2. Competence Target
Able to recognize schizophrenia symptoms
Able to make therapeutic plan for acute
psychosis
Able to manage antipsychotic agent side effect
Able to recognize altered mental status in
bipolar disorder
Able to prrovide appropriate pharmacological
therapy in acute mania
Able to determine monitoring strategy for
anticonvulsion therapy in bipolar disorder
3.
4. Consideration
clinical
syndrome
several
poverty of
disease
speech
entities
Schizophrenia
loss of
psychotic
emotional
symptoms
range
insight &
cognitive
motivation impairement
disorder
5. Epidemiology
Present in late adolescence &
early adulthood
1% suffer Equally prevalent between
schizophrenia gender
Symptoms appear earlier in
males
World’s
population
6. Etiology
Monozigot twin 50% if other
diagnosed
Both parents diagnosed 40% risk
1st degree relatives 10% risk
Evidence supports genetic basic no single
“schizophrenic gene”
??? (intrauterine viral/bacterial
infections; environmental stimuli)
8. Characteristic symptoms
Two (or more) of the following, each present for a
significant portion of time during a 1-month period:
Delusions
Hallucinations
Disorganized speech
Grossly disorganized behavior
Negative symptoms
9. Schizophrenia Criteria
Characteristic
symptoms
Ruling out Social/occu
other pational
disorders dysfunction
Continuous signs of
disturbance persist
10.
11. Dopaminergic Treatment of Parkinson Disease
May Lead Symptoms of Schizophrenia
• increased formation and release of dopamine
L-dopa
• inhibit the breakdown of dopamine and thus increase its availability for
MAO release in the synaptic cleft
inhibitors
• stimulates dopamine release in the synaptic cleft
Cocaine
• inhibits dopamine uptake in presynaptic nerve endings and thus at the
Amphetamine
same time raises the transmitter concentration in the synaptic cleft
12. Antidopaminergic Substance Can
Improve Schizophrenia
phenothiazines,
• displace dopamine from receptors
haloperidol
Reserpine • Dopamine-depleting agent
at present not used therapeutically
22. Desired Outcomes
to receive comprehensive treatment designed to achieve
functional outcomes
to decrease positive symptoms and the associated hostile
and aggressive behaviors
to not only reduce symptomatology and psychotic relapses,
but also to improve functional and social outcomes
25. Consideration
1 or more history of one
Mood episodes of or more major Bipolar
disorder mania or depressive disorder
hypomania episodes
can be mixed
Increase suicide With/without
risk psychosis
26. Epidemiology
Bipolar disorder
Mean age onset: 20
Bipolar disorder I Bipolar disorder II
one or more major
one or more manic
affects men and depressive episodes more common in
or mixed mood
women equally and at least one women
episodes
hypomanic episode
27. Etiology
Environmental
Trauma
factors
Anatomic
Genetic
abnormalities
Exposure to
Others chemicals or
drugs
Remain unclear
29. Pathophysiology Hypothesis
elevation of
norepinephrine
Imbalance of mechanisms of
(NE) and dopamine Inositol depletion
cholinergicand
(DA) caused mania, action of lithium and cause poor neuronal
catecholaminergic
and a other mood stabilizers growth
neuronal activity
reduction caused
depression
30. Bipolar Disorder Clinical
Presentation
hypomanic, Mood elevation, Agitation, Impulsivity,
Physical/behavioral
General
Mood and affect
Aggression, Rapid &
manic, depressed Expansive mood, pressured speech,
or mixed state; Decreased need for
Irritable mood, sleep, Insomnia
may or may not (sometimes for days
be in acute Depression, or weeks),
distress Hopelessness, Hypersexuality,
Increased physical
Suicidality energy,
Heightened interest
in pleasurable
activities with high
risk of negative
consequences,
Fatigue,
Hypersomnia
44. Bipolar Disorder Medicine Side
Effect
Valproic acid Carbamazepine Lamotrigin Lithium salts
loss of appetite, drowsiness, maculopapular rash, gastrointestinal upset,
nausea, dyspepsia, dizziness, ataxia, occurring in up to 10% tremor, & polyuria
and diarrhea, tremor, lethargy, and of (dose-related).
and drowsiness. confusion, teratogenic Patients Nausea, dyspepsia, &
(gastrointestinal diarrhea can be
distress minimized by
can be reduced by co- coadministration with
administration with food, use of
food), teratogenic sustained-release
formulations,
& giving smaller doses
more frequently to
reduce the
amount of drug in the
gastrointestinal tract
at a given time
45. Bipolar Disorder Medicine Drug
Interaction
Valproic acid Carbamazepine Lamotrigine Lithium salts
•The risk of a •Carbamazepine •Divalproex slows the •The ACEIs increase
dangerous rash due induces the hepatic rate of elimination serum lithium with
to lamotrigine is metabolism of many of lamotrigine by the potential for
increased when drugs & also about half acute and fatal
given concurrently autoinducer (necessitating toxicity
with divalproex •Antidepressants, dosage reduction) •Thiazide diuretics &
•The metabolism of macrolide antibiotics •Carbamazepine NSAIDs increase
divalproex can be including increases the rate of Lithium retention
increased by erythromycin and lamotrigine
enzyme-inducing clarithromycin, azole metabolism
drugs such as antifungal drugs
carbamazepine & including
phenytoin ketoconazole &
•While divalproex itraconazole, and
may simultaneously grapefruit juice may
slow metabolism of decrease the
the other agents metabolism of
Carbamazepine
47. Primary References
Wells, B., Dipiro, J.T., Schwinghammer, T.L., Dipiro, C.V.,
2009. Pharmacotherapy Handbook. 7th Ed. Mc Graw Hill
Companies. Inc. New York
Schwinghammer, T.L. & Koehler, J.M. 2009.
Pharmacotherapy Casebook: A Patient-Focused
Approach. 7th Ed. Mc Graw Hill Companies. Inc. New
York
Fletcher, A.J., Edwards, L.D., Fox, A.W., Stonier, P. 2002.
Principles and Practice of Pharmaceutical Medicine.
John Wiley & Sons, Ltd. UK
49. Post Test
1. Jelaskan peranan dopamin dalam pembentukan
schizophrenia!
2. Sebutkan sekurangnya 2 penggunaan lain dari antagonis
reseptor D2!
3. Bagaimanakah efek pemberian clozapine bersamaan
dengan penggunaan antibiotik ciprofloksasin?
Bagaimana mekanisme terjadinya efek tersebut?
4. Bagaimanakah efek pemberian asam valproat
bersamaan dengan pemberian lamotrigin?
Bagaimanakah mekanisme terjadinya efek tersebut?
5. Bagaimanakah cara meminimalisasi efek samping terapi
Lithium terhadap saluran cerna?