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 people suffering from many 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 which can alter the way in which the brain produces, stores and releases these neurotransmitter chemicals, alleviating the symptoms of the illness.

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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 the painful emotional and mental symptoms, psychiatric medicines can produce unwanted side effects. People suffering from mental illness should work closely with their physicians to understand what medicines 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 medicine that maintains the benefits but reduces the side effects. The psychiatrist may also prescribe a different medicine if the first one does not alleviate symptoms within a reasonable period of time.

Classes of Medications

Anti-depressant 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 its victims 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 suffer from a relapse, psychiatrists may prescribe anti-depressant medications for six months or longer, even if the symptoms disappear.

Types of anti-depressant medication

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 also 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. Anti-depressant 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. They 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 positive 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 due to dietary restrictions their use requires. Psychiatrists will sometimes turn to these medications when a person hasn't responded to other anti-depressants. 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 anti-depressants 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 suffered 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 suffer 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 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 treats both the manic symptoms in seven to ten days and reduces depressive symptoms when they may 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 which 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. It has 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 eight 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 medicine 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, this 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 for short periods. Side effects can include drowsiness, impaired coordination, muscular weakness and 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 anti-depressant medication. Alprazolam helps control those anxiety problems until the anti-depressant takes effect. Though alprazolam works quickly and has fewer side effects than anti-depressants, 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 anti-depressant medications. In February 1990, the U.S. Food and Drug Administration (FDA) approved clomipramine, a heterocyclic anti-depressant, 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, 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 victims may begin to avoid places and situations that remind them of those under which previous panic attacks occurred. Over time the victim may even refuse to leave home.

Currently, many psychiatrists may prescribe alprazolam for people who suffer with panic attacks. However, as already stated, this medication can cause dependency when used for an extended period. Once an anti-depressant has taken effect, physicians treating panic with alprazolam and an anti-depressant 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 anti-depressant 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 anti-depressants 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 Drugs

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, or 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 which 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 beginning urination to complete inability to do so, 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 for 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 antipsychotic 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 one and eight percent of patients taking antipsychotic 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 gate. It affects up to one third of those taking antipsychotic 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 one to two 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 medicine'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 effect, 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 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.

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(c) Copyright 1993 American Psychiatric Association
Produced by the APA Joint Commission on Public Affairs and the Division of Public Affairs. This document contains the text of a pamphlet developed for educational purposes and does not necessarily reflect opinion or policy of the American Psychiatric Association.

Additional Resources

Andreasen, Nancy. The Broken Brain: The Biological Revolution in Psychiatry. New York: Harper and Row, 1984.

Gold, Mark S. The Good News About Depression: Cures and Treatments in the New Age of Psychiatry. New York: Villard Books, 1987.

Gold, Mark S. The Good News About Panic, Anxiety & Phobias. New York: Villard Books, 1989.

Goodwin, Frederick K. Depression and Manic-Depressive Illness in Medicine for the Layman. Bethesda, MD: U.S. Department of Health and Human Services, 1982.

Gorman, Jack M. The Essential Guide to Psychiatric Drugs. New York: St. Martin's Press, 1990.

Greist and Jefferson, Eds. Depression and its Treatment: Help for the Nation's Number One Mental Problem. Washington, DC: American Psychiatric Press, Inc., 1984

Henley, Arthur. Schizophrenia: Current Approaches to a Baffling Problem (pamphlet). New York: Public Affairs Pamphlets, 381 Park Ave. South, NY, 1986.

Moak, Rubin, Stein, Eds. The Over-50 Guide to Psychiatric Medications. Washington, DC: American Psychiatric Press, Inc., 1989.

Sargent, M. Depressive Illnesses: Treatments Bring New Hope. U.S. Department of Health and Human Services (ADM 89-1491), 1989.

Torrey, E. Fuller. Surviving Schizophrenia: A Family Manual. New York: Harper and Row, 1988.

Walsh, Maryellen. Schizophrenia: Straight Talk for Families and Friends. New York: William Morrow and Company, Inc., 1985.

Yudofsky, Hales, and Ferguson, Eds. What You Need to Know About Psychiatric Drugs. New York: Grove Weidenfeld, 1991.

Other Resources

Anxiety Disorders Association of America
(301) 231-9350, (703) 524-7600

National Depressive and Manic Depressive Association Merchandise Mart
(312) 939-2442

National Institute of Mental Health Public Information Branch
(301) 443-4536

National Mental Health Association
(703) 684-7722

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