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(Mental Disorders, Psychiatric Illnesses) ( ) ( ) 3
(Etiology) 力 理 力 力 理 力 力 理 力 理 臨 理 臨 理 理 路 路 路 療 惡 4
(Classification) 5
(WHO) ICD- 10 F0-F9 75 DSM-IV-TR 6
7
8
(Mental Status Examination, MSE) 9
10
11
12
Alzheimer 13
14
15
16
17
18
19
20
40 0.5% 1.5% 0.5 5 40% 80% 50% 10% 21
22
23
10% 15% 15% 25% 15% 20% 24
35% 5% 10% 2 50% 60% 70% 25
26
27
0.4% 1.6% 0.5% 2% 18% 28
29
30
anxiety disorders somatoform disorders minor mental disorders 10% 31
32
33
34
35
36
37
38
39
(Personality Disorders) 40
A 41
B 42
C 43
A B B C C 44
(Impulse Control Disorders) 45
(Adjustment Disorders) 46
47
48
(Mental Retardation, MR) IQ70 IQ 50-55 70 IQ IQ IQ 35-40 50-55 20-25 35-40 20-25 49
50
51
52
7 2 1 9 1 53
(Drug Treatment) 54
55
(Community Psychiatry) 1960 deinstitutionalization movement Social reintegration 56
57
58
59
60
61
62
63
79 12 7 80 10 23 64
65
66
67
68
6 A s (Appropriate choice) 69
(Adequate dose) (Adequate duration) (Adequate maintenance or termination) 70
(Adequate therapy) (Adequate alternative) 71
(Assessment). 72
6 73
(Antipsychotics Antipsychotics) 量 ( ) ( ) Benzisothiazolyl Ziprasidol (Zeldox) 40~160 10 Benzisoxazole Risperidone (Risperidol) 4~8 Dibenzothiazepine Quetiapine fumarate (Seroquel) 150~160 Dibenzodiazepine Clozapine (Clozaril) 100~900 Imidazolidine Sertindole (SerLect) 20~24 Thienobenzodiazepine Olanzapine (Zyprexa) 10~20 Benzamide Sulpiride (Dogmatyl) 400~1200 Butyrophenone Haloperidol (Haldol) 5~20 Haloperidol decanoate 50~300/2-4 Dibenzooxazepine Loxapine (Doxapac) 60~100 Dibenzothiazepine 74
(Antipsychotics Antipsychotics) 量 75
76
77
Gilles de la Tourette 78
79
80
81
82
83
84
beta Benzodiazepines(BZDs) 85
(Antidepressants) Tricyclic antidepressants (TCAs): Amitriptyline, Imipramine, Doxepin Tetracyclic antidepressants: Maprotiline Monoamine oxidase inhibitors (MAOIs): Phenelzine, Tranylcypromine Reversible inhibitors of monoamine oxidase A (RIMAs): Moclobemide Selective serotonin reuptake inhibitors (SSRIs): Fluoxetine, Sertraline, Fluvoxamine, Paroxetine, Citalopram Norepinephrine dopamine reuptake inhibitors (NDRIs): Bupropion 86
(Antidepressants) Serotonin norepinephrine reuptake inhibitors (SNRIs): Venlafaxine Selective noradrenergic reuptake inhibitors (NRIs): Reboxetine Serotonin 2A antagonist/reuptake inhibitors (SARIs): Nefazodone Alpha 2 antagonists: Mianserin, Setiptilene Noradrenergic and specific serotonergic antidepressants (NaSSAs): Mirtazapine Beta agonists Pure 5-HT2 antagonists 5-HT1 agonists 87
療 療 療 療 療 療 療 88
量 ( ) 量 ( ) ( ) TCAs Amitriptyline (Tryptanol) 75~300 50 10~46 Clomipramine (Anafranil) 75~300 50 17~37 Desipramine (Norpramin) 75~300 50 21~76 Doxepin (Sinequan) 75~300 50 8~36 Imipramine (Tofranil) 75~300 50 4~34 Nortriptyline (Aventyl) 40~200 25 13~88 Protriptyline (Vivactil) 20~60 15 54~124 Trimipramine (Surmntil) 75~300 50 7~30 Maprotiline (Ludiomil) 100~225 50 27~58 Mianserin (Tolvon) 30~80 20 14~33 Dibenzoxazepine Amoxapine (Asendin) 100~600 100 8 SSRIs Citalopram (Cipram) 20~40 10 33 Fluoxetine (Prozac) 20~80 10 24~330 89
量 ( ) 量 ( ) ( ) Fluvoxamine (Luvox) 50~300 50 17~22 Paroxetine (Paxil) 10~50 10 3~65 Sertraline (Zoloft) 50~200 25 24~66 Triazolopyridine Nefazodone (Serzone) 100~600 100 27~58 Trazodone (Mesyrel) 150~600 100 4~9 RIMA Moclobemide (Aurorix) 300~600 150 1~3 Irreversible MAOIs Phenelzine (Nardil) 49~90 15 1.5~4 SDRI Bupropion (Wellbutin) 225~450 200 10~14( ) 20~27( ) Bupropion SR (Zyban) SNRI Venlafaxine (Effexor) 75~225 50 3~ 7( ) 9~13( ) NaSSA Mirtazapin (Remreron) 15~45 13 20~40 90
91
92
(TCAs) (TCAs) 93
(TCAs) (TCAs) 94
(TCAs) (TCAs) 95
(MAOIs) (MAOIs) (ADHD) 96
(MAOIs) (MAOIs) 97
(MAOIs MAOIs) tyramine noradrenaline 98
(MAOIs MAOIs) L- Ddopa L-Tryptophan Fluoxetine Meperidine Dextromethorphan Disulfiram Hydralazine Propranolol. 99
(SSRIs) (SSRIs) 100
(SSRIs) P-450 101
(SSRIs SSRIs) 102
SSRIs MAOIs Li SSRIs 103
T3 TCA+MAOI SSRI+TCA RIMA+TCA RIMA+SSRI SSRI + Pindolol 104
(Antianxiety Agents) Benzodiazopines (BZDs) Buspirone Tetracyclic antidepressants (TCAs) Selective serotonin reuptake inhibitors (SSRIs) Serotonin norepinephrine reuptake inhibitors (SNRIs) Barbiturates Antihistamines Beta blockers 105
Benzodiazepines (BZDs) 2-Keto Bromazepam (Lexotan) Chlordiazepoxide (Librium) Clobazam (Frisium) Clorazepate (Tranxene) Diazepam (Valium) Fludiazepam (Erispan) Fluzazepam (Dalmane) Nordazepam (Calmday) Prazepam (Centrax) 106
Benzodiazepines (BZDs) 3-Hydroxy Lorazepam (Ativan) Lormetazepam (Loramet) Oxazepam (Serax) Quazepam (Doral) Temazepam (Restoril) 7-Nitro Clonazepam (Rivotril) Flunitrazepam (Rohypnol) Nimetazepam (Erimin) Nitrazepam (Mogadon) 107
Benzodiazepines (BZDs) Triazolo Alprazolam (Xanax) Brotizolam (Lendormin) Estazolam (Eurodin) Triazolam (Halcion) Imidazo Loprazolam Midazolam (Dormicum) Oxazolo Cloxazolam (Sepazon) Oxazolam (Serenal) 108
Benzodiazepines 量 ( ) (Short-acting) Brotizolam (Lendormin) 0.125~0.25 Midazolam (Dormicum) 7.5~45 Triazolam (Halcion) 0.125~0.25 (Intermediate) Alprazolam 0.5~6 Bromazepam (Lexotan) 3~24 Estazolam (Eurodin) 1~2 Fludiazepam (Erispam) 0.5~1 Lorazepam (Ativan) 2~6 Lormetazepam 1~2 (Loramet) Oxazolam (Serenal) 30~60 Temazepam (Restoril) 15~30 109
Benzodiazepines (Long-acting) Chlordiazepoxide 15~100 (Librium) Clonazepam (Rivotril) 0.5~10 Clorazepate (Tranxene) 7.5~60 Cloxazolam (Sepazon) 3~6 Diazepam (Valium) 2~60 Flunitrazepam (Rohypnol) 0.5~2 Flurazepam (Dalmane) 15~30 Nitrazepam (Mogadon) 5~15 Nordazepam (Calmday) 5~10 Prazepam (Centrax) 30~60 Quazepam (Doral) 7.5~30 量 ( ) 110
Benzodiazepines (BZDs) 111
Benzodiazepines (BZDs) 112
Benzodiazepines (BZDs) (floppy baby) 113
Buspirone 114
(Hypnotics) Bromides Paraldehyde Sulfonal Barbiturates Melatonin Benzodiazepines (BZDs) Antihistamines Antipsychotics Antidepressants Cyclopyrrolone: Zopiclone Imidazopyridine: Zolpidem L-Tryptophan Meprobamate Methaqualone Thalidomide 115
Benzodiazepines (BZDs) ( ) (NREM) ( ) (NREM) ( ) (REM) (REM) 116
Zolpidem Zopiclone BZDs Zolpidem REM NREM Zopiclone NREM 117
(Lithium) (Lithium) 118
0.8~1.2 mmol/l 0.6~1.0 mmol/l 119
(Monitoring) 120
121
122
(1.5~2.0 mmol/l) 123
(>2.0 mmol/l) 124
4.0 mmol/l aminophylline. 125
6 12 126
Carbamazepine 127
Carbamazepine 惡 128
Carbamazepine 3 2 3 Carbamazepine 17~50 u mol/l ( 4~12 ug/ml) 2 129
Valproate 130
Valproate GOT GPT 131
Valproate 6 Valproate 500~100 ug/ml 132
(Cognitive Enhancers) Cholinergic agents Acetylcholinesterase inhibitors Tetrahydroaminoacridine Donepezil Velnacrine Galantamine Cholinergic agonists Bethanechol Arecoline Xanomeline Nicotine Oxotremorine RS-86 AF102B ENA713 133
(Cognitive Enhancers) Selegiline Glutamatergic agents Vitamin C Vitamin D Vitamin E Aspirin Estrogen Folate 134
Donepezil Tetrahydroaminoacridine Donepezil (Aricept) Tetrahydroamineacridine (Tacrine) Acetylcholinesterase 不 率 100% 17% 3 4 1 2 率 96% 55% CYP450 2D6, 3A4 1A2 70 80 2 4 廓 量 5 40 量 10 160 5~10% 10~30% 暈 2~10% >10% 5~10% 5~15% 135
136
Benzodiazepines (BZDs) Diazepam Midazolam Clonazepam Paraldehyde Antipsychotics Thiamine 137
Benzodiazepines (BZDs) Chlordiazepoxide Diazepam Lorazepam Thiamine Folate Carbamazepine Carbamazepine Thiamine Clonidine Clonidine 0.4 0.6 / Clonidine 138
Disulfiram Buspirone Selective serotonin reuptake inhibitors (SSRIs) Naltrexone Nalmefene Acamprosate Topirmate Lithium Ondansetron Anticonvulsants Anxiolytics Others 139
(CNS Stimulants) Amphetamines Dextroamphetamine (Dexedine) Methoamphetamine (Dexoxyn) Benzphetamine (Didrex) Chlorphetamine (Prestate) Clortermine (Voranil) Diethylpropion (Tenuate) Fenfluramine (Pondimin) Methyl phenidate (Ritalin) Phenmetrazine (Preludin), Phendimetrazine (Plegine) Magnesium pemoline (Cylert) 140
(ADHD) (AIDS) 141
(Sex Drive Depressants) Cyproten (Androcur) Medroxprogesterone (Provera) Louprolide (Lupren) Goserelin (Zoladex) (Testersterone) (Androgen) 142
143
144
38 17 20 ( ) 21 145
Haloperidol 5mg, 1# b.i.d., p.o. Haloperidol decanoate 50mg, 1amp, i.m., q2w Haloperidol solution, 50 drops Biperidin 1amp, i.m., p.r.n. Trihexyphenidyl 5mg, 1# b.i.d., p.o. Estazolam 2mg, 1# h.s., p.o. 146
21 19. 147
Clozapine 100mg, 2# h.s., p.o. Zolpidem 10mg, 2# h.s., p.o. 148
67 2 149
Risperidone 2mg 1/2# a.m., p.o. Zopiclone 7.5mg 1# h.s., p.o. 150
43 5 3 151
Fluoxetine 20mg, 1# a.m., p.o. Nitrazepam 5mg, 1# h.s., p.o. 152
35 1. 3 4 2 9 153
Lithium bicarbonate 300mg, 1# b.i.d. 1# h.s., p.o. Clonazepam 0.5mg, 1# t.i.d., p.o. Flupenthixol 3mg, 1# t.i.d., p.o. Chlorprothixene 50mg, 2# h.s., p.o. Zuclopenthixol acuphase 50mg, 1amp, i.m., p.r.n. 154
47 3.. 155
Bromazepam 3mg, 1# t.i.d., p.o. Flunitrazepam 1mg, 1# h.s., p.o. Buspirone 10mg, 1# b.i.d., p.o. Flunitrazepam 1mg, 1# h.s., p.o. 156
52 2. 1 1 2 157
Alprazolam 0.25mg, 1# t.i.d., p.o. Propranolol 10mg, 1# t.i.d., p.o. Sertraline 50mg, 1# b.i.d., p.o. 158
83 3 2. 159
Risperidone 2mg, 1/2# a.m., p.o. Zolpidem 10mg, 1# h.s., p.o. Donepezil 5mg, 1# b.i.d., p.o. 160
45 25 10 2. 161
Thiamine 25mg, 1# q.i.d., p.o. Haloperidol 2mg, 1# h.s., p.o. Diazepam 5mg, 1# t.i.d., p.o. Lorazepam 2mg, 2# h.s., p.o. 162
34 11 3 15 20 28 2 163
Phenobarbital 30mg, 1# t.i.d., p.o. Carbamazepine 200mg, 1# b.i.d., p.o. Diazepam 5mg, 1# t.i.d., p.o. Haloperidol 2mg, 1/2# b.i.d., p.o. Trihexyphenidyl 2mg, 1/2# b.i.d., p.o. Diazepam 10mg, 1amp, i.v., p.r.n. 164
165
166