Over view of mental disorder

OVER VIEW OF MENTAL ILLNESS
By dr wafa sheikh
Consultant family medicine
8/1/2021
OVER VIEW OF MENTAL ILLNESS DR WAFA SHEIKH 1

Mental health disorders
 Depression
 Anxiety disorders
 Generalized anxiety disorder
 Obsessive compulsive disorder
 Post traumatic stress disorder
 Schizophrenia
 Bipolar disorder
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In saudi arabia
 Al sughayer and farwana 2012 in riyadhThe overall prevalence of
mental disorders was found to be 48% (41% in males and 51% in
females); more than 80% of these cases were mild to moderate.
Females showed significantly more severe disorders than males (P =
0.017)
3
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OVER VIEW OF MENTAL ILLNESS DR WAFA SHEIKH

 Anxiety and Depressive disorders are the two most
common mental health problems encountered in
everyday medical practice ( Marsland et al, 1976 ).
 Anxiety has been found to be the fifth most common
clinical diagnosis in primary care ( Marsland et al, 1976 ; Valbona,
1973 ).
 anxiety was provided by a survey of 350 primary care
physicians, in which anxiety disorders were rated as the
most common psychiatric problem seen in their clinics (
Orleans et al, 1985 ).
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Case 1
You are seeing a 48-year-old female who presents with a 3-month
history of low mood, low energy, poor concentration, and irritability.
She has lost interest most things she had enjoyed and has also
noticed a 20-pound weight gain.
She has been having frequent headaches and has noticed that it is
hard to wake up in the morning. She comes in today because she is
having trouble at work. She has been short-tempered with
colleagues, and her boss has spoken with her once already about her
attitude. She reports no thoughts of suicide but has wondered if
death would be a relief.
She says she has felt restless for a while and feels that she is a bad
person. Her mother suffered from depression. She does not consume
alcohol or any other substances. She is divorced and has no children.
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DSM-5 Criteria for Major Depressive Episode:
( Must have a total of 5 symptoms for at least 2 weeks).
One of the symptoms must be depressed mood or loss of interest.
1. Depressed mood
2. Markedly diminished interest or pleasure in all or almost all
activities
3. Significant (> 5% body weight) weight loss or gain, or increase
or decrease in appetite
4. Insomnia or hypersomnia
5. Psychomotor agitation or retardation
6. Fatigue or loss of energy
7. Feeling of worthlessness or inappropriate guilt
8. Diminished concentration or indecisiveness
9. Recurrent thoughts of death or suicide
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DSM-IV recognizes the following subclasses of
anxiety disorders:
 Generalized anxiety disorder
 Panic disorder
 Obsessive-compulsive disorder
 Phobic disorder
 Social phobia.
 Post-traumatic stress disorder
 panic disorder and agoraphobia in particular
are the most common and severe anxiety
disorders seen in family medicine.
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A 27-year-old female comes to your office expressing concern about a number
of bothersome issues. She says things were going “pretty well” until a few
months ago when she started feeling restless and on edge. She notes feeling
tired and run down and “constantly stressed out.
” She also describes problems falling asleep as she lies awake worrying about
all of the things she needs to get done: “But even though I’m worrying
about all of the things I need to get done, I have such a hard time
concentrating that I can’t even start in my to-do list!”
She is seeking help now because this problem with focus and concentration is
affecting her job performance and threatening her relationship with her job.
At this point in the interview, she becomes very tense and tells you, “You
know, doctor, this is really getting out of control; I feel I can’t function
anymore.”
her physical examination was normal .
CASE 2
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Generalized Anxiety Disorder
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Generalized anxiety disorder
 This patient has GAD, which is defined as unrealistic or excessive worry
about several life events or activities for a period of at least 6 months
during which the person has been bothered more days than not by these
concerns.
 The anxiety and worry are associated with at least three of the
following six symptoms .
 muscle tension, restlessness or feeling keyed up or on edge, easy
fatigability, difficulty concentrating or a sensation of the “mind going
blank” because of anxiety, trouble falling or staying asleep, and
irritability.
 physical symptoms significantly interfere with the
person’s normal routine or usual activities,
or they cause marked distress.
( American PsychiatricAssociation, 2000 )
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 For some patients, the symptoms of GAD are lifelong and
persistent, whereas for others the symptoms are acute,
intermittent, and closely related to environmental stressful
events.
 The 1-year prevalence of GAD in the National Comorbidity
Study was 3.1% (4.3% in women, 2.0% in men) ( Kessler et al,
1994 ).
 The prevalence of GAD in primary care settings has been
estimated to be between 2.8% and 8.5%, with a median
prevalence of 5.8% ( Roy-Byrne and Wagner, 2004 ).
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 In family medicine, symptoms of GAD develop in most
patients secondary to another major DSM-IV disorder, such as
panic disorder, major depression, alcohol abuse, or an axis II
personality disorder
( Breslau and Davis, 1985 ; Katon et al, 1987a).
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GAD treatment
 a. Nonpharmacologic treatment options combine
behavioral interventions including (i) CBT that challenges
distortions in thinking and uses positive affirmations;
(ii) relaxation training, including Abdominal breathing,
and progressive muscle relaxation techniques;
(iii) systematic desensitization using imagery
and/or biofeedback; and (iv) assertiveness training.
 b. Pharmacologic treatment options include the following:
(i) SSRIs, (ii) tricyclic antidepressants, (iii) venlafaxine,
(iv) benzodiazepines, and (v) buspirone.
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GAD treatment
 The heterogeneous nature of GAD makes evaluation of treatment
difficult. GAD is often associated with many other anxiety disorders,
such as panic disorder, PTSD, and agoraphobia, as well as affective
disorders such as major depression ( Breslau and Davis, 1985 ; Katon et al, 1987a, 1987b .
 SSRIs, benzodiazepines, buspirone, β-blockers,
serotoninnorepinephrine reuptake inhibitors, and tricyclic
antidepressants have been found to be more effective than
placebo in patients with GAD ( Roy-Byrne and Katon, 1987 ).
 Numerous studies have demonstrated the efficacy of
benzodiazepines in GAD.
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Benzodiazepines for Treatment of Anxiety
Benzodiazepine
Adult Dosage, Range
(mg/day)[*] Tablet or Capsule (mg)
Alprazolam (Xanax) 0.25-4.00 0.25, 1.0, 2.0
Chlordiazepoxide hydrochloride
Librium 10–100 5, 10, 25
Librium, injectable 50–200 50-mg/mL ampule
Clorazepate dipotassium
Tranxene 15–60 3.75, 7.5, 15.0
Tranxene-SD[†] 11.25-22.50 11.25, 22.5
Diazepam
Valium 4–40 2, 5, 10
Valium, injectable 5–100[‡] 2-mg ampules, 5 mg/mL
Flurazepam (Dalmane) 15–30 15, 30
Lorazepam (Ativan) 1–6 1, 2
Oxazepam (Serax) 30–120 10, 15, 30
Clonazepam (Klonopin) 1–6 0.5, 1.0
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 An important development was the demonstration that SSRIs,
serotonin-norepinephrine reuptake inhibitors (e.g., venlafaxine),
and tricyclics are effective in the treatment of GAD ( Baldwin and
Polkinghorn, 2005 ; Kahn et al, 1986 ).
 Given that most patients with GAD also have a comorbid disorder
such as major depression or panic disorder, it is reasonable to use
similar treatments that are effective for panic disorder.
 With venlafaxine, clinicians can start with 18.75 or 37.5 mg of
sustained-release venlafaxine in the morning and increase by 18.75
mg every 5 days until dosages of 75 to 300 mg are reached.
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 Finally, β-blockers have been used to treat anxiety, but they
generally have a less robust anxiolytic effect than the three
classes of medication described earlier and have the added risk of
precipitating depression ( Roy-Byrne and Katon, 1987 ).
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Case 3
 A 21-year-old college student presents to your
office for evaluation. She complains of feeling
stressed out. She is taking classes full-time and is
also in one of the military reserve units at the
college.
 One weekend each month, she must attend drill
which involves handling weapons. Although she
did not have problems handling the weapons
initially, she now gets very emotional and upset
when she thinks about having to use them at the
next drill weekend. She is nervous and is afraid
that she might accidentally fire a weapon.
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CASE 3 continue
 She knows that her fears are silly and she has
been telling herself to “just get over it.” Last
weekend, at drill, she suddenly felt that she was
going to have a heart attack. She developed
tightness in her chest, her heart was racing, and
she felt unable to breathe.
 Although the symptoms eventually abated, the
episode made her even more alarmed, and now
she is worried that it will happen again and she
will have a heart attack. She comes to see if you
can help……
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Panic Disorder
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Diagnostic criteria for panic disorder
 The key distinguishing feature of panic disorder is the episodic
and recurrent nature of the panic attacks.
 Panic attacks are manifested by the sudden onset of intense
apprehension, fear, or terror and the abrupt development of at
least four of the following symptoms, which reach a peak within
10 minutes:
 dyspnea (actually, the patient often hyperventilates),
palpitations, chest pain or discomfort, choking or smothering
sensations,
 dizziness or faintness, a feeling of unreality or of being detached
from one's self, paresthesia, diaphoresis, trembling or shaking,
chills or hot flashes,
 nausea or abdominal distress, fears of dying, and a fear of going
crazy or losing control during an attack .
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 To meet DSM-IV criteria for panic disorder, at least one
of the attacks must be followed by 1 month of persistent
concern about having additional attacks, worry about the
implications of the attack or its consequences (e.g.,
having a heart attack or “going crazy”), or a significant
change in behavior related to the attack.
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Stage 1 Stage 2 Stage 3
Initial acute panic attack or
cluster of attacks➙
Panic attacks increase in
frequency; phobias develop;
anticipatory anxiety and
avoidance behavior develop;
medical care seeking
dramatically increases for
somatic complaints➙
Agoraphobia; increased
dependence; dramatic
changes in family system;
chronic somatization
develops
Table 57-2 -- Three Stages in the Development of Panic Disorder
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Relationship between PD and other Anxiety Disorders
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Panic disorder
 A patient with panic disorder has cognitive, affective, and
somatic symptoms, as well as social consequences related
to the development of the disorder ( Grant et al, 1983 )
 The patient often selectively focuses on the somatic
components of the panic syndrome and attributes the
increased anxiety and tension to the frightening nature of
these somatic symptoms.
 Studies have demonstrated that the most common initial
somatic symptoms are cardiac (chest pain and tachycardia),
neurologic (headache, dizziness, faintness, paresthesia),
and gastrointestinal (irritable bowel symptoms and
epigastric pain) ( Katon, 1984 ).
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Panic disorder
 The occurrence of cardiac symptoms may especially lead
to costly and potentially dangerous medical tests in
patients with panic disorder.Three studies have
documented that nearly 50% of patients with chest pain
and negative angiographic studies suffer from panic
disorder ( Bass and Wade, 1984 ; Beit man et al, 1987 ; Katon et al, 1988 ).
 Two studies have documented that one quarter to one
third of primary care patients with palpitations meet the
criteria for panic disorder ( Barsky et al, 1995 ; Weber and Kapoor, 1996 ).
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 Labile hypertension develops in some patients with panic
disorder during an attack.The finding of labile
hypertension with associated chest pain, flushing
tachycardia, and shortness of breath often leads to an
aggressive cardiac workup, as well as a potential workup
for pheochromocytoma.
 One study demonstrated that approximately 40% of
patients evaluated for pheochromocytoma suffered from
panic disorder, as compared with less than 5% of
hypertensive controls ( Fogarty et al, 1994 ).
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 In a subgroup of patients with panic disorder, intolerable side effects
develop with all tricyclic antidepressants or SSRIs. Some of these
patients can be treated with very low dosages of SSRIs or tricyclics,
such as 5 mg of paroxetine or 5 to 10 mg of imipramine initially, with
a gradual increase in dosage.
 Another alternative is to couple a low dosage of alprazolam or
lorazepam with the tricyclic, which often decreases the initial
anxiety and jitteriness that may be a transient side effect of
tricyclics.
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 Limited research has also suggested that venlafaxine, a selective
serotonin and norepinephrine reuptake inhibitor, is also more
effective than placebo for panic disorder ( Pollack et al, 1996 ).
 This medication can be started at 37.5 mg, extended-release form,
each morning and gradually increased by 37.5 mg every 5 to 7 days.
Most clinicians recommend twice-daily dosing once the dosage is
increased over 75 mg.
 A small subgroup of patients does not tolerate tricyclic
antidepressants, SSRIs, or selective selective serotonin-
norepinephrine reuptake inhibitors and, for these patients, the
high-potency benzodiazepines are an effective second line of
treatment.
 Alprazolam, lorazepam, and clonazepam have all been
demonstrated to be more effective than placebo for the
treatment of panic disorders ( Lydiard, 1988 ).
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 Patients should start with 0.25 mg of clonazepam three times
daily, with a gradual increase by 0.25-mg increments every 2 to 3
days until the panic attacks cease.
 Dosages of lorazepam and alprazolam equivalent to 0.25 mg
of clonazepam are 0.5 mg lorazepam and 0.5 mg alprazolam ( Roy-
Byrne, 1992 ).
 Monoamine oxidase inhibitors are effective more than placebo
for panic disorder ( Sheehan et al, 1980 ).
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Case 4
 A 19-year-old female comes to your office as a new
patient to establish care. She has recently moved to the
area to start school at a nearby university. As you
examine her, you notice that the skin on her hands is
quite dry and cracked in places. She says, “I have to
wash them a lot. I can’t stand leaving them dirty.’
 After you examine her, you notice that she is becoming
increasingly restless. Suddenly, she stands up from the
exam table and moves to the sink, where she washes
her hands. “I’m so sorry … I know this seems weird, but I
really can’t stand having germs on my hands!” As you
begin to question her further, the patient tells you that
although she has always been a “clean freak,” she has
recently started washing her hands countless times per
day.
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Case continue…..
“I wish I could stop but I just can’t.” She admits that
the recent move away from home has been
stressful. In her new apartment, her organizational
prowess is beginning to affect her relationship with
her new roommate. “I have to organize the spice
rack alphabetically. My roommate never puts them
back in the right place, but I feel like I always have
to check and make sure they’re in the right order
before I leave the house.” At the end of your visit
with you, she says, “Please help me … I’m tired of
this!”
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Obsessive-Compulsive Disorder
(OCD)
 Obsessions defined by:
 recurrent and persistent thoughts, impulses or images
that are intrusive and unwanted that cause marked
anxiety or distress
 The person attempts to ignore or suppress such
thoughts, urges or images, or to neutralize them with
some other thought or action (i.e. compulsion)
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OCD …………continued
 Compulsions as defined by:
 Repetitive behaviors or mental acts that the person
feels driven to perform in response to an obsession or
according to rigidly applied rules.
 The behaviors or acts are aimed at reducing distress or
preventing some dreaded situation however these
acts or behaviors are not connected in a realistic way
with what they are designed to neutralize or prevent.
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Case 5
 A 22-year-old law student comes to your office in a state
of anxiety. He is taking a law class in which 50% of the
class grade is based on class participation. Although he
knows the material well, he is unable to answer the
questions when posed to him by the professor. He now
has gone through 2 months of the 6-month class and has
not been able to answer one of the 14 questions that the
professor has asked him in class.
 The professor asked him to make an appointment for a
“little chat” the other day. At that time, he was told that
he would (in the professor’s words) “fail the class” unless
he began to participate.

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Case continue….
 The student describes himself as a loner. He tells you
that he has always been shy, but this is the first time the
shyness has really threatened to have a major impact on
him. His family history is significant for what he terms
“this shyness.” His mother has the same characteristics,
but for her it does not seem to be causing the kind of life
difficulties that it is causing him.
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Phobic Disorders
 The essential feature of a phobic disorder is the
persistent and irrational fear of a specific object, activity,
or situation that results in a compelling desire to avoid
the dreaded object, activity, or situation.
 The fear is recognized by the individual as excessive or
unreasonable in proportion to the actual danger of the
situation, object, or activity.
( American PsychiatricAssociation, 2000 ).
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Phobic disorder
 Phobic disorders are classified as agoraphobia, the most
pervasive and severe form, which almost always occurs
secondary to the onset of panic attacks; social phobia; and
specific phobia.
 A specific phobia involves a persistent irrational fear and
compelling desire to avoid an object or a situation.
Common specific phobias are fears of heights (acrophobia),
animals, insects, airplanes, and closed-in spaces
(claustrophobia).
 The term generalized social phobia is used when the fears
are related to most social situations (e.g., initiating
conversations, dating, participating in small groups,
attending parties).
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 Patients with social phobia have high lifetime psychiatric
comorbidity (80% with one or more other psychiatric
disorders), especially major depression (37%), other
anxiety disorders (57%), and alcohol or substance abuse
(40%) ( Magee et al, 1996 ).
 Social phobia has marked effects on patients functioning
and social and work achievement.
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Social phobia treatment
a. Nonpharmacologic: CBTs (including relaxation
training, systematic desensitization, flooding, and
cognitive reframing) are most effective for decreasing
symptoms of hyperarousal.
b. Pharmacologic:The drug class of choice is the
SSRIs. Other drug classes of benefit are MAOI
(particularly phenelzine) and beta blockers (particularly
atenolol and propranolol .
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Phobic Disorders
(Specific Phobias, Agoraphobia, Social Phobias)
 SSRIs such as paroxetine have been found to be effective in
randomized placebo-controlled trials in treating generalized
social phobia( Stein et al, 1998) .
 Clonazepam was also shown to be effective in randomized trials
at dosages effective for treating panic disorder ( Davidson et al, 1993 ).
 Finally, phenelzine, a monoamine oxidase inhibitor, was
demonstrated to be effective in treating social phobia in a
randomized controlled trial ( Liebowitz et al, 1992 ).
 Exposure-based treatments such as cognitive-behavioral therapy
have also been shown to be effective ( Alstrom et al, 1984 ) for
generalized social phobia.
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Case 6
 A 41-year-old female comes to your office with
complaint of difficulty trusting people, irritability, low
mood, and recurrent nightmares. Her symptoms started
when she was a teenager following the death of her
parents in a house fire.
 She was rescued by firefighters but has never been able
to forgive herself for surviving when her parents died.
She has not been able to form close relationships, and
she is seeking help because of renewed nightmares.
 They were common in the first 2 years following the
incident but had faded away until recently.
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Case continue….
 Continuing news reports of terrorist activities and
bombings have brought all of this back to the forefront
again. She sometimes wakes up in a fright after
dreaming that her own house is on fire.
 She is afraid to go near any bright lights or fireworks
displays. When she is forced to be in the presence of
fires, she frequently notices palpitations, dyspnea, and a
sense of doom.
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Post Traumatic Stress
Disorder(PTSD)
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PTSD criteria for diagnosis
 The first cluster involves reexperiencing a previous traumatic experience (eg,
flashbacks, nightmares, psychological distress in response to triggers that evoke
the experience).
 The second cluster involves avoidance of stimuli associated with the trauma
(efforts to avoid thoughts, feelings, or conversations associated with the trauma;
efforts to avoid activities, places, or people that arouse recollections of the
trauma; inability to recall an important aspect of the trauma); a numbing of
general responsiveness (markedly diminished interest or participation in
significant activities; feeling of detachment or estrangement from others;
restricted range of affect; a sense of a foreshortened future).
 The third cluster involves persistent symptoms of increased arousal, such as
difficulty falling or staying asleep, irritability or outbursts of anger, difficulty
concentrating, hypervigilance, or an exaggerated startle response.
 *To meet the symptom criteria for PTSD, the patient needs 1 symptom from
the first cluster, 3 from the second, and 2 from the third.
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PTSD treatment
 a. Nonpharmacologic therapy includes the following:
(i) CBT, (ii) psychodynamic therapy (iii)hypnotherapy.
 b. Pharmacologic therapy: Drug classes that have been
shown to be effective for various symptoms include
SSRIs, other antidepressants, beta blockers, mood
stabilizers, and buspirone.
 *Long-term use of benzodiazepines is contraindicated
when treating this disorder because of the increased
association with substance dependence.
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Case 7
 A 21-year-old man presents to your clinic because He
just started his first year in college but quit 2 days ago
because he feels that “they are all out to get me.” He has
not been sleeping because he thinks he might be
murdered in his sleep. He tells you that the FBI has
bugged your office and, therefore, he does not want to
answer your questions.
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 Which of the following would you NOT
expect to find on mental status exam?
A) Delusions.
B) Hallucinations.
C) Lack of insight.
D) Decreased psychomotor activity.
E) Poverty of speech.
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Schizophrenia
 Schizophrenia is a heterogeneous group of disorders characterized
by the following:
 positive symptoms (delusions hallucinations,disorganized
behavior, disorganized speech);
 Negative symptoms (poverty of speech, anhedonia, affective
flattening, avolition, asociality); mood symptoms (dysphoria,suicidal
thoughts, hopelessness); and
 cognitive symptoms (attention and memory deficits and
difficulty with abstract thinking).
 It is the most common of the psychotic disorders.
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 Which of the following medication options is
the proper treatment choice?
A) Olanzapine (Zyprexa).
B) Risperidone (Risperdal).
C) Haloperidol (Haldol).
D) Aripiprazole (Abilify).
E) Any of the above.
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Schizophrenia
 1. Acute treatment: (a) Hospitalization is required for acute
mania with psychosis, (b) antipsychotic agents (olanzapine,
clozapine, risperidone, and haloperidshould be used when psychosis
is present, and(c) benzodiazepines (lorazepam and clonazepam)
maybe useful for severe agitation during mania.
 2. Maintenance and prevention of relapse:
 (a) Lithiumcarbonate is the agent of first choice (usual dosage is 900
to 1200 mg/day),
 (b) anticonvulsive agents (carbamazepine or divalproex) are useful
when lithiumis ineffective or contraindicated, and
 (c) other anticonvulsants such as lamotrigine may be used when the
previously mentioned agents are ineffective when used alone or in
combination.
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Case 8
A 31-year-old patient comes in to your office complaining of
several years of low mood and irritability. He is a writer, but he
has been having trouble for the past few years with getting his
work done.
Every once in a while, he will have a few weeks when he is
quite productive, staying awake for days at a time on a
caffeine-fueled writing marathon.
He feels that these “high” episodes have enabled him to keep
his job as a professor at the local liberal arts college. In
between these episodes, several students have complained to
his department head that he is late to lectures, slow at
returning papers and tests, and hard to contact when they
have questions. He finds himself angry with the students for
being so demanding.
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Bipolar disorder
 Bipolar I disorder One or more manic or mixed episodes, usually
accompanied by one or more major depressive episodes.
 Bipolar II disorder Recurrent major depressive episodes with one or more
hypomanic (milder than manic) episodes.
 Cyclothymic disorder Chronic (> 2 years), fluctuating mood disturbance
involving numerous periods of mild hypomanic and depressive symptoms
that do not meet criteria for a major depressive episode.
 Bipolar disorder (not otherwise specified) Disorders with bipolar features
that do not meet criteria for any specific bipolar disorder .
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Antidepressant
Serotoni
n
Norepine
phrine
Dosage
(mg)
H1
Blocking
Anticholiner
gic Action
Sedation Orthostatic
Hypotension
SelectiveSerotonin Reuptake Inhibitors
Fluoxetine (Prozac) ++++ 0 20–80 0 Lowest Low 0
Sertraline (Zoloft) ++++ 0 50–200 0 Lowest Low 0
Paroxetine (Paxil) ++++ 0 20–50 0 Lowest Low 0
Citalopram (Celexa) ++++ 0 20–40 0 Lowest Low 0
Fluvoxamine (Luvox) ++++ 0 100–300 0 Lowest Low 0
Serotonin-Norepinephrine Reuptake Inhibitors
Venlafaxine extended release
(Effexor XR)
++++ +++ 75–300 Low Lowest Low 0
Mirtazapine (Remeron) ++++ ++++ 30–60 Moder
ate
Lowest Moderat
e
0
Duloxetine (Cymbalta) ++++ ++++ 60–120 Low Lowest Low 0
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Tertiary Amines
Doxepin (Sinequan) +++ ++ 100–
300
Highest Moderate High +++
Amitriptyline (Elavil) ++++ ++ 100–
300
Modera
te to
high
Highest High +++
Imipramine (Tofranil) ++++ ++ 100–
300
Low Moderate Moderate ++
Trimipramine (Surmontil) + + 100–
300
High Moderate High +++
Secondary Amines
Nortriptyline (Pamelor) +++ +++ 50–125 Low Low Moderate +
Protriptyline (Vivactil) +++ ++++ 20–60 Low High Low +
Desipramine (Norpramin) ++ ++++ 100–300 Low Low Low +
Amoxapine (Asendin) ++ +++ 100–300 ? Low Low ++
Triazolopyridine
Trazodone (Desyrel) +++ + 150–500 Low Lowest High +++
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Tricyclic Antidepressants
TCAs can generally be divided into two classes:
1-Tertiary amines (e.g., imipramine, amitriptyline), which tend to be strongly
anticholinergic and antihistaminergic .
2- secondary amines (e.g., nortriptyline, desipramine), which tend to be less so.
Thus, secondary amines are associated with fewer or less severe side effects.
TCAs slow cardiac conduction, making them potentially lethal in overdose and
dangerous for use after myocardial infarction. Because there is a therapeutic
serum drug window and because of toxicity concerns, serum trough levels
should be determined after initiating the medication and at least annually
afterwards.
ECG should be performed for all patients taking more than minimal doses.
Those with heart block or QT prolongation should receive a different class of
drug.TCAs can be sedating and are typically given in a single dose at bedtime.

8/1/2021

Selective Serotonin Reuptake Inhibitors.
 SSRIs are generally better tolerated thanTCAs but have
not been shown to be more effective than other
antidepressants.
 They are safer in overdose and are useful in treating several
anxiety disorders.
 Common side effects include gastrointestinal disturbance,
sexual side effects, akathisia, and hyperhidrosis.
 They are generally safe to use in older adults or the
medically ill (typically used at lower doses) but can alter
cytochrome P450 activity, thus affecting serum drug levels
and pharmacologic activity of other medications ( Crewe et al 1992
).
8/1/2021

Serotonin syndrome
 Although rare, agents that increase serotonin
levels can cause serotonin syndrome, a severe
and potentially fatal reaction marked by
diaphoresis, flushing, nausea, confusion,
autonomic instability, fever, and myoclonus.
 Serotonin syndrome can occur when SSRIs are
used alone, but is more commonly associated
with the combined use of SSRIs and other
medications that can increase serotonin levels,
such as MAOIs,TCAs, lithium, and buspirone.
8/1/2021

SSRI discontinuation syndrome
 More common is the SSRI discontinuation syndrome,
characterized by a flulike syndrome of nausea, dizziness,
paresthesia, headache, anxiety, and a crawling sensation
under the skin.
 The symptoms are usually seen 3 to 4 days after sudden
discontinuation of an SSRI and rapidly dissipate after re
administration.
 Although uncomfortable, this syndrome is not thought to
be dangerous and can be easily avoided by tapering SSRIs
gradually over 1 to 2 weeks.
 This syndrome is more common with shorter half-life
agents, and patients should be alerted to this side effect so
that they do not miss doses of the medication for several
days at a time.
8/1/2021

Screening question…..?
 How ever experienced a panic attack? (Panic)
 Do you consider yourself a worrier? (GAD)
 Have you ever had anything happen that still haunts
you? (PTSD)
 Do you get thoughts stuck in your head that really
bother you or need to do things over and over like
washing your hands, checking things or count? (OCD)
 When you are in a situation where people can observe
you do you feel nervous and worry that they will judge
you? (SAD)
8/1/2021

Thank you
8/1/2021

Over view of mental disorder

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