PSYCHIATRIC CONDITIONS

1- Depression (MDD)
2- Schizophrenia/Psychosis
3- Bipolar Disorder
4- Attention De cit Hyperactivity Disorder (ADHD)
5- Anxiety Disorder
6- Sleeping Disorders
fi
 Definition: people with depression suffer greatly
with persistent feelings of hopelessness
dejection constant worry poor concentration
⬆⬇and
and lack of energy and inability to sleep
sometimes suicidal tendencies. ⬇ ⬇
⬇ ⬆⬇ ⬇
Mood , Sleep , Interest , Feeling
Guilty, Energy , Concentration , Appetite
Diagnosis: DSM-5 Criteria
, Psychomotor agitation, Suicidal Ideation.
Remember (M SIG E CAPS)
⬇ !⚠
QT prolongation: do not exceed
Citalopram 20mg (Cipram) (LECITAL, LOPRAM)
citalopram 20 mg/day in elderly(> 60 years),
!⚠
SSRIs: increase serotonin by inhibiting it’s
reuptake in the neuronal synapse. QT prolongation: do not exceed
Escitalopram 10mg (Cipralex) (ESCITAM)
Side effects : Sexual side effects: , libido, escitalopram 10mg/day in elderly(> 60 years),
ejaculation difficulties, anorgasmia,erectile
dysfunction Fluoxetine 20mg (ANXETIN)
Somnolence,insomnia, nausea,dry mouth,
diaphoresis (dose-related),weakness, tremor, Paroxetine 12.5,25mg (Seroxat) PAXIDEP
dizziness,headache """
⬆ ⬆ ⬆ ONLY -APPROVED- FOR
Fluvoxamine 50,100mg (FAVERIN)
OBSESSIVE-COMPULSIVE DISORDER.

Venlafaxine used also for GAD, panic disorder,

VEXAL
SNRIs :same as SSRIs + inhibit reuptake of social anxiety .. 75,150mg (,Effexor)
norepinephrine.
Side effects: Similar to SSRl + Side effects Duloxetine used also peripheral neuropathy,
due to NE: HR, BP dilated pupils (can fibromyalgia, chronic musculoskeletal pain and MODEXA
lead to an episode of GAD .. 60mg (Cymbalta,) $
narrow angle glaucoma),dry mouth, #
excessivesweating and constipation (PRISTIQ) MAY CUZ GHOST TABLET IN
Desvenlafaxine 50mg
STOOL .

Amitryptyline 10,25mg (Amitryptyline tablets,by accord),(Amirol)

Tricyclics: primarily inhibit serotonin and Clomipramine 10,25mg (ANAFRANIL)

norepinephrine reuptake. Side effects: QT
prolongation with overdose, Dry mouth, blurred Imipramine used also off-label for urinary
(TOFRANIL)
Treatment: suitable trial takes at least 4-8 vision, urinary retention, constipation incontinance 10,25mg
weeks.
Maprotiline 25mg (Ludiomil)
⬆ (Epalon)

Tetracyclic antidepressant: has central

Mirtazapine used also to induce sleep
presynaptic alpha-2 adrenergic antagonist
side effects: sedation, appetite , weight gain. TAZMERON, REMERON
effects which results in increase the release of
30mg (Mirzagen)
norepinephrine and serotonin

Dopamine and norepinephrine reuptake

inhibitor. Contraindicated in Seizure disorder. It can be used also for seasonal affective
Side effects: Dry mouth, CNS stimulation ( Bupropion 150mg (WELLBUTRIN XR) disorder (SAD) and in combination with
insomnia, restlessness),tremors/seizures (dose- naltrexone for weight management.
related), weight loss
!➡
Cardiac/QT risk sertraline preferred
%➡
Smoker Bupropion is FDA approved for
smoking cessation
➡
Peripheral neuropathy or pain consider
Duloxetine&❌
➡
Seizure disorder avoid
Tips
bupropion
(➡ ⚠
Pregnant Don't use (paroxetine ), if
mild-moderate use psychotherapy as first line,
if severe use SSRIs

Day time sedating : paroxetine, Mirtazapine

Day time activating: bupropion and fluoxetine

‫ذكورة بالخط العريض‬0‫سماء التجارية ا‬7‫ا‬ &
‫توفره في مستشفى‬0‫حرف الكبيرة هي ا‬7‫وا‬ )
‫الصحة النفسية بأبها )في وقت تواجدي في‬ higher risk with SSRIs and SNRIs.
✅
‫ قد تتوفر شركات وجرعات أخرى‬،‫ستشفى‬0‫ا‬ Sexual dysfunction
‫توفره‬0‫ذكوره هي ا‬0‫مستقب[( وكذلك الجرعات ا‬
ً Lower risk with bupropion and Mirtazapine
‫ستشفى‬0‫في نفس ا‬
+ 1-Change to new antidepressant
MDD
2-Increase the antidepressant dose

Major Depressive Resistant Depression: depression that does not 3-Use a combination of antidepressants with

Disorder fully respond to 2 full treatment trials (each trail

4-8 weeks at therapeutic doses) is considered
different mechanisms of actions

treatment resistant. 4-Augmentation with buspirone or low dose

antipsychotics (quetiapine, olanzapine,
aripiprazole).
Prepared by: Mohammed Ogran
5-Augmentation with lithium, thyroid hormone (i.
Good luck
e., T3) or use electroconvulsive therapy(ECT)

ADHD medications

Atomoxetine (Strattera).

lndomethacin

Antiretrovirals (NNRTls)

Efavirenz

Rilpivirine
,
Cardiovascular medications Beta-blockers (
Drugs may cuz depression
especially propranolol)

Honmones Hormonal contraceptives Anabolic steroids

Antidepressants

Systemic steroids

Interferons

Varenicline

Ethanol "

Stroke, Parkinson disease, dementia, multiple

-
sclerosis, hypothyroidism, low vit D levels,
Medical conditions may cuz depression metabolic disorders (hypercalcemia),
malignancy, overactive bladder, and infectious
diseases can contribute to depression.

To avoid serotonin syndrome and hypertensive

crisis*
■ 2-week washout is required between MAO
inhibitors and:
* SSRls(seefluoxetine, below) and *SNRls
MAO inhibitors (e.g. lsocarboxazid, Phenelzine * TCAs
Tranylcypromine ) keep them spread * Bupropion
■ 5-week washout is required when
changing from:
* Fluoxetine ➔ MAO inhibitor (due to fluoxetine'
s long
half-life)

All antidepressants carry boxed warning of a

⚠⚠ ⚠⚠
possible increase in suicidal thoughts or
Boxed Warning actions in some children , teenagers or young
adults with the first few months of treatment or
When the dose is changed

Adult Dosing per Micromedex for major

depressive disorder, depressive symptoms of
patients with acute suicidal ideation or
behaviour; Adjunct: 84 mg intranasally twice
weekly for 4 weeks in combination with an oral
antidepressant; dosage may be reduced to 56
mg twice per week based upon tolerability;
evaluate therapeutic benefit to determine need
Last week I saw a case (with severe resistant for continued treatment after 4 weeks, use
depression and with previous suicidal attempts) beyond 4 weeks has not been systematically
which had been treated with (Esketamine) as it evaluated).
had been indicated for major depressive
Note
disorder, depressive symptoms of patients with Adult Dosing per Micromedex for major
acute suicidal ideation or behaviour; Adjunct, depressive disorder treatment resistant;
and also for major depressive disorder Adjunct: Induction, 56 mg intranasally on day 1,
treatment resistant; Adjunct. then 56 or 84 mg twice a week during weeks 1
through 4 based on efficacy and tolerability;
give with an oral antidepressant
Maintenance, 56 or 84 mg intranasally once a
week during weeks 5 through 8, then 56 or 84
mg every 2 weeks or once a week during week
9 and thereafter; individualize frequency with
the least frequent dosing to maintain remission/
response; give with an oral antidepressant).
 Schizophrenia is a chronic severe and
Definition disabling thought disorder .

Hallucinations: Which Is Sensing Something

That Is Not Present Such As Imaginary
Voices

Delusions: A Believe About Something Real

That Is Not True Such As Imagine That Your
Common symptoms Family Which Is (Real) Wishes To Hurt You (
Delusions)

Disorganised thinking/behaviour: inability to

focus attention and communicate organised
thoughts

Loss of interest in every day activities, lack

of emotion (apathy), inability to plan or carry
Negative signs and symptoms out activities, poor hygiene, social
withdrawal, loss of motivation (avolition), lack
Diagnosis using DSM-5 of speech (alogia).
Criteria
hallucinations, delusions and disorganised
Positive signs and symptoms
thinking/behaviour

Anticholinergics (centerally acting high

Drugs may cuz psychotic doses), Dextromethorphan, dopamine or
dopamine Agonist, interferons, stimulants
symptoms systemic steroids (typically with lack of
sleep - ICU psychosis).

‫ذكورة بالخط العريض هي‬2‫سماء التجارية ا‬9‫ا‬ Low potency Chlorpromazine 100mg , 25mg Largactil
‫توفره في مستشفى الصحة النفسية بأبها‬2‫( ا‬ First generation antipsychotics (FGAs) cuz
‫ قد تتوفر‬،‫ستشفى‬2‫في وقت تواجدي في ا‬ EPS MORE THAN SGAs, MOA: work mainly Haldol available as Oral, IM-50mg/ml, oral
‫( وكذلك الجرعات‬S‫مستقب‬
ً ‫شركات وجرعات أخرى‬ by blocking the dopamine-2 receptors (D2) Haloperidol 1.5mg, 5mg, 10mg
drop 2mg/ml
‫ستشفى‬2‫توفره في نفس ا‬2‫ذكوره هي ا‬2‫ا‬ with minimal serotonin receptors (5-HT2A)
blockade.
High potency Trifluperazine -Remedica-, Trifluperazine
Trifluperazine 1mg, 5mg
Tablets BP.

⬆ Fluphenazine
⬆ Available as 25mg/1ml IM injection

Aripiprazole 10mg, 15mg (Abilify) Zolinda 15mg

⚠ " ⬇
❗
⚠
❗ Smoking will Drug level.
⬇
Prepared by: Mohammed Ogran
Clozapine 25mg, 100mg, BOXED Monitoring: start treatment if baseline ANC
Note: clozapine is very effective and has
WARNING potential agranulocytosis/ above or equal 1500/mm3, check ANC
risk of EPS/TD but used no sooner than
neutropenia, Seizures, Cardiomyopathy and Leponex weekly for 6 months then every 2 weeks for
3rd due to severe side-effects potential
Myocarditis, SEs: Metabolic syndrome ( 6 months then monthly stop the treatment if
metabolic effects, neutropenia.
weight, Dyslipidemia,
⬆ BG). ANC less than 1000/mm3. # #
Schizophrenia / ⬆
Hold as High Alert Medication
Psychosis " ⬇
Treatment Second generation antipsychotics (SGAs) cuz Olanzapine 5mg, 10mg (Zyprexa), SEs:
⬆
lesser EPS THAN FGAs, MOA: work by somnolence, metabolic syndrome ( weight, Pranza Smoking will Drug level.
Good blocking dopamine (D2) receptors and Dyslipidemia, BG).
Luck serotonin (5-HT2A) receptors.
Paliperidone-active metabolite of
Risperidone-3mg, 6mg (Invega), SEs: EPS
Palipra
especially at higher doses, Prolactin,
⬆
Metabolic Syndrome, QT prolongation.

Risperidone 2mg, 4mg (Risperidal), SEs: SEs: , (Ridon-2mg,4mg) oral

EPS especially at higher doses, Prolactin,
Metabolic Syndrome, QT prolongation. also available as syrup 1mg/ml

Quetiapine 100mg, 200mg, 300mg (

➡ Quetta 200mg, Sequit 100mg, 200mg, Note: LOW EPS RISK- Often used for
seroquel), SEs: somnolence, Metabolic
300mg psychosis in Parkinson’s disease.
Syndrome.
Paliperidone 100mg, 150mg (invega
sustenna) every 4 weeks Sulpiride 50mg, 200mg Dogmatil, Genprid
➡ Others
Aripiprazole 400mg (Abilify Maintena) Amisulpiride 100mg, 200mg, 400mg Solian
➡
every 4 weeks

Haloperidol 50mg/ml (Halodol decanoate) prolonged contraction of muscles during

➡
every 4 weeks drug initiation including painful muscle
Long Acting IM injection spasms; life-threatening if airways
Risperidone 25mg, 37.5mg, 50mg (Risperdal Dystonia compromised, higher risk with the younger
➡
consta) every 2 weeks males, centrally acting anticholinergics (
%& diphenhydramine and benzotropine) can be
Zuclopenthixol 200mg/ml (Clopixol Depot) used for prophylaxis or treatment.
every 2 weeks $
Restlessness with an inability to remain still.
Fluphenazine 25mg/1ml (Fluphenazine Akathisia
treated with benzodiazepines or propranolol.
Decanoate sterop)
Since antipsychotics may cause
Looks similar to Parkinson disease with
extrapyramidal side-effects ( because they
Extrapyramidal side-effects are a group of tremors, abnormal gait and Bradykinesia;
Verbenz Benzotropine 2mg, Oral and IV/IM (cogentin) Treatment side effects block DOPAMINE; and when dopamine
side-effects related to a regular movements
Parkinsonism
treated with anticholinergics or propranolol if
is reduced it cuz EPS) what is
tremors are the main symptoms.
Kemadrin Procyclidine 5mg EPS ? ❗❗
'
Drugs Used to control side effects (I.e. EPS) Abnormal movements more common with
Indicardin Propranolol 10mg, 40mg (Inderal), for tremors Dyskinesias
dopamine replacement for Parkinson disease.
⬆
Trihexphenidyl 2mg, 5mg (hold as controlled Abnormal facial movements primarily in the
Artane
in Abha Psychiatry hospital) tongue or mouth, high risk with elderly
females , tardive dyskinesia can be
Tardive Diskynesias irreversible must stop the drug and
replace with second-generation
antipsychotics with low extrapyramidal side-
effects (e.g. Quetiapine,clozapine).

#Cardiac risk/QT risk

Do not choose a QT-prolonging drug like
ziprasidone, haloperidol, thioridazine or
chlorpromazine.
#History of movement disorder (e.g.,
Parkinson disease)
Do not choose a drug with high risk of EPS [
e.g., FGAs, risperidone, paliperidone (at
higher doses)]. Quetiapine is preferred.
Tips #Overweight/metabolic risk (e.g., TG)
Do not choose a drug that worsens
metabolic issues like olanzapine or
quetiapine. There is a lower metabolic risk
with aripiprazole, ziprasidone, lurasidone and
asenapine.
#Nonadherence or experiencing
homelessness
Choose a long-acting injection
 Bipolar disorder

Introduction

Drug treatment

Lithium
Definitions

Bipolar disorder

Dose
characterized by fluctuations in mood from
an extremely sad or hopeless state to an
abnormally elevated, overexcited or irritable
START: 300-900mg divided BID-TID/day mood called mania or hypomania (a milder
form of mania).

Bipolar depression
In Abha Psychiatry Hospital the available
dose is 300mg lithium (licarb, Lithosun)

Usual range: 900-1800mg divided BID-TID/ Predominant symptoms of a depressive

day episode include feelings of sadness or
depressed mood and/or loss of interest in
previously enjoyed activities.
Lithium therapeutic range: 0.6-1.2mEq/L (
trough level).

Psychosis
Acute mania may require 1.5mEq/L initially.

Severe mental condition where there is a

loss of contact with reality,involves
abnormal thinking and perception (e.g.,
Side effects hallucinations and delusions).

Cyclothymia
GI upset (nausea/diarrhea), cognitive
effects, cogwheel rigidity, fine hand tremor,
thirst, polyuria/polydipsia, weight gain,
hypothyroidism, is a related disorder consisting of periods
of hypomanic and depressive symptoms
without meeting criteria for a major
depressive, manic or hypomanic episode.

Types of Bipolar
Toxicity

Bipolar I
> 1.5 mEq/l: ataxia, coarse hand tremor,
vomiting, persistent diarrhea, confusion,
sedation
At least one episode of mania,and usually,
> 2.5 mEq/l: CNS depression, arrhythmia, bouts of intense depression (a depressive
seizure, coma episode is not required for diagnosis).
Mania is associated with at least one of the
following: significant impairment in social/
work functioning, psychosis/delusionsor
requires hospitalization.

Monitoring
Bipolar II

Serum lithium levels, renal function, thyroid

function (TSH, FT4). At least one episode of hypomania(lasting,,
4 consecutive days)and at least one
depressive episode (lasting" 2 weeks).
Hypomania does not affect social/work
functioning,does not cause psychosis or
require hospitalization.
Note!
$

Symptoms
⚠" #
Avoid in pregnancy ; associated
with cardiac malformations in first
trimester; avoid in breastfeeding .
■ Inflated self-esteem
Key counselling points ■ Needs less sleep
■ More talkative than normal
■ Jumping from topic to topic
■ Easily distracted
■ Increase in goal-directed activity
■ Take with food or at end of meal to
■ High-risk,pleasurable activities
reduce nausea.
(e.g.,buying sprees ,gambling).
■ Maintain consistent salt intake. Changes
in salt intake can
alter lithium levels in the body.
■ Maintain adequate hydration with non-
caffeinated fluids.
■ Avoid dehydration (e.g., excessive
sweating, diarrhea, vomiting and prolonged
heat/sun exposure). Can increase lithium
Treatment
levels and side effects.
■ Avoidin pregnancy/breastfeeding.
■ Notify healthcare provider immediately
for worsening
nausea or diarrhea, slurred speech or ■ The goal of treatment is to stabilize the
confusion. mood without inducing a depressive or
■ Can impair alertness, use caution while manic state. The traditional mood
driving or during stabilizers, such as lithium and antiepileptic
other tasks requiring you to be alert. drugs (valproate, lamotrigine and
carbamazepine), treat both mania and
depression without inducing either
Prepared by: Mohammed Ogran
state.

Good Luck

■ Antidepressants can induce or

exacerbate a manic episode when used as
monotherapy, so they should only be used
in combination with a mood stabilizer.

■ Antipsychotics, while not traditional

mood stabilizers, can help stabilize the
mood when mania occurs with psychosis.

Acute treatment

Acute treatment will depend on the type of

episode (mania vs. depression).
■ Manic episode: first-line treatment is
valproate, lithium or an antipsychotic. A
combination of an antipsychotic + lithium or
valproate is preferred for severe episodes.
■ Depressive episode: first-line treatment
is antipsychotics (e.g. Quetiapine). lithium,
valproate ,lamotrigine can be added or
used as an alternative.

Maintenance

■ Medications that were effective for a

acute episodes should be continued as
maintenance treatment to prevent relapse.
■ These include lithium antiepileptic drugs
and second-generation antipsychotics(
SGAs).
#
Treatment in pregnancy

During pregnancy, lamotrigine is a safer

option relative to the other mood stabilizers
 ⬇
!
SIDE EFFECTS
Insomnia, appetite/weight loss, headache,
$
irritability, N/V, blurry vision, dry mouth.
# $
OROS: An osmotic oral drug delivery system
Monitoring: Consider EEG prior to is one which depends on the mechanics of
treatment; monitor BP and HR cardiac osmotic pressure variations to regulate the
symptoms, CNS effects, abuse potential and delivery of the drug or active agent. This is
height and weight (children) a step forward in ensuring controlled,
Methylphenidate ( %
Concerta), -stimulating stable, and precise delivery of the drug. It
NOTES: makes it independent of gut factors, being
agent-
Concerta is an (OROS) delivery: the outer regulated only by the nature of the
coat dissolves fast to give immediate action, formulation.
and the rest is released slowly; can see a
ghost tablet in stool; harder to crush which
decreases abuse potential

Start 18-36mg QAM, Max dose is 72mg/day

Atomoxetine (strattera) is available in Abha

psychiatry hospital in 10mg,18mg,25mg,40mg.

+ ADHD is
characterized by
Key counselling points symptoms of
inattention,
hyperactivity and
Stimulants: impulsivity. Patients
often have difficulty
■ Can cause: focusing, are easily
□ Increased heart rate and blood distracted, have
pressure trouble staying still
and are frequently
□ Serious cardiovascular events unable to control
□ Insomnia impulsive behavior.
□ Psychosis Atomoxetine (Strattera),
a non-stimulant >70kg: start 40mg/day, ≤70kg 0.5mg/kg/
□ Priapism medication, can be day, (Max dose is: 100mg/day).
■ Decreased appetite: eat a most common tried when stimulants
neuro- do not work well MOA: selective norepinephrine reuptake
larger breakfast to prevent weight developmental enough {after trials of inhibitor
loss; check height and weight disorder in children, 2 - 3 medications). ⚠
regularly in children. occurring almost Strattera can be used BOXED WARNINGS
twice as often in first line when
■ Ghost tablet in stool (Concerta). boys compared to
Risk of suicidal ideation; monitor for suicidal
prescribers are thinking or behavior, worsening mood, or
girls. This is a concerned about the unusual behavior
ATOMOXETINE chronic illness that possibility of abuse by ☠(
frequently continues the patient or family.
■ Can cause: to cause symptoms ⬇
CONTRAINDICATIONS
□ Liver damage IMAO inhibitor use within the past 14 days,
throughout
glaucoma, pheochromocytoma, severe
□ Suicidal ideation adolescence and
cardiovascular disorders
adulthood. ⬇
□ Somnolence !
SIDE EFFECTS
Defects in the appetite. insomnia, somnolence, dry
dopamine pathways mouth, hypertension, tachycardia, headache,
that regulate reward nausea, abdominal pain, erectile dysfunction,
anticipation and libido.
emotional self-
#
regulation can play a
role in ADHD MONITORING
BP,HR, ECG,mood, height and weight (
)➡
children)
The primary treatment %
for ADHD is stimulant NOTES
medications (e.g., Don’t open the capsule ocular
methylphenidate and irritants.
amphetamine) because
they raise dopamine
and norepinephrine Stimulants are the first-
levels. line medications for
ADHD

ADHD medications are Guanfacine ER and

considered first line in clonidine ER are non-
patients ≥ 6 years old stimulant medications
and should be used that can be used alone
with behavioral or in combination with
interventions when stimulants.
available.

Drug
ATTENTION DEFICIT Diagnostic
Background treatment
HYPERACTIVITY criteria

DISORDER (ADHD)

Fails to pay attention, has trouble holding

≥ 6 symptoms of inattention for children up attention, does not pay attention when
to age 16 (≥ 5 symptoms for ages 17 and someone is talking, does not follow through
older), symptoms must have been present for on instructions, fails to finish school work,
INATTENTION Symptoms
at least 6 months and are inappropriate for has difficulty organizing tasks, avoids or
the developmental level. dislikes tasks which require mental effort,
loses things, is easily distracted and is
forgetful.

The DSM-5 diagnostic

Often fidgets or squirms, leaves seat
criteria for ADHD are ≥ 6 symptoms of hyperactivity-impulsivity for
!‫ تم ذكر الدوائ‬Concerta ‫و‬ unexpectedly, runs about when not
based on an children up to age 16 (≥ 5 symptoms for
appropriate, unable to play quietly, is "on the
strattera ‫بحكم توفرهم في‬ assessment of the
HYPERACTIVITY & IMPULSIVITV
ages 17 and older), symptoms must have
Symptoms go" as
primary symptoms, been present for at least 6 months and are
‫مستشفى الصحة النفسية بأبها‬ if "driven by a motor," talks excessively,
inattention and/or inappropriate for the developmental level.
blurts out answers, has trouble waiting his/
hyperactivity and
her turn and interrupts or intrudes on others.
impulsivity

THE FOLLOWING CONDITIONS MUST BE

Prepared by: Mohammed Ogran MET:
■ Several inattentive or hyperactive-
impulsive symptoms were present before age
Good luck
12.
■ Symptoms must have been present in 2 or
more settings (e.g.,at home, school, work,
with friends or relatives, babysitters).
■ Symptoms interfere with functioning and
are not caused by another disorder.
 The symptoms of occasional anxiety (fear,
worry) and any physical symptoms (
tachycardia, palpitations, shortness of
breath, stomach upset, chest pain or other
pain, insomnia or fatigue) resolve once the
Occasional anxiety issue is gone.

With an anxiety disorder, the symptoms are

chronic, severe and cause great distress. The
disorder can interfere with the ability to do
well at school or work and can harm
Anxiety Disorder relationships.
!
Generalized Anxiety Disorder (GAD)
"
Panic Disorder (PD)
#
Social Anxiety Disorder (SAD)
Major types of anxiety disorder
Background
Other disorders that have symptoms of
anxiety include obsessive compulsive
disorder (OCD)and posttraumatic stress
disorder (PTSD)

-Albuterol (if used too frequently or

incorrectly)
-Antipsychotics (e.g.,aripiprazole, haloperidol)
-Bupropion
-Caffeine, in high doses
-Decongestants (e.g.,pseudoephedrine)
-Illicit drugs (e.g.,cocaine, LSD,
methamphetamine)
-Levothyroxine (if therapeutic overdose
occurs) Steroids
-Stimulants (e.g.,amphetamine,
methylphenidate)
Selected drugs cause anxiety -Theophylline
&
⬆
Lifestyle modification, Physical activities,
community engagement, yoga , CBT-
)
cognitive behavioural therapy- in some cases
$
will provide adequate relief without need of
)
Non-Drug treatment medications.
Anxiety Disorder ☘
Natural Products St. John’s wort, valerian, kava, passionflower.
)
Prepared by: Mohammed Ogran
Start at half the initial dose used for
depression and slowly titrate to minimize
Good luck
anxiousness and* jitteriness (common during
the first couple of weeks)
Will not provide immediate relief; takes
Escitalopram, Fluxetine, paroxetine, at least four weeks at higher doses for a
sertraline, Duloxetine, venlafaxine XR, -have noticeable
* effect Other SSRlsand SNRls
First line: SSRI & SNRI been described in MDD page. may be used off-label for anxiety disorder
*
Can use in combination with
antidepressants (e.g., when there is a poor
response) Considered a more favorable
add-on medication than benzodiazepines in
elderly patients
(less sedating) or if there is a risk for
benzodiazepine abuse Does not provide
immediate relief; takes 2-4 weeks for effect

Do not use with MAO inhibitors (or within 14

+
days of discontinuation), linezolid or IV
Treatment Contraindications methylene blue

Buspirone: start 7.5mg PO BID, Can increase ⚠

Risk of serotonin syndrome alone or in
by S mg/day every 2-3 days, to a max dose Warning combination with other serotonergic drugs.
of 30 mg PO BID /
Takewith or without food, but must be ☠
consistent. / Dizziness, drowsiness, headache,
Side effects lightheadedness, nausea, excitement.
/
No potential for abuse, tolerance or
physiological dependence
When switching from a benzodiazepine
to buspirone, the benzodiazepine must be
.
tapered off slowly Avoid use in severe
0 Notes kidney or liver impairment
0
1
Not FDA-approved for anxiety
Tricyclic Antidepressants
1 (TCA): Risk of adverse effects (e.g.,
Amitriptyline, nortriptyline, imipramine. anticholinergic side effects) limit use
Second line 1
Sedating antihistamine with
anticholinergic activity
FDA-approved for anxiety but does not
( treat the underlying condition
Drug treatment Should not be used long-term;
2 use only
short-term, as needed, as an alternative to
Hydroxyzine benzodiazepines
2
3
Not FDA-approved for anxiety but
3 hasshown benefit in patients with anxiety
and neuropathic pain
Has immediate anxiolytic effects similar
Pregabalin (lyrica), Gabapentin (Nurontin) to benzodiazepines
3
Not FDA-approved for anxiety but can
reduce symptoms of stage fright or
performance anxiety (e.g.,tremor,
tachycardia)
Dose: 10-40 mg one hour prior to an
event (such as a public speech)
Can cause CNS side effects (e.g.,
Special situations Propranolol (Inderal, Indicardin) dizziness, confusion)
Use with opioids can result in sedation,
respiratory depression, coma and death
■ BZDs enhance gamma aminobutyric acid ( Risks for abuse, misuse and addiction which
GABA), an inhibitory neurotransmitter. This can lead to overdose or death
causes CNS depression, resulting in Continued use can lead to physical
anxiolytic, anticonvulsant, sedative and/or dependence; abrupt discontinuation can
muscle relaxant properties. ⚠
cause withdrawal symptoms (taper off
Boxed warning slowly).
■ They provide fast relief of symptoms (
antidepressants have a longer onset of Acute narrow-angle glaucoma, sleep apnea,
action) severe respiratory insufficiency, severe liver
disease (clonazepam and diazepam),
myasthenia gravis (diazepam),not for use
■ BZDs can be useful for short-term
ininfants < 6 months of age (diazepam oral),
treatment of acute anxiety that is preventing
premature infants (lorazepam parenteral
restful sleep and disrupting life.
products)
Contraindications
■ If taken long-term, patients can become
addicted to BZDs and develop tolerance, Due
Physiological dependence and tolerance
to the risk of dependence, they should only
develop with chronic use - do not
be used for 1- 2 weeks and then
Benzodiazepines Safety/ side effects/ monitoring discontinue abruptly (taper off slowly), CNS
discontinued. If used for longer periods of
depression, anterograde amnesia, potential
time, they must be tapered off slowly to
for abuse, safety risks in patients age
prevent withdrawal symptoms.
65 years and older {impaired cognition,
delirium, falls/fractures), extravasation with
4
■ Beers Criteria: BZDs are potentially IV use, paradoxical reactions, severe renal or Cross placenta,can cause birth defects and
inappropriate in patients > 65 years old. Warnings hepatic impairment Pregnancy neonatal withdrawal syndrome.
BZDshave a high risk of confusion, dizziness
and falls in the elderly, which is increased if
Somnolence, dizziness, ataxia, weakness,
used with other CNSdepressants.
Side effects lightheadedness
. 5
Clonazepam (Rivotril) 0.25-0.5 mg PO BID. Notes Antidote: flumazenil

Lorazepam (Ativan), 2-3 mg PO daily in

BDZs
divided doses.

Diazepam (Valium) 2-10 mg PO BID-QID.

 There are several types of sleep disorders.
This chapter discusses the primary types
managed with medications: chronic insomnia,
Background restless legs syndrome (RLS)and narcolepsy.
Another common sleep disorder is
obstructive sleep apnea, which is primarily
treated with non-drug measures, including
continuous positive airway pressure (CPAP).

!"

Prepared by: Mohammed Ogran

Good luck Sleep Disorders

# / "0
Chronic insomnia Restless leg syndrome Narcolepsy

) )
Insomnia: is the most common sleep Restless leg syndrome: is an urge to move Drug treatment Narcolepsy is excessive daytime sleepiness Drug treatment
condition and is characterized by difficulty the lower legs, which is sometimes described with cataplexy (sudden loss of muscle tone)
falling asleep (sleep initiation or sleep as a "creeping" sensation. It is worse at night and sleep paralysis. Narcolepsy causes
latency), reduced sleep duration and/or poor and is relieved with movement. The primary treatment of RLS includes Dopamine agonists: can cause orthostasis, Gabapentin: Gabapentin enacarbil is an sudden daytime "sleep attacks" due to poor Narcolepsy is treated with stimulants, such
sleep quality (e.g., awakenings after sleep dopamine agonists and the anticonvulsant somnolence and nausea that is dose-related. extended-release form of gabapentin control of normal sleep-wake cycles. as modafinil orarmodafinil, or with
onset). gabapentin. Pramipexole and ropinirole are approved for postherpetic neuralgia (PHN) sodiumoxybate or calcium, magnesium,
dopamine agonists primarily used in longer- and RLS. potassium and sodium oxybate ,both of
$ %⚔
acting formulations for -Parkinson disease ( which are derived from the inhibitory
Diagnosis Treatment PD)-.For RLS, the immediate-release (IR) neurotransmitter GABA.
formulation is taken 1 - 3 hours before
' ☘ ) bedtime. Rotigotine is a dopamine agonist 1
A diagnosis of chronic insomnia occurs when Non-Drug treatment Natural products Drug Treatment that comes in a patch {applied once daily} Stimulants for wakefulness Sodium oxybates: These drugs are derived Other treatments
the patient has symptoms at least three formulation (used for both PD and RLS). from GABAand are indicated for narcolepsy
times per week for at least three months, 2 with cataplexy.
despite adequate opportunity to sleep. Cognitive behavioral therapy for insomnia ( It is important to treat any underlying Melatonin (3 - 5 mg in the evening) or Hypnotics: The non-benzodiazepines act Modafinil Armodafinil Side effects Notes Histamine-3 (H3) receptor antagonist/ Dopamine and norepinephrine reuptake
CBT-I)is preferred and includes changes to medical conditions that may be contributing ( valerian is used by some patients. Melatonin selectively at benzodiazepine receptors to inverse Agonist (pitolisant) inhibitor (DNRI) - (e.g. solriamfetol)-.
sleep hygiene that can reduce the need for e.g., pain, shortness of breath due to heart is also used for jet lag and can cause increase GABA,an inhibitory Sodium oxybate Calcium, magnesium,
drugs failure, anxiety, bipolar disorder, depression, additive adverse effects (e.g., drowsiness, neurotransmitter. This causes CNSdepression. 200mg PO QAM. 150-250mg PO QAM. Severe rash ,can be life-threatening (e.g., Other indications include obstructive sleep potassium and sodium oxybates
alcoholism) and discontinue medications that daytime somnolence) if used with other CNS Stevens-Johnson syndrome) ,headache , apnea (to help with excessive daytime
can worsen insomnia (see Key Drugs Guy depressants. insomnia, anxiety, nausea. sleepiness)and shift work disorder.
below ), if possible. Zolpidem (Zolonia 10mg) available in Abha Eszopiclone Orexin receptor antagonists: The orexin Melatonin receptor againsts: These drugs are TCA: Tricyclic antidepressants inhibit Benzodiazepines Antihistamines: These drugs compete with {i.
psychiatry hospital and hold as controlled. * ⬆ neuropeptide signaling system promotes agonists at the melatonin receptors, MTl and norepinephrine and 5-HT reuptake. They e.,block) histamine Hl receptors.
wakefulness. Orexin receptor antagonists MT2. This promotes sleepiness and regulates also block acetylcholine and histamine
1-3mg PO QHS, Start with 1mg immediately block the orexin neuropeptide signaling the circadian rhythm to coordinate the sleep- receptors which contribute to side effects (e. Lorazepam, oxazepam and temazepam (L-O-
♀ Female/elderly: 5mg PO/SL/spray QHS, before bedtime , and to 2mg or 3mg system, resulting in drowsiness. wake cycle. g., somnolence). T) are preferred for elderly patients; Doxylamine Diphenhydramine
♂ Males: 5-10mg PO/SL/Spray QHS. if necessary. temazepam can be used for sleep; lorazepam
✅
and oxazepam are indicated for anxiety.
Ramelteon 8mg PO QHS. Tasimelton 20mg PO QHS. Doxepin FDA-APPROVED for treatment of 25mg PO QHS. 50mg PO QHS.
-
Suvorexant 10-20mg PO QHS. Lemborexant 5-10mg P.O. QHS. insomnia, 3-6mg PO QHS, 3mg if ≥ 65years.

⚠ Side effects

-
Sedation (tolerance to sedative effects
can develop after 10 days of use),
Peripheral anticholinergic side effects: dry
mouth, urinary retention {makes it very
difficult for maleswith BPH to urinate), dry/
blurry vision, constipation, Best to avoid
use in BPH (can worsen symptoms) and
glaucoma (can elevate IOP)
 The End.
Good Luck💙
Done by: Mohammed Ogran