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SPECIAL MESSAGE

This booklet is designed to help mental health patients and their families understand how and why medications can be used as part of the treatment of mental health problems.

It is important for you to be well informed about medications you may need. You should know what medications you take and the dosage, and learn everything you can about them. Many medications now come with patient package inserts, describing the medication, how it should be taken, and side effects to look for. When you go to a new doctor, always take with you a list of all of the prescribed medications (including dosage), over-the-counter medications, and vitamin, mineral, and herbal supplements you take. The list should include herbal teas and supplements such as St. John's wort, echinacea, ginkgo, ephedra, and ginseng. Almost any substance that can change behavior can cause harm if used in the wrong amount or frequency of dosing, or in a bad combination. Drugs differ in the speed, duration of action, and in their margin for error.

If you are taking more than one medication, and at different times of the day, it is essential that you take the correct dosage of each medication. An easy way to make sure you do this is to use a 7-day pillbox, available in any pharmacy, and to fill the box with the proper medication at the beginning of each week. Many pharmacies also have pillboxes with sections for medications that must be taken more than once a day.

This booklet is intended to inform you, but it is not a "do-it-yourself" manual. Leave it to the doctor, working closely with you, to diagnose mental illness, interpret signs and symptoms of the illness, prescribe and manage medication, and explain any side effects. This will help you ensure that you use medication most effectively and with minimum risk of side effects or complications.

INTRODUCTION

Anyone can develop a mental illness-you, a family member, a friend, or a neighbor. Some disorders are mild; others are serious and long-lasting. These conditions can be diagnosed and treated. Most people can live better lives after treatment. And psychotherapeutic medications are an increasingly important element in the successful treatment of mental illness.

Medications for mental illnesses were first introduced in the early 1950s with the antipsychotic chlorpromazine. Other medications have followed. These medications have changed the lives of people with these disorders for the better.

Psychotherapeutic medications also may make other kinds of treatment more effective. Someone who is too depressed to talk, for instance, may have difficulty communicating during psychotherapy or counseling, but the right medication may improve symptoms so the person can respond. For many patients, a combination of psychotherapy and medication can be an effective method of treatment.

Another benefit of these medications is an increased understanding of the causes of mental illness. Scientists have learned much more about the workings of the brain as a result of their investigations into how psychotherapeutic medications relieve the symptoms of disorders such as psychosis, depression, anxiety, obsessive-compulsive disorder, and panic disorder.

RELIEF FROM SYMPTOMS

Just as aspirin can reduce a fever without curing the infection that causes it, psychotherapeutic medications act by controlling symptoms. Psychotherapeutic medications do not cure mental illness, but in many cases, they can help a person function 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 psychosis and help them to see reality more clearly. And antidepressants can lift the dark, heavy moods of depression. The degree of response--ranging from a little relief of symptoms to complete relief--depends on a variety of factors related to the individual and the disorder being treated.

How long someone must take a psychotherapeutic medication depends on the individual and the disorder. Many depressed and anxious people may need medication for a single period--perhaps for several months--and then never need it again. People with conditions such as schizophrenia or bipolar disorder (also known as manic-depressive illness), or those whose depression or anxiety is chronic or recurrent, may have to take medication indefinitely.

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 have side effects, and others do not. Age, sex, body size, body chemistry, physical illnesses and their treatments, diet, and habits such as smoking are some of the factors that can influence a medication's effect.

QUESTIONS FOR YOUR DOCTOR

You and your family can help your doctor find the right medications for you. The doctor needs to know your medical history, other medications being taken, and life plans such as hoping to have a baby. After taking the medication for a short time, you should tell the doctor about favorable results as well as side effects. The Food and Drug Administration (FDA) and professional organizations recommend that the patient or a family member ask the following questions when a medication is prescribed:

  • What is the name of the medication, and what is it supposed to do?
  • How and when do I take it, and when do I stop taking it?
  • What foods, drinks, or other medications should I avoid while taking the prescribed medication?
  • Should it be taken with food or on an empty stomach?
  • Is it safe to drink alcohol while on this medication?
  • What are the side effects, and what should I do if they occur?
  • Is a Patient Package Insert for the medication available?

MEDICATIONS FOR MENTAL ILLNESS

This booklet describes medications by their generic (chemical) names and in italics by their trade names (brand names used by pharmaceutical companies). They are divided into four large categories--antipsychotic, antimanic, antidepressant, and antianxiety medications. Medications that specifically affect children, the elderly, and women during the reproductive years are discussed in a separate section of the booklet.

Lists at the end of the booklet give the generic name and the trade name of the most commonly prescribed medications and note the section of the booklet that contains information about each type. A separate chart shows the trade and generic names of medications commonly prescribed for children and adolescents.

Treatment evaluation studies have established the effectiveness of the medications described here, but much remains to be learned about them. 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.

ANTIPSYCHOTIC MEDICATIONS

A person who is psychotic is out of touch with reality. People with psychosis may hear "voices" or have strange and illogical ideas (for example, thinking that others can hear their thoughts, or are trying to harm them, or that they are the President of the United States or some other famous person). They may get excited or angry for no apparent reason, or spend a lot of time by themselves, or in bed, sleeping during the day and staying awake at night. The person may neglect appearance, not bathing or changing clothes, and may be hard to talk to--barely talking or saying things that make no sense. They often are initially unaware that their condition is an illness.

These kinds of behaviors are symptoms of a psychotic illness such as schizophrenia. Antipsychotic medications 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 an episode of the illness as well.

There are a number of antipsychotic (neuroleptic) medications available. These medications affect neurotransmitters that allow communication between nerve cells. One such neurotransmitter, dopamine, is thought to be relevant to schizophrenia symptoms. All these medications have been shown to be effective for schizophrenia. 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 prescribed, the more serious the illness; but this is not always true.

The first antipsychotic medications were introduced in the 1950s. Antipsychotic medications have helped many patients with psychosis lead a more normal and fulfilling life by alleviating such symptoms as hallucinations, both visual and auditory, and paranoid thoughts. However, the early antipsychotic medications often have unpleasant side effects, such as muscle stiffness, tremor, and abnormal movements, leading researchers to continue their search for better drugs.

The 1990s saw the development of several new drugs for schizophrenia, called "atypical antipsychotics." Because they have fewer side effects than the older drugs, today they are often used as a first-line treatment. The first atypical antipsychotic, clozapine (Clozaril), was introduced in the United States in 1990. In clinical trials, this medication was found to be more effective than conventional or "typical" antipsychotic medications in individuals with treatment-resistant schizophrenia (schizophrenia that has not responded to other drugs), and the risk of tardive dyskinesia (a movement disorder) was lower. However, because of the potential side effect of a serious blood disorder--agranulocytosis (loss of the white blood cells that fight infection)-patients who are on clozapine must have a blood test every 1 or 2 weeks. The inconvenience and cost of blood tests and the medication itself have made maintenance on clozapine difficult for many people. Clozapine, however, continues to be the drug of choice for treatment-resistant schizophrenia patients.

Several other atypical antipsychotics have been developed since clozapine was introduced. The first was risperidone (Risperdal), followed by olanzapine (Zyprexa), quetiapine (Seroquel), and ziprasidone (Geodon). Each has a unique side effect profile, but in general, these medications are better tolerated than the earlier drugs.

All these medications have their place in the treatment of schizophrenia, and doctors will choose among them. They will consider the person's symptoms, age, weight, and personal and family medication history.

Dosages and side effects. Some drugs are very potent and the doctor may prescribe a low dose. Other drugs are not as potent and a higher dose may be prescribed.

Unlike some prescription drugs, which must be taken several times during the day, some antipsychotic medications can be taken just once a day. In order to reduce daytime side effects such as sleepiness, some medications can be taken at bedtime. Some antipsychotic medications are available in "depot" forms that can be injected once or twice a month.

Most side effects of antipsychotic medications are mild. Many common ones lessen or disappear after the first few weeks of treatment. These include drowsiness, rapid heartbeat, and dizziness when changing position.

Some people gain weight while taking medications and need to pay extra attention to diet and exercise to control their weight. Other side effects may include a decrease in sexual ability or interest, problems with menstrual periods, sunburn, or skin rashes. If a side effect occurs, the doctor should be told. He or she may prescribe a different medication, change the dosage or schedule, or prescribe an additional medication to control the side effects.

Just as people vary in their responses to antipsychotic medications, they also vary in how quickly they improve. Some symptoms may diminish in days; others take weeks or months. Many people see substantial improvement by the sixth week of treatment. If there is no improvement, the doctor may try a different type of medication. The doctor cannot tell beforehand which medication will work for a person. Sometimes a person must try several medications before finding one that works.

If a person is feeling better or even completely well, the medication should not be stopped without talking to the doctor. It may be necessary to stay on the medication to continue feeling well. If, after consultation with the doctor, the decision is made to discontinue the medication, it is important to continue to see the doctor while tapering off medication. Many people with bipolar disorder, for instance, require antipsychotic medication only for a limited time during a manic episode until mood-stabilizing medication takes effect. On the other hand, some people may need to take antipsychotic medication for an extended period of time. 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.

Multiple medications. Antipsychotic medications can produce unwanted effects when taken with other medications. Therefore, the doctor should be told about all medicines being taken, including over-the-counter medications and vitamin, mineral, and herbal supplements, and the extent of alcohol use. Some antipsychotic medications interfere with antihypertensive medications (taken for high blood pressure), anticonvulsants (taken for epilepsy), and medications used for Parkinson's disease. Other antipsychotics add to the effect of alcohol and other central nervous system depressants such as antihistamines, antidepressants, barbiturates, some sleeping and pain medications, and narcotics.

Other effects. Long-term treatment of schizophrenia with one of the older, or "conventional," antipsychotics may cause a person to develop tardive dyskinesia (TD). Tardive dyskinesia is a condition characterized by involuntary movements, most often around the mouth. It may range from mild to severe. In some people, it cannot be reversed, while others recover partially or completely. Tardive dyskinesia is sometimes seen in people with schizophrenia who have never been treated with an antipsychotic medication; this is called "spontaneous dyskinesia."1 However, it is most often seen after long-term treatment with older antipsychotic medications. The risk has been reduced with the newer "atypical" medications. There is a higher incidence in women, and the risk rises with age. The possible risks of long-term treatment with an antipsychotic medication must be weighed against the benefits in each case. The risk for TD is 5 percent per year with older medications; it is less with the newer medications.

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