精神疾病的更体与药物治疗散案 Subject Psychiatry Teacher ZHAO Jing-ping Target Clinical Medicine Teaching place The second classroon Chapters Chapter 9.section 1 Teaching hour:100 minutes Content Drugs and other physical treatments of neatal disorders ate12004 【Purpose and requirement】 1.To understand concepts and classification of psychotropic drugs. 2.To master the Indfcations,Contraindfcations,Admimistration and dosage, Side effects and treatments of Antipsychotics.Antidepressants,Antimanic drugs (Mood stabilizers)and Anxiolytics. 【Key points of teaching】 The Indications,Contraindications,Adninistration and dosage.Side effects and treatnents of Antipsychoties,Antidepressants.Antimanie drugs (Mood stabilizers) and Anxiolytics. 【Difficult points of teaching】 Adinistration and dosage.side effects and treatments of Antipsychotics, Antidepressants,Antimanic drugs Olood stabilizers)and Anxiolytics. 【Type of teaching.】 New knowledge teaching. 【Teaching nethod】 Bilinguistic teaching.lecture and heuristic method. 【Teaching aid】
精神疾病的躯体与药物治疗教案 Subject ： Psychiatry Teacher ：ZHAO Jing-ping Target ： Clinical Medicine Teaching place ：The second classroom Chapters : Chapter 9, section 1 Teaching hour ：100 minutes Content ：Drugs and other physical treatments of mental disorders Date ：2004 【Purpose and requirement 】 1. To understand concepts and classification of psychotropic drugs. 2. To master the Indications, Contraindications, Administration and dosage, Side effects and treatments of Antipsychotics, Antidepressants, Antimanic drugs (Mood stabilizers) and Anxiolytics. 【Key points of teaching 】 The Indications, Contraindications, Administration and dosage, Side effects and treatments of Antipsychotics,Antidepressants, Antimanic drugs (Mood stabilizers) and Anxiolytics. 【Difficult points of teaching】 Administration and dosage, side effects and treatments of Antipsychotics, Antidepressants, Antimanic drugs (Mood stabilizers) and Anxiolytics. 【Type of teaching】 New knowledge teaching. 【Teaching method】 Bilinguistic teaching, lecture and heuristic method. 【Teaching aid 】
Multimedia mix and lanterm slide. 【Contemt and step of teaching】 1.General considerations.(2min) 2.Introduction of psychotropie drugs.(8min) 3.Antipsychotic drugs.(30min) 4.Antidepressants.(20min) 5.Antimanic drugs nood stabilizers )(20min) 6.Amxiolytic drugs.(10min) 7.Electroconvulsive therapy.(5ain) 8.Sumary and discussion.(5min) CHAPTER 9 SECTION 1 DRUGS AND OTHER PHYSICAL TREATVENTS OF MENTAL DISORDERS 1.General considerations Drug therapy chenical therapy ECT:electrocomulsive therapy Mental surgery Insulin coma therapy Physical treatment are always combined with psychological treatment 2.Introduction of psychotropie drugs 2.1 Drugs be called psycbotropics 2.2 Classification of psychotropics According to their principal actions: Antipsychotics Antidepressants Antimanic drugs or mood stabilizers Antianxiety drugs,anxiolytics 3.Amtipsychotic drugs 3.1 Definition Neuroleptic Ma jor tranquillizer
Multimedia mix and lantern slide. 【Content and step of teaching 】 1. General considerations. (2min) 2. Introduction of psychotropic drugs. (8min) 3. Antipsychotic drugs. (30min) 4. Antidepressants. (20min) 5. Antimanic drugs （ mood stabilizers ）. (20min) 6. Anxiolytic drugs. (10min) 7. Electroconvulsive therapy. (5min) 8. Summary and discussion. (5min) CHAPTER 9 SECTION 1 DRUGS AND OTHER PHYSICAL TREATMENTS OF MENTAL DISORDERS 1. General considerations Drug therapy ， chemical therapy ECT: electroconvulsive therapy Mental surgery Insulin coma therapy Physical treatment are always combined with psychological treatment 2. Introduction of psychotropic drugs 2.1 Drugs be called psychotropics 2.2 Classification of psychotropics According to their principal actions: Antipsychotics Antidepressants Antimanic drugs or mood stabilizers Antianxiety drugs, anxiolytics 3. Antipsychotic drugs 3.1 Definition Neuroleptic Major tranquillizer
3.2 Mechanisn of action Antipsychotic (dopaninergic receptor antagonisn) Sedation (block noradrenergic receptor) Urmanted effects (side effects):antidopaminergic action an hasal ganglia (EPS). anticholinergic and antiadrenergic actions. 3.3 Indications for antipsychotics 3.4 List of antipsychotics Conventional (first generation)AP:Phenothiazines:Butyrophenones:et al. Nower agents (second gemeration,atypical):clozapine,risperidone,olanzapine, quetiapine.et al. 3.5 Adinistration and dosage Treatneat dose acute):4-8w Stabilization treatment:after iprovement,keep treatment dose for 4-8v. Maintenance treatment:use 1/2 or 1/4 treatment dose to prevent recurresce (continuous over 2 years). Lower dose in childrem,elderly,brain damage. 3.6 Side effects 5 Increasing of prolaetin level Anti-adrenergic effects Anticholinergic effeets Other effects Malignant syndrome 3.7 Choice of drugs 4.Antidepressants 4.I Definition and classification Tricyclic antidepressants (TCAs) Monoanine oxidase inhibitors (MADIs) Never antidepressants:SSRIs,SNRIs,and NESSA 4.2 Mechanisn of aetion
3.2 Mechanism of action Antipsychotic (dopaminergic receptor antagonism) Sedation (block noradrenergic receptor) Unwanted effects (side effects): antidopaminergic action an basal ganglia (EPS), anticholinergic and antiadrenergic actions 。 3.3 Indications for antipsychotics 3.4 List of antipsychotics Conventional (first generation) AP: Phenothiazines; Butyrophenones; et al. Newer agents (second generation, atypical): clozapine, risperidone, olanzapine, quetiapine, et al. 3.5 Administration and dosage Treatment dose ( acute): 4-8w Stabilization treatment: after improvement, keep treatment dose for 4-8w. Maintenance treatment: use 1/2 or 1/4 treatment dose to prevent recurrence (continuous over 2 years). Lower dose in children, elderly, brain damage. 3.6 Side effects EPS Increasing of prolactin level Anti-adrenergic effects Anticholinergic effects Other effects Malignant syndrome 3.7 Choice of drugs 4. Antidepressants 4.1 Definition and classification Tricyclic antidepressants (TCAs) Monoamine oxidase inhibitors (MAOIs) Newer antidepressants: SSRIs, SNRIs, and NESSA 4.2 Mechanism of action
4.3 Indication and Clinical action features 43.1T4s 4.3.1.I Drugs of comronly used: Anitriptyline:has antidepressive efficacy and sedative effect,for treating depressionaccompanied by anxiety or agitation. Inipramine:less sedation,for retarded depression.Avoid take medication at night because ofits inscmnia. Clomipramine:has antidepressive and anti-OCD effects.First line choice for treating OCD. 4.3.1.2 Adninistration and dosage: Lower titration,gradually and slowly increasing dose (1-2v). Acute treatnent dose:150-300ng/d.4-8v. Stabilization treatnent:after improvement,keep treatnent dose for 4-6w. Maintenance treatment:1/2 or 1/4 treatment dose to prevent. Recurrence (continuous over 6 months). Lower dose in children and elderly. L3.1.3 Side effects: Anticholinergic side effects include antuncnic and cardiovascular effects.Autononic:dry mouth.urine retention,constipation.worsening of glaucoma, blurred vision.Cardiovascular:tachyreardia.hypotension.ECG changes.cardiac conduction deficits,and ventricular arrythmias. Neurological:tremor,inco-ordination,and epfleptfe seizures. Overdose toxic effects: Including: Cardiovascular:ventricular fibrillation,conduction disturbance,and low blood pressure: Respiratory:respiratory depression: CNS:agitation,convulsion.deliriun,coma,EPS: Vorsening anticholinergic side effects. 4.3.1.4 Contraindications of TCAs:
4.3 Indication and Clinical action features 4.3.1 TCAs 4.3.1.1 Drugs of commonly used: Amitriptyline: has antidepressive efficacy and sedative effect, for treating depressionaccompanied by anxiety or agitation. Imipramine: less sedation, for retarded depression. Avoid take medication at night because ofits insomnia. Clomipramine: has antidepressive and anti-OCD effects. First line choice for treating OCD. 4.3.1.2 Administration and dosage: Lower titration, gradually and slowly increasing dose (1-2w). Acute treatment dose: 150-300mg/d, 4-8w. Stabilization treatment: after improvement, keep treatment dose for 4-6w. Maintenance treatment: 1/2 or 1/4 treatment dose to prevent. Recurrence (continuous over 6 months). Lower dose in children and elderly. 4.3.1.3 Side effects: Anticholinergic side effects include antunomic and cardiovascular effects.Autonomic: dry mouth, urine retention, constipation, worsening of glaucoma, blurred vision.Cardiovascular: tachycardia, hypotension, ECG changes, cardiac conduction deficits, and ventricular arrythmias. Neurological: tremor, inco-ordination, and epileptic seizures. Overdose toxic effects: Including: Cardiovascular: ventricular fibrillation, conduction disturbance, and low blood pressure; Respiratory: respiratory depression; CNS: agitation, convulsion, delirium, coma, EPS; Worsening anticholinergic side effects. 4.3.1.4 Contraindications of TCAs:
Agranulocytosis Glaucoms Prostatic hypertrophy Cardiopathy Severe liver damage 4.3.2 Monoanine oxidase inhibitors (MADIs) MAOIs are seldon used as first line antidepressants.because of their side effects and hazardous interactions with other drugs and foods:Hepatotoxicity. Hypertension crisis. RIMO (reversible inhibitor of monoanine oxidase). Moclobenide:less drug and food interactions,less hypertension crisis. 4.3.3 Selective serotonin reuptake inhibitors (SSRIs) 4.3.3.1 Advantages of S5RIs (vs.TCAs/HCAs): Not anticholinergic. Not antihistaminic. Not alphal-adrenergie antagonists. Unlikely to cause:postural hypotension,tachycardia,delayed cardiac conduction.blurredvision,dry mouth.sedation,and overdose toxic effects. Not need dosage adjustment,once medication per day. More broad indications 4.3.3.2 Available compounds and indication: Fluoxetine:depression,OCD.bulinia Paroxetine:depression,OCD,anxiety/panic,PTSD,SAD Sertraline:depression,OCD.anxiety/panic 4.3.3.3 Side effects of SSRIs: High serotonic functions in digestive tract:nausea.diarrhea,dry mouth CNS:nervousness,agitation,insomnia,tremor.beadache Sexual function:erectile dysfunction Excess CNS serotonin syndrome (SSRI combined with MAOI or high dose of TCAs): mentalstatus changes,agitation.restlessness.myoclomus,hyperreflexia
Agranulocytosis Glaucoma Prostatic hypertrophy Cardiopathy Severe liver damage 4.3.2 Monoamine oxidase inhibitors (MAOIs) MAOIs are seldom used as first line antidepressants, because of their side effects and hazardous interactions with other drugs and foods: Hepatotoxicity, Hypertension crisis. RIMO (reversible inhibitor of monoamine oxidase). Moclobemide: less drug and food interactions, less hypertension crisis. 4.3.3 Selective serotonin reuptake inhibitors (SSRIs) 4.3.3.1 Advantages of SSRIs (vs. TCAs/HCAs): Not anticholinergic. Not antihistaminic. Not alpha1-adrenergic antagonists. Unlikely to cause: postural hypotension, tachycardia, delayed cardiac conduction, blurredvision, dry mouth, sedation, and overdose toxic effects. Not need dosage adjustment, once medication per day. More broad indications 4.3.3.2 Available compounds and indication: Fluoxetine: depression, OCD, bulimia Paroxetine: depression, OCD, anxiety/panic, PTSD, SAD Sertraline: depression, OCD, anxiety/panic 4.3.3.3 Side effects of SSRIs: High serotonic functions in digestive tract: nausea, diarrhea, dry mouth CNS: nervousness, agitation, insomnia, tremor, headache Sexual function: erectile dysfunction Excess CNS serotonin syndrome (SSRI combined with MAOI or high dose of TCAs): mentalstatus changes, agitation, restlessness, myoclonus, hyperreflexia
diaphoresis,shivering,tremor,diarrhea.abdominal pain,ataxia,convulsions,and COm. 4.3.4 Anti-0CD drugs TCAs:only clomipranine Al1 SSRIs Dosage for treating CCD is higher than those for treating depressio Loeger stabilization treatnent period (6-8) 5.Antimanic drugs mood stahilizers 5.1 Definition and classification Drugs are used as a treatment for acute episodes of mamia,and prevention recurrence of ania and depression (hipolar disorders). Including:Lithium carbomate: Antiepileptic drugs:Carbamazepine,Valproate (sodiun,mgnesiun). 5.2 Indications Treateent for mania and hypomania Combined with antipsychotics or benxodiazepam for treating acute mania Prophylaxis therapy for recurrence of mania and depression Combined with antidepressants for treating depression episode of bipolar disorders,preventing mania induced by antidepressants 5.3 Dosage and plasma concentrations of lithiun Therapeutic and toxic dose are close together.need to measure plasma lithiun concentration during treatrent. Measurement of plasaa lithiun should be made weekly in first three weeks during adjusting drug dose. Conceatration is neasured twelve hours after last dose. Range for acute treatsent is 0.8-1.2mol/L Range for prophylaxis is 0.5-0.8mol/L Toxic concentration is >1.4mmol/I
diaphoresis, shivering,tremor, diarrhea, abdominal pain, ataxia, convulsions, and coma. 4.3.4 Anti-OCD drugs TCAs: only clomipramine All SSRIs Dosage for treating OCD is higher than those for treating depression Longer stabilization treatment period (6-8w) 5. Antimanic drugs （ mood stabilizers ） 5.1 Definition and classification Drugs are used as a treatment for acute episodes of mania, and prevention recurrence of mania and depression (bipolar disorders). Including: Lithium carbonate; Antiepileptic drugs: Carbamazepine, Valproate (sodium, magnesium). 5.2 Indications Treatment for mania and hypomania Combined with antipsychotics or benzodiazepam for treating acute mania Prophylaxis therapy for recurrence of mania and depression Combined with antidepressants for treating depression episode of bipolar disorders, preventing mania induced by antidepressants 5.3 Dosage and plasma concentrations of lithium Therapeutic and toxic dose are close together, need to measure plasma lithium concentration during treatment. Measurement of plasma lithium should be made weekly in first three weeks during adjusting drug dose. Concentration is measured twelve hours after last dose. Range for acute treatment is 0.8-1.2mmol/L Range for prophylaxis is 0.5-0.8mmol/L Toxic concentration is >1.4mmol/L
Lower titration.gradually and slowly increasing dose (1-2v),adninistration after food taken,lower dose in children and elderly 5.4 Side effects Early effects:dry nouth.diuresis,tremor.metallic taste.weakness and 【atigue Later effects:fine tremor (coarse trenor is a sign of toxicity),polyuria and polydipsia.thyroid enlargement and hypothyroidism impaired memory.ECG changes (T wave flattening.QRS widening). Long-tern effects on the kidney Toxic effects of lithium:Nausea,voniting.diarrbea,coarse tremor.Ataxia. dysarthria.Musele twitching.hyper-reflexia.Confusion.coma,Convulsion,Renal failure,cardiovascular collapse. Preveation and treatrent of toxic effects Monitoring therapeutic drug (MTD), adjusting doseappropriately,especfally in high-risk population.Avoiding low sodiun food.Treatment:stop lithiun at ooce,high intake fluid and sodium chloride,renal dialysis for severe cases. 5.5 Carbanzepine and valproate For patients unresponsive to lithium For patients vith rapidly cyclic bipolar For patients who cam not tolerate lithium Side effects: Carbamazepine: drowsiness.digziness,nausea. double vision. agranulocytosis. Valproate:sedation,tiredness,tremor,gastrointestinal disturbance. 6.Anxciolytfe drugs 6.I Definition:To reduce anxiety,in large doses produce drowsiness and sleep,Anti-convulsion,to reduce dystonia 6.2 Drugs used to treat anxiety Primary anxiolytics:Benzodiazepine,Buspirone
Lower titration, gradually and slowly increasing dose (1-2w), administration after food taken, lower dose in children and elderly 5.4 Side effects Early effects: dry mouth, diuresis, tremor, metallic taste, weakness and fatigue. Later effects: fine tremor (coarse tremor is a sign of toxicity), polyuria and polydipsia, thyroid enlargement and hypothyroidism, impaired memory, ECG changes (T wave flattening, QRS widening). Long-term effects on the kidney Toxic effects of lithium: Nausea, vomiting, diarrhea, coarse tremor, Ataxia, dysarthria, Muscle twitching, hyper-reflexia, Confusion, coma, Convulsion, Renal failure, cardiovascular collapse. Prevention and treatment of toxic effects ：Monitoring therapeutic drug (MTD), adjusting doseappropriately, especially in high-risk population. Avoiding low sodium food. Treatment: stop lithium at once, high intake fluid and sodium chloride, renal dialysis for severe cases. 5.5 Carbamazepine and valproate For patients unresponsive to lithium For patients with rapidly cyclic bipolar For patients who can not tolerate lithium Side effects: Carbamazepine: drowsiness, dizziness, nausea, double vision, agranulocytosis. Valproate: sedation, tiredness, tremor, gastrointestinal disturbance. 6. Anxiolytic drugs 6.1 Definition: To reduce anxiety, in large doses produce drowsiness and sleep, Anti-convulsion, to reduce dystonia 6.2 Drugs used to treat anxiety Primary anxiolytics: Benzodiazepine, Buspirone
Other drugs with anxiolytic properties:Some TCAs,SSRI,and Beta-adrenergie agonists. i.3 How to use Bis Short aeting (<12 hrs):lorazepan (t.1.d) Long acting 024 hrs):diazepan,chlorazepate,alprazolan (b.i.d or t.i.d) For using insomnia as hypnotics: Short:triaxolan,temazepan Long:nitraxepan,fluraxepan 6.4 Side etfects Drowsiness At large dose,ataxia,impairing driving and operating nchinery. Withdramal syndrome:anxiety,insomia,trenor,heightened sensitivity to stimuli,muscle twitching.seizures (rarely). Buspirone Neekly stimlates 5-HT 1A receptor,no affinity foe B2 receptor, not cause s6dhti0道nd dependence,slower action Hypnotics Promote sleep and treatment for insomnia. Short acting:Zopiclone,Zolpidem.Zaleplon. 7.Electroconvulsive therapy (ECT) Indication. The need for an urgent response:refusal to drink or eat,intense suicidal ideation. For resistant mental disorders. For stupor symdromes:catatonic schixophrenia.depressive stupor. 8.Summary and discussion 【Reference material 1.Sadock,B.J..Sadock,V.A.Kaplan Sadock's Comprehensive Textbook of Psychiatry.7th edition.Lippincott Villiams Nilkins,Philadelphia.2000
Other drugs with anxiolytic properties: Some TCAs, SSRI, and Beta-adrenergic agonists. 6.3 How to use BZs Short acting (24 hrs): diazepam, chlorazepate, alprazolam (b.i.d or t.i.d) For using insomnia as hypnotics: Short: triazolam, temazepam Long: nitrazepam, flurazepam 6.4 Side effects Drowsiness At large dose, ataxia, impairing driving and operating machinery. Withdrawal syndrome: anxiety, insomnia, tremor, heightened sensitivity to stimuli, muscle twitching, seizures (rarely). Buspirone : Weekly stimulates 5-HT 1A receptor, no affinity foe BZ receptor, not cause sedation and dependence, slower action Hypnotics : Promote sleep and treatment for insomnia. Short acting: Zopiclone, Zolpidem, Zaleplon. 7. Electroconvulsive therapy (ECT) Indication. The need for an urgent response: refusal to drink or eat, intense suicidal ideation. For resistant mental disorders. For stupor syndromes: catatonic schizophrenia, depressive stupor. 8. Summary and discussion 【Reference material 1. Sadock, B. J., Sadock, V. A.: Kaplan & Sadock's Comprehensive Textbook of Psychiatry. 7th edition. Lippincott Williams & Wilkins, Philadelphia, 2000
2.Waldinger R J.Psychiatry for Medical Students.(Third edition).American Psychiatric Press.1997 3.Michael Gelder,Dennis Gath.Richard Mayou,et al.Oxford Textbook of Psychiatry.3th edition.Oxford Medical Publications.1996 【riting design】 See the lantern slide. 【Summary after class】 1.What are the main side effects of antipsychotics.how to treat them? 2.How to manage the malignant syndrome? 3.Why we can't use adrenalin to the post-hypotension ill-effeet patient? 4.What are the main clinical traits of lithiu carbonate?
2. Waldinger R.J. Psychiatry for Medical Students. (Third edition). American Psychiatric Press. 1997 3. Michael Gelder, Dennis Gath, Richard Mayou, et al. Oxford Textbook of Psychiatry.3th edition. Oxford Medical Publications.1996. 【Writing design 】 See the lantern slide. 【Summary after class 】 1. What are the main side effects of antipsychotics, how to treat them? 2. How to manage the malignant syndrome? 3. Why we can't use adrenalin to the post-hypotension ill-effect patient? 4. What are the main clinical traits of lithium carbonate?