Anyone can develop a mental illness--you, a family member, a friend, or the fellow down the block. Some disorders are mild, while others are serious and long-lasting. These conditions can be helped. One way--an important way--is with psychotherapeutic medications. Compared to other types of treatment, these medications are relative newcomers in the fight against mental illness. It was only about 35 years ago that the first one, chlorpromazine, was introduced. But considering the short time they've been around, psychotherapeutic medications have made dramatic changes in the treatment of mental disorders. People who, years ago, might have spent many years in mental hospitals because of crippling mental illness may now only go in for brief treatment, or might receive all their treatment at an outpatient clinic.
Psychotherapeutic medications also may make other kinds of treatment more effective. Someone who is too depressed to talk, for instance, can't get much benefit from psychotherapy or counseling; but often, the right medication will improve symptoms so that the person can respond better.
Another benefit from these medications is an increased understanding of the causes of mental illness. Scientists have learned a great deal more about the workings of the brain as a result of their investigations into how psychotherapeutic medications relieve disorders such as psychosis, depression, anxiety, obsessive compulsive disorder, and panic disorder.
(Note: He is used within text to refer to both men and women.)
SYMPTOM RELIEF, NOT CURE
Just as aspirin can reduce a fever without clearing up the infection that causes it, psychotherapeutic medications act by controlling symptoms. Like most drugs used in medicine, they correct or compensate for some malfunction in the body. Psychotherapeutic medications do not cure mental illness, but they do lessen its burden. These medications can help a person get on with life despite some continuing mental pain and difficulty coping with problems. For example, drugs like chlorpromazine can turn off the "voices" heard by some people with schizophrenia and help them to perceive reality more accurately. And antidepressants can lift the dark, heavy moods of depression.
How long someone must take a psychotherapeutic medication depends on the disorder. Many depressed and anxious people may need medication for a single period--perhaps for several months--and then never have to take it again. For some conditions, such as schizophrenia or manic-depressive illness, medication may have to be take indefinitely or, perhaps, intermittently.
Like any medication, psychotherapeutic medications do not produce the same effect in everyone. Some people may respond better to one medication than another. Some may need larger dosages than others do. Some experience annoying side effects, while others do not. Age, sex, body size, body chemistry, habits, and diet are some of the factors that can influence a medication's effect.
QUESTIONS FOR YOUR DOCTOR
To increase the likelihood that a medication will work well, patients and their families must actively participate with the doctor prescribing it. They must tell the doctor about the patient's past medical history, other medications being taken, anticipated life changes--such as planning to have a baby--and, after some experience with a medication, whether it is causing side effects. When a medication is prescribed, the patient or family member should ask the following questions recommended by the U.S. Food and Drug Administration (FDA) and professional organizations:
In this booklet, medications are described by their generic (chemical) names and by their trade names (brand names used by drug companies). They are divided into four large categories based on the symptoms for which they are primarily used--antipsychotic, antimanic, antidepressant, and antianxiety medications. Some are used for more than one purpose; antidepressants, for example, have been found helpful for treating some anxiety disorders.
An index at the end of the booklet provides two alphabetical lists. One provides the generic names of the most commonly prescribed medications, the other provides the trade names of the medications.
Treatment evaluation studies have established the efficacy of the medications described here; however, much remains to be learned about these medications. The National Institute of Mental Health, other Federal agencies, and private research groups are sponsoring studies of these medications. Scientists are hoping to improve their understanding of how and why these medications work, how to control or eliminate unwanted side effects, and how to make the medications more effective.
A person who is psychotic is out of touch with reality. He may "hear voices" or have strange and untrue ideas (for example, thinking that others can hear his thoughts, or are trying to harm him, or that he is the President of the United States or some other famous person). He may get excited or angry for no apparent reason, or spend a lot of time off by himself, or in bed, sleeping during the day and staying awake at night. He may neglect his appearance, not bathing or changing clothes, and may become difficult to communicate with--saying things that make no sense, or barely talking at all.
These kinds of behaviors are symptoms of psychotic illness, the principal form of which is schizophrenia. All of the symptoms may not be present when someone is psychotic, but some of them always are. Antipsychotic medications, as their name suggests, act against these symptoms. These medications cannot "cure" the illness, but they can take away many of the symptoms or make them milder. In some cases, they can shorten the course of the illness as well.
There are a number of antipsychotic medications available. They all work; the main differences are in the potency--that is, the dosage (amount) prescribed to produce therapeutic effects--and the side effects. Some people might think that the higher the dose of medication, the more serious the illness, but this is not always true.
A doctor will consider several factors when prescribing an antipsychotic medication, besides how "ill" someone is. These include the patient's age, body weight, and type of medication. Past history is important, too. If a person took a particular medication before and it worked, the doctor is likely to prescribe the same one again. Some less potent drugs, like chlorpromazine (Thorazine), are prescribed in higher numbers of milligrams than others of high potency, like haloperidol (Haldol).
If a person has to take a large amount of a "high-dose" antipsychotic medication, such as chlorpromazine, to get the same effect as a small amount of a "low-dose" medication, such as haloperidol, why doesn't the doctor just prescribe "low-dose" medications? The main reason is the difference in their side effects (actions of the medication other than the one intended for the illness). These medications vary in their side effects, and some people have more trouble with certain side effects than others. A side effect may sometimes be desirable. For instance, the sedative effect of some antipsychotic medications is useful for patients who have trouble sleeping or who become agitated during the day.
Unlike some prescription drugs, which must be taken several times during the day, antipsychotic medications can usually be taken just once a day. Thus, patients can reduce daytime side effects by taking the medications once, before bed. Some antipsychotic medications are available in forms that can be injected once or twice a month, thus assuring that the medicine is being taken reliably.
Most side effects of antipsychotic medications are mild. Many common ones disappear after the first few weeks of treatment. These include drowsiness, rapid heartbeat, and dizziness when changing position.
Some people gain weight while taking antipsychotic medications and may have to change their diet to control their weight. Other side effects that may be caused by some antipsychotic medications include decrease in sexual ability or interest, problems with menstrual periods, sunburn, or skin rashes. If a side effect is especially troublesome, it should be discussed with the doctor who may prescribe a different medication, change the dosage level or schedule, or prescribe an additional medication to control the side effects.
Movement difficulties may occur with the use of antipsychotic medications, although most of them can be controlled with a prophylactic medication. These movement problems include muscle spasms of the neck, eye, back, or other muscles; restlessness and pacing; a general slowing-down of movement and speech; and a shuffling walk. Some of these side effects may look like psychotic or neurologic (Parkinson's disease) symptoms, but aren't. If they are severe, or persist with continued treatment with an antipsychotic, it is important to notify the doctor, who might either change the medication or prescribe an additional one to control the side effects.
Just as people vary in their responses to antipsychotic medications, they also vary in their speed of improvement. Some symptoms diminish in days, while others take weeks or months. For many patients, substantial improvement is seen by the sixth week of treatment, although this is not true in every case. If someone does not seem to be improving, a different type of medication may be tried. Drug treatment for a psychotic illness can continue for up to several months, sometimes even longer.
Even if a person is feeling better or completely well, he should not just stop taking the medication. Continuing to see the doctor while tapering off medication is important. Some people may need to take medication for an extended period of time, or even indefinitely, to remain symptom-free. These people usually have chronic (long-term, continuous) schizophrenic disorders, or have a history of repeated schizophrenic episodes, and are likely to become ill again. Also, in some cases a person who has experienced one or two severe episodes may need medication indefinitely. In these cases, medication may be continued in as low a dosage as possible to maintain control of symptoms. This approach, called maintenance treatment, prevents relapse in many people and removes or reduces symptoms for others.
While maintenance treatment is helpful for many people, a drawback for some is the possibility of developing long-term side effects, particularly a condition called tardive dyskinesia. This condition is characterized by involuntary movements. These abnormal movements most often occur around the mouth, but are sometimes seen in other muscle areas such as the trunk, pelvis, or diaphragm. The disorder may range from mild to severe. For some people, it cannot be reversed, while others recover partially or completely. Tardive dyskinesia is seen most often after long-term treatment with antipsychotic medications. There is a higher incidence in women, with the risk rising with age. There is no way to determine whether someone will develop this condition, and if it develops, whether the patient will recover. At present, there is no effective treatment for tardive dyskinesia. The possible risks of long term treatment with antipsychotic medications must be weighed against the benefits in each individual case by patient, family, and doctor.
Two approaches that are designed to provide the advantages of medication while reducing the risks of tardive dyskinesia and other possible side effects are sometimes used in long-term treatment. They are a "low-dosage" approach that uses far lower maintenance dosages of antipsychotic medications than have generally been employed, and an "intermittent dosage" treatment that involves stopping the medication when the patient is symptom-free and beginning it again only when symptoms reappear.
In 1990, clozapine (Clozaril), an "atypical" antipsychotic drug, was introduced in the United States. In clinical trials, this medication was found to be more effective than traditional antipsychotic medications in individuals with treatment-resistant schizophrenia, and the risk of tardive dyskinesia is lower. However, because of the potential side effect of a serious blood disorder, agranulocytosis, patients who are on clozapine must have a blood test each week. The expense involved in this monitoring, together with the cost of the medication, has made maintenance on clozapine difficult for many persons with schizophrenia.
Antipsychotic medications can also produce unwanted effects when taken in combination with other medications. Therefore, the doctor should be told about all medicine being taken, including over-the-counter preparations, and the extent of the use of alcohol. Some antipsychotic medications interfere with the action of antihypertensive medications (taken for high blood pressure), anticonvulsants (taken for epilepsy), and medications used for Parkinson's disease. Some antipsychotic medications add to the effects of alcohol and other central nervous system depressants, such as antihistamines, antidepressants, barbiturates, some sleeping and pain medications, and narcotics.
Bipolar disorder (manic-depressive illness) is characterized by cycling mood changes: severe highs (mania) and lows (depression). Cycles may be predominantly manic or depressive with normal mood between cycles. Mood swings may follow each other very closely, within hours or days, or may be separated by months to years.
When someone is in a manic "high," he may be overactive, overtalkative, and has a great deal of energy. He will switch quickly from one topic to another, as if he cannot get his thoughts out fast enough; his attention span is often short, and he can easily be distracted. Sometimes, the "high" person is irritable or angry and has false or inflated ideas about his position or importance in the world. He may be very elated, full of grand schemes which might range from business deals to romantic sprees. Often, he shows poor judgment in these ventures. Mania, untreated, may worsen to a psychotic state.
Depression will show in a "low" mood, lack of energy, changes in eating and sleeping patterns, feelings of hopelessness, helplessness, sadness, worthlessness, and guilt, and sometimes thoughts of suicide.
These "highs" and "lows" may vary in intensity and severity. The medication used most often to combat a manic "high" is lithium. It is unusual to find mania without a subsequent or preceding period of depression. Lithium evens out mood swings in both directions, so that it is used not just for acute manic attacks or flare-ups of the illness, but also as an ongoing treatment of bipolar disorder.
Lithium will diminish severe manic symptoms in about 5 to 14 days, but it may be anywhere from days to several months until the condition is fully controlled. Antipsychotic medications are sometimes used in the first several days of treatment to control manic symptoms until the lithium begins to take effect. Likewise, antidepressants may be needed in addition to lithium during the depressive phase of bipolar disorder.
Someone may have one episode of bipolar disorder and never have another, or be free of illness for several years. However, for those who have more than one episode, continuing (maintenance) treatment on lithium is usually given serious consideration.
Some people respond well to maintenance treatment and have no further episodes, while others may have moderate mood swings that lessen as treatment continues. Some people may continue to have episodes that are diminished in frequency and severity. Unfortunately, some manic-depressive patients may not be helped at all. Response to treatment with lithium varies, and it cannot be determined beforehand who will or will not respond to treatment.
Regular blood tests are an important part of treatment with lithium. A lithium level must be checked periodically to measure the amount of the drug in the body. If too little is taken, lithium will not be effective. If too much is taken, a variety of side effects may occur. The range between an effective dose and a toxic one is small. A lithium level is routinely checked at the beginning of treatment to determine the best lithium dosage for the patient. Once a person is stable and on maintenance dosage, a lithium level should be checked every few months. How much lithium a person needs to take may vary over time, depending on how ill he is, his body chemistry, and his physical condition.
Anything that lowers the level of sodium (table salt is sodium chloride) in the body may cause a lithium buildup and lead to toxicity. Reduced salt intake, heavy sweating, fever, vomiting, or diarrhea may do this. An unusual amount of exercise or a switch to a low-salt diet are examples. It's important to be aware of conditions that lower sodium and to share this information with the doctor. The lithium dosage may have to be adjusted.
When a person first takes lithium, he may experience side effects, such as drowsiness, weakness, nausea, vomiting, fatigue, hand tremor, or increased thirst and urination. These usually disappear or subside quickly, although hand tremor may persist. Weight gain may also occur. Dieting will help, but crash diets should be avoided because they may effect the lithium level. Drinking low-calorie or no-calorie beverages will help keep weight down. Kidney changes, accompanied by increased thirst and urination, may develop during treatment. These conditions that may occur are generally manageable and are reduced by lowering the dosage. Because lithium may cause the thyroid gland to become underactive (hypothyroidism) or sometimes enlarged (goiter), thyroid function monitoring is a part of the therapy. To restore normal thyroid function, thyroid hormone is given along with lithium.
Because of possible complications, lithium may either not be recommended or may be given with caution when a person has existing thyroid, kidney, or heart disorders, epilepsy, or brain damage. Women of child-bearing age should be aware that lithium increases the risk of congenital malformations in babies born to women taking lithium. Special caution should be taken during the first 3 months of pregnancy.
Lithium, when combined with certain other medications, can have unwanted effects. Some diuretics--substances that remove water from the body--increase the level of lithium and can cause toxicity. Other diuretics, like coffee and tea, can lower the level of lithium. Signs of lithium toxicity may include nausea, vomiting, drowsiness, mental dullness, slurred speech, confusion, dizziness, muscle twitching, irregular heart beat, and blurred vision. A serious lithium overdose can be life-threatening.
With regular monitoring, lithium is a safe and effective drug that enables many people, who otherwise would suffer from incapacitating mood swings, to lead normal lives.
Not all patients with symptoms of mania benefit from lithium. Some have been found to respond to another type of medication, the anticonvulsant medications that are usually used to treat epilepsy. Carbamazepine (Tegretol) is the anticonvulsant that has been most widely used. Manic-depressive patients who cycle rapidly--that is, they change from mania to depression and back again over the course of hours or days, rather than months--seem to respond particularly well to carbamazepine.
Early side effects of carbamazepine, although generally mild, include drowsiness, dizziness, confusion, disturbed vision, perceptual distortions, memory impairment, and nausea. They are usually transient and often respond to temporary dosage reduction. Another common but generally mild adverse effect is the lowering of the white blood cell count which requires periodic blood tests to monitor against the rare possibility of more serious, even life-threatening, bone marrow depression. Also serious are the skin rashes that can occur in 15 to 20 percent of patients. These rashes are sometimes severe enough to require discontinuation of the medication.
Neither carbamazepine nor any other anticonvulsants have been approved by the Food and Drug Administration for manic-depressive illness. These drugs must undergo further study before they merit FDA approval and general use.
The kind of depression that will most likely benefit from treatment with medications is more than just "the blues." It's a condition that's prolonged, lasting 2 weeks or more, and interferes with a person's ability to carry on daily tasks and to enjoy activities that previously brought pleasure.
The depressed person will seem sad, or "down," or may show a lack of interest in his surroundings. He may have trouble eating and lose eight (although some people eat more and gain weight when depressed). He may sleep too much or too little, have difficulty going to sleep, sleep restlessly, or awaken very early in the morning. He may speak of feeling guilty, worthless, or hopeless. He may complain that his thinking is slowed down. He may lack energy, feeling "everything's too much," or he might be agitated and jumpy. A person who is depressed may cry. He may think and talk about killing himself and may even make a suicide attempt. Some people who are depressed have psychotic symptoms, such as delusions (false ideas) that are related to their depression. For instance, a psychotically depressed person might imagine that he is already dead, or "in hell," being punished.
Not everyone who is depressed has all these symptoms, but everyone who is depressed has at least some of them. A depression can range in intensity from mild to severe.
Antidepressants are used most widely for serious depressions, but they can also be helpful for some milder depressions. Antidepressants, although they are not "uppers" or stimulants, take away or reduce the symptoms of depression and help the depressed person feel the way he did before he became depressed.
Antidepressants are also used for disorders characterized principally by anxiety. They can block the symptoms of panic, including rapid heartbeat, terror, dizziness, chest pains, nausea, and breathing problems. They can also be used to treat some phobias.
The physician chooses the particular antidepressant to prescribe based on the individual patient's symptoms. When someone begins taking an antidepressant, improvement generally will not begin to show immediately. With most of these medications, it will take from 1 to 3 weeks before changes begin to occur. Some symptoms diminish early in treatment; others, later. For instance, a person's energy level or sleeping or eating patterns may improve before his depressed mood lifts. If there is little or no change in symptoms after 5 to 6 weeks, a different medication may be tried. Some people will respond better to one than another. Since there is no certain way of determining beforehand which medication will be effective, the doctor may have to prescribe first one, then another, until an effective one is found. Treatment is continued for a minimum of several months and may last up to a year or more.
While some people have one episode of depression and then never have another or remain symptom-free for years, others have more frequent episodes or very long-lasting depressions that may go on for years. Some people find that their depressions become more frequent and severe as they get older. For these people, continuing (maintenance) treatment with antidepressants can be an effective way of reducing the frequency and severity of depressions. Those that are commonly used have no known long-term side effects and may be continued indefinitely. The prescribed dosage of the medication may be lowered if side effects become troublesome. Lithium can also be used for maintenance treatment of repeated depressions whether or not there is evidence of a manic or manic-like episode in the past.
Dosage of antidepressants varies, depending on the type of drug, the person's body chemistry, age, and, sometimes, body weight. Dosages are generally started low and raised gradually over time until the desired effect is reached without the appearance of troublesome side effects.
There are a number of antidepressant medications available. They differ in their side effects and, to some extent, in their level of effectiveness. Tricyclic antidepressants (named for their chemical structure) are more commonly used for treatment of major depressions than are monoamine oxidase inhibitors (MAOIs); but MAOIs are often helpful in so-called "atypical" depressions in which there are symptoms like oversleeping, anxiety, panic attacks, and phobias.
A tricyclic antidepressant introduced in 1990, clomipramine (Anafranil), is used primarily in the treatment of obsessive compulsive disorder. A bicyclic antidepressant, fluoxetine (Prozac), was approved by the FDA in late 1987 and has been prescribed extensively. Another recently approved antidepressant, bupropion (Wellbutrin), is chemically unrelated to the other antidepressants. Some newer antidepressants are currently being studied and may be released in the next few years.
Side Effects of Antidepressant Medications
There are a number of possible side effects with tricyclic antidepressants that vary, depending on the medication. For example, amitriptyline (Elavil) may make people feel drowsy, while protriptyline (Vivactil) hardly does this at all and, in some people, may have an opposite effect, producing feelings of anxiety and restlessness. Because of this kind of variation in side effects, one antidepressant might be highly desirable for one person and not recommended for another. Tricyclics on occasion may complicate specific heart problems, and for this reason the physician should be aware of all such difficulties. Other side effects with tricyclics may include blurred vision, dry mouth, constipation, weight gain, dizziness when changing position, increased sweating, difficulty urinating, changes in sexual desire, decrease in sexual ability, muscle twitches, fatigue, and weakness. Not all these medications produce all side effects, and not everybody gets them. Some will disappear quickly, while others may remain for the length of treatment. Some side effects are similar to symptoms of depression (for instance, fatigue and constipation). For this reason, the patient or family should discuss all symptoms with the doctor, who may change the medication or dosage.
Tricyclics also may interact with thyroid hormone, antihypertensive medications, oral contraceptives, some blood coagulants, some sleeping medications, antipsychotic medications, diuretics, antihistamines, aspirin, bicarbonate of soda, vitamin C, alcohol, and tobacco.
An overdose of antidepressants is serious and potentially lethal. It requires immediate medical attention. Symptoms of an overdose of tricyclic antidepressant medication develop within an hour and may start with rapid heartbeat, dilated pupils, flushed face, and agitation, and progress to confusion, loss of consciousness seizures, irregular heartbeats, cardiorespiratory collapse, and death.
2. Monoamine Oxidase Inhibitors (MAOIs)
MAOIs may cause some side effects similar to those of the other antidepressants. Dizziness when changing position and rapid heartbeat are common. MAOIs also react with certain foods and alcoholic beverages (such as aged cheeses, foods containing monosodium glutamate (MSG), Chianti and other red wines), and other medications (such as over-the-counter cold and allergy preparations, local anesthetics, amphetamines, antihistamines, insulin, narcotics, and antiparkinsonian medications). These reactions often do not appear for several hours. Signs may include severe high blood pressure, headache, nausea, vomiting, rapid heartbeat, possible confusion, psychotic symptoms, seizures, stroke, and coma. For this reason, people taking MAOIs MUST stay away from restricted foods, drinks, and medications. They should be sure that they are furnished, by their doctor or pharmacist, a list of all foods, beverages, and other medications that should be avoided.
Precautions To Be Observed When Taking Antidepressants
When taking antidepressants, it is important to tell all doctors (and dentists) being seen--not just the one who is treating the depression--about all medications being used, including over-thecounter preparations and alcohol. Antidepressants should be taken only in the amount prescribed and should be kept in a secure place away from children. When used with proper care, following doctors' instructions, antidepressants are extremely useful medications that can reverse the misery of a depression and help a person feel like himself again.
Everyone experiences anxiety at one time or another--"butterflies in the stomach" before giving a speech or sweaty palms during a job interview are common symptoms. Other symptoms of anxiety include irritability, uneasiness, jumpiness, feelings of apprehension, rapid or irregular heartbeat, stomach ache, nausea, faintness, and breathing problems.
Anxiety is often manageable and mild. But sometimes it can present serious problems. A high level or prolonged state of anxiety can be very incapacitating, making the activities of daily life difficult or impossible.
Phobias, which are persistent, irrational fears and are characterized by avoidance of certain objects, places, and things, sometimes accompany anxiety. A panic attack is a severe form of anxiety that may occur suddenly and is marked with symptoms of nervousness, breathlessness, pounding heart, and sweating. Sometimes the fear that one may die is present.
Antianxiety medications help to calm and relax the anxious person and remove the troubling symptoms. There are a number of antianxiety medications currently available. The preferred medications for most anxiety disorders are the benzodiazepines. In addition to the benzodiazepines, a non-benzodiazepine, buspirone (BuSpar), has recently been approved for generalized anxiety disorders. Antidepressants are also very effective for panic attacks and some phobias and are often prescribed for these conditions. Antidepressants are also sometimes used for more generalized forms of anxiety, especially when accompanied by depression.
The most commonly used benzodiazepines are alprazolam (Xanax) and diazepam (Valium), followed by chlordiazepoxide (Librium, Librax, Libritabs). Benzodiazepines are relatively fast-acting medications. Most will begin to take effect within hours, some in even less time. Benzodiazepines differ in duration of action in different individuals; they may be taken two or three times a day, or sometimes only once a day. Dosage is generally started at a low level and gradually raised until symptoms are diminished or removed. The dosage will vary a great deal depending on the symptoms and the individual's body chemistry.
Benzodiazepines have few side effects. Drowsiness and loss of coordination are most common; fatigue and mental slowing or confusion can also occur. These effects make it dangerous to drive or operate some machinery when taking benzodiazepines--especially when the patient is just beginning treatment. Other side effects are rare.
Benzodiazepines combined with other medications can present a problem, notably when taken together with commonly used substances such as alcohol. It is wise to abstain from alcohol when taking benzodiazepines, as the interaction between benzodiazepines and alcohol can lead to serious and possibly life-threatening complications. Following the doctor's instructions is important. The doctor should be informed of all other medications the patient is taking, including over-the-counter preparations. Benzodiazepines increase central nervous system depression when combined with alcohol, anesthetics, antihistamines, sedatives, muscle relaxants, and some prescription pain medications. Particular benzodiazepines may influence the action of some anticonvulsant and cardiac medications. Benzodiazepines have also been associated with abnormalities in babies born to mothers who were taking these medications during pregnancy.
With benzodiazepines, there is a potential for the development of tolerance and dependence as well as the possibility of abuse and withdrawal reactions. For these reasons, the medications are generally prescribed for brief periods of time--days or weeks--and sometimes intermittently, for stressful situations or anxiety attacks. For the same reason, ongoing or continuous treatment with benzodiazepines is not recommended for most people. Some patients may, however, need long-term treatment.
Consult with the doctor before discontinuing a benzodiazepine. A withdrawal reaction may occur if the treatment is abruptly stopped. Symptoms may include anxiety, shakiness, headache, dizziness, sleeplessness, loss of appetite, and, in more severe cases, fever, seizures, and psychosis. A withdrawal reaction may be mistaken for a return of the anxiety, since many of the symptoms are similar. Thus, after benzodiazepines are taken for an extended period, the dosage is gradually tapered off before being completely stopped.
Although benzodiazepines, buspirone, or tricyclic antidepressants are the preferred medications for most anxiety disorders, occasionally, for specific reasons, one of the following medications may be prescribed: antipsychotic medications; antihistamines (such as Atarax, Vistaril, and others); barbiturates such as phenobarbital; propanediols such as meprobamate (Equanil), and propranolol (Inderal, Inderide).
CHILDREN, THE ELDERLY, AND PREGNANT, NURSING, OR CHILD-BEARING AGE WOMEN: SPECIAL CONSIDERATIONS
Children, the elderly, and pregnant and nursing women have special concerns and needs when taking psychotherapeutic medications. Some effects of medications on the growing body, the aging body, and the childbearing body are known, but much remains to be learned. Research in these areas is ongoing.
While, in general, what has been said in this booklet applies to these groups, below are a few special points to bear in mind:
Pregnant, Nursing, or Childbearing-Age Women
The decision to use a psychotherapeutic medication should be made only after a careful discussion with the doctor concerning the risks and benefits to the woman and her baby.
For more detailed information, talk to your doctor or mental health professional, consult your local public library, or write to the pharmaceutical company that produces the medication or the U.S. Food and Drug Administration, 5600 Fishers Lane, Rockville, MD 20857.
INDEX OF MEDICATIONS
To find the section of the text that describes the medication you or a friend or family member is taking, find either the generic (chemical) name and look it up on the first list, or the trade name and look it up on the second list. If you do not find the name of the medication on the label, ask your doctor or pharmacist for it. (Note: some drugs, such as amitriptyline and chlordiazepoxide, are marketed under numerous trade names, not all of which can be mentioned in a brief publication such as this. If your medication's trade name does not appear in this list, look it up by its generic name or ask your doctor or pharmacist for more information.)
Alphabetical Listing of Medications by GENERIC NAME
GENERIC NAME| Trade Name|
Tourette's Syndrome)| Orap|
lithium carbonate| Eskalith|
lithium citrate| Cibalith-S|
ANTIDEPRESSANT MEDICATIONS (* indicates serotonin reuptake inhibitor)
isocarboxazid (MAOI)| Marplan|
phenelzine (MAOI)| Nardil|
tranylcypromine (MAOI)| Parnate|
(All of these antianxiety medications except buspirone are benzodiazepines)
Alphabetical Listing of Medication by TRADE NAME
TRADE NAME| Generic Name|
Tourette's Syndrome)| pimozide|
Cibalith-S| lithium citrate|
Eskalith| lithium carbonate|
Lithane| lithium carbonate|
Lithobid| lithium carbonate|
ANTIDEPRESSANT MEDICATIONS (* indicates serotonin reuptake inhibitor)
Marplan (MAOI)| isocarboxazid|
Nardil (MAOI)| phenelzine|
Parnate (MAOI)| tranylcypromine|
(All of these antianxiety medications except buspirone are benzodiazepines)
At one time, two combination medications not included in the above list were often prescribed, but are prescribed only occasionally today. They are: a combination of amitriptyline (antidepressant) and perphenazine (antipsychotic) marketed as Triavil or Etrafon; and a combination of amitriptyline (antidepressant) and chlordiazepoxide (antianxiety) marketed as Limbitrol.
AHFS Drug Information, 91. McEvoy, G.K., ed. Bethesda, MD: American Society of Hospital Pharmacists, Inc. 1991.
Bohn, J., and Jefferson, J.W. Lithium and Manic Depression: A Guide. Madison, WI: Lithium Information Center. Rev. ed. 1990.
Goodwin, F.K., and Jamison, K.R. Manic-Depressive Illness. New York, NY: Oxford University Press, 1990.
Johnston, H.F. Stimulants and Hyperactive Children: A Guide. Madison, WI: Lithium Information Center, 1990.
Medenwald, J.R.; Greist, J.H.; and Jefferson, J.W. Carbamazepine and Manic Depression: A Guide. Madison, WI: Lithium Information Center. Rev. ed. 1990.
Physicians' Desk Reference, 45th ed. Oradell, NJ: Edward R. Barnhart, Publisher. Medical Economics Data, 1991 (available in public libraries).
Schizophrenia Bulletin (Issue Theme: New Developments in the Pharmacologic Treatment of Schizophrenia). Shore, D., and Keith, S.J., eds. Vol. 17:4, 1991 (available in most medical libraries).
This brochure was revised by Margaret Strock, staff member in the Information Resources and Inquiries Branch, Office of Scientific Information, National Institute of Mental Health (NIMH). Expert assistance was provided by Jerry M. Cott, Ph.D., I. Deborah Dauphinais, M.D., Harry E. Gwirtsman, M.D., Henry J. Haigler, Sr., Ph.D., Dorothy Karp, Ph.D., Matthew Rudorfer, M.D., and David Shore, M.D., NIMH staff members. Their help in assuring the accuracy of this pamphlet is gratefully acknowledged. An earlier version of the brochure was written under contract for NIMH by Brana Lobel.
MESSAGE FROM THE NATIONAL INSTITUTE OF MENTAL HEALTH
Research conducted and supported by the National Institute of Mental Health brings hope to millions of people who suffer from mental illness and to their families and friends. During the past 10 years, researchers have advanced our understanding of the brain and vastly expanded the capability of mental health professionals to diagnose, treat, and prevent mental and brain disorders.
Now, in the 1990s, which the President and Congress have declared "The Decade of the Brain," we stand at the threshold of a new era in brain and behavioral sciences. Through research, we will learn even more about mental disorders such as depression, bipolar disorder, schizophrenia, panic disorder, and obsessive-compulsive disorder. And we will be able to use this knowledge to develop new therapies that can help more people overcome mental illness.
The National Institute o Mental Health is part of the National Institutes of Health (NIH), the Federal Government's primary agency for biomedical and behavioral research. NIH is a component of the U.S. Department of Health and Human Services.
This booklet is designed to help people understand how and why drugs can be used as part of the treatment of mental health problems. It is important for persons who use mental health services to be well informed about medications for mental illnesses, but this booklet is NOT a "doit -yourself" manual. Self-medication can be dangerous. Interpretation of both signs and symptoms of the illness and side effects are jobs for the professional. The prescription and management of medication, in all cases, must be done by a responsible physician working closely with the patient--and sometimes the patient's family or other mental health professionals. This is the only way to ensure that the most effective use of medication is achieved with minimum risk of side effects or complications.
All material appearing in this brochure is in the public domain and may be reproduced or copied without permission from the Institute. Citation of the source is appreciated.
U.S. Department of Health and Human Services Public Health Service
National Institutes of Health
DHHS Publication No. (ADM)92-1509
The material contained herein is provided for informational purposes only and should not be considered as medical advice or instruction. Consult your health care professional for advice relating to a medical problem or condition.
Lamictal and Neurontin
Consider the novel anticonvulsants lamotrigine and gabapentin for patients with treatment-resistant bipolar disorder, Dr. Norman Sussman said at a psychopharmacology update sponsored by New York University.
Experience and data are limited with both agents, but the seriousness of the disorder, a high degree of tolerability, and positive clinical experience argue for their use in treatment-resistant cases, said Dr. Sussman, director of the Psychopharmacology Research and Consultation Service at Bellevue Hospital Center, New York.
The two drugs, which have attracted increasing attention for the treatment of bipolar disorder, appear to work quite differently. Lamotrigine (Lamictal) is best considered an antidepressant with low potential for inducing mania, while gabapentin (Neurontin) is a "serenic," more useful for treating mania and most appropriate as an add-on drug, he said.
Like many antidepressants, lamotrigine appears to inhibit serotonin reuptake. Case reports and series suggest the drug is in fact effective for the depressive phase of bipolar illness, particularly in rapid-cycling patients.
In a 12-month open-label trial of lamotrigine as monotherapy or add-on therapy, 70% of 75 bipolar patients had "marked improvement" in depression. In the first controlled study of the drug, involving nearly 200 patients, it was significantly more effective than placebo in measures of depression and clinical global improvement, he said.
Although lamotrigine is well tolerated, the risk of the potentially life-threatening Stevens-Johnson syndrome is cause for concern. The incidence of this syndrome is 1 per 1,000, which is comparable with the risk of Stevens-Johnson with carbamazepine. However, the risk of developing the syndrome rises when lamotrigine is used with other agents, and is twice as common in children.
The condition is heralded by a morbilliform, erythematous rash, which is otherwise mild to moderate and resolves spontaneously. "Be wary of Stevens-Johnson syndrome if the rash begins to look ugly, with lesions in the mouth and elevations," Dr. Sussman said.
A low starting dose and slow titration reduce the incidence of rash and the risk of Stevens-Johnson syndrome. He suggests beginning at 25 mg per day, then doubling the dose every 2 weeks until it reaches a therapeutic level.
Gabapentin, on the other hand, resembles an anxiolytic in its mechanism of action, increasing the synthesis of gamma-aminobutyric acid (GABA) and reducing glutamate, Dr. Sussman said.
The drug is an amino acid that is not metabolized and does not bind to plasma protein. Therefore, drug interactions are not a problem, the dose can be titrated rapidly to an effective level, and laboratory monitoring is not necessary, he said.
The only side effects seen with gabapentin are sedation (usually at the beginning of treatment), dizziness and weight gain at high doses, and (very rarely) edema. "The drug is remarkably well tolerated," Dr. Sussman said.
Initial interest in gabapentin as a psychotropic came from observations of mood and cognition improvements in patients who were given the drug for epilepsy.
Clinical experience and results in case series with gabapentin (usually added to other drugs) have been encouraging. In a retrospective study of 73 bipolar patients, 67 responded positively to the drug; cycling ceased in all who remained on it, and 23 reported improved mood.
A chart review of 47 bipolar patients who took gabapentin for 6 months found improvements in mood in nearly two-thirds and in concentration in over half. Most notable was a reduction in irritability, seen in over four-fifths of the patients.
But the results of two controlled trials were disappointing. A double-blind crossover study found that lamotrigine monotherapy was superior to placebo, but gabapentin was not. The high dose used (3,800 mg) might have "overshot the therapeutic window," Dr. Sussman suggested.
A controlled study of 114 bipolar patients in which gabapentin was added to lithium and/or valproate found the drug no better than placebo. A heterogeneous patient population, poor compliance, and the effect of background treatments -- lithium was adjusted in 11 placebo patients but in none on gabapentin -- might have compromised results, he said.
Interestingly, case reports and a few controlled trials have shown gabapentin quite effective in anxiety disorders, particularly panic and social phobia. Its antianxiety properties may make gabapentin most useful against mania, both in acute applications and as part of a maintenance regimen, Dr. Sussman said.
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