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The Handbook:

Table of Contents

Introduction

Brain Disorders

Coping in Crisis

Medications

Resources for Care

Effects on the Family

Public Health Services

Financial Resources

Working with the System


Appendices:

NAMI Phone Numbers

DuPage Health Services

Chicago Area Hospitals

Community Resources

Legal Resources

Books, Videos, Journals

Hospitalization Form

Judicial Admission Form

Declaration of Treatment

Drug Reimbursement

Medications

Please note: This chapter is provided as general information and description only. Medications listed with an asterisk are not yet approved for use in the United States by the F.D.A.

For a specific diagnosis or prescription, you must consult your physician.

Medication can help people with brain disorders by controlling the symptoms, by relieving the distress of acute illness, and by preventing relapses of schizophrenia, mood disorders, and other psychiatric disorders. However, medication does not "cure" the illness and, of course, often has side effects.

The names of prescribed medications (both the manufacturer's brand name and the chemical generic name) are important to know, as are the dosage, therapeutic benefits, and possible side effects. Keeping a written record of this information can be very useful at a later date. Any treating non-psychiatric doctor or dentist should be aware of all medications taken. Medications vary as to the amount of time needed before taking full effect (from several days to several months). Also, some side effects are only temporary and may disappear after several days or weeks. In any case, ongoing treatment with medications should be supervised carefully by a doctor.

The main groups of drugs and their uses are:

Antipsychotics

Antipsychotics (also known as neuroleptics or major tranquilizers) are used to counteract psychotic thinking. They help reduce hallucinations, delusions, and agitation. Included in this group are the medications listed on the next page:

Several of these medications are sometimes referred to as "atypical" or "novel" antipsychotic agents. These include clozapine, olanzapine, quetiapine, risperidone and ziprasidone. These agents are atypical because they seem to be effective for some persons who have responded poorly to more traditional agents, because their action in the brain differs from that of older medications, and because they seem to cause far fewer side effects of movement disorders and lethargy (see below). These agents are probably not significant causes of tardive dyskinesia. After more than 10 years of widespread use in the United States, clozapine does not appear to cause this long-term side effect. The others in this category have not been released for general use for long enough to determine this for certain, but so far do not seem to cause tardive dyskinesia.

Some antipsychotics are injectable at one to four week intervals and can be advantageous for persons who either resist taking medication on their own or forget to take their doses. Included in this group are:

Side Effects

Use of antipsychotic drugs can produce side effects which generally may be grouped as allergic, autonomic, and extrapyramidal.

• Allergic reactions associated with this group of medications are uncommon and may be flu-like symptoms usually occurring during the first month of treatment. If any of the following occur during this time: rash, fever, sore throat, wheezing, shortness of breath; notify the physician.
• Autonomic reactions can include a drop in blood pressure when first standing up or sitting up, causing lightheadedness or faintness as well as dry mouth, blurred vision, difficulty urinating, and constipation. These reactions may decrease or disappear with time. Notify your physician if you are unable to urinate or if constipation is severe and persistent.
• Extrapyramidal reactions include stiffness, shakiness, restlessness, muscle spasms (especially neck, eyes, or tongue) and physical slowness. These symptoms are worse in young males, especially those with darker skin (the relationship with dark skin is a statistical correlation and the reason is unknown), and often another medication is required to counter these effects. "Atypical" or novel antipsychotic agents seem to cause these side effects far less frequently than other more traditional agents; in some studies atypical agents caused these side effects no more frequently than did a placebo (sugar tablet that appears identical to the active drug).

Medications used for these reactions include:

Tardive Dyskinesia (TD)

When anti-psychotics are used for longer periods, some people develop tardive dyskinesia, characterized by involuntary movements. While TD is usually most noticeable about the mouth and face, it can occur in any part of the body. Steps can be taken to prevent TD, such as keeping the dose of medication at its lowest effective level. Some inconclusive studies have suggested that taking Vitamin E while using an antipsychotic drug may help to prevent TD. It is possible, however, to take too much Vitamin E, so don't do this without a physician's supervision. Although TD often improves if medication can be safely discontinued, sometimes it is irreversible.

My feelings can come in cycles. At one point, I feel anger, then become sad and very sorry for myself. I then experience pain and fear and I wonder how I come across to others around me.

Antidepressants

These drugs are used to treat severe depression and the agitation or anxiety that may accompany depression. Some antidepressants are toxic when taken in overdose; therefore, the prescribed dosage should be carefully followed. Many antidepressants are on the market. Broadly speaking, most antidepressants can be divided into three groups: the cyclics, monoamine oxidase inhibitors (MAOIs), and the selective serotonin reuptake inhibitors (SSRIs). Other antidepressants do not fit into any of these categories.

Cyclics

Allergic and autonomic reactions can occur with this group of antidepressants and are similar to those described for the antipsychotic medications. The most common side effects are dry mouth, constipation and blurred vision. In some cases they may cause stomach upset, weight gain, nightmares, inability to sleep, sexual difficulties or increased seizure activity in those people who already have epilepsy. Many of these side effects may diminish or disappear, either with time or changes in dose, or by using other medications.

The most common cyclical antidepressants include:

Monoamine Oxidase Inhibitors (MAOIs)

Overall side effects of the MAOIs may be similar to the cyclical antidepressants but may also include ringing in the ears. A major difference is that certain foods and certain medications must be avoided in order to prevent a serious, potentially fatal interaction with the MAOI. This can lead to severe hypertension (high blood pressure). Following a restricted diet is essential (cheese, red wine, or beer—including nonalcoholic beer—are prohibited, along with restrictions on a number of other foods), and this diet must be well understood and started prior to starting on MAOIs. Also, there are potentially severe and fatal interactions if MAOIs are taken in combination with most other antidepressants, especially SSRIs and other MAOIs. In spite of these restrictions, MAOIs still have important uses, and often are effective when no other antidepressant works.

The MAOIs include:

Selective Serotonin Reuptake Inhibitors

Selective serotonin reuptake inhibitors (SSRIs), act on serotonin receptors in the brain. These drugs usually have fewer side effects than cyclics or MAOIs and are safer and often better tolerated. They are generally as effective as the cyclic compounds, though not for every individual.

Other Antidepressants

Several other, generally newer, antidepressants, do not structurally resemble cyclics, MAOIs or SSRIs. Their mechanisms of action either combine those of other agents, are different and unique, or are not fully known. These medications have variable side effects. For instance, bupropion (Wellbutrin) may lead to a higher likelihood of epileptic-like seizures than other antidepressants but only in its highest recommended dosage range and in a non-sustained release form. Venlafaxine (Effexor) causes mild to moderate rises in blood pressure in a small number of those taking it. Nefazodone (Serzone) should not be taken with certain other medications, because of potentially serious drug interactions, and has—extremely rarely—been associated with serious liver damage. As with any other medication, the possible risks and benefits of the drug should be discussed with your doctor before starting treatment.

Some of the drugs which are structurally and functionally distinct from the other classes of antidepressant are:

Antimanic - Mood Stabilizers

Drugs in this category are used to treat a person who is in a state of great excitement, usually accompanied either by emotional distress or euphoria, called mania or hypomania. The most common medications in this group are:

Lithium is the oldest known mood stabilizer. Lithium is not a tranquilizer but works in a more fundamental way to settle the person's mood so that she or he can sleep, eat, think, feel and relate to others more normally. Like antidepressant medication, lithium can take up to several weeks to work and has to attain a minimum concentration in the body before it is effective. In treating acute mania, lithium is often combined with other medications including anxiolytics or antipsychotics. People with bipolar disorder (previously known as manic-depressive illness) take lithium continuously, even when well, in order to prevent episodes of mania or depression from recurring.

Lithium has side effects that may include tremor, nausea, diarrhea, frequent urination, weight gain, marked thirst and water retention. If the lithium level gets too high in the blood, side effects may include lethargy, changes in mental functions, vomiting and diarrhea, and if severe, heart or kidney damage, and/or coma. For this reason, blood tests and regular visits to the doctor are used to carefully monitor the dose of lithium. Long-term side effects of lithium can include abnormal functioning of the thyroid gland and decreased kidney function, so these too are checked regularly.

Carbamazepine (Tegretol), gabapentin (Neurontin), lamotrigine (Lamictal), topiramate (Topamax), and valproic acid (Depakote) were originally used to treat epileptic seizures. Over the past ten years or more, research has shown that often these drugs are also effective in treating bipolar disorder (manic depressive illness). Valproic acid is now used almost interchangeably with lithium, depending on the person's symptoms, medical condition, and other factors. Carbamazepine also has a long track record in treating bipolar disorder but is used somewhat less frequently because of potential side effects. Both may require careful monitoring of the level of drug in the blood, depending upon the person's response in terms of reduction of manic or hypomanic symptoms.

Additionally, carbamazepine requires regular (more frequent at first) checks of blood counts, and valproic acid requires regular checks of liver function tests. Both of these are checked by taking a blood sample and must be monitored because of very rare but possibly serious side effects of each drug. Cold or flu symptoms must be quickly reported to a doctor while taking carbamazepine, and flu-like symptoms, especially accompanied by yellow eyes or skin, must be reported immediately to a doctor while taking valproic acid. Gabapentin (Neurontin), lamotrigine (Lamictal) and topiramate (Topamax) are newer anti-epileptic agents which have been demonstrated in some studies to have similar mood-stabilizing effects to those of valproic acid (Valproate) and carbamazepine. Many psychiatrists now use these newer drugs, especially for those patients who have not responded favorably to other, more established medications.

Anxiolytics

These drugs are used to relieve the distress of anxiety, relax muscles, and sometimes to produce sedation. They should be used for short periods of time because they are potentially addictive and may unpredictably add to the effects of alcohol or other sedating substances. The most commonly used anxiolytic medications are:

Side effects of benzodiazepines can include dizziness, drowsiness, and loss of muscle coordination, blurred vision, agitation, decreased memory, increased appetite, and diarrhea. However, apart from drowsiness, these side effects are rare. Anxiolytics can often be quite helpful when a person is receiving regular mental health care. Estazolam, Flurazepam, temazepam, and triazolam are not usually used as anxiolytics; instead, they are prescribed to induce sleep.

A number of the medications described above have more than one indication, that is, can be used to treat more than one illness or set of symptoms. For instance, several of the SSRI antidepressants are commonly used to treat generalized anxiety or prevent panic attacks, and SSRIs and some tricyclics are effective in helping symptoms of Obsessive-Compulsive Disorder. Also, olanzapine, an atypical antipsychotic, has also been demonstrated and approved by the FDA for the treatment of acute mania. Your doctor should be able to explain to you the reasons for prescribing a specific medication for your symptoms.

The mental health treatment team best includes a combination of client, family, and professionals.

Many of the medications listed in this chapter are expensive. When prescribed, purchasing them may constitute a hardship for those whom they can help. Most pharmaceutical companies have some provision for providing discount coupons, reimbursement or free medication to those who need but cannot afford them. A list of drug manufacturers who provide drugs for treating brain disorders and how to contact them for financial help are listed in Appendix J.

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