Psych Medication

by Alan Brandis, Ph.D.

How Medications Work The Antidepressants
Anti-Anxiety Medicines Anti-Psychotic / Major Anxiety Drugs
Next-Generation Psychotropics The Anticonvulsants
Stimulants / ADHD Drugs Guidelines For Taking Psychiatric Meds

Although we strongly believe in the value of psychotherapy and behavioral interventions, there are times when the extra help of medication is necessary in order to make the fullest adjustment, or in order to achieve the maximum relief from symptoms.

There are several types of medication which may be used to assist in the treatment of emotional or behavioral disorders. We will discuss each type individually. Please understand that this information is in no way intended to take the place of advice from a physician or psychiatrist, and no medication should be taken without being properly supervised by a person who is licensed and adequately trained to prescribe it.

Technical Brain Stuff (How Meds Work)

Nerve impulses are transmitted between the end of one nerve cell and the beginning of another across a microscopic space called the synapse. When the nerve impulse reaches the end of the nerve (the part of the nerve cell called the axon), it causes a chemical, called a neurotransmitter, to be released into the synapse. The neurotransmitter is stored in tiny chambers called vesicles. When it is released, it travels into the synapse and reaches the beginning of the next nerve cell, a part called a dendrite. The dendrite has receptor sites which only certain chemicals can attach to, and the neurotransmitter attaches to it.

When enough receptor sites are occupied, the nerve cell fires an impulse down its axon to the next nerve cell, and so on. After the nerve impulse is fired, the neurotransmitter is released by the dendrite and it travels back, across the synapse, to the axon of the nerve which released it, where it is taken back into the vesicles in a process called reuptake. Some of the neurotransmitter may remain in the synapse, where it is broken down by enzymes.

Most psychoactive meds perform their magic in one of these ways:

  • The drug occupies lots of receptor sites without stimulating the nerve to fire, thus blocking the "real" neurotransmitter from attaching to those receptors, reducing the activity of that part of the nervous system; and example would be the “dopamine blockade” of the antipsychotic drugs like Haldol and Thorazine.
  • The drug occupies lots of receptor sites, artificially causing the nerves to fire rapidly, increasing the activity of that part of the nervous system; examples would be the stimulant medications like Ritalin and Dexedrine.
  • The drug blocks the enzyme that breaks down the neurotransmitter, causing there to be more of it in the synapse, which increases the likelihood that receptor sites will be occupied and increasing the activity in that part of the nervous system; this is how the MAO Inhibiter antidepressants work.
  • The drug blocks the reuptake of the neurotransmitter, causing there to be more of it in the synapse, which increases the likelihood that receptor sites will be occupied and increasing the activity in that part of the nervous system; this is how the newer antidepressants like Lexapro work.

At least, that is what scientists think happens in there.

The Antidepressants

When suffering from a depression which is long-lasting and seems to be resistant to other interventions (such as psychotherapy, exercise, stress-reduction, etc.) or which is severe enough to cause thoughts of suicide, antidepressant medication should probably be considered. There are three main types of antidepressants, and a couple of less-used ones.

The most widely prescribed (and widely known) antidepressant is probably Prozac, which is one of the newest type, called Selective Serotonin Reuptake Inhibitors or SSRI's. There are a number of other, newer variations of Prozac. The main advantage of these SSRI's is that they seem to cause fewer side effects in most people. They appear to block the reuptake of Serotonin, a neurotransmitter, as well as other neurotransmitters.

The Tri-Cyclic antidepressants (so named because of the three interlocked rings of atoms in their molecules) block the reuptake of norepinephrine, another neurotransmitter. Another group of medicines, called MAOI's (monoamine oxidase inhibitors), block the action of an enzyme, monoamine oxidase, which breaks down norepinephrine in the synapse. MAOI's are rarely used today, largely because they remove the body's ability to defend itself against chemicals which could stimulate the sympathetic nervous system and cause rapid heartbeat and other symptoms if certain foods are eaten, including chocolate, cheese, nuts, bananas, etc. (foods which contain phenylalanine, which is a stimulant).

Sometimes, symptoms of depression can be caused by Bipolar Illness (formerly called "manic depression"), characterized by severe mood changes from depression to euphoria. Although the depressed phase of bipolar illness seems to be similar to other depressions, the manic phase is easily recognizable. The individual stays up (without drugs) for days or weeks at a time, is impulsive and may spend money foolishly, may behave promiscuously, may start many things and not finish them, may make gigantic, unrealistic plans for things that can never happen, and may become agitated or defensive when questioned about their behavior. In such cases, Lithium Carbonate may be prescribed, or several other medicines such as Tegretal or Depakote may substitute for Lithium. (It's interesting to note that the Lithium-substitute drugs are primarily used to treat seizure disorders.)

Sometimes, depression may be caused by an underlying psychotic process, in which the person may be having severe anxiety with feelings of alienation or framentation, may be having hallucinations or believe bizarre things, such as that others are plotting against him or that people are stealing his thoughts. In such cases, antipsychotic medicines would be the first choice of medications to try.

Symptoms of depression which could indicate a need for a trial on antidepressant medications include repeated difficulty falling asleep, frequent waking in the early AM with the inability to fall back to sleep, excessive worrying and obsessing about things, extreme fatigue or excessive sleeping, suicidal thoughts or attempts at self-harm, crying spells or feelings of hopelessness.

Antidepressants, including Prozac and Anafranil, are also being used effectively to treat Obsessive-Compulsive Disorder (OCD), a sometimes-disabling condition in which the individual worries repetitively about things, and may develop a severe fear of dirt or germs which causes them to wash their hands up to a hundred times a day. Some sufferers of OCD engage in "checking" behavior in which they constantly check and reassure themselves that they have done certain things, such as lock the door, pick lint off of their coat, comb their hair, etc., and may do these behaviors hundreds of times a day.

If you or someone you love has symptoms of depression, bipolar illness or OCD, take the problem seriously and do what you can to get them professional help.

The Anxiety Medicines (Anxiolytics)

Anxiety is a psychological and physiological condition which can cause symptoms of worry, rapid heartbeat, rapid and/or shallow breathing, perspiration, tremors (shakiness), and a sensation that the world is pushing in on one or a fear that one is going to die. Most people with anxiety have mild to moderate symptoms, but a small percentage have severe, disabling symptoms. If the anxiety seems to have a sudden, severe onset it may be called a "panic attack."

Since the advent of Miltown in the 1950's, medication for anxiety has been widely available. By some estimates, Xanax (first cousin of Valium ) is now the most widely prescribed drug in the U.S. Add to this the number of people who use other similar medicines, alcohol, and recreational drugs, and it appears that the population of the U.S. has a tremendous anxiety problem.

Taken regularly, medications which reduce the activity of the central nervous system (which includes tranquilizers, "sleeping pills," alcohol, some painkillers and a number of recreational drugs) almost always result in the development of tolerance, which means that the body gets used to the drug and its effect at a given dose gets weaker. So, more has to be taken in order to get the same effect. And, if the drug is stopped, a withdrawal effect occurs. This is how drug addiction begins, whether to a "street" drug or to a prescription.

So, we recommend that if your physician feels that a tranquilizer will temporarily reduce your anxiety and prescribes a limited quantity of medication, go ahead and use it. However, these medications are not usually recommended as a long-term solution for anxiety or insomnia. They treat the symptoms but not the problem. If you fear that you might run out or that you might forget to bring your medication with you, or if you come to feel that you need the drug in order to function, you may be addicted to it.

We recommend other ways of handling the problem of anxiety, including psychotherapy, biofeedback therapy, stress reduction or relaxation training, lifestyle change, exercise, etc. You may benefit from simply doing a deep-breathing exercise several times a day. When we teach patients to do these simple things to relax their bodies and minds, many of them find that their need for anxiety medications is reduced or eliminated. In severe or complex cases, however, medication may be helpful if it is not abused.

There are a few, newer, medications for anxiety which do not seem to create a tolerance, and thus their addiction potential is almost nonexistent. Buspirone (BuSpar) is one of them. It seems to work more like an antidepressant, in that it takes several weeks to work and it does not provide an immediate "rush" of anxiety relief, like the Valium-type drugs do. Sometimes, a low dose of an antidepressant medicine helps to reduce anxiety as well, especially anxiety which is related to worrying excessively.

The Antipsychotic Drugs (Major Tranquilizers)

The antipsychotic drugs got their accidental start when researchers were testing new antihistamines (drugs for allergy symptoms such as hay fever). In the 1940's, 50's and 60's, medical research was sometimes conducted on prisoners and committed mental patients. A new antihistamine candidate called Thorazine was given to a group of mental patients, and their hallucinations were stopped or reduced.

There is now a wide range of medicines to help people who suffer from mental illnesses which cause them to see or hear things that others do not (hallucinations), or to believe bizarre things which others do not (delusions) such as that the television is broadcasting messages to their brain, etc. The general aim in the research on these drugs is to get more effective symptom relief with fewer and less severe side effects. In the last 20 years, we have found that severe anxiety may also respond well to the use of these drugs in lower doses.

The side effects of the older medicines in this category tend to be the most difficult to live with, including severe sedation, motor agitation, Parkinson's-Syndrome-like problems such as muscle tremors and tics, and in some patients during long-term use a permanent nervous system disorder called tardive dyskinesia, in which the Parkinson's-like symptoms persist. A couple of these medicines can also cause serious blood disorders in a very small percentage of patients, so they have to be monitored closely while taking them.

Often, an additional medicine must be prescribed along with the antipsychotic drug, to counteract the Parkinson's-like symptoms, such as Cogentin or Artane. This is especially important in patients who have paranoid delusions, since if they get side effects they may believe that they are being poisoned.

The Next-Generation Psychotropics

There are newer medications which seem to be very effective in reducing both anxiety problems and the more serious psychotic disorders. They also seem to be less likely to cause side effects. Drugs like Zyprexa and Seroquel are changing how we think about anxiety problems. They are being used as secondary enhancers for the anticonvulsant medications that treat bipolar disoder.Also, some medications that are used to treat psychosis at higher doses, like Risperdal, are being used at much lower doses to treat severe anxiety conditions (4-16 mg. vs. 0.2 mg.).

The Anti-Convulsants

Years ago, it was discovered that some people with severe mood swings (from high and euphoric to low and depressed) seemed to respond well to Lithium salts. Lithium was used for years as the primary treatment for bipolar disorder. However, it has several drawbacks, including that its toxic level is not much higher than the therapeutic level, necessitating regular blood testing to prevent toxicity. Also, since it it essentially a salt, it is affected significantly by fluid content of the body, sweating, and table salt intake. Another problem is that, since it is a salt, it can cause fluid retention and bloating, which makes it very unpopular with women.
The newer anticonvulsant medications include Neurontin (gabapentin), Depakote (valproic acid) and Lamictal. They seem to stabilize the brain’s functioning and raise the seizure threshold. This may indicate that bipolar disorder is related in some way to the malfunction that causes seizures. In fact, seizure disorders that did not result in complete loss of consciousness, but apparently caused personality shifts, were called “petit mal” seizures (to contrast with “grand mal” in which loss of consciousness occurs).

The Stimulant Medications

Stimulant medicines include Dexedrine, Ritalin, Cylert, Adderall, and others. Stimulants are used primarily for two types of problems - for rare sleeping diseases (narcolepsy), and for Attention-Deficit Disorder. For ADHD, these medicines seem to slow and calm the patient, allowing them to stay focused and lessening their tendency to lose control and act negatively or destructively. This is called a paradoxical effect , since in non-ADD people these drugs speed up mental and physical processes.

There is a lot of controversy about using powerful stimulant drugs with children. We believe that there is still significant overdiagnosis of ADHD, and many kids who have been on stimulant meds may not actually have ADD or ADHD - but they may perform better on meds anyway. Stimulant medication increases the speed and performance of certain cognitive functions, even in people who are otherwise “normal.”

A new medication called Strattera is available to treat Attention-Deficit Disorder. It is a Norepinephrine Reuptake Inhibiter, and it works like an antidepressant, but acts on the parts of the brain that control attention (the prefrontal cortex). Like the antidepressants, it takes several weeks to ahieve the therapeutic effect. And, like the antidepressants, its effect is indirect, so the addiction potential is minimal. Psychiatrists we have spokento tell us that, of people who try to switch from a stimulant to Strattera, about half are able to function as well or better on Strattera. The benefits are the avoidance of the ups and downs of using the stimulants, and once-daily dosing.

To determine whether you or your child genuinely has an attention problem, we offer specialized testing that was developed specifically for the purpose of differentiating ADD people from non-ADD people.

General Guidelines For Taking Psychotropic Medications

  1. Take the medication as prescribed. If you miss a dose, you miss a dose - do not "double up" on your next dose, as you will increase your chance of having side effects. More is not necessarily better.
  2. Reduce or eliminate the use of alcohol. Alcohol can block the effects of some medicines, and can increase the effect or increase the side effects of others. If you can't not drink when you have to take medicine, you may have a drinking problem.
  3. Report any side effects other than very mild ones to your physician immediately. If you feel worse because of the side effects, you may be exchanging one problem for another. If you don't report problems to your physician, he or she can't make corrections by changing your dosage or trying a different medicine.
  4. Inform your physician of any other medicines you are taking, even over-the-counter ones, and of any other physicians you are being treated by. One of the most dangerous situations is when you have two doctors treating you for different problems, and neither of them knows what the other one is prescribing for you.
  5. Get feedback from family members. Often, people who are close to you can tell if your medicine is working by observing your mood and behavior, even before you may feel any different. We usually ask family members for feedback, if possible.
  6. Give it time. Some medicines, especially the antidepressants, don't seem to work for two or three weeks, then they "kick in." If after two or three weeks you don't feel it is working, let your physician know. It may be time to increase your dose, or change medicines, or add another medicine. Regular contact with the person who is prescribing for you is important until you have achieved the correct medicine and dose.