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Let's
Talk Facts About...
PSYCHIATRIC
MEDICATIONS
Mental
illnesses are among the most common conditions affecting
health today: One in five American adults suffers a
diagnosable mental illness in any six-month period.
According to the National Institute of Mental Health,
though, some 90 percent of these people will improve
or recover if they get treatment. Psychiatrists and
other physicians treating mental illnesses have a wide
variety of treatments available today to help them help
their patients. Most often, psychiatrists will work
with a new patient to construct a treatment plan that
includes both psychotherapy and a psychiatric medication.
These medications, combined with other treatments such
as individual psychotherapy, group therapy, behavioral
therapy or self-help groups, help millions each year
to return to normal, productive lives in their communities,
living at home with loved ones and continuing their
work.
Mental
Illnesses and Medications
Psychiatric researchers believe that many people suffering
from mental illnesses have imbalances in the way their
brain metabolizes certain chemicals, called neurotransmitters.
Because neurotransmitters are the messengers the nerve
cells use to communicate with one another, these imbalances
may result in the emotional, physical and intellectual
problems that mentally ill people suffer. New knowledge
about how the brain functions has permitted psychiatric
researchers to develop medications that can alter the
way in which the brain produces, stores and releases
these neurotransmitter chemicals, alleviating the symptoms
of the illness.
Psychiatric
Medications
Psychiatric medications are like any other medicine
your doctor would prescribe. They are formulated to
treat specific conditions, and they must be monitored
by a physician, such as a psychiatrist, who is skilled
in treating your illness. Like most medications, psychiatric
prescriptions may take a few days or a few weeks to
become fully effective.
All
medicines have positive and negative effects. Antibiotics,
which cure potentially serious bacterial infections,
can cause nausea. Heart disease medication can cause
low blood pressure. Even over-the-counter drugs such
as cold remedies can cause drowsiness, while aspirin
can cause stomach problems, bleeding and allergic reactions.
The same principle applies to psychiatric medications.
While very effective in controlling painful emotional
and mental symptoms, psychiatric medications can produce
unwanted side effects. People suffering from mental
illness should work closely with their physicians to
understand what medications they are taking, why they
are taking them, how to take them and what side effects
to watch for.
Before
deciding whether or not to prescribe a psychiatric medication,
psychiatrists either conduct or order a thorough psychological
and medical evaluation, which may include laboratory
tests. After a patient has begun taking a medication,
the psychiatrist closely monitors his or her patient's
health throughout the time the patient is taking the
medicine. Often, the side effects disappear after several
days on the medication; if they don't, the psychiatrist
may change the dose or switch to another medication
that maintains the benefits but reduces the side effects.
The psychiatrist may also prescribe a different medication
if the first one does not alleviate symptoms within
a reasonable period of time.
Classes
of Medications
Antidepressant
Medications
Depression, which afflicts 9.4 million Americans in
any six-month period, is the most common form of mental
illness. Far different from the normal mood shifts everyone
feels on occasion, depression causes a profound and
unremitting sense of sadness, hopelessness, helplessness,
guilt and fatigue. People suffering from depression
find no happiness or joy in activities once enjoyed
or in being with family and friends. They may be irritable
and develop sleeping and eating problems. Unrecognized
and untreated, depression can kill, as those with depression
are at high risk for suicide.
However,
up to 80 percent of people suffering from major depressive
disorder, bipolar disorder (manic-depression), and other
forms of this illness respond very well to treatment.
Generally treatment will include some form of psychotherapy
and, often, a medication that relieves the excruciating
symptoms of depression. Because people suffering from
depression are likely to have a relapse, psychiatrists
may prescribe antidepressant medications for six months
or longer, even if the symptoms disappear.
Types
of Antidepressant Medications
Three
classes of medication are used as anti-depressants:
heterocyclic antidepressants (formerly called tricyclics),
monoamine oxidase inhibitors (MAOIs) and serotonin-specific
agents. A fourth medication,the mineral salt lithium,
works with bipolar disorder. The benzodiazepine alprazolam
is sometimes used with depressed patients who also have
an anxiety disorder (see section on anxiety disorder
medications).
Taken
as prescribed, these medications can mean the difference
between life and death for many patients. Antidepressant
medications alleviate the terrible emotional suffering
and give people a chance to benefit from the non-drug
therapies that enable them to deal with the psychological
issues that may also be part of their depression.
Heterocyclic
Antidepressants
This group of antidepressants comprises amitriptyline,
amoxapine, desipramine, doxepin, imipramine, maprotiline,
nortriptyline, protriptyline, and trimipramine. They
are safe and effective for up to 80 percent of all people
with depression who take them.
At
first, heterocyclics may cause blurred vision, constipation,
a feeling of light-headedness when standing or sitting
up suddenly, a dry mouth, retention of urine or feelings
of confusion. A small percentage of people will have
other side effects such as sweating, a racing heartbeat,
low blood pressure, allergic skin reactions or sensitivity
to the sun. Though bothersome, these side effects can
be lessened with practical suggestions such as increasing
fiber in the diet, sipping water, and getting up from
a seat more slowly. Side effects generally disappear
after a few weeks, when the therapeutic effects of the
medication take hold.
More
serious side effects are extremely rare. However, a
very small percentage of people being treated with these
medications have aggravation of narrow-angle glaucoma
and seizures.
As
the bothersome side effects clear, the benefits of these
medications take hold. Gradually insomnia clears up
and energy returns. The person's self-esteem improves,
and the feelings of hopelessness, helplessness and sadness
ease.
MAOIs
Though they are as effective as heterocyclic medications,
MAOIs such as isocarboxazid, phenelzine, and tranylcypromine,
are prescribed less frequently because of the dietary
restrictions their use requires. Psychiatrists will
sometimes turn to these medications when a person hasn't
responded to other antidepressants. MAOIs also help
depressed people whose health conditions, such as heart
problems or glaucoma, prevent them from taking other
types of medications.
People
who take MAOIs should not eat foods, such as cheese,
beans, coffee, chocolate or other items, that contain
the amino acid tyramine. This amino acid interacts with
MAOIs and causes a severe and life-threatening increase
in blood pressure. MAOIs also interact with decongestants
and several prescription medications. People using these
antidepressants should always consult their physicians
before taking any other drug, and should rigorously
follow dietary instructions.
Serotonin-Specific
Agents
Serotonin-specific medicines, such as fluoxetine and
sertraline, represent the newest class of medication
for people suffering from depression. These medications
have less effect on the cardiovascular system and therefore
are helpful for depressed people who have had a stroke
or heart disease. They generally have fewer side effects
than other classes of anti-depressants.
However,
during the first few days of taking them, patients may
feel anxious or nervous and may have sleep disturbances,
stomach cramps, nausea, skin rash and, rarely, sleepiness.
In extremely rare cases, a person may develop a seizure.
A
few patients reported that, though they had had no suicidal
thoughts before taking fluoxetine, they developed a
preoccupation with suicide after medication began. There
have also been some reports that a very few patients
developed violent behavior after beginning to take fluoxetine.
Scientific data do not support these claims, however.
No studies have shown that the medication itself caused
these preoccupations or behaviors, which are also symptoms
of depression.
Bipolar
Medications
People suffering from bipolar disorder go through phases
of severe depression that alternate with periods of
feeling normal and/or periods of excessive excitement
and activity known as mania. During the manic phase,
people have extremely high energy, develop grandiose
and unrealistic ideas about their abilities, and commit
themselves to unrealistic projects. They may go on spending
sprees, for example, buying several luxury cars despite
moderate income. They may go for days without sleeping.
Their thoughts become increasingly chaotic; they speak
rapidly and they may become quite angry if interrupted.
Lithium
The medication of first choice for bipolar illness is
lithium, which both treats the manic symptoms in seven
to ten days and reduces depressive symptoms if they
develop.
Though
it is very effective in controlling the wild thoughts
and behaviors of mania, lithium does have some side
effects, including tremor, weight gain, nausea, mild
diarrhea, and skin rashes. People taking lithium should
drink 10 to 12 glasses of water a day to avoid dehydration.
Adverse reactions that may develop in a small number
of people include confusion, slurred speech, extreme
fatigue or excitement, muscle weakness, dizziness, difficulty
in walking or sleep disturbances.
Physicians
also sometimes prescribe anticonvulsant drugs such as
carbamazepine or valproate for people with bipolar disorder,
though the FDA has not yet approved them for this purpose.
They have been known to cause potentially serious blood
disorders in a minority of cases.
Anti-Anxiety
Medications
Anxiety disorders, in addition to generalized anxiety,
include such disorders as phobias, panic disorder, obsessive-compulsive
disorder, and post-traumatic stress disorder. Studies
indicate that 8 percent of all adults have suffered
from a phobia, panic disorder or other anxiety disorder
during the preceding six months. For millions of Americans,
anxiety disorders are disruptive, debilitating and often
the reason for loss of job and serious problems in family
relationships.
Often
an anxiety disorder, such as a simple phobia or post-traumatic
stress disorder, responds well to psychotherapy, support
groups and other non-medication treatments. But in severe
cases, or with certain diagnoses, a person may require
medication to control the unrelenting and uncontrollable
tension and fear that rule their lives.
Psychiatrists
can prescribe highly effective medications that relieve
the fear, help end the physical symptoms such as pounding
heart and shortness of breath, and give people a greater
sense of control. Psychiatrists often prescribe one
of the benzodiazepines, a group of tranquilizers that
can reduce debilitating symptoms and enable a person
to concentrate on coping with his or her illness. With
a greater sense of control, the person can learn how
to reduce the stress that can trigger anxiety, developing
new behaviors that will lessen the effects of the anxiety
disorder.
Benzodiazepines,
such as chlordiazepoxide and diazepam, and several other
medications effectively treat mild to moderate anxiety,
but these medications should be taken only for short
periods. Side effects can include drowsiness, impaired
coordination, muscular weakness, impaired memory and
concentration, and dependence after long-term use.
Alprazolam,
which is a high-potency benzodiazepine, is effective
against anxiety disorders that are complicated by depression.
People with this combination of symptoms who begin treatment
may find that their anxiety symptoms worsen when they
begin antidepressant medication. Alprazolam helps control
those anxiety problems until the antidepressant takes
effect. Though alprazolam works quickly and has fewer
side effects than antidepressants, it is rarely the
medication of first choice because it has a high potential
for dependency. Its side effects include drowsiness,
impaired coordination, impaired memory and concentration,
and muscular weakness.
Another
anti-anxiety medication, buspirone, has different side
effects than those sometimes caused by benzodiazepines.
Though it has little potential for dependency and doesn't
cause drowsiness or impair coordination or memory, buspirone
can cause insomnia, nervousness, light-headedness, upset
stomach, nausea, diarrhea, and headaches.
Medications
for Obsessive-Compulsive Disorder
Obsessive-compulsive disorder, which causes repeated,
unwanted and often very disturbing thoughts and compels
repetition of certain ritualistic behaviors, is a painful
and debilitating mental illness. A person with obsessive-compulsive
disorder might, for instance, develop a fear of germs
that compels him or her to wash his or her hands so
often that they continually bleed.
Though
obsessive-compulsive disorders are officially classified
as anxiety disorders, they respond best to antidepressant
medications. In February 1990, the U.S. Food and Drug
Administration (FDA) approved clomipramine, a heterocyclic
antidepressant, for use against obsessive-compulsive
disorder. This medicine acts on serotonin, a neurotransmitter
thought to affect mood and alertness. Though this medicine
may not take full effect for two or three weeks, it
is effective in reducing the uncontrollable thoughts
and behaviors and the devastating disruptions they cause
in a person's life.
Clomipramine's
side effects, like those of all heterocyclic antidepressants,
may include drowsiness, hand tremors, dry mouth, dizziness,
constipation, headache, and insomnia.
While
its use in treating anxiety disorders has not yet been
approved by the FDA, fluoxetine has shown some promise
in research.
Anti-Panic
Medications
Like other anxiety illnesses, panic disorder has both
physical and mental symptoms. People suffering from
a panic attack often think they are having a heart attack:
their heart pounds; their chest is tight; they sweat
profusely, feel they are choking or smothering, have
numbness or tingling around their lips or their fingers
and toes, and may be nauseated and chilled. Panic attacks
are so terrifying and unpredictable that many who have
them may begin to avoid places and situations that remind
them of those under which previous panic attacks occurred.
Over time those suffering from panic attacks may even
refuse to leave home.
Currently,
many psychiatrists may prescribe alprazolam for people
with panic attacks. However, as already stated, this
medication can cause dependency when used for an extended
period. Once an antidepressant has taken effect, physicians
treating panic with alprazolam and an antidepressant
in tandem will usually reduce the alprazolam dosage
slowly.
Learning
new ways of thinking, modifying behavior, learning relaxation
techniques and participating in support groups are among
the non-medication treatments that are also important
parts of the overall treatment plan for panic disorder.
While
alprazolam is the only medication the FDA has approved
for treatment of panic disorder, research continues
into the positive effects of other medications as well.
In
clinical trials, panic disorder has responded well to
heterocyclic antidepressant medications. In fact, antidepressant
medications such as imipramine have been effective in
reducing panic symptoms in 50 to 90 percent of the patients
studied. When combined with psychological and behavioral
treatments, the effectiveness of the medications increases.
When the panic symptoms lessen, the patient can begin
working with the psychiatrist in understanding his or
her illness and coping with its effects on daily life.
Likewise,
studies have suggested that MAOIs such as phenelzine
or tranylcypromine can be as effective as heterocyclic
antidepressants in the treatment of panic.
Fluoxetine,
which is also awaiting FDA approval for treatment of
panic, has had promising results in tests of its effects
on panic.
Anti-Psychotic
Medications
Psychosis is a symptom, not a disease. It can be part
of several mental illnesses, such as schizophrenia,
bipolar disorder, or major depression. It also can be
a symptom of physical illnesses such as brain tumors,
of drug interactions, of substance abuse, or of other
physical conditions.
Psychosis
alters a person's ability to test reality. A person
may suffer from hallucinations, which are sensations
that he or she thinks are real but don't exist; delusions,
which are ideas that he or she believes despite all
proof that they are false; and thought disorders, in
which his or her thought processes are chaotic and illogical.
Schizophrenia
is the mental illness most often associated with psychosis.
Researchers do not know the specific causes of schizophrenia,
though most believe that it is primarily a physical
brain disease. Some believe that the neurotransmitter
dopamine is involved with the hallucinations, delusions,
thought disorders and blunted emotional responses of
this mental illness. Most medications prescribed for
schizophrenia affect the dopamine levels in the brain
at the same time they reduce the extremely painful mental
and emotional symptoms.
Anti-psychotic
medications-acetophenazine, chlorpromazine, chlorprothixene,
clozapine, fluphenazine, haloperidol, loxapine, mesoridazine,
molindone, perphenazine, pimozide, piperacetazine, trifluoperazine,
triflupromazine, thioridazine, and thiothixene-lessen
the psychotic symptoms and allow the person to participate
more fully in life.
Anti-psychotic
medications do have side effects. They include dry mouth,
blurred vision, constipation, and drowsiness. Some people
taking the medications can experience a difficulty in
urinating that ranges from mild problems in beginning
urination to complete inability to urinate, a condition
that requires prompt medical attention.
For
many, these side effects lessen over several weeks as
their bodies adapt to the medication. To lessen constipation,
people taking antipsychotic medications can eat more
fruits and vegetables and drink at least eight glasses
of water per day.
Other
side effects include greater risk of sunburn, changes
in white blood cell count (with clozapine), low blood
pressure when standing or sitting up, akathisia, dystonia,
parkinsonism, and tardive dyskinesia.
Patients
with akathisia (which to some degree affects up to 75
percent of those treated with anti-psychotic medications)
feel restless or unable to sit still. While this side
effect is difficult to treat, some medications, among
them propranolol, clonidine, lorazepam and diazepam,
can help. Those with dystonia (between 1 and 8 percent
of patients taking anti-psychotic medications) feel
painful, tightening spasms of the muscles, particularly
those in the face and neck. This side effect is also
treatable with other medications, including benztropine,
trihexyphenidyl, procyclidine, and diphenhydramine,
that act as antidotes. Parkinsonism is a group of symptoms
that resemble those brought on by Parkinson's disease,
including loss of facial expression, slowed movements,
rigidity in arms and legs, drooling, and/or shuffling
gait. It affects up to one-third of those taking anti-psychotic
medications, and is also treatable with the medications
mentioned for treatment of dystonia, with the exception
of diphenhydramine. Tardive dyskinesia is one of the
most serious side effects of anti-psychotic medications.
This condition affects between 20 and 25 percent of
persons taking antipsychotic drugs. Tardive dyskinesia
causes involuntary muscular movements, and though it
can affect any muscle group, it often affects facial
muscles. There is no known cure for these involuntary
movements (though some drugs, including reserpine and
levodopa, may help), and tardive dyskinesia may be permanent
unless its onset is detected early. Psychiatrists emphasize
that patients and their family members should watch
closely for any signs of this condition. If it begins
to develop, the physician can discontinue the medication.
Clozapine,
which the FDA approved for prescription in 1990, now
offers hope to patients who, because they suffer from
so-called "treatment-resistant" schizophrenia,
could not be helped before by anti-psychotic medications.
Though clozapine has not been associated with tardive
dyskinesia, this anti-psychotic medication does cause
a serious side effect in 1 to 2 percent of the people
who take it. This side effect, a blood disorder called
agranulocytosis, is potentially fatal because it means
the body has stopped producing the white blood cells
vital to its protection from infections. To guard against
development of this condition, the medication's manufacturer
requires weekly monitoring of the white blood cell count
of each person taking the medication. As a result, use
of clozapine and its accompanying monitoring system
can be expensive.
Though
anti-psychotic medications have side effects, they offer
benefits that far outweigh the risks. The hallucinations
and delusions of psychosis can be so terrifying that
some people are willing to endure their side effects
for relief from the terrors of the illness. The thought
disorders can be so confusing and frightening, they
isolate those afflicted with them in a lonely world
from which no escape seems possible. Unable to know
whether the insects they see crawling on their bodies
are real, unable to control the voices that harass and
degrade them, unable to express their thoughts so others
can understand them, people suffering from psychotic
symptoms lose their jobs, their friends and their families.
Cast into a hostile world of people who are afraid of
or unable to understand their disease, these people
often become suicidal.
Conclusion
No
medication, whether an over-the-counter drug such as
aspirin or a carefully prescribed psychiatric medication,
is without side effects. But just as relief from the
pain and discomfort of a cold is worth the potential
side effects, so is the relief from the excruciating
and potentially fatal symptoms of mental illnesses.
Psychiatrists are trained to carefully weigh the benefits
and risks of prescribing these medications.
No
one should fear taking a psychiatric medication if he
or she has received a complete medical and physical
examination and is properly monitored for both the medicine's
benefit and its side effects. Not only do psychiatric
medications offer relief from the terror, loneliness,
and sorrow that accompany untreated mental illnesses,
but they enable people to take advantage of the psychotherapy
(which psychiatrists usually prescribe in tandem with
medication), self-help groups, and supportive services
available through their psychiatrist. Better, these
medications and the other services available through
mental health care enable people who have mental illness
to enjoy their lives, their families and their work.
Bibliography
Gorman, Jack M. The Essential Guide to Psychiatric Drugs.
New York: St. Martin's Press, 1995.
Liska,
Ken. Drugs and the Human Body: with Implications for
Society. New York: Macmillan, 1994.
Minirith,
Frank, Paul Meier, and Stephen Arterburn. Miracle Drugs.
Nashville: Thomas Nelson Publishers, 1995.
Robson,
Philip. Forbidden Drugs. New York: Oxford University
Press, 1994.
Yudofsky,
Stuart, Robert Hales, and Tom Ferguson. What You Need
to Know About Psychiatric Drugs. New York: Ballantine,
1991.
Other
Resources
Anxiety
Disorders Association of America
6000 Executive Blvd. Suite 513
Rockville, MD 20852-3801
(301) 231-9350
National
Alliance for the Mentally Ill
200 North Glebe Road
Suite 1015
Arlington, VA 22203-3754
(703) 524-7600
National
Institute of Mental Health
Information Resources and Inquiries Branch
Room 7C-02
5600 Fishers Lane
Rockville, MD 20857
(301) 443-4513
National
Mental Health Association
1021 Prince St.
Alexandria, VA 22314
(703) 684-7722
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