1. Biological Therapies

2. SSRIs Fluoxetine Fluvoxamine Paroxetine Citalopram Sertraline escitalopram

3. 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

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

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

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

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

8. SSRIs Drug-drug interactions Dosage and administration

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

10. 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

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

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

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

14. MAOIs Phenelzine Isocarboxazid Tranylcypromine Selegiline

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

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

17. Tyramine-Rich Foods Cheese Fish Sausage Pates Mortadella banana

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

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

20. 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

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

22. 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

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

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

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

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

27. Sodium valproate Effects on GABA neurotransmitter system. Therapeutically effective at serum concentrations above 50 -100 microgr/ml Half-life : 8-17 hours Maintaining effective plasma concentrations with dosing 1 to 4 times a day

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

29. 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

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

31. Sodium Valproate Administration R/O liver and pancreatic disease Dose on the first day : 250 mg plasma concentrations : 50-100 mg/ml Daily dose : 1200-1500mg Mood-stabilizing effects appear between 5-15 days after initiation

32. Carbamazepine Steady-state levels in 2-4 days on a steady dosage Half-life : 12-17 h after 1 month of administration Metabolized in liver decreasing synoptic transmission Reduction of currents through NMDA channels Antagonism of adenosine A1 receptors

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

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

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

36. Carbamazepine Treatment CBC,LFT,ECG,Serum Electrolytes Initiate with 200mg to 600-1200mg Anticonvulsant Blood Concentration : 4- 12microgr/ml Laboratory Monitoring :CBC,Billirubin,LFT,CBZ Level

37. Carbamazepine Treatment Discontinuation WBC<3000/mm3 Erythrocyte Count < 4000000/mm3 PMN<1500/mm3 HCT <32% HB<11gr/100ml Reticulocyte Count<0.3 % Serum Iron Concentration,150mg/100ml