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BIOLOGICAL TREATMENT
dr. A.A.A.A. Kusumawardhani,SpKJ(K)
2009
Psychiatric treatment
 Comprehensive
–
Eclectic-Holistic
Organobiologic
Sociocultural
Psychoeducative
Therapy in Psychiatry

Biological / Physical treatment:
a. Drugs / Psycho-pharmacotherapy
b. ECT/ Electro Convulsion Therapy
c. Others

Psychological treatment:
- Psychotherapy  individual/group
- Psychotherapy - supportive
- re-educative
- re-constructive
Psycho-pharmacotherapy
 PSYCHOTROPIC
DRUGS
> Major action at CNS :
- Thinking process
- Mood
- Motoric function / behaviour

Clinical effect  Clasification:
1.
2.
3.
4.
Antipsychotics/Neuroleptic/Major Tranquilizer
Antidepresant
Antianxiety/Anxyolytic sedatives/Minor Tranq.
Antimanic/Mood stabilizer
Antipsychotics
 Classification:
* Typical  DA 
phenothiazine &
Nonfenothiazine
* Atypical SDA
# High Potency
# Low Potency
Pharmacokinetic of antipsychotics (1)
Age : geriatric  clearence
 Genetic : ethnics  different metabolism
 Substance Abuse behaviour :
* smoking 
metabolisms
* alcohol 
metabolisms,
 liver function & nutrition
 Medical condition :
* liver diseases, ex. Cirrhosis hepatis
* Congestive Heart failureblood flow
clearence

Pharmacokinetic of antipsychotics (2)
 Enzyme
inducers
*carbamazepine, phenytoin,
ethambutol, barbiturate
 Clearance Inhibitors
* SSRI, TCA, beta blocker dll.
 Changes in binding protein
* stress, hipoalbumin,
hepatic/renal failure.
Pharmacodynamic
Mode of action : DA & SDA
 psychotics symptoms (hallucination,
delusion, etc.)

Dopamine Receptor Antagonis:
* nigrostriatal system
* mesolimbocortical system
* tuberoinfundibuler system
Nigrostriatal pathway
Substantia Nigra to Striatum
. Motor control
. Death of neurons in
this pathway can result in
Parkinson's Disease
Mesolimbic and Mesocortical pathways
Ventral Tegmental Area to Nucleus
Accumbens, Amygdala & Hippocampus,
and Prefrontal Cortex
. Memory
. Motivation and emotional response
. Reward and desire
. Addiction
. Can cause hallucinations and
schizophrenia if not functioning properly
Dopamine Pathway
Tuberoinfundibular pathway
Hypothalamus to Pituitary gland
. Hormonal regulation
. Maternal behavior (nurturing)
. Pregnancy
. Sensory processes
Release of dopamine (green)
at synapses from an axon
terminal (left). Dopamine is
shown binding to receptors on
the postsynaptic membrane
(right).
Dopamine receptors being blocked
by an antipsychotic drug (red).
Dopamine can no longer bind to the
receptors on the post-synaptic
membrane, so it is as if there is less
dopamine in the brain.
Classification (chemical structure)

-
-
Phenothiazines
Aliphatic : Chlorpromazine,
Promazine,
Triflupromazine
Piperidine : Thioridazine,
Promazine,
Piperazine : Fluphenazine,
Trifluoperazine
Classification (chemical structure)
Thioxanthenes : Chlorprothixine,
Thiothixene
 Butyrophenones : Haloperidol,
Droperidol
 Dibenzoxazepine : Loxapine
 Dihydroindoles : Molindone
 Diphenylbutylpiperidines : Pimozide

Side effects (1)

Neurologic :
*acute
(acute extrapyramidal syndrome)
# acathisia
# acute dystonia
# parkinsonism
# Neuroleptic Malignan Syndrome
*chronic
# tardive dyskinesia
Side effects (2)
 Cardiovascular
effect
* Orthostatic (Postural) Hypotension
* Sudden Unexplained Death
 GIT
* peripheral anticholinergic effects
 Liver, hepatology, renal, skin & eye
 Endocrinal dysfunction
 Sexual dysfunction
Treatment Principal
 Initial
gradually increase dosage -->
optimal dose ( 1 – 3 weeks)
 Stabilisation (up to 8-10 weeks)
 Maintenance (months – years)
Side effects management (1)
SE Parkinsonism  use antiparkinsons
drugs, such as:
* artane (trihexyphenidil)
* congentin (benztropin)
* diphenhydramin (benadryl)
(do not use routinely)
 NMS :
*stop antypsychotic
*treat symptomatically
*observe vital signs

Side effects management (2)

Tardive dyskinesia :
* make a clear diagnosis  ensure
effective AP
* use only minimal dose
* caution in usage for children, geriatric,
and patients with mood disorders
* do regular examination for side effects
* TD +  give an informed consent, lower
the dosage  change drug
* when TD getting worse  stop the drug
 change/try Clozapin
ANTIDEPRESANT
 Classification.
* derivative of tricyclic AD
Imipramin - Tofranil
Amitriptilin- Laroxyl
Amineptin - Survector
* derivative of tetracyclic AD
Maproptilin - Ludiomil
Mianserin - Tolvon
Antidepresant (1)
•Monoaminoxidase Inhibitor
MAOI & RIMA
-moclobemide (Aurorix)
•Serotonergic (SSRI)
- Sertralin
- Fluoxetine
- Fluvoxamin
- Paroxetin
Antidepresant (2)
 Purpose:
Heal / decrease depresive symptoms
 Mode
of action :
Increase NT concentration especially
norepinephrin & serotonin
Antidepresant (3)

Side effects:
1. Hypotension (geriatric)
2. Cardio effects (EKG abnormality)
3. Otonomic symptoms
4. CNS effect
5. Allergy
6. hematology problems
7. psychological symptoms (manic,
restlessness)
Antidepresant (3)

MAOI side effects:
- hypotension & hypertension
- hepatologic problem
- otonomic
- neurological (paresthesia,convulsion)
- oedema
- hematologic
- psychologic disturbances
- crisis hypertention
Antidepresant (4)
 Treatment
Principals:
- start from low dosage 
therapeutical effect appears within
2 / 3 weeks
- maintenance phase minimal 6
months & can last for 3 – 5 years
Tricyclic Antidepressant
Selective Serotonin Reuptake Inhibitors
Monoamine Oxidase Inhibitor
MAOI
ANTIANXIETY

CLASSIFICATION
1. Derivative of Benzodiazepine
-
diazepam
bromazepam
lorazepam
clobazam
alprazolam
-
valium
lexotan
ativan
frisium
xanax
Buspiron
-buspar
2. Derivative of Gliserol - meprobamat
3. Der. Of Barbiturate - phenobarbital
Antianxiety (1)
Purpose :
Decrease anxiety
- sedative effects
- relaxation
- amnesia
- antiepilepsy
 Therapeutic Principal:
- do not use high dosage
- do not use more than 1 month

Antianxiety (2)
 Side
-
Effects
drowsiness
headache
dysarthri
ataxia
appetite
dependent
withdrawal effects
MOOD STABILIZER
 Main
purpose: control manic
condition & prevent relapses
Lithium :
Indications: manic/depressive
episode
Effective doses :
0.8 – 1.5 mEq/l plasma level
(start with 300 mg/day p.o)
Antimanic (1)

Side Effecs :
- soft tremor
- diarrhea & vomiting
- fatigue & vertigo
- ataxia & rough tremor
- declining consciousness
- convulsion
- oligouria & anuria
- oedeme
Antimanic (2)

“Mood Stabilizer”
1. Lithium salt
Lithium carbonate - Priadel
- Theralith
2. Others
Carbamazepine
- Tegretol
Valproic Acid/Devalproate - Depakote
ELECTRO CONVULSION
THERAPY (ECT)
 Main
Indication: Major Depression
 Electrify
the brain (using 2
elektrodes placed on temporal
region)
 convulsion like that of grandmal
epileptic
ECT (1)

Preparation :
- patient physical check up
(Cardiovascular,pulmo,bones,brain)
- Informed consent
- fasting minimal 6 hours before ECT
- prepare the patient to remain calm :
distract their attention, give
premedication
- remove false teeth, jewelry, hair pin
- nurse assistance for preventing
luxasio/fracture
ECT (2)
 Tools
preparation :
- ECT machine
- wet cotton for underlying
electrodes
- oxygen tube & mask
- mucous suction
- drugs : coramine, adrenalin
- rubber teeth holder
- flat bed
ECT (3)

Execution :
- Patient is laid down without pillow, in
baggy hospital clothes
- Rubber teeth holder
Nurses hold : lower jaw/ head;
shoulder; hip & knee
- Doctor place the elektrodes tonic
convulsion -->clonic convulsion
apneubreath normally (important
phase)
ECT (4)
 Post
ECT observation :
- important
- until vital condition become normal,
still unconcious, usually falling
asleep; sometimes restless & moving
uncontrollably
 nurses must keep watching until
the patient is fully councious.
ECT (5)
- after regaining consciousness, the
patient often confused, disoriented
and amnestic
 nurses help orientation and
memory by communicating in
stages, giving a calming and nonirritating environment.
OTHER BIOLOGICAL
THERAPY
 Light
therapy
 Sleep Deprivation & Alteration of
Sleep Schedules
 Psychosurgery
 Orthomolecular therapy
 Subcoma Insulin therapy
 Coma therapy
 Carbon Dioxide therapy
Resource:
 Comprehensive
Texbook of
Psychiatry –Kaplan HI, Saddock BJ