University of Baghdad/ College of Nursing
Psychiatric Mental Health Nursing Department
Psychiatric Mental Health Nursing
2019-20209/ Lecture 7th
7. Treatment Modalities in Psychiatry
Treatment modalities can be classified into different types, which are:
A. Physical treatment: 1. Psychopharmacology; 2. Electro-convulsive Therapy (ECT)
B. Psychotherapy; and
C. Psychosurgery
A. Physical treatment
1. Psychopharmacology
1. Antidepressants
- Most antidepressants will hinder the breakdown of serotonin or norepinephrine or both.
- These drugs can be used alone or in combination with other medications but only when prescribed.
Classes of Antidepressants:
1. Selective Serotonin Reuptake Inhibitors (SSRIs);
- SSRIs act on serotonin transporters in the brain to increase levels of serotonin in the synaptic cleft.
- SSRIs will often take 3-5 weeks to have a noticeable effect, as the regulation of receptors in the brain
adapts.
- SSRIs are used to treat major depressive disorder and Anxiety.
- Citalopram (Celexa) - Paroxetine (Paxil, Seroxat) - Fluoxetine (Prozac) - Sertraline (Zoloft, Lustral)
2. Serotonin-norepinephrine Reuptake Inhibitors (SNRIs);
- Venlafaxine (Effexor) - Tofenacin (Elamol, Tofacine)
3. Tricyclic Antidepressants (TCAs);
- Amitriptyline (Elavil, Endep) -Amitriptylinoxide (Amioxid, Ambivalon, Equilibrin) - Clomipramine
(Anafranil) - Desipramine (Norpramin, Pertofrane) - Imipramine (Tofranil) - Lofepramine (Lomont,
Gamanil) - Nortriptyline (Pamelor, Aventyl) - Trimipramine (Surmontil)
4. Monoamine Oxidase Inhibitors (MAOIs);
Non-selective: - Isocarboxazid (Marplan) - Phenelzine (Nardil)
Selective: - Selegiline (Eldepryl, Zelapar, Emsam)
5. Tetracyclic antidepressants (TeCAs);
- Amoxapine (Asendin)
6. Noradrenergic and Specific Serotonergic Antidepressant (NaSSAs)
- Mianserin (Bolvidon, Norval, Tolvon) - Mirtazapine (Remeron, Avanza, Zispin)
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Uses of antidepressants
1. Major depressive disorder; 2. Dysthymia; 3. Anxiety disorders; 4. Obsessive-compulsive disorder;
5. Eating disorders; 6. Chronic pain; 7. Neuropathic pain
- And, in some cases such as Dysmenorrhoea, Snoring, Migraine, Attention-deficit hyperactivity
disorder (ADHD), Addiction, Dependence, and Sleep disorders.
General side effects of antidepressants: Some of the various side effects from the different
antidepressants are: - Dry mouth - Urinary retention - Blurred vision - Constipation - Sleep
disruption - Sedation (can interfere with driving or operating machinery) - Weight gain - Headache -
Nausea - Gastrointestinal disturbance/diarrhea - Abdominal pain -Inability to achieve an
erection - Inability to achieve an orgasm (men and women) - Loss of libido - Agitation - Anxiety
2. Antipsychotics
- Also known as neuroleptics or major tranquilizers, are a class of psychiatric medication primarily
used to manage psychosis (including delusions, hallucinations, or disordered thought), in particular in
schizophrenia and bipolar disorder, and are increasingly being used in the management of non-
psychotic disorders.
Types
A. Typical:
1. Benzamides: - Levosulpiride - Nemonapride - Sulpiride - Sultopride - Tiapride
2. Butyrophenones: - Azaperone - Bromperidol - Droperidol - Haloperidol
3. Diphenylbutylpiperidines: Clopimozide · Fluspirilene · Penfluridol · Pimozide
4. Phenothiazines: Acepromazine · Acetophenazine - Chlorpromazine - Fluacizine
- Fluphenazine - Perazine · Perphenazine · Piperacetazine · Pipotiazine · Prochlorperazine
- Promazine · Thioridazine · Trifluoperazine · Triflupromazine
5. Thioxanthenes: Chlorprothixene · Clopenthixol · Flupentixol · Thiothixene
6. Tricyclics: · Fluotracen · Loxapine · Trimipramine
B. Atypical
1. Benzamides: Amisulpride · Remoxipride
2. Butyrophenones: Cinuperone · Melperone · Setoperone
3. Benzo(iso)oxazolepiperidines: Iloperidone · Ocaperidone · Paliperidone · Risperidone
4. Benzo(iso)thiazolepiperazines: Lurasidone · Perospirone · Revospirone · Tiospirone
5. Diphenylbutylpiperazines: Amperozide
6. Phenylpiperazines: Aripiprazole · Bifeprunox · Brexpiprazole
7. Tricyclics: Amoxapine · Asenapine · Carpipramine · Clocapramine · Clorotepine
Side effects of Antipsychotics
- Abnormal gait (manner of walking) - Agitation - Akathisia - Anxiety - Birth defects - Blood
disorders - Blood-sugar abnormalities - Blurred vision - Breastmilk production - Cardiac arrest
- Changes in behavior - Chest pain - Confusion - Constipation - Death from liver failure
Decreased sexual interest or ability - Depression - Diabetes - Diarrhea - Difficulty breathing,
- swallowing or fast breathing - Difficulty falling asleep or staying asleep - Difficulty urinating or
loss of bladder control - Dizziness - Dreaming more than usual - Drowsiness - Dry mouth - Dry
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or discolored skin - Excess sweating - Excessive weight gain - Extreme inner anxiety - Eye pain
or discoloration - Fainting - Fast, irregular, or pounding heartbeat - Fatal blood clots – Fever
3. Anxiolytics (Anti-anxiety)
An anxiolytic (also anti-panic or antianxiety agent) is a medication or other intervention that inhibits
anxiety. This effect is in contrast to anxiogenic agents, which increase anxiety. Together these
categories of psychoactive compounds or interventions may be referred to as anxiotropic
compounds/agents.
A. Barbiturates
- They are drugs that act as central nervous system depressants, and can therefore produce a wide
spectrum of effects, from mild sedation to total anesthesia. They are also effective as anxiolytics,
hypnotics, and anticonvulsants. Barbiturates also have analgesic effects;
- Barbiturates exert an anxiolytic effect linked to the sedation they cause.
- The risk of abuse and addiction is high.
- Many experts consider these drugs outdated for treating anxiety but valuable for the short-term
treatment of severe insomnia, though only after benzodiazepines or non-benzodiazepines have failed.
- allobarbital - amobarbital - aprobarbital - alphenal - barbital - brallobarbital
B. Benzodiazepines
- Benzodiazepines are prescribed for short-term relief of severe and disabling anxiety.
- Benzodiazepines may also be indicated to cover the latent periods associated with the medications
prescribed to treat an underlying anxiety disorder.
- They are used to treat a wide variety of conditions and symptoms and are usually a first choice when
short-term CNS sedation is needed.
- Longer-term uses include treatment for severe anxiety.
- If benzodiazepines are discontinued rapidly after being taken daily for two or more weeks there is a
risk of benzodiazepine withdrawal and rebound syndrome, and tolerance and dependence may also
occur, but may be clinically acceptable.
- There is also the added problem of the accumulation of drug metabolites and adverse effects.
Benzodiazepines include:
- Alprazolam (Xanax) - Bromazepam (Lectopam, Lexotan) - Chlordiazepoxide (Librium)
- Clonazepam (Klonopin, Rivotril) - Clorazepate (Tranxene) - Diazepam (Valium)
- Lorazepam (Ativan) - Oxazepam (Serax, Serapax).
Side effects
- Acute hyperexcited states - Aggressive behavior - Agitation - Agranulocytosis (condition
affecting white blood - cells causing susceptibility to infection) - Akathisia - Amnesia
- Anxiety - Blurred vision - Changes in appetite - Changes in sex drive or ability
- Chest pain - Confusion - Constipation - Diarrhea - Difficulty urinating
- Disorientation - Dizziness or lightheadedness - Drowsiness - Dry mouth - Epileptic seizures
and death have resulted from suddenly stopping - Fast or irregular heartbeat – Fatigue - Fear
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4. Lithium
- Since the 1950s, lithium salts have been the main line of treatment for bipolar disorder (BD), both as
a prophylactic and as an episodic treatment agent.
- Response to lithium seems to cluster in families and can be used as a predictor for recurrence of
Bipolar disorder (BD) symptoms.
- Bipolar disorder is often treated with what are called mood stabilizers, which include lithium,
valproate, or carbamazepine. These medications can be very effective in treating hypomania or mania
and preventing the recurrence of bipolar episodes.
- Lithium therapy remains a key component in the treatment of psychiatric conditions where the main
symptoms are mood changes.
- Lithium requires strict monitoring as it works within a relatively narrow therapeutic range - too little
and it will be ineffective, too much and it could be toxic.
- Patients who are prescribed lithium must have access to robust monitoring protocols to reduce the risk
of physical harm caused by toxicity.
Side effects
- Acne - Birth defects if given to a pregnant woman - Blackout spells - Blurred vision
- Cardiac arrhythmia - Change in the ability to taste food - Chest tightness - Coma - Confusion
Constipation - Decreased appetite - Depression - Diabetes - Diarrhea - Difficulty thinking
- Dizziness - Drowsiness - Dry mouth - Excessive saliva in the mouth - Fast, slow, irregular, or
pounding heartbeat - Frequent urination - Gas - Giddiness - Hair loss - Hallucinations
- Incontinence - Increased thirst - Indigestion - Insomnia - Itching - Joint or muscle pain
- Lethargy - Lightheadedness - Loss of appetite - Loss of coordination - Movements that are
unusual or difficult to control - Muscle weakness, stiffness, twitching, or tightness - Nausea
- Painful, cold, or discolored fingers and toes - Paleness - Persistent headache
5. Stimulants
A stimulant is a drug that stimulates the central nervous system, increasing arousal, attention and
endurance. Stimulants are used in psychiatry to treat attention deficit-hyperactivity disorder. Because
the medications can be addictive, patients with a history of drug abuse are typically monitored closely
or treated with a non-stimulant.
Common stimulants:
∑ Methylphenidate (Ritalin, Concerta), a norepinephrine-dopamine reuptake inhibitor
∑ Dexmethylphenidate (Focalin), the active dextro-enantiomer of methylphenidate
∑ Mixed amphetamine salts (Adderall), a 3:1 mix of dextro/levo-enantiomers of amphetamine
∑ Dextroamphetamine (Dexedrine), the dextro-enantiomer of amphetamine
∑ Lisdexamfetamine (Vyvanse), a prodrug containing the dextro-enantiomer of amphetamine
∑ Methamphetamine (Desoxyn), a potent but infrequently prescribed amphetamine
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2. Electro-convulsive Therapy (ECT):
- ECT is a physical therapy in which with the help of electrodes, electrical current is passed to the brain
to produce generalized seizures.
- Modified electroconvulsive therapy (ECT) is a controlled medical procedure in which a seizure is
induced in an anaesthetized patient to produce a therapeutic effect.
- Electroconvulsive therapy (ECT) is a highly technical procedure requiring a team that consists of an
anesthetist, a psychiatrist, psychiatric nurses, and recovery nurses.
- Psychiatric nurses have an important role in caring patients who receive ECT.
* Indications for ECT
- Severe depression - Acute mania - Mood disorders with psychotic features
- Intolerance to side effects of medication or other treatments - Deterioration in condition, or
appearance of suicidality or pronounced lethargy. - Acute catatonia
* Contra-indications: Contraindications to ECT include brain tumours, space-occupying lesions, and
other brain diseases that cause increased intracranial pressure.
B. Psychotherapy
Types
A. Psychodynamic Therapy:
- Psychodynamic approaches explore how events that have happened in early life may have affected
the way they people feel about them, relate to others and deal with emotions.
- Often these things are deeply buried and people do not realise how they have been affected until they
start to think about it in therapy. Gaining a better understanding can help people to make sense of what
might be causing their non-epileptic attacks (NEAs), and to develop strategies for making helpful
changes in their lives.
B. Cognitive Behavioural Therapy (CBT):
- CBT is more focused towards the ‘here and now’ of situations and aims to identify thoughts and
actions which make a person's problems worse or fail to resolve them.
- The therapist then works with the patient to use ways of thinking and of addressing difficulties which
deal with problems more effectively.
- CBT involves elements such as monitoring yourself (for instance by completing diaries).
- CBT techniques are often suggested in self-help manuals, but are also used in individual or group
settings.
C. Interpersonal Therapy (IPT):
- Looks at the connections between symptoms and current interpersonal problems (such as problems in
relationships with partners or family members)
- Therapy focuses on current social relationships and how expectations within these relationships may
be causing a patient’s symptoms
- Treatment involves resolving relationship problems or finding new relationships or activities as
compensation.
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D. Cognitive Analytical Therapy (CAT):
- Therapy aims to help the patient recognise patterns of unhelpful actions and recognise their origin.
- Attention is given to the link between patterns of behaviour in childhood and current thoughts and
behaviours. Treatment involves learning new and better strategies to cope with ongoing difficulties.
E. Family Therapy:
- A family therapist works with several members of the family or couples at the same time. Therapy
focuses on relationships within the family and looks at how the family solves problems (or how
ineffective ways of solving problems may make them worse).
C. Psychosurgery (Neurosurgery)
- Psychosurgery or neurosurgery is the neurosurgical treatment of mental disorders.
- The modern history of psychosurgery begins in the 1880s.
- The first significant foray into psychosurgery in the twentieth century was conducted by the
Portuguese neurologist Egas Moniz who during the mid-1930s developed the operation known as
leucotomy (the surgical operation of cutting some of the nerve fibres in the frontal lobes of the brain for
treating intractable mental disorders).
- Some countries have abandoned psychosurgery altogether; in others, for example the US and the UK,
it is only used in a few centres on small numbers of people with depression or obsessive-compulsive
disorder (OCD).
- Psychosurgery is collaboration between psychiatrists and neurosurgeons.
- During the operation, which is carried out under a general anaesthetic and using stereotactic method, a
small piece of brain is destroyed or removed.
- About a third of patients show significant improvement in their symptoms after operation.
- Advances in surgical technique have greatly reduced the incidence of death and serious damage from
psychosurgery; the remaining risks include seizures, incontinence, decreased drive and initiative,
weight gain, and cognitive and affective problems.
- Currently, interest in the neurosurgical treatment of mental illness is shifting from ablative
psychosurgery (where the aim is to destroy brain tissue) to deep brain stimulation (DBS) where the aim
is to stimulate areas of the brain with implanted electrodes.
Assist. Professor
Dr. Maan Hameed
2019-2020
