Transcript Treatment of Psychotic Disorders

Treatment of Psychotic
Disorders
With a focus on Bipolar Disorder
Outline
• History of Bipolar
Disorder
• Symptoms of
Bipolar Disorder
• Diagnosis of Bipolar
Disorder
• Treatment of Bipolar
Disorder
• Future of Bipolar
Disorder
History of Bipolar Disorder
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The earliest written descriptions of a
relationship between mania and
melancholia are attributed to Aretaeus of
Cappadocia. Aretaeus was an eclectic
medical philosopher who lived in
Alexandria somewhere between 30 and
150 AD. Aretaeus is recognized as having
authored most of the surviving texts
referring to a unified concept of manicdepressive illness, viewing both
melancholia and mania as having a
common origin in black bile.
Emil Kraepelin (1856-1926), a German
psychiatrist categorized and studied the
natural course of untreated bipolar
patients long before mood stabilizers
were discovered. Describing these
patients in 1902, he coined the term
manic depressive psychosis. He noted in
his patient observations that intervals of
acute illness, manic or depressive, were
generally punctuated by relatively
symptom-free intervals in which the
patient that was able to function normally.
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In 1949, John Cade discovered that
lithium carbonate could be used as a
successful treatment of manic depressive
psychosis
In the 1950s, U.S. hospitals began
experimenting with lithium on their
patients.
By the mid-1960s, reports started
appearing in the medical literature
regarding lithium's effectiveness.
The U.S. Food and Drug Administration
did not approve of lithium's use until
1970.
Emil Kraepelin (1856-1926)
Symptoms of Bipolar Disorder
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Mania • Feeling very high on life
• Talking rapidly
• Feeling grandiose
• Racing thoughts and speech
• Erratic and impulsive actions
• Delusions and hallucinations
(severe)
Hypomania • Like but less severe that mania
• Euphoric, energetic and
productive
• No hallucinations or delusions
• Characterized by an unusually
good mood
Depression • Feeling hopeless, sad or empty
• Fatigue, energy and
concentration loss
• Thoughts of death or suicide
Diagnosis: Bipolar Disorder
• What is it?
• Not a single disorder but one of Mania and Depression
• Usually involves “Rapid Cycling”
• Subdivided
• Bipolar I - one or more manic or mixed episodes with or
without depressive episode
• Bipolar II - one or more Major Depressive Episodes along
with at least one Hypomanic episode
• Cyclothymia - one or more Hypomanic episodes and
Dysthymic (chronic depression) episodes
Brain scans indicating the differences in
brain activity when a patient is switching
between a depressive episode and
hypomanic episode
Brain scans showing the increased
amount of brain matter with the use
of lithium utilizing the growth
promoter called brain-derived
neurotrophic factor
Treatments
• Medications:
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Mood stabilizers - Lithium (Lithobid, Lithane, Eskalith, ect.)
Anticonvulsants - Depakote, Tegretol
Bipolar Depression - Lamotrigine
Antipsychotic - Seroquel, Zyprexa, Risperdal, ect.
Antidepressants are questionable due to the fact that some believe
that it induces a manic episode especially if there is no mood
stabilizers used.
• Hospitalization
• May occur, especially with manic episodes. This can be voluntary
or involuntary.
• Long-term inpatient stays are now less common due to
deinstitutionalization, although can still occur.
• Following a hospital admission, support services available can
include drop-in centers, visits from members of a community mental
health team or Assertive Community Treatment team, supported
employment and patient-led support groups.
Mood Stabilizer - Lithium
• Recent research suggests three different
mechanisms which may act together to deliver the
mood-stabilizing effect of this ion.
• The excitatory neurotransmitter glutamate is the key factor in
understanding how lithium works.
• Other mood stabilizers such as valproate and lamotrigine
exert influence over glutamate, suggesting a possible
biological explanation for mania.
• The other mechanisms by which lithium might help to
regulate mood include the alteration of gene expression and
the non-competitive inhibition of an enzyme called inositol
monophosphatase.
Mood Stabilizer - Lithium
• Absorption:
• Readily absorbed from the GI tract. Absorption is not
significantly impaired by food. T max is 0.5 to 3 h. Therapeutic
serum level is 0.4 to 1 mEq/L. Steady state is reached in 5 to
7 days
• Distribution:
• Distribution space of lithium approximates that of total body
water. Not protein bound. Distribution across the blood-brain
barrier is slow; however, the CSF lithium level is about 40%
of the plasma concentration
• Elimination:
• About 95% eliminated by the kidney; primarily excreted in
the urine. Renal excretion is proportional to its plasma
concentration. The half-life is about 24hrs.
Eskalith
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Preclinical studies have shown that lithium alters sodium transport in nerve and
muscle cells and effects a shift toward intraneuronal metabolism of
catecholamines, but the specific biochemical mechanism of lithium action in
mania is unknown.
Indicated in the treatment of manic episodes of manic-depressive illness.
Maintenance therapy prevents or diminishes the intensity of subsequent
episodes in those Bipolar patients with a history of mania.
Fine hand tremor, polyuria, and mild thirst may occur during initial therapy for the
acute manic phase, and may persist throughout treatment.
Transient and mild nausea and general discomfort may also appear during the
first few days of lithium administration.These side effects usually subside with
continued treatment or a temporary reduction or cessation of dosage.
If persistent, cessation of lithium therapy may be required.
Diarrhea, vomiting, drowsiness, muscular weakness, and lack of coordination
may be early signs of lithium intoxication, and can occur at lithium levels below
2.0 mEq/L
Because lithium theraputic levels are so close to the toxic levels lithium
concentration levels must be monitored constantly and before treatment is given
Depakote
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Dissociates to the valproate ion in the gastrointestinal tract. The mechanisms by
which valproate exerts its therapeutic effects have not been established. It has
been suggested that its activity in epilepsy is related to increased brain
concentrations of gamma-aminobutyric acid (GABA).
Depakote ER (divalproex sodium extended-release) is indicated for the
treatment of acute manic or mixed episodes associated with bipolar disorder,
with or without psychotic features
Side Effects:
• Fever, sore throat, body aches, diarrhea, tremors, ect.
Lamotrigine
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Lamotrigine tablets are
indicated for the maintenance
treatment of Bipolar I Disorder
to delay the time to occurrence
of mood episodes (depression,
mania, hypomania, mixed
episodes) in patients treated for
acute mood episodes with
standard therapy.
If used in conjunction with
valproate (Depakote) the dosing
should be cut in half due to the
absorption rate in its presence.
Side effects:
• Dizziness, headache,
blurred or double vision,
nausea, vomiting, rash, ect.
Seroquel
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Used in the treatment of both
depressive episodes and acute
manic episodes associated with
Bipolar I disorder
It has been proposed that the
efficacy of Seroquel in its mood
stabilizing properties in bipolar
depression and mania are mediated
through a combination of dopamine
type 2 (D2) and serotonin type 2
(5HT2) antagonism.
Antagonism at receptors other than
dopamine and 5HT2 with similar
receptor affinities may explain some
of the other effects of Seroquel.
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Tardive Dyskinesia - A syndrome of
potentially irreversible, involuntary,
dyskinetic movements may develop
in patients treated with antipsychotic
drugs.
Chronic antipsychotic treatment
should generally be reserved for
patients who appear to suffer from a
chronic illness that (1) is known to
respond to antipsychotic drugs, and
(2) for whom alternative, equally
effective drugs have no effect
Problems with Bipolar
Disorder
• Many things are
unknown about
Bipolar Disorder
including:
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Mechanisms
Causes
Exact Treatments
Prevention
• Not only are these things
not known about the
disorder but the
implications of the drugs
on the body are not
completely known either.
• The complete mapping of
the human genome will
help with these issues and
the research being done
on neurotransmitters will
also help.
Future of Disorder
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It has been discovered that lithium protects neurons by increasing the
levels of a neuroprotective protein called Bcl-2.
Lithium has been found to help stimulate the production of new neurons
(neurogenesis) in the hippocampus – part of the limbic system that
control emotions and behavior.
A major breakthrough came in 2000, with the demonstration that lithium
increases the amount of gray matter in the human brain, probably by
stimulating the production of a growth promoter called brain-derived
neurotrophic factor
When the researchers compared the brains of bipolar patients on
lithium with those of people without the disorder and those of bipolar
patients not on lithium, they found that the volume of gray matter in the
brains of those on lithium was as much as 15 percent higher in the
cingulate and paralimbic regions of the brain, that are critical for
attention, motivation and emotional control.
Works Cited
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www.drugs.com
www.wikipedia.org
www.wrongdiagnosis.com
www.helpguide.org
http://richardgpettymd.blogs.com/my_weblog/neurotoxicity