Pharmacological treatment of mental health problems.

Sammy OheneFaculty of Psychiatry

Pre-conference workshop @ 9th AGSM, GCPSAccra, November 27, 2012

PRE TESTAnswer each question True or False

1. Chlorpromazine was discovered before Phenobarbitone.

2. Haloperidol has similar chemical structure to Thioridazine but different from Chlorpromazine

3. Risperidone is superior to Haloperidol in efficacy in treatment of Mania.

4. Venlafaxine is a pure SSRI.5. 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 Atypicals-

risperidone,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

• 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 treatment-resistant depression?