittledifferenceforseveralweeks.
□Nobodylikeshavinginjections

30. Cont…
□Extrapyramidal symptoms (EPS)
Parkinsonism
Akinesia
Akathisia
Dystonia
Tardive dyskinesia
Neuroleptic malignant syndrome
Hyperglycemia and diabetes

31. Cont…
□SIDE EFFECT PSYCHOTIC DRUGS
□MovementeffectsTremors,musclestiffnessandtics
canoccur.
□Thehigherthedose,themoreseveretheseeffects.
□DizzinessFeelingsofdizzinessmayoccur,especially
whengettingupfromasittingorlyingposition.
□Weightgainsomeofthesecondgenerationdrugsare
thoughttoaffectpeople’ssenseofhavinghad
enoughtoeat.Theycanalsobesedating.Thesetwo
effectscanresultinweightgain,whichcanincreasea
person’sriskofdiabetesandheartdisease.

32. Cont…
□Controllingside-effects
□Youcanhelptocontrolpossibleside-effectsonyourownby:
□gettingregularexerciseandeatingalow-fat,low-sugar,
high-fibrediet(e.g.,roughage,fruitsandvegetables)to
reducetheriskofdiabetesandhelppreventweightgainand
constipation
□usingsugarlesscandyorgum,drinkingwaterandbrushing
yourteethregularlytoincreasesalivationandeasedry
mouth
□Gettingupslowlyfromasittingorlyingpositiontohelp
preventdizziness

33. Drugs used in Affective disorders
Antidepressantsarecompoundsusedtotreatdepression.
Specificallytheyreducesymptomsofdepression.Theagents
approvedforthetreatmentofdepression,however,arealso
usefulinanarrayofotherdisorders,includinganxiety
disorders,painsyndromes,attentiondeficithyperactivity
disorder(ADHD),smokingcessation.

34. Drugs used in Affective disorders
Depression: Symptoms
Depressed mood –irritable mood
Decreased interest or pleasure
Decreased body weight
Increased or decreased sleep
Psychomotor agitation or retardation
Fatigue or loss of energy
Worthlessness, excessive guilt
Decreased concentration, indecisiveness
Recurrent thoughts of death

35. Drugs used in Affective disorders
Mostantidepressantsprescribedtodaybelongtothe
selectiveserotoninreuptakeinhibitorclass,orSSRIs,a
newertypeofantidepressantthatspecificallyworkson
serotoninlevelsinthebrain.
Otherantidepressantsaffectnorepinephrineand
dopaminelevelsinthebrain,otherbrainchemicalswhich
affectmoodandbehavior.
Olderantidepressantscalledmonoamineoxidase
inhibitors,orMAOIs,tendtohavemoresideeffectssuch
asdrymouthandconstipation,andcanhaveseveralfood
interactionswiththingslikewineandcheese.

36. Anti-depressant drugs
□Cyclicanti-depressants-e.g.Imipramine,amitriptyline
(1
st
generation)
□Selectiveserotoninreuptakeinhibitorseg.Fluoxetine,
sertraline
□Monoamine oxidaseinhibitorseg.Phenolzine,
tranyleypromine
□Atypicalanti-depressants(secondgenerationAD)eg.
Maprotiline,mainserin

37. Anti-depressant drugs
Mechanism of action of AD drugs
TCAs acts by inhibiting uptake of nor adrenaline and/or
serotonin transmission.
MAOI-inhibits MAO in the brain leads to increase stores
of NA and 5-HT(Serotonin) in the nerve terminals.
SSRIs-act by inhibiting reuptake of 5-HT.
Atypical Ads-some act like TCAs some by un known
mechanisms.

38. Anti-depressant drugs....
Assessmentofthe5Ds(diagnosis,drug,dose,durationof
therapyanddifferenttreatment)shouldbedone.Then
after:
Trywithadrugofanothergroup
Improvepatientcompliance
Finally,astreatmentoflastresortElectroConvulsive
Therapy(ECT)canbeemployed.

39. Anti-depressant drugs....
Itsefficacyintreatingseveredepressionhasbeen
repeatedlyconfirmed.
Epilepsyandschizophreniaarecontraindicationswith
ECT.
Responseraterangesfrom60-80%.
ECTisthemosteffectivetreatmentforseveresuicidal
depression.

40. Mania
□At least 1 week in duration
□Abnormally & persistently elevated , expansive or
irritable mood
□Additionally –3 or 4 symptoms
Inflated self esteem or grandiosity
Decreased need for sleep
More talkative –pressure to talk

41. Mania
Flight of ideas or thought racing
Distractibility
Increased in goal directed activity or psychomotor
agitation
Excessive involvement in pleasurable activities –
buying sprees, sexual indiscretion, foolish investment
•Functional impairment or need hospitalization*

42. Mania
□Mood stabilizers
□People with bipolar disorder usually try mood
stabilizers first . In general, people continue treatment
with mood stabilizers for years .
□Lithium is a very effective mood stabilizer . It was the
first mood stabilizer approved by the FDA in the 1970’s
for treating both manic and depressive episodes .
□

43. Mania
□Anticonvulsantmedicationsarealsousedasmood
stabilizers
□Theywereoriginallydevelopedtotreatseizures,butthey
werefoundtohelpcontrolmoodsaswell.
□Oneanticonvulsantcommonlyusedasamoodstabilizer
isvalproicacid,alsocalleddivalproexsodium(Depakote)
.

44. Mania....
To Treat Mania
□Mood Stabilizers
□Lithium Valproate
□Antipsychotics
□Atypical:Olanzapine,Risperidone,Quetiapine
Typical:Chlorpromazine, Haloperidol
□Benzodiazepines
Diazepam
Lorazepam
Clonazepam

45. •sideeffects
•Lithiumcancauseseveralsideeffects,andsomeof
themmaybecomeserious.Theyinclude:
•Lossofcoordination
•Excessivethirst
•Frequenturination
•BlackoutsSeizures
•SlurredspeechFast,slow,irregular,orpounding
heartbeat

46. •Hallucinations(seeingthingsorhearingvoicesthatdonot
exist)
•ChangesinvisionItching,rashSwellingoftheeyes,face,
lips,tongue,throat,hands,feet,ankles,orlowerlegs.
•Ifapersonwithbipolardisorderisbeingtreatedwith
lithium,heorsheshouldmakesurethekidneysandthe
thyroidareworkingnormally.

47. • ADHD
•isoneofthemostcommondisordersofchildhood.
•SymptomsofADHDincludehyperactivity,impulsivityand
difficultypayingattentionorcontrollingbehavior.
•Medicinesclassifiedas“stimulants”arethemost
commonlyuseddrugstotreatthesymptomsofADHD.

48. •
•Stimulantsarethoughttoincreasethelevelofabrain
chemicalcalleddopamine,whichisassociatedwith
pleasure,movement,andattention.
•Themostcommonsideeffectsassociatedwithstimulant
medicationsincludesleepproblemsanddecreased
appetite.

49. • ADHD
List of commonly prescribed stimulants:
•Adderall
•Concerta
•Dexedrine
•Dextrostat
•Ritalin
•Vyvanse
In addition to stimulants, non-stimulant medicines are
sometimes added to help control the symptoms of ADHD

50. side effects
•Mostsideeffectsareminoranddisappearwhen
dosagelevelsarelowered.
•Themostcommonsideeffectsinclude:Decreased
appetite.
•Childrenseemtobelesshungryduringthemiddleof
theday,buttheyareoftenhungrybydinnertimeasthe
medicationwearsoff.

51. •Sleepproblems.Ifachildcannotfallasleep,thedoctor
mayprescribealowerdose.
•Stomachachesandheadaches.
•Afewchildrendevelopsudden,repetitivemovementsor
soundscalledtics.Theseticsmayormaynotbe
noticeable.Changingthemedicationdosagemaymake
ticsgoaway