Jitka Hüttlová
Department of Psychiatry,
University Hospital Brno and
Faculty of Medicine of
Masaryk University
Treatment
in
Psychiatry
Treatment in Psychiatry
 A. BIOLOGICAL treatment
 Psychopharmacotherapy
 Electroconvulsive Therapy (ECT)
 Repetitive Transcranial Magnetic Stimulation
(rTMS)
 Deep Brain Stimulation (DBS)
 Vagus Nerve Stimulation
 Light Therapy
 B. PSYCHOSOCIAL treatment
 Psychotherapy
 Psychiatric rehabilitation
 Other (music therapy, art therapy,
ergotherapy…)
Treatment in Psychiatry
Main Psychopharmacological
Drugs
1. Antidepressants
2. Mood stabilizers
3. Antipsychotics
4. Anxiolytics
5. Hypnotics
6. Cognition-Enhancing Drugs
7. Psychostimulants
Psychopharmacotherapy
General guidelines for
antidepressant use
 Antidepressant efficacy is very similar so
selection is based on past history of a response,
side effect profile and coexisting medical
conditions.
 There is a delay typically of 2-4 weeks after a
therapeutic dose is achieved before symptoms
improve.
 If no improvement is seen after a trial of
adequate length and adequate dose, either
switch to another antidepressant or augment
with another agent.
1.Antidepressants
Neurobiology
 Lack of monoamine neurotransmitters →
depression
 Increase in monoamine neurotransmitters
→ treatment of depression
(Stahl 1997)
1.Antidepressants
Neurotransmitter Reuptake Inhibition
and Binding Affinity to Receptors
1.Antidepressants
Classification Name Example
st generation Tricyclics (TCAs) and tetracyclics (TeCAs) amitriptyline
clomipramine
2nd generation viloxazine
3rd generation SSRI
(Selective Serotonin Reuptake Inhibitors )
citalopram
escitalopram
sertralin
SARI (Serotonin antagonist and reuptake
inhibitor)
trazodon
NRI (Nor-Adrenaline Reuptake inhibitors) reboxetin
4th generation SNRI (Serotonin/Norepinephrine reuptake
inhibitors)
venlafaxine
milnacipran
DNRI (Dopamine/Norepinephrine reuptake
inhibitors
bupropione
Other Blockators of α2 -adrenoceptors mirtazapin
mianserin
(MAOIs) Monoamine Oxidase Inhibitors moclobemide
selegiline
Classification Name Mechanism of
Therapeutic
Efficacy
Specific
character
Examples
1st
generation
Tricyclics
(TCAs) and
tetracyclics
(TeCAs)
•Inhibition of
Serotonin and/or
Norepinephrine
reuptake
followed by
increase of their
concentrations in
synaptic cleft
(react with other
types of
receptors →
more side
effects)
•Severe side
effects -
antihistaminic
(sedation,
weight gain),
anticholinergic
(dry mouth,
constipation,
potentially
delirium),
antiadrenergic
(orthostatic
hypotension,
sexual
dysfunction)
•Can cause
dangerous QT
lengthening
•Danger of
Intoxication
•Many
Interactions
amitriptyline
nortriptyline
clomipramine
dosulepin
Classification Mechanism of
Therapeutic
Efficacy
Specific character Examples
2nd generation Norepinephrine
Reuptake
Inhibition
•Less anticholinergic
side effects then 1st
generation
viloxazine
Classification Name Mechanism of
Therapeutic
Efficacy
Specific character Examples
3rd
generation
SSRI
(Selective
Serotonin
Reuptake
Inhibitors )
Block the
presynaptic
serotonin
reuptake
•The most
commonly used
•Side effects: GI
upset, sexual
dysfunction,
anxiety,
restlessness,
insomnia, fatigue
or sedation,
dizziness
•Very little risk of
cardiotoxicity in
overdose
citalopram
escitalopram
sertralin
fluoxetin
fluvoxamin
paroxetin
Classification Name Mechanism of
Therapeutic
Efficacy
Specific
character
Examples
3rd
generation
SARI (Serotonin
antagonist
and reuptake
inhibitor)
Antidepressants
with Doubled
Serotonergic
Efficacy
•A risk of
serotonin
syndrome
trazodon
NRI
(Selective Nor-
Adrenaline
Reuptake
inhibitors)
Increase
norepinephrine
reboxetin
Classification Name Mechanism of
Therapeutic
Efficacy
Specific
character
Examples
4th
generation
SNRI
(Serotonin/N
orepinephrin
e reuptake
inhibitors )
Inhibit both
serotonin and
noradrenergic
reuptake
•Side effects:
nauzea,
dizziness, blood
preasure
increase
venlafaxine
milnacipran
DNRI
(Dopamine/
Norepinephri
ne reuptake
inhibitors)
Inhibit
Dopamine and
Norepinephrine
reuptake
•No weight
gain, no sexual
side effects, no
sedation or
cardiac
interactions
bupropione
Classification Name Mechanism of
Therapeutic
Efficacy
Specific
character
Examples
other Blockators of
α2-
adrenoceptors
Increasing
Synthesis and
Releasing of
Norepinephrine,
Blockade
Alpha-2
Adrenoceptors
on Serotonergic
Neurons and
Increasing
Production and
Releasing of
Serotonin
•Side effects:
Weight gain,
sedation,
mirtazapin
mianserin
Classification Name Mechanism of
Therapeutic
Efficacy
Specific
character
Examples
Other (MAOIs)
Monoamine
Oxidase
Inhibitors
Bind irreversibly
to monoamine
oxidase thereby
preventing
inactivation of
biogenic amines
such as
norepinephrine,
dopamine and
serotonin leading
to increased
synaptic levels.
•Side effects:
weight gain,
dry mouth,
sedation,
sexual
dysfunction
and sleep
disturbance
•Hypertensive
crisis can
develop when
MAOI’s are
taken with
tyramine-rich
foods or
sympathomim
etics
moclobemide
selegiline
Main Psychopharmacological
Drugs
1. Antidepressants
2. Mood stabilizers
3. Antipsychotics
4. Anxiolytics
5. Hypnotics
6. Cognition-Enhancing Drugs
7. Psychostimulants
Psychopharmacotherapy
Mood stabilizers
Indications: Bipolar, cyclothymia,
schizoaffective, impulse control and
intermittent explosive disorders.
Classes: Lithium, anticonvulsants,
antipsychotics
Which you select depends on what you
are treating and again the side effect
profile.
2. Mood stabilizers
Classification Example Characteristics
Lithium Lithium •Only medication to reduce suicide rate
•I:Effective in long-term prophylaxis of both
mania and depressive episodes
•SE: Thyroid abnormalities, Polyuria/polydypsia ,
intention tremor
•BS: examination of renal, cardiac and
thyreoidal function, pregnancy
Antiepil. 2nd
generation
carbamazepine •I: acute mania and mania prophylaxis
•SE: Rash, nauzea, vomiting, drug interactions!!!
•BS: baseline liver function tests, CBC and an
EKG
salts of valproic
acid
•I: as effective as Lithium in mania prophylaxis
but is not as effective in depression prophylaxis
Effective in dysforic mania
•SE: Thrombocytopenia and platelet
dysfunction, transaminitis, sedation
•BS: liver function, CBC, pregnancy
Antiepil. 3rd
generation
lamotrigine •I: Also used for neuropathic/chronic pain
•SE: Nausea/vomiting, dizziness, toxic
epidermal necrolysis and Stevens Johnson's
Syndrome
BS: liver function
Main Psychopharmacological
Drugs
1. Antidepressants
2. Mood stabilizers
3. Antipsychotics
4. Anxiolytics
5. Hypnotics
6. Cognition-Enhancing Drugs
7. Psychostimulants
Psychopharmacotherapy
Neurobiology
 Excess of DOPAMINE → schizophrenia
 Decrease in Dopamine → treatment of
schizophrenia
3. Antipsychotics
Neurobiology
 MESOCORTICAL- associated with negative and
cognitive symptoms
 MESOLIMBIC- associated with positive symptoms
(hallucinations, delusions, and thought disorders)
 NIGROSTRIATAL- associated with movement
regulation, Parkinsonian movements i.e. rigidity,
bradykinesia, tremors), akathisia and dystonia
 TUBEROINFUNDIBULAR - associated with
hyperprolactinemia(gynecomastia/galactorrhea
/decreased libido/menstrual dysfunction).
3. Antipsychotics
Classification
A. Typical antipsychotics
(=1st generation antipsychotics,
classical neuroleptics,)
B. Atypical antipsychotics
(=2nd generation antipsychotics)
3. Antipsychotics
A.Typical antipsychotics
(1st generation)
 previous generation
 are D2 dopamine receptor antagonists
 High potency typical antipsychotics bind to the D2
receptor with high affinity. As a result they have
higher risk of extrapyramidal side effects.
 Examples: fluphenazine, haloperidol, flupenthixol
 Low potency typical antipsychotics have less
affinity for the D2 receptors but tend to interact
with nondopaminergic receptors resulting in more
cardiotoxic and anticholinergic adverse effects
including sedation, hypotension.
 Examples: chlorpromazine, thioridazine
3. Antipsychotics
B.Atypical Antipsychotics
(2nd generation)
 dopamine D2 receptor-blocking effect is
lowered in affinity
 combined with effects on other receptors
 better influencing of negative and affective
symptoms
 significantly reduce or prevent the cognitive
impairment
 signifinantly less side effects
 examples: risperidon, olanzapin, quetiapin
3. Antipsychotics
Adverse effects
 Extrapyramidal side effects (EPS): Acute
dystonia, Parkinson syndrome, Akathisia
 Neuroleptic Malignant Syndrome (NMS):
Characterized by severe muscle rigidity, fever,
altered mental status, autonomic instability,
elevated WBC, CPK Potentially fatal.
 Weight gain, sedation, dyslipidemia,
hyperprolactinemia, agranulocytosis, sexual
dysfunctions…
3. Antipsychotics
Main Psychopharmacological
Drugs
1. Antidepressants
2. Mood stabilizers
3. Antipsychotics
4. Anxiolytics
5. Hypnotics
6. Cognition-Enhancing Drugs
7. Psychostimulants
Psychopharmacotherapy
General information
 Used to treat many diagnoses including
panic disorder, generalized anxiety disorder,
substance-related disorders and their
withdrawal, insomnias and parasomnias.
 In anxiety disorders often use anxiolytics in
combination with SSRIS or SNRIs for
treatment.
 Main group – Benzodiazepines – cave – the
risk of addiction !!!!
4. Anxiolytics
Action Profiles of
Benzodiazepines
4. Anxiolytics
Examples
Short-term: oxazepam, lorazepam
Medium-term: alprazolam,
bromazepam
Long-term: diazepam, clonazepam
4. Anxiolytics
Non-benzodiazepine
anxiolytics
Non-addictive
Delayed onset of therapeutic effect
Examples: guaiphenesine,
hydroxyzine, buspirone
4. Anxiolytics
Main Psychopharmacological
Drugs
1. Antidepressants
2. Mood stabilizers
3. Antipsychotics
4. Anxiolytics
5. Hypnotics
6. Cognition-Enhancing Drugs
7. Psychostimulants
Psychopharmacotherapy
General information
drugs with sedative effect
primary function is to induce sleep
and to be used in the treatment of
insomnia
5. Hypnotics
Classification Name Example
1st Generation barbiturates phenobarbital
2nd Generation benzodiazepines midazolam,
flunitrazepam,
cinolazepam
3rd Generation Z-drugs zolpidem, zopiclone,
zaleptone
Other Drugs with
Hypnotic Efficacy
Antihistaminics promethazine
antidepressants mirtazapine, trazodone
melatonins
antipsychotics quetiapin
Main Psychopharmacological
Drugs
1. Antidepressants
2. Mood stabilizers
3. Antipsychotics
4. Anxiolytics
5. Hypnotics
6. Cognition-Enhancing Drugs
7. Psychostimulants
Psychopharmacotherapy
General information
 improve cognition
 to treat Alzheimer's disease and other
cognitive deficits
 A. ACETYLCHOLINESTERASE INBITORS
 -rivastigmine, donepezil
 B. NMDA (N-methyl-D-aspartate)
RECEPTOR ANTAGONISTS
 -memantine
6. Cognition-Enhancing Drugs
Main Psychopharmacological
Drugs
1. Antidepressants
2. Mood stabilizers
3. Antipsychotics
4. Anxiolytics
5. Hypnotics
6. Cognition-Enhancing Drugs
7. Psychostimulants
Psychopharmacotherapy
General information
 reduce fatigue, promote alertness and
wakefulness and have possible mood
enhancing properties
 indicated for attention deficit hyperactivity
disorder (ADHD), narcolepsy
 Blocators of re-uptake dopamine and
norephinephrine→ increase of dopamine and
norephinephrine in synaptic cleft
 Adverse effects: insomnia, agitation, anxiety
and confusion
 Methylphedinate, atomoxetine
7. Psychostimulants
Main Psychopharmacological
Drugs
1. Antidepressants
2. Mood stabilizers
3. Antipsychotics
4. Anxiolytics
5. Hypnotics
6. Cognition-Enhancing Drugs
7. Psychostimulants
Psychopharmacotherapy
Treatment in Psychiatry
 A. BIOLOGICAL treatment
 Psychopharmacotherapy
 Electroconvulsive Therapy (ECT)
 Repetitive Transcranial Magnetic Stimulation
(rTMS)
 Deep Brain Stimulation (DBS)
 Vagus Nerve Stimulation
 Light Therapy
 B. PSYCHOSOCIAL treatment
 Psychotherapy
 Psychiatric rehabilitation
 Other (music therapy, art therapy,
ergotherapy…)
Treatment in Psychiatry
Electroconvulsive therapy
 procedure, in which small electric currents
are passed through the brain, intentionally
triggering a brief seizure
 ECT seems to cause changes in brain
chemistry that can quickly reverse
symptoms of certain mental illnesses
 when other treatments are unsuccessful
ECT
Electroconvulsive therapy
 informed consent must be signitured
 ECT is administered under anesthetic with
a muscle relaxant
 ECT can differ in its application in three
ways: electrode placement, frequency of
treatments, and the electrical waveform
of the stimulus.
 side effects: confusion and memory lost
 main indications: major depressive
disorder, mania, and catatonia
ECT
Repetitive transcranial
magnetic stimulation (rTMS)
 a magnetic method used to stimulate small
regions of the brain
 a magnetic field generator, or "coil", is placed
near the head
 The coil produces small electric currents in the
region of the brain just under the coil via
electromagnetic induction. The coil is connected
to a pulse generator, or stimulator,
that delivers electric current to the coil.
 Indication: major depressive disorder,
negative symptoms of schizophrenia,
auditory hallucinations,
 Side effects: epileptiform paroxysm,
mild headaches
rTMS
Deep brain stimulation (DBS)
 a neurosurgical procedure
 involving the implantation of a medical device called
a neurostimulator (sometimes referred to as a 'brain
pacemaker'), which sends electrical impulses,
through implanted electrodes, to specific targets in
the brain (brain nuclei) for the treatment of
movement and neuropsychiatric
disorders (major depression, OCD)
 has been used in a small number of
clinical trials
DBS
Vagus nerve stimulation
 is a medical treatment that involves
delivering electrical impulses to the vagus
nerve. It is used as an adjunctive treatment
for certain types of intractable epilepsy and
treatment-resistant depression.
 the device sends electrical
signals along the vagus nerve
to the brainstem, which then sends
signals to certain areas in your
brain.
Vagus nerve stimulation
Light Therapy
 involves daily scheduled exposure to bright artificial light
 During light therapy, you sit or work near a device called a light
therapy box. The box gives off bright light that mimics natural
outdoor light.
 Light therapy is thought to affect brain chemicals linked to
mood and sleep
 Biorhythm
 Indication: treatment for SAD (Seasonal Affective Disorder),
other types of depression, sleep disorders and other conditions
 Side effects: eye strain, headache, nausea,
irritability or agitation
Light Therapy
Treatment in Psychiatry
Thank you very much
for your attention