For Second Year Diploma in Pharmacy.

1. PSYCHIATRIC
DISORDER
Mr. Kiran B. Dhamak

3. Introduction
 Many people have mental health concerns
from time to time.
 But a mental health concern becomes a
mental illness when ongoing signs and
symptoms cause frequent stress and affect
your ability to function.
 A mental illness can make you miserable and
can cause problems in your daily life, such as
at school or work or in relationships.
 In most cases, symptoms can be managed
with a combination of medications and talk
therapy (psychotherapy).

4. Symptoms
 Feeling sad or down
 Confused thinking or
reduced ability to
concentrate
 Excessive fears or worries,
or extreme feelings of guilt
 Extreme mood changes of
highs and lows
 Withdrawal from friends and
activities
 Significant tiredness, low
energy or problems sleeping
 Detachment from reality
(delusions), paranoia or
hallucinations
 Inability to cope with
daily problems or stress
 Trouble understanding
and relating to situations
and to people
 Problems with alcohol or
drug use
 Major changes in eating
habits
 Sex drive changes
 Excessive anger, hostility
or violence
 Suicidal thinking

5. Types of Psychiatric Disorders
 Depression
 Anxiety
 Psychosis

6.  A psychiatric disorder is a mental illness refers
to a broad range of problems that disturb
person's thoughts, feelings, behavior or mood.
 It can significantly affect a person's ability to
perform at work or school, or maintain healthy
social relationships.
 Psychiatric disorders are treatable.

7.  Examples of psychiatric disorders are:
 (1) Major depressive disorder (Depression)
which is characterized by persistent low
moods and loss of energy and enthusiasm.
 (2) Generalized anxiety disorder (Anxiety)
which is characterized by excessive,
persistent, unrealistic worry about everyday
things.
 (3) Psychosis which is characterized by a
disconnection from reality (may have
hallucinations or delusions).

8.  (4) Post-traumatic stress disorder which is
characterized by intense, disturbing thoughts
and feelings related to a traumatic experience
long after the experience is over.
 (5) Bipolar disorder which is characterized by
extreme shifts in mood, energy, and activity
level.

9. DEPRESSION
 Depression, also known as major depressive
disorder (MDD) or clinical depression is
achronic episodic and relapsing mood disorder
primarily characterized by depressed or sad
mood and anhedonia lasting for at least 2
weeks.
 Anhedonia is an inability to feel pleasure
normally pleasurable activities MDD can cause
significant distress and impairment is leading
cause of suicide Occurrence of MDD in
females is almost twice than in males There
are various subtypes of MDD characterized by
additional symptoms or occurrenc in

10.  (a) Atypical depression additionally
characterized by weight gain and increase
appetite
 (b) Psychotic depression with additional
psychotic features such as hallucinations an
delusions
 (c) Peripartum depression which occurs during
or shortly after pregnancy.

11. Etiopathogenesis of Depression
 The etiology of depression is very complex. It
includes both biological and psychological factors.
 Decreased levels of monoamine
neurotransmitters (serotonin, noradrenaline,
dopamine) are believed to be the
pathophysiological basis in most cases.
 Psychological factors such as traumatic and
stressful experiences and comorbidities like
neurodegenerative and chronic inflammatory
diseases also play important role in developing
depression.
 Complications of depression include self-

12. Clinical Manifestations of
Depression
 Depression symptoms can vary from mild to
severe and can include: sad mood, a feeling of
deep sadness (melancholia), anhedonia, low
energy, worthlessness, guilt, psychomotor
retardation or agitation, change in appetite
and/or sleep, increase in purposeless physical
activity (e.g, hand-wringing or pacing) or
slowed movements and speech, suicidal
thoughts etc.
 In elderly patients, memory loss and other
symptoms seen in dementia may be there.

13. Diagnosis and Investigation of
Depression
 First of all, rule out medical causes of
depression and drug induced depression.
Follow the DSM-5 criteria to make a diagnosis
of depression DSM-5 is Diagnosis Statistical
Manual of Mental Disorders, 5 Ed. Available at
 https://psychiatry.org/psychiatrists/practice/ds
m Use screening tools
 eg. Patient Health Questionnaire PHQ9, PHQ2

14. Management of Depression
 Goals of Therapy
 1. Resolution of all signs and symptoms of
depression (i.e, remission) and restoration of
functioning
 Reduction of further episodes of depression (ie,
relapse or recurrence).
 Prevention of occurrence of new episode of
depression and suicide.
 Resolving residual symptoms (eg, fatigue,
cognitive impairment, anhedonia, anxiety).
 Restoration of occupational, psychosocial and
interpersonal function

15. Treatment Modalities Available:
 1. Psychotherapy alone
 2. Pharmacotherapy alone
 3. Psychotherapy combined with pharmacological
therapy
Selection of treatment modality is based on
following factors
 1. Severity of symptoms (mild, moderate or
severe)
 2. Presence of other diseases (comorbidities) or
psychosocial stressors
 3. Preference of patient
 4. History of prior treatment

16.  Psychotherapy or pharmacological therapy
may be used alone if patient has mild to
moderate depression.
 Psychotherapy combined with
pharmacological therapy may be useful for
patients with moderate to severe depression.

17. Non-Pharmacological Management of
Depression
 Psychotherapy
 Psychotherapy is the initial choice of treatment
for mild to moderate depression.
 It is also he treatment of choice for pregnant
patients or those who desire pregnancy. It is
given in combination with antidepressants in
patients who have moderate to severe
depression.
 Types of psychotherapy include:

18. (a) Cognitive behavioral therapy
(CBT)
(b) Interpersonal therapy
(c) Psychodynamic psychotherapy
(d) Family and couples therapy

19.  (a) Cognitive-Behavioral Therapy (CBT):
Cognitive behavioral therapy helps the patient
to recognize negative or unhelpful thought and
behavior patterns. It promotes self control over
thinking patterns.
 (b) Interpersonal Therapy (IPT):
Interpersonal therapy aims at resolving
interpersonal problems (eg, social isolation,
prolonged grief, reducing stress involving
family and work, improving communication
skills and symptomatic recovery.

20.  (c) Psychodynamic Psychotherapy:
Psychodynamic psychotherapy aims at
promoting personality change through
understanding of major conflicts, ego
distortions providing role model, permitting
emotional release of aggression.
 (d) Family and Couples Therapy: It is
considered for patients with significant marital
or family distress

21. Pharmacological managements
 1. The goal of pharmacotherapy of depression
is the resolution of current symptoms
(ie.remission) and the prevention of further
episodes of depression (ie. relapse or
recurrence)
 2. Selection of antidepressant drugs will be
based on side effect profile, prior respons
history of patient or family member presence
of comorbidities, concurrent medication risk of
death from overdose and patient preference
and cost.

22.  3. Patients should be informed that adverse
effects might occur immediately, whereas
resolution of symptoms can take 2 to 4 weeks
or longer. If side effects occur, eithe decrease
the dose of the drug or shift to another
antidepressant which does not cause the
same adverse effect.
 4. Always start with the lowest dose of drug
and increase in small steps to full therapeutic
dose.
 5. It is recommended that antidepressant dose
be increased in patients who non-improvers

23. Classification of
Antidepressants
 Selective serotonin reuptake inhibitors
(SSRIs). Health care providers often start by
prescribing an SSRI. These antidepressants
generally cause fewer bothersome side effects
and are less likely to cause problems at higher
therapeutic doses than other types of
antidepressants. SSRIs include
 fluoxetine (Prozac),
 paroxetine (Paxil, Pexeva),
 sertraline (Zoloft),
 citalopram (Celexa) and
 escitalopram (Lexapro).

24.  Serotonin and norepinephrine reuptake
inhibitors (SNRIs). Examples
of SNRIs include
 duloxetine (Cymbalta, Drizalma Sprinkle),
 venlafaxine (Effexor XR),
 desvenlafaxine (Pristiq) and
 levomilnacipran (Fetzima).

25.  Atypical antidepressants. These
antidepressants are called atypical because
they don't fit neatly into any of the other
antidepressant categories. More-commonly
prescribed antidepressants in this category
include trazodone, mirtazapine (Remeron),
vortioxetine (Trintellix), vilazodone (Viibryd)
and bupropion (Forfivo XL, Wellbutrin SR,
others). Bupropion is one of the few
antidepressants not frequently associated with
sexual side effects.

26.  Tricyclic antidepressants. Tricyclic
antidepressants — such as imipramine,
nortriptyline (Pamelor), amitriptyline, doxepin
and desipramine (Norpramin) — tend to cause
more side effects than newer antidepressants.
So tricyclic antidepressants generally aren't
prescribed unless you've tried other
antidepressants first without improvement.

27.  Monoamine oxidase inhibitors
(MAOIs). MAOIs — such as tranylcypromine
(Parnate), phenelzine (Nardil) and isocarboxazid
(Marplan) — may be prescribed, often when
other medicines haven't worked. This is because
they can have serious side effects. Using
an MAOI requires a strict diet because of
dangerous (or even deadly) interactions with
foods that contain tyramine — such as certain
cheeses, pickles and wines — and some
medicines, including pain medicines,
decongestants and certain herbal supplements.
Selegiline (Emsam), an MAOI that you stick on
your skin as a patch, may cause fewer side

28.  Other medications. Your health care provider
may recommend combining two
antidepressants. Or your provider may add
other medicines to improve antidepressant
effects. This is called augmentation. Examples
of antidepressant augmentation medicines
include aripiprazole (Abilify), quetiapine
(Seroquel) and lithium (Lithobid).

29. Anxiety
 The term anxiety has been used for decades
to refer to thoughts and behaviours that were
distressful in nature.
 But before they referred to these as “anxiety
disorders”, they are called “neurosis” which
means nervousness that was not based in
fact.
 Anxiety can be described as a feeling of alarm
or worry. It may be about something specific or
it may be non-specific in nature.
 At certain level it improves our performance
and allow people to avoid dangerous

30.  This normally lasts for a short period causing
no impairment in social or occupational
functioning.
 When this anxiety is prolonged and affects
social or occupational functioning, it is
abnormal and accounts for anxiety “disorder”.

31. Etiopathogenesis
 Anxiety is of a greater degree than just everyday
worries and patients do mention that they are not
able to control these worries. They are frequently
accompanied with physical symptoms as well.
These symptoms have to present for most days at
least for several weeks at a time.
 Patients often experience a state of intense
apprehension, uncertainty, and fear resulting from
the anticipation of a threatening event or situation,
often to a degree that normal physical and
psychological functioning is disrupted. This may be
precipitated due to several reasons which are
generally easily identified by patient himself.

32. Clinical manifestations
 Feelings that something undesirable.
 Dry mouth, swallowing difficulty, hoarseness.
 Rapid breathing and heartbeat, palpitations.
 Twitching or trembling.
 Muscle tension headaches backache.
 Dizziness or faintness.
 Difficulty in concentrating.
 Nausea, diarrhoea, weight loss.
 Memory problems and difficulty in concentrating.
 Sweating, fatigue, irritability.
 Sleeplessness and nightmare.

33. Non-pharmacological
managements
 Follow the diet rules and pattern because any
disturbance in the digestive activity leads to the
mental manifestations.
 Visit the religious and graceful places and try to
spending much time on that place.
 Avoid the over thinking and bad habits and try to
always indulges with your own work, which makes
you pleasant.
 Regular practice of yoga and meditation it is the
most important factor for managing the psychiatric
disorders.
 Multimedia, internet etc. are one among the cause
of the psychiatric disorder, so try to use those
such things with proper time and need.

34. Pharmacological Management of
Anxiety
 Selective serotonin reuptake inhibitors
(SSRIs). Health care providers often start by
prescribing an SSRI. These antidepressants
generally cause fewer bothersome side effects
and are less likely to cause problems at higher
therapeutic doses than other types of
antidepressants. SSRIs include
 fluoxetine (Prozac),
 paroxetine (Paxil, Pexeva),
 sertraline (Zoloft),
 citalopram (Celexa) and
 escitalopram (Lexapro).

35.  Serotonin and norepinephrine reuptake
inhibitors (SNRIs). Examples
of SNRIs include
 duloxetine (Cymbalta, Drizalma Sprinkle),
 venlafaxine (Effexor XR),
 desvenlafaxine (Pristiq) and
 levomilnacipran (Fetzima).

36. Psychosis
 Psychosis and the specific diagnosis of
schizophrenia represent a major psychiatric
disorder (or cluster of disorders) in which a
person’s perceptions, thoughts, mood and
behaviour are significantly altered.
 Psychosis is a common and functionally
disruptive symptom of many psychiatric,
neurodevelopmental, neurologic, and medical
conditions and an important target of
evaluation and treatment in neurologic and
psychiatric practice.

37. Etiopathogenesis
 A psychotic episode or disorder will result in
the presence of one or more of the following
five categories: delusions, hallucinations,
disorganized thought, disorganized behaviour,
negative symptoms.
 Some common causes similar to the anxiety
but is also induced as-
 Genetic/heredity.
 Chemical imbalances.

38. Clinical manifestations
 Unusual and extremely slowed movements.
 Incoherent or disorganized speaking.
 Hallucinations, usually related to hearing
voices or strange sounds.
 Delusions
 Isolating behaviour.
 Feeling suspicious paranoid or afraid.
 Not caring about their hygiene and
appearance.
 Depression anxiety and suicidal thought.

39. Non-pharmacological
managements.
 Follow the diet rules and pattern because any
disturbance in the digestive activity leads to the
mental manifestations.
 Visit the religious and graceful places and try to
spending much time on that place.
 Avoid the over thinking and bad habits and try to
always indulges with your own work, which makes
you pleasant.
 Multimedia, internet etc. are one among the cause
of the psychiatric disorder, so try to use those
such things with proper time and need.
 Regular practice of yoga and meditation it is the
most important factor for managing the psychiatric
disorders.

40. Pharmacological managements