Transcript Pharmacological treatment of mental health problems.

Pharmacological treatment of
mental health problems.
Sammy Ohene
Faculty of Psychiatry
Pre-conference workshop @ 9th AGSM, GCPS
Accra, November 27, 2012
PRE TEST
Answer each question True or False
1.
2.
3.
4.
5.
Chlorpromazine was discovered before
Phenobarbitone.
Haloperidol has similar chemical structure to
Thioridazine but different from Chlorpromazine
Risperidone is superior to Haloperidol in efficacy
in treatment of Mania.
Venlafaxine is a pure SSRI.
Most bipolar patients require a single drug
during an episode of mania.
Introduction
• Treatment of mental disorders is determined
among other factors by knowledge and beliefs
about causes. The following preceded drug
therapy:
• Exorcism – “demon possession”
• Sacrifices – “ affliction of gods”
• Prayers/fasting -- ‘spiritual illness’
• Convulsive therapy
• Behavior therapy, psychotherapy,
Drug treatment
ISAAC NEWTON
(GRAVITY)
AND THE FALLING APPLE
“ Discoveries“ in early 1950s
• Antipsychotic effect of antihistamine drug,
chlorpromazine, (CPZ) observed during
testing on schizophrenic patients.
• Antidepressant action of antituberculosis drug
iproniazid noted. Effect found to be due to
inhibition of MAO,
Psychopharmacological actions are
based on biological theories of
psychiatric disorders.
• In both cases the discoveries came before the
neurobiological basis of their actions were
found.
• Antipsychotic action of CPZ and conventional
antipsychotics due to D2 receptor blockade in
mesolimbic pathways of brain.
Progress!
• Increasing knowledge in neurosciences with
greater understanding of actions of more
neurotransmitters have led to discovery of
many more effective psychoactive drugs.
• In clinical practice, most psychoactive drugs
used act on dopamine, serotonin,
noradrenaline, acetylcholine, glutamate and
GABA neurotransmitters.
Principles of psychoactive drug use.
• To reverse observed dysfunctions in mental
health problems.
• Prevent mental disorders or recurrence where
possible.
• Minimise or reduce severity of symptoms.
• Restore function to or as close as possible to
normal with minimal side effects.
IMPORTANT NOTES!
• ALMOST ALL MENTAL HEALTH PROBLEMS ARE
A CULMINATION OF, OR RESULT IN MULTIPLE
FACTORS THAT AFFECT THE INDIVIDUAL AND
HIS ENVIRONMENT.
• A HOLISTIC BIOPSYCHOSOCIAL APPROACH TO
MANAGEMENT IS OFTEN THE MOST
REWARDING.
• DO NOT “THROW PILLS AT PROBLEMS”!!!
Deciding on drug treatments for
mental health problems.
For each condition, consider the following:
• Effectiveness and target symptoms.
• Initiation of treatment
• Continuation/stabilization phase
• Duration of treatment
• Side effects
• Adjunct drugs ?
• Special populations- children, elderly, pregnant,
comorbidities
PSYCHOSES- Schizophrenia, delusional
disorders, others.
• ANTIPSYCHOTICS
Atypicalsrisperidone,olanzapine,quetiapine,ziprasidone
,aripiprazole
Conventional
Haloperidol, chlopromazine, fluphenazine,
sulpiride,
Anticholinergics? Antidepressants?
BIPOLAR DISORDER
• Mood stabilizers
Lithium, Valproate, Carbamazepine,
Lamotrigine
• Antipsychotics
• ? Antidepressants
DEPRESSIVE DISORDERS (UNIPOLAR)
• Antidepressants- SSRIs, SNRIs,NDRIs,TCAs, etc
fuoxetine, paroxetine, duloxetine, venlafaxine,
imipramine, amitryptiline etc
• ?Antipsychotics
General Anxiety Disorder
• Antidepressants – SSRIs, bupropion
• Anxiolytics/sedatives
• B-blockers
PANIC DISORDER
• SSRI
• Anxiolytics
• B-blockers
Obsessive Compulsive Disorder (OCD)
• SSRIs
PHOBIC CONDITIONS
• SOCIAL PHOBIA
SSRIs
• SPECIFIC PHOBIA ( Flying phobia)
Diphenhydramine
Post Traumatic Stress Disorder (PTSD)
• SSRIs
• Anxiolytics
DEMENTIA
• Anticholinestrases- - Memantine, Donepezil,
Tacrine, Rivastigmine, Galantamine
• Antidepressants ?
• Antipsychotics? Caution with atypicals
SLEEP DISORDERS
• NARCOLEPSY
• PRIMARY INSOMNIA
ALCOHOL ABUSE
• Dependence - Naltrexone
• Withdrawal – Benzodiazepines, Vit-B1,B6, B12
• Prevention- Disulfiram, Naltrexone
• Psychosis - Antipsychotics
OPIATES
• Methadone (opiate full agonist)
• Buprenorphine (opiate partial agonist)
COCAINE
• Methylphenidate
• Imipramine ?
A. D. H. D.
• Atomoxetine
• Methylphenidate
• Tricyclics?
• Anticonvulsants? Lithium??
IATROGENIC CONDITIONS
• Acute dystonia:- anticholinergics( benztropine,
benzhexol), diphenhydramine
• Akathisia: propranolol
• Pseudoparkinsonism- anticholinergics
PRACTICE POINTS
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Choice of drug
Effectiveness
Compliance potential
Side effects
Oral vrs paranteral
Availability
Cost
Monotherapy vrs. Combination
Practice points contd.
• Techniques of administration
• Adequate dosing vrs. treatment response
• Long acting preparations
• How long do you treat?
• Treatment resistance
DILEMMAS
• Duration of drug treatment in acute psychosis
• Evidence based Treatment guidelines vrs.
Reality
• When do you begin drug treatment?
• What if patient accepts illness but wants no
medication?
• Forced administration.
• Spiritual care and medication
• Drug treatment and stigma
• “PRN administration
• Allergic reactions!
THE FUTURE OF
PSYCHOPHARMACOLOGY.
• The ‘IDEAL” antipsychotic drug. What would
be its features?
• Designer drugs tailored to a particular
individual by virtue of specific information on
genetic make up.
• Gene manipulation to fit predicted drug
response?
• Ketamine- new wonder drug in treatmentresistant depression?