Biological Therapies

SSRIs Fluoxetine Fluvoxamine Paroxetine Citalopram Sertraline escitalopram

SSRIs Share no molecular features Half life:20 hours&3days Hepatic metabolism Specific activity in the inhibition of serotonin reuptake No activity on other receptors Occurring 90% of clinical response at the starting dose

SSRIs Therapeutic Indications Depression Anxiety dis. Eating dis. PMS Premature ejaculation Paraphilias ADHD Autistic dis. chronic pain syndromes. Psychosomatic conditions

SSRIs Adverse Effects Sexual dysfunction GI effects Headache CNS effects Antichoinergic effects Hematologic effects Electrolyte and glucose disturbances Endocrine and allergic reactions

Serotonin syndrome Hyperthermia shivering Diarrhea Agitation Hyperreflexia Myoclonus Seizures Rigidity Delirium coma

SSRI withdrawal Dizziness Weakness Nausea Headache Rebound depression Anxiety Insomnia Poor concentration

SSRIs Drug-drug interactions Dosage and administration

TCAs Tertiary amines: Imipramine Amitriptyline Trimipramine Doxepine Clomipramine Secondary amines: Desipramine Nortriptyline Protriptyline Tetracyclic drugs: Maprotiline Amoxapine

TCAs: Half life :10-70h(longer HL in Nortriptyline,Maprotiline) Hepatic metabolism Blocking of reuptake of serotonin and NE Antagonism of muscarinic,H1,alfa1,2 Type A antiarrhytmic effects 40-fold difference in plasma concentrations in different persons

TCAs Therapeutic Indications MDD Panic disorder with Agoraphobia GAD OCD Eating dis. Pain dis. Sleep dis.

TCAs Adverse Effects Psychiatric effects Anticholinergic effects Sedation Autonomic effects Cardiac effects Neurological effects Allergic and hematological effects Weight gain

TCAs Drug – Drug Interactions Antihypertensives Antipsychotics CNS depressants Sympathomimetics OCPs SSRIs Lithium Primidon Ascorbic Acid

MAOIs Phenelzine Isocarboxazid Tranylcypromine Selegiline

MAOIs Therapeutic Indications Panic disorder with agoraphobia Social phobia PTSD Atypical depression Eating dis. Pain dis.

MAOIs Adverse Reactions Or HTN Insomnia Weight gain Edema Sexual dysfunction Hypertensive crisis paresthesia.,myoclonus,muscle pain

Tyramine-Rich Foods Cheese Fish Sausage Pates Mortadella banana

drugs to be avoided Antiasthmatics Antihypertensives Buspirone Levodopa Opioids Sympathomimetics SSRIs Clomipramine

Mood Stabilizers Lithium Sodium Valproate Carbamazepine Lamotrigine Topiramate Gabapentin Calcium Channel Inhibitors

lithium No binding to plasma proteins No metabolism Slow crossing BBB Half- life : 20 hours Decreasing of renal clearance in renal insufficiency and puerperium / increasing during pregnancy

Lithium therapeutic indications Bipolar mood disorder Schizophrenia/schizoaffective disorders MDD Aggression PMS Bulimia Binge drinking BPD OCD PTSD Trichotilomania

Lithium maintenance treatment After the second episode of BMD1 After the first episode in : 1.Adolescents 2.High suicide risk 3.Poor support systems 4.No percipitating factors 5.Sudden onset 6.First episode of mania 7.FH of BMD1

LITHIUM Adverse effects Gastrointestinal effects Neurological effects Renal effects Cardiac effects Thyroid effects Dermatological effects

Lithium toxicity Coarse tremor Dysarthria Ataxia GI symptoms Cardiovascular changes Renal dysfunction Fasciculations Myoclonus Seizures coma

LITHIUM Drug interactions DAs Anticonvulsants Thiazids Potassium sparing diuretics NSAIDs ACEIs Calcium channel inhibitors Osmotic diuretics Loop diuretics Xantins Carbonic anhydrase inhibitors

Lithium Clinical Guidelines Initial medical work up Dosage Serum concentrations Discontinuation Patient education

Sodium valproate Effects on GABA neurotransmitter system. Therapeutically effective at serum concentrations above microgr/ml Half-life : 8-17 hours Maintaining effective plasma concentrations with dosing 1 to 4 times a day

Sodium Valproate Therapeutic Indications Bipolar 1Disorder (acute – prophylaxis ) Schizoaffective Disorder Behavioral dyscontrol syndromes Dementia Organic brain diseases TBI Other mental disorders

Sodium Valproate Adverse Reactions GI effects Sedation Ataxia Dysarthria Tremor Weight gain Hair loss Elevation of liver transaminases Thrombocytopenia Platelet dysfunction Hyponatremia Hepatotoxicity Pancratitis PCO

Sodium Valproate Drug interactions Lithium Carbamazepin Antidepressants SDAs DAs Phenytoin Phenobarbital BZDs

Sodium Valproate Administration R/O liver and pancreatic disease Dose on the first day : 250 mg plasma concentrations : mg/ml Daily dose : mg Mood-stabilizing effects appear between 5-15 days after initiation

Carbamazepine Steady-state levels in 2-4 days on a steady dosage Half-life : h after 1 month of administration Metabolized in liver decreasing synoptic transmission Reduction of currents through NMDA channels Antagonism of adenosine A1 receptors

Carbamazepine Therapeutic Indications Bipolar disorder (manic-depressive episodes) Schizophrenia and schizoaffective disorder Impulse-control dis. PTSD Alcohol and BZD withdrawal

Carbamazepine Adverse Reactions Blood Dyscrasias Hepatitis Exfoliative dermatitis GI Effects CNS Effects Cardiac Effects Hyponatremia

Carbamazepine Drug Interactions SSRIs Anti psychotics Cimetidine Erythromycin Isoniazide Ketoconazole Verapamil allopurinol OCP TCAs Na-valproate Bupropion MAOIs Clomipramine Primidone Phenytoin

Carbamazepine Treatment CBC,LFT,ECG,Serum Electrolytes Initiate with 200mg to mg Anticonvulsant Blood Concentration : 4- 12microgr/ml Laboratory Monitoring :CBC,Billirubin,LFT,CBZ Level

Carbamazepine Treatment Discontinuation WBC<3000/mm3 Erythrocyte Count < /mm3 PMN<1500/mm3 HCT <32% HB<11gr/100ml Reticulocyte Count<0.3 % Serum Iron Concentration,150mg/100ml