1. Maryam Tabatabaee M.D Assistant professor of psychiatry

2.  No one drug is certain to produce clinical improvement in all patients.  All drugs have side effects

3.  Side effects are unavoidable  Be familiar with the more common and serious adverse effects

4. Side effects cause : compliance and QOL HARM

5. Duration of side effects: Nausea with SSRIs is transient Dry mouth with TCAs is persistent

6.  Patient related factors: past treatment response response in family member concurrent medical or psychiatric disorder

7.  Dosing time of dosing maximum dosage duration of treatment

8.  Combination Monotherapy is ideal

9.  Special population children eldery: start low, go slow, full dosage medically ill patients

10.  Antidepressant  Mood stabilizer  Anxiolytics  Antipsychotics

11.  TCAs  SSRIs  MAOIs  Other

12. Serotonin Specific Reuptake Inhibitors (SSRIs) FIRST CHOISE Least preferred usage: Sexual dysfunctions secondary refractiveness consistent insomnia agitation

13. SSRIs  Fluoxetine Cap 10, 20  Citalopram Tab 20, 40  Sertraline Tab 50, 100  Fluvoxamine Tab 25, 50, 100

14.  Adverse effects : Headache Yawning Agitation Sexual dysfunction GI disturbance Insomnia or hypersomnia

15.  Imipramine 150-300  Amitriptyline  Clomipramine130-250  Trimipramine  Doxepine  Nortriptyline50-150  Desipramine

16. Least preferred : cannot tolerate sedation, constipation,over weight, Dementia suicidal patients cardiac patients Preferred usage: Pain migraine fibromyalgia severe depression sedative hypnotics

17.  Adverse effects : Dry mouth Other anticholinergic effects Sedation Cardiac Hematologic

18. MAOIs MAOIs Preferred usage:  second line  atypical  refractory  compliant patient  with panic attacks Least preferred:  noncompliant  first line for insomniac agitated

19. A.RENAL IMPAIREMENT  TCA ↦ level monitoring  Fluoxetine and Serteraline ↦ no adjustment B.HEPATIC IMPAIREMENT  TCA ↦ level monitoring  SSRI ↦ safe, but lower dosage,1/2 in cirrhosis

20. C.EPILEPSY  TCA ↦ lower seizure threshold,SSRI lower risk,  Bupropione ↦ contraindicated,fluvoxamine and carbamazpine D.ENDOCRINE  treatment then antidepressant,fluoxetine improve insulin act E.IATROGENIC DEPRESSION:  Anti HTN,sedative,steroid,antiulcer,digitals,antiparkinson  First remove offending agent then antidepressant

21. Venlafaxine - fewer side effects than TCAs( clean amitriptyline) Mirtazapine - causes sedation, weight gain Reboxetine - minimal side effects Bupropion

22. Bipolar disorder

23. For individual with more pure or euphoric mania (0.8_1.2) It is also helpful in depression but less effective in mixed episodes and rapid cycling Lithium clearance decrease in elderly,peurperium,increase in pregnancy ADVERSE EFFECT : Thirst, polyuria,gastric distress,tremor,nausea,vomiting,diarrhea, thyroid effect, cardiac effect, dermatologic effect

24. It has been used as an anticonvulsant Valproate is equally effective in both euphoric and mixed episodes, and effective in rapid cycling, substance disorder Adverse effects: nausea,vomiting,diarrhea, tremor, weight gain, alopecia

25. CARBAMAZEPINE:  It is effective in both euphoric and mixed episodes  bone marrow suppression and liver inflammation periodic blood testing is also needed during carbamazepine treatment. LAMOTRIGINE  It can act as a mood stabilizer and may be especially useful for depressed phase of bipolar disorder.  0.3 % taking the medication develop a serious rash.  Overly trend to have fewer troublesome side effect.

26. GABAPENTIN It has become popular as a mood stabilizer. It is unlikely to interact with other medication. Fatigue,sedation,dizziness TOPIRAMATE This new anticonvulsant may be helpful in mania. It does not appear to cause weight gain Sedation,dizziness,and cognitive slowing

27.  Alpearzolam 0.5, 1  Lorazepam 1, 2  Oxazepam 10,20  Clonazepam 1, 2  Chlordiazepoxide 5, 10, 20  Diazepam ???

28. Dependency AbuseZolpidemBuspirone

29.  Indication psychosis mania severe agitation delirium …

30.  P.r.n(haloperidol)  Depot (flupentixol, fluphenazine,haldol)

31.  Adverse effects EPS NMS Sedation Cardiac, weight gain, liver, hematologic, orthostatic hypotention, reduce seizure thereshold …

32.  Typical Haloperidole Trifluperazine Perphenazine Chlorpromazine Thioridazine …

33.  Atypical Risperidone1,2,4 Olanzapine5,10 Clozapine …