Therapeutic psychiatry

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I- lntroduction :

Therapeutic psychiatry are currently many used in different mental disorders.

They were inaugurated by the discovery of the antipsychotic properties of chlorpromazine ( Largactil ) in 1952 then antidepressant Tofranil (imipramine . in 1957 then after tranquilizers and mood stabilizers.

Pharmacological treatments include 4 classes of drugs: neuroleptics, lace thymorégulateurs, antidepressants, anxiolytics.

II- drug treatments :

psychotropic :

The name psychotropic applies to substances that possess or elective prevalent mental activity operation.

Psychotropic drugs are drugs that act on different receptors involved in neurotransmission: dopamine, serotonin, GABA

It exists 3 psychotropic groups :

  • Psycholeptics : sedatives Psychic (hypnotics, tranquilizers, neuroleptic) "Reduces psychotic productions, induce neurological signs, autonomic and endocrine "
  • Psychoanaleptics : psychic stimulants: antidepressants, Stimulants vigilance
  • psychodysleptics : Disruptors of mental activity Hallucinogens : "Induce psychotic disorders: are not used in psychiatry " .

There are 4 classes:

1- neuroleptic :

They act on the dopaminergic system: regulation of emotional life, control motivation, modulation of perception, motor control, inhibition of prolactin secretion.

It exists 2 generation antipsychotics, according to whether or not they adverse neurological effects, extrapyramidal generally: the so-called conventional neuroleptics and atypical antipsychotics or second generation antipsychotics.

These neurological effects are less frequent with the new generation of antipsychotics but don & rsquo; have not completely disappeared.

There are a dozen pharmacological classes of neuroleptics.

a- Indications :

Main indications neuroleptic: psychoses

  • acute psychosis: trouble schizophréniforme, manic episode, delirious melancholy.
  • chronic psychosis: schizophrenia, delusional disorder.

Additional indications neuroleptic

  • Psycho-behavioral disturbances of dementia.
  • behavioral manifestations of personality disorders ( antisocial, borderline…)
  • TOC.

b- Side effects :

1- neurological effects :
Syndrome extrapyramidal
– dyskinesia
– hyperkinetic syndrome inability to sit still and forward of the lower limbs.

2- autonomic effects :
– Cardiovascular : hypotension orthostatique
– digestive syndrome : Dry mouth with constipation
– endocrine syndrome : weight gain, disruption of the menstrual cycle
– Allergy
– Photosensitivity
– Eczema
– cholestatic jaundice

c- Cons-indications :

– Hepatic insufficiency
– Heart failure
– Renal failure
– Disorder of blood grime
– Degenerative diseases of the CNS
– Myasthénie
– Angle-closure glaucoma
– Pregnancy and breast feeding

d- Long acting neuroleptic :

It follows from the esterification of a neuroleptic having its formula in an alcohol with a long chain fatty acid (low solubility) .Introduced intramuscularly, neuroleptic behaves like an implant releasing very slowly and steadily its active ingredient.

  • Their route of administration is parenteral ( IM ) exclusively
  • Their duration of action varies 2 at 4 weeks
  • Half-life 3 weeks about
  • Always prescribe the equivalent in neuroleptic orally for 15 days before moving on to the late form to test the sensitivity of the patient to NLP, often in hospital
  • Adding a correction if possible
  • If failure, reduce the intervals between injections or change NLP per os to a passage to another NAP

Complication majeure : "Neuroleptic Malignant Syndrome" is the most dreaded complication Life threatening patient issue

diagnostic criteria :

3 major criteria :
– Fever
– Rigidity
– Increased K CP

6 minor criteria :
– tachycardia
– tensionnelle Abnormalities
– Altered consciousness
– Tachypnée
– profuse sweating
– Hyperleucocytose.
Diagnosis highly probable if the presence of: three major criteria or two major criteria and four minor criteria.

2- antidepressants :

They are active only after 2 at 3 week treatment of depressed subjects. They are defined by their ability to correct the pathological sadness. Antidepressants increase synaptic monoamines lethal intra- (serotonin, catecholamines).

Various classes of antidepressants

HAD

  • iproniazid: Marsilid ®.

ADT : Tricyclic antidepressants

  • Imipramine: Tofranil ®.
  • Clomipramine: Anafranil ®.
  • Amitryptiline: Laroxyl ®.

IRS : Inhibitor of serotonin reuptake

  • Chiltopram: Seropram ®.
  • fluoxetine: Prosac ®.
  • paroxetine: Paxil ®.
  • Fluvoxamine: Floxyfral ®.
  • Setrline: Zoloft ®

other antidepressants ( which SNRIs: Inhibiteurde the serotonin reuptake and noradrenaline ):

  • Viloxazine: Vivalan ®.
  • Venlafaxine: Effexor ®.
  • Mirtapazine: Norset ®

a- lndications :

– Episodes major depressive : all antidepressants
+ Depression associated with psychosis: adding in this case an antipsychotic
+ prophylactic treatment because of a recent depressive episode: only in the case of unipolar depression.

– Obsessive Compulsive Disorder OCD :
+ Clomipramine, sertraline, paroxetine, fluvoxamine, fluoxetine
+ Efficiency outside a depressive comorbidity.

– panic disorder with or without agoraphobia :
+ Clomipramine, citalopram
+ Efficiency outside a depressive comorbidity.

b- Side effects :

  • tricyclic :

– Anti cholinergique : dry mouth, constipation, urinary retention,, disorder accommodation.
– Cardiovascular : hypotension orthostatique, tachycardia, rhythm disorder
– Psychic : excitation, show inhibition, suicide risk, delirium, insomnia, nightmares.
– neurologic : sedation, memory disorders, dysarthrie, tremors, polyneuropathy.
– hematologic : thrombocytopenia, hyper eosinophilia.
– stomatology : glossite, stomatitis when prolonged treatment.

  • ISRS :

– headaches, tremor, nausea, vomiting, gastralgies, cytolytic and cholestatic hepatitis, weightloss.
– serotonin syndrome : mental confusion, myoclonies, agitation tremor, rigidity, hypotension or hypertension.

c- Contraindication :

absolute :

  • Glaucoma acute angle
  • Benign prostatic hyperplasia
  • Heart disease unstabilized – IDM
  • 1st trimester
  • Association with non-selective MAO inhibitors

Relatives :

  • Epilepsy
  • Hepatic and renal impairment.

3- Thymorégulateurs :

Mood regulators are limited pharmacological class represented by lithium salts :

  • d & rsquo; firstly the (Téralithe®, Neurolithium®), and anticonvulsants,
  • d & rsquo; other : were carbamazepine (Tégrétol®), valproic acid (Dépakine®), or valpromide (Dépamide®).

Mood stabilizers act directly on neurotransmitters such as serotonin, have a membrane stabilizing effect and modify the enzymatic protein-G dependent activities

Principles prescription :

The introduction of a mood stabilizer treatment requires pretherapeutic including :
– The research against-indications,
– A complete physical examination, including neurological, with measurement of the body weight (allowing initiai dosage adjustment),
– paraclinical examinations looking for a cardiovascular pathology, hepatic, kidney or thyroid :
+ ECG, hepatic check (before administration & rsquo; an anti-epileptic mood stabilizer), renal function tests (before administration of lithium salts : creatinine, creatinine clearance, proteinuria, glycosurie, ),
+ TSH (before administration of lithium salts),
+ Serum electrolytes (before administration of lithium salts : search for sodium depletion or potassium), NFS platelets
+ A pregnancy test for women of childbearing age,
– Initiation of treatment is carried out gradually under clinical and laboratory monitoring, with regular monitoring of plasma concentrations to equilibrium.
– A clear and accurate patient information is needed on the effects of both beneficial and undesirable treatment and the need to maintain the same dose throughout the course.
– Surveillance, adverse effects and against indications.
Forms LP (delayed forms) are available for these 3 substances.

a- Indications :

  • Bipolar disorder.
  • Behavior disorder.
  • Aggressiveness.

b- Side effects :

  • digestive disorders
  • Syndrome polyuro-polydipsique,
  • weight gain and trembling,

c- Cons-indications :

  • insufficiency (Ice) kidney-
  • sodium diet – hyponatremia
  • Heart failure and thyroid dysfunction.

4- anxiolytic :

Are drugs that reduce the emotional tension or anxiety. They are easy to distinguish neuroleptics and antidepressants, because they have no effect on psychotic and mood disorders. These are substances whose main pharmacological property is to act on the GABAergic system are represented by distinct chemical classes:

  • benzodiazepines: Valium ®, Tranxène ®, …
  • Carbamates: Equanil ®.
  • antihistamines: Atarax ®.
  • Azapirones: Buspar ®.
  • Other: etifoxine: stress ®, Captodiame: Covatine ®,

All these substances have similar properties combining actions:

  • anxiolytic.
  • sedative.
  • Myorelaxante.
  • anticonvulsants.
  • amnesic.
  • Orexigène (increase in & rsquo; appetite).

These pharmacological properties resulting indications and precautions.

a- lndications :

anxiety states, insomnia, confusional states.

Anxiety attack (panic attack) -panic disorder

IDM – Coronary artery disease,

Trouble, psychosomatic,

operative premedication, rheumatologic disorders

Status epilepticus.

b- Side effects :

sedative;

addictive effects;

cognitive effects;

Reactions paradoxical rebound phenomenon

c- Cons-indications :

severe respiratory failure, myasthénie,

Association with alcoholic beverages.

d- Accident tranquilizers :

Lack of awareness- circulation accident.

Cours du Pr Yekhlef – Faculty of Constantine