Management Of Mental Disease

Management of Mental Disease Department of psychology The first affiliated hospital of ZZU Huirong guo

Contents  Part one: Drugs treatment( 药物治疗 )  Part two: ECT （电休克治疗）  Part three: Psychological treatment （精神治疗 或心理治疗）

Part one: Drugs treatment( 药物治疗 ) 

Antipsychotic drugs( 抗精神病药 )



Antidepressant （抗抑郁药）



Mood stabilizer （情感稳定剂）



Anxiolytic drugs （抗焦虑药）



Hypnotic drugs （催眠剂）



Psychostimulant （精神兴奋剂）

Antipsychotic drugs( 抗精神病 药)  Also called “major tranquillizers” & “neuroleptics”  These drugs reduce psychomotor excitement, hallucinations, and delusions occurring in schizophrenia, mania, and organic psychoses  Antipsychotic drugs block dopaminergic receptors, and this action may account for their therapeutic effects, and certainly explains their extrapyramidal side effects  They also block noradrenergic and cholinergic receptors and these actions account for some of their many side effects

Antipsychotic drugs( 抗精神病 药)  Antipsychotic drugs are well absorbed, and partly metabolized in the liver into numerous metabolities, some of which have antipsychotic properties of their own  “Typical” antipsychotics bind strongly to post-synaptic dopamine D2 receptors. This action seems to account for their therapeutic effect but also their propensity to cause movement disorders. Most antipsychotics are in this group

Antipsychotic drugs  There are several newer “atypical” antipsychotics which vary in the extent to which they bind to dopamine D2/D4, 5-HT2, alphal-adrenergic and muscarinec antipsychotics and do not cause hyperprolactinaemia. This group of drugs includes clozapine( 氯氮平 ), risperidone （利培酮） , olanzapine （奥氮平） , quetiapine （奎的平）  Side effects the numerous side effects of the typical antipsychotic drugs are related mainly to the antidopaminergic, antiadrenergic, and anticholinergic effects of the drugs

Antipsychotic drugs Side effects of typical antipsychotic drugs:  Antidopaminergic effects ： acute dystonia ； Akathisia ； Parkinsonism ； Tardive dyskinesia  Antiadrenergic effects :Postural hypotension ; Nasal congestion ; Inhibition of ejaculation  Anticholinergic effects :Dry mouth; Reduced sweating ; Urinary hesitancy and retention ; Constipation of glaucoma

Antipsychotic drugs  Neuroleptic malignant syndrone mental symptoms :  Motor symptoms :increased muscle tone, dysphgia  Autonomic symptoms :hyperpyrexia, salivation  Laboratory findings :raised white cell count  Consequent problems (pneumonia)

Antipsychotic drugs  Clinincal features of extrapyramidal effects :  Acute dystonia : Torticollis ; Tongue protrusion ; Grimacing ; Spasm of ocular muscles ; Opisthotonus  Akathisia: Physical restlessness ; Need to move  Parkinsonism : Akinesia ;Expressionless face ; Lack of associated movements when walking ; Stooped posture ; Rigidity of muscles ; Coarse tremor; Festinant gait  Tardive dyskinesia :Chewing and sucking movement ; Grimacing ; Choreo-athetoid movement ; Akathisia

Antipsychotic drugs  Management of the side effects induced by antipsychotics:  Acute extrapyramidal effects :  Reducing the dosage of antipsychotics  Anticholinergic drugs  Replaced by the other kinds of antipsychotics  Tardive dyskinesia:  Stop the antipsychotic drug  Prevention

Antipsychotic drugs  Choice of drug :  A more sedating drug—chlorpromazine ( 氯丙嗪 )  A less sedating drug—trifluoperazine （三氟拉嗪） or haloperidol （氟哌啶醇）  A drug with fewer extrapyramidal side effects —sulpiride or risperidone （利培酮）  An intramuscular preparation for rapid calming — chlorpromazine （氯丙嗪） or haloperidol （氟哌啶醇）  A depot preparation—fluphenazinedecanoate （氟奋乃静葵脂 酸） or flupenthixol decanoate （ 氟哌啶醇 葵脂酸 ）  For patients resistant to other antipsychotics—clozapine （氯氮 平）

Antidepressant （抗抑郁药 ）  Antidepressant drugs have therapeutic effects in depressive illness, but do not elevate mood in healthy people (contrast the effects of stimulants like amphetamine)  Drugs with antidepressant properties are divided conveniently into:  tricyclic antidepressants (TCAs)  modified tricyclic and related drugs  selective serotonin reuptake inhibitors (SSRIs)  serotonin and noradrenaline reuptake inhibitors (SNRIs)  monoamine oxidase inhibitors (MAOIs) etc  These drugs have not been shown to differ in efficacy or speed of action but only in their side effects

Antidepressant  All antidepressant drugs increase 5-HT function and increase noradrenaline function  The development of specific 5-HT reuptake inhibitors suggested that the antidepressant effects result from increased 5-HT function  However, specific noradrenaline reuptake inhibitors have been developed and they too are antidepressants. Thus, the mechanism of antidepressant action remains uncertain

Antidepressant  Tricyclic antidepressants (TCAs) ：  These drugs are so named because their chemical structure has three bezene rings  They have many side effects and toxic effects on the cardiovascular system  Because of these effects tricyclics are being replaced for many purposes by drugs without these side effects  However, they are still important because they are of proven effectiveness in severely depressed patients  Also, they are generally less expensive than other antidepressant drugs

Antidepressant  Side effects of tricyclic antidepressants:  Anticholinergic effects ： Dry mouth ； Constipation ； Impaired visual accommodation ； Difficulty in mictutrition ； Confusion (especially in elderly)  Alpha-adrenoceptor blocking effects ： Drowsiness ； Postural hypotension ； Sexual dysfuction  Cardiovascular effects ： Tachycardia ； Hypotension ； Cardiac conduction deficits  Other effects ： Seizures ； Weight gain

Antidepressant  Difficulty in micturition may lead to retention of urine in patients with prostatic hypertrophy － Cardiac conduction deficits are more frequent in patients with pre-existing heart disease. If it is necessary to prescribe a tricyclic drug to such a patient, a cardiologist’s opinion should be sought

Antidepressant Toxic effects ： In over-dosage, tricyclic antidepressants can produce serious effects requiring urgent medical treatment. These effects include: ventricular fibrillation, conduction disturbances, and low blood pressure; respiratory depression; agitation, twitching, convulsions; hallucinations, delirium, and coma; retention of urine, and pyrexia

Antidepressant Contraindications ： Include agranulocytosis, severe liver damage, glaucoma, and prostatic hypertrophy. The drugs should be used cautiously in epileptic patients because they are epileptogenic, in the elderly because they cause hypotention, and after myocardial infarction because of their effects on the heart

Antidepressant  Selective serotonin reuptake inhibitors (SSRIs)  These drugs selectively inhibit the reuptake of serotonin (5HT) into presynaptic neurons. Examples are fluoxetine, fluvoxamine, paroxetine, and sertraline  Their antidepressant effect is comparable to that of the tricyclic antidepressant drugs and because they lack anticholinergic side effects they are safer for patients with prostatism or glaucoma, and when taken in overdose. They are not sedating

Antidepressant  Side effects of SSRIs:  Gastrointestinal ： Nausea ； Flatulence ； Diarrhoea  Central nervous system ： Insomnia ； Restlessness ； Irritability ； Agitation ； Tremor ； Headache  Sexual ： Ejaculatory delay ； Anorgasmia

Antidepressant  SSRIs with MAOIs should be avoided since the combination may produce a 5-HT toxicity syndrome with hyperpyrexia, rigidity, myoclonus, coma, and death  Choice of antidepressant ：  A sedating tricyclic—amitriptyline or trazodone;  A less sedating tricyclic—imipramine or lofepramine;  A drug with few anticholinergic effects—one of the SSRIs  Since there are no difference between antidepressants in efficacy or speed of action, choice depends on an assessment for each patient of the likely importance of side effects, toxic effects, and interactions with other drugs. Finally cost should be taken into account

Anxiolytic drugs （抗焦虑药 ）  Anxiolytic drugs reduce anxiety, and in larger doses produce drowsiness (they are sedative) and sleep (they also hypnotics)  These drugs are prescribed widely, and sometimes unnecessarily for patients who would improve without them  Anxiolytics used most appropriately to reduce severe anxiety. They should be prescribed for a short time usually a few days, seldom for more than 2-3 weeks  Longer courses of treatment may lead to tolerance and dependence  Types of anxiolytic drugs:  Benzodiazepines （苯二氮卓类）  Buspirone

Anxiolytic drugs  Benzodiazepines （苯二氮卓类）  Benzodiazepines act on specific receptor sites, linked with GABA (gamma- aminobutyric acid) receptors. They enhance GABA neurotransmission and affect indirectly 5HT (serotonin or 5-hydroxtrypamine) and noradrenaline systems. As well as anxiolytic, sedative, and hypnotic effects benzodiazepines have muscle relaxant and anticonvulsant properties  Benzodiazepines are rapidly absorbed and metabolized into a large number of compounds many of which have their own therapeutic effects

Anxiolytic drugs  Side effects are mainly drowsiness, with ataxia at larger doses (especially in the elderly). These effects, which may impair driving skills and the operation of dangerous machinery, are potentiated by alcohol. Patients should be warned about both these potential hazards

Anxiolytic drugs  Like alcohol, benzodiazepines can release aggression by reducing inhibitions in people with a tendency to this kind of behavior. This should be remembered, for example, when prescribing for women judged to be at risk of child abuse, or anyone with a history of impulsive aggressive behavior  Toxic effects are few, and most patients recover even from large overdoses. There is no convincing evidence of teratogenic effects; nevertheless, these drugs should be avoided in the first trimester of pregnancy unless there is a strong indication for their use

Anxiolytic drugs  Withdrawal effects occur after benzodiazepines have been prescribed for more than a few weeks; they have been reported in up to half the patients taking the drugs for more than six months  The frequency depends on the dose and the type of drugs. The obvious similarity between benzodiazepine withdrawal symptoms and those of an anxiety disorder makes it difficult, in practice, to decide whether they arise from withdrawal of the drug, or the continuous presence of the anxiety disorder for which treatment was initiated

Anxiolytic drugs  A helpful point is that withdrawal symptoms generally begin 2-3 days after withdrawing a short-acting drug, or 7 days after stopping a long-acting one, and diminish again after 3-10 days. Anxiety symptoms often start sooner and persist for longer. Withdrawal symptoms are less likely if the drug is withdrawn gradually over several weeks

Anxiolytic drugs  Benzodiazepines withdrawal syndrome :  Apprehension and anxiety  Insomnia  Tremor  Heightened sensitivity to stimuli  Muscle twitching  Seizures (rarely)

Anxiolytic drugs  General advice about use of anxiolytics:  Use sparingly. Usually, attention to life problems, an opportunity to talk about feelings, and reassurance are enough to reduce anxiety to tolerable levels  Brief treatment. Benzodiazepines should be given seldom more than three weeks  Withdraw drugs gradually to reduce withdrawal effects. When the drug is stopped, patients should be warner that they may feel more tense for a few days

Anxiolytic drugs  General advice about use of anxiolytics:  Short- or long-acting drugs. If anxiety is intermittent, a short-acting compound is used; if anxiety lasts throughout the day a long-acting drug is appropriate  Consider an alternative. As explained in the section on anxiety disorders some antidepressant and antipsychotic drugs have secondary anxiolytic effects and are useful alternatives to benzodiazepines

Electroconvulsive therapy (ECT)  In ECT, an electric current is applied to the skull of a patient to produce seizure activity. The electrodes which deliver the current can be placed with one on each side of the head (bilateral ECT) or with both on the same side (unilateral ECT)  Unilateral placement on the non-dominant side results in less memory impairment but may be less effective than bilateral ECT. Bilateral placement is therefore preferred when a rapid response is essential, or when unilateral ECT has not been effective

Electroconvulsive therapy (ECT)  The beneficial effect which depends on the cerebral seizure, not on the motor component, is thought to result from neurotransmitter changes probably involving 5-HT and noradrenaline transmission. ECT acts more quickly than antidepressant drugs, although the outcome after three months is similar

ECT  The main indications for ECT are:  The need for an urgent response  When life is threatened in a severe depressive disorder by refusal to drink or eat or very intense suicidal ideation  In puerperal psychiatric disorders when it is important that the mother should resume the care of her baby as quickly as possible  For a resistant depressive disorder, following failure to respond to thorough treatment with antidepressant medication  For two uncommon syndromes: Catatonic schizophrenia ; Depressive stupor

ECT Side effects of ECT :  ECT has few side effects; some patients have a brief period of headache after the treatment. There are occasional effects from the anesthetic procedure; the teeth, tongue, or lips may be injured while the airway is introduced and, rarely, muscle relaxants cause prolonged apnoea  Some patients fear long-lasting impairment of memory following ECT but memory tests have not confirmed this. The few patients who complain of lasting poor memory after ECT generally have persistent depressive symptoms, suggesting that the poor memory is related to the depressive disorder and not to the ECT

ECT Side effects of ECT :  The death rate from ECT is about 4per 100,000 treatments, closely similar to that of an anesthetic given for minor procedure to a similar group of patients. Mortality is greater in patients with cardiovascular disease, and due usually to ventricular fibrillation or myocardial infarction

ECT The technique :  ECT is administered by a psychiatrist, who applies the current, and nurses, and sometimes, with anesthetist. ECT is usually given twice a week with a total of 6-12 treatments, according to progress. Response begins usually after 2 or 3 treatments; if there has been no response after 6-8 treatments, it is unlikely that more ECT will produce useful change  As some patients relapse after ECT, antidepressants are usually started towards the end of the course to reduce the risk of relapse

Psychological treatment  There are many kinds of psychological treatment but only a few are of direct concern to non-specialists. All doctors need to be able to employ basic psychological procedures in their everyday practice  They also need to know enough about the commonly used special methods of psychological treatment to be able to decide when to refer patients appropriately

Psychological treatment  Basic procedures:  Use of the doctor-patient relationship to gain patients’ confidence, improve their compliance with more specific methods, and sustain them through periods of distress. Although helpful in these ways, the doctor-patient relationship can become too intense and impede progress  Patients should feel that the doctor is concerned about them but understand that the relationship is professional, clearly concerned about them but understand that the relationship is professional, clearly distinct from a friendship, and one that the doctor maintains with other patients

Psychological treatment  Listening to patients’ concerns. Patients feel helped when they can describe their problems to a sympathetic person, and many complain that doctors do not spend enough time listening to their concerns before giving advice  Adequate time needs to be provided for listening and patients should feel that they have the doctor’s undivided attention and have been understood. Non-verbal signs of attention and occasional rephrasing of what has been said help to achieve this

Psychological treatment  The expression of emotion to relieve distress. It is everyday experience that the expression of strong emotion is followed by a sense of relief. Some patients feel ashamed to reveal their feelings to a doctor and need to be assured that the process is not a sign of personal weakness. Sometimes the process has to be gone through more than once but frequently repeated outpourings of emotion are not generally helpful unless accompanied by constructive efforts to improve the situation that is giving rise to distress

Psychological treatment  Information, explanation, and advice should of course be accurate and relevant to the patient’s physical and mental condition. It should correct any misunderstandings about the nature of the condition or the likely outcome  Such misunderstandings are common and often arise because patients were so anxious when the information was first given that they could not concentrate on it. Explanations of the cause of symptoms should be clear, free form jargon, and positive. It is not enough, for example, to explain that no organic cause has been found for symptoms, a convincing account should be given of their psychological origin

Psychological treatment  Improving morale patients who have prolonged or recurrent medical or social problems may understandably give up hope of improvement. Low morale undermines efforts at treatment and rehabilitation. Even if the doctor cannot offer hope of recovery, it is usually possible to improve morale; for example, by describing ways of reducing pain and distress, or discussing with a disabled patients how remaining abilities could be developed

Psychological treatment  Encourage self-help patients should be helped to achieve an appropriate balance between compliance with treatment, and determination to be self-sufficient. It is usually possible to achieve this important aim even with the most handicapped patients provided a dependent relationship is not allowed to develop

Psychological treatment  The problem of excessive dependency it is important that the relationship between patient and doctor does not become too dependent. This problem is most likely to arise during psychological treatment but it can occur whenever time is spent in talking with patients about their problems  An intense relationship between patient and doctor is called a transference. The term is used because in such a relationship the patient transfers to the doctor feelings and thoughts that originated in another closer relationship —often with one or other parent

Psychological treatment  When the transferred feelings are negative, there is said to be a negative transference. Not only may patients transfer to their doctors feelings that properly belong elsewhere, doctors may do the same with their patients dealing strongly about them because they remind them, consciously or unconsciously, of an aspect of a parent or another close figure in their lives

Psychological treatment  These feelings of the therapist toward the patient are called counter-transference and referred to as positive or negative as explained under transference. If countertransference is not recognized in its early stages and corrected, it may impair the doctors’ ability to provide impartial advice for that patient and to maintain an appropriate professional relationship

Psychological treatment  Supportive treatment  Supportive treatment is a part of all clinical practice. It is used to relive distress during a short episode of illness or personal misfortune, or in the early stages of treatment before specific measures have had time to act  Supportive therapy is used also to sustain a patient who has a medical or psychiatric condition that cannot be treated, or stressful life problems that cannot be resolved completely

Psychological treatment  Problem-solving techniques  These are useful for patients with adjustment disorders and similar conditions

 Behavioral and cognitive treatment  These are used to alter patterns of behavior and thinking that prevent recovery from certain psychiatric disorders

 Psychodynamic methods  These enable patients to recognize unconscious determinants of their behavior and thereby gain more control over it

Next Week : Monday: review Wednesday: Terminal test

Thank you See you next time

Thank you See you next time