A Framework for Understanding Treatment with Psychiatric Medications

by Kevin Furmaga, Pharm.D.

Introduction
This article is intended to provide the reader with a framework for understanding the potential therapeutic benefits and limitations of psychiatric medications. The goal of this commentary is to foster patient-care provider interaction so those suffering from psychiatric symptoms will be better able to 1) participate in treatment decisions, 2) establish realistic expectations for improvement with drug treatment, and 3) optimize the therapeutic benefits possible for an individual’s circumstances.

Although the focus of this article is drug treatment, it would be negligent not to mention the long-term benefits of psychotherapy (counseling) in the treatment of psychiatric disorders. The fact is the first episodes and often subsequent episodes of psychiatric symptoms are triggered by what are termed “psychosocial stressors.” These are stressful life events such as loss of a loved one, loss of job, divorce, or financial problems that initiate the brain chemical imbalances responsible for psychiatric symptoms. Psychotherapy can impact the long-term course of psychiatric illness. It can reduce the frequency of psychiatric episodes because psychotherapy focuses on the triggers of those episodes. Psychotherapy helps one understand him- or herself better, can assist people in identifying the types of behavior that trigger stress, and guide people towards lifestyle changes that will reduce stress. Because not all stress is avoidable, the role of a therapist is to also help people predisposed to stress-induced illness identify ways to deal with problematic life events that will reduce the risk of triggering an episode of psychiatric symptoms. Optimal treatment for most psychiatric disorders involves a combination of drug therapy and psychotherapy.

History of Psychiatric Medications
Before the 1950s, medication use was virtually unheard of in the treatment of psychiatric symptoms. Psychoanalysis and other forms of “talk therapy” were the principle approaches used during the first half of the twentieth century to help people suffering from depression, anxiety, compulsions, and phobias. People afflicted with schizophrenia, bipolar disorders (manic depression), and other illnesses involving severe mood, thought, and behavioral disturbances were frequently institutionalized for long periods of time and prevented by family members to interact socially. The few medications that were available, such as barbiturates and related drugs, were useful for temporary sedation of patients with severe agitation or violent behavior. They did not offer long-term benefits such as increased independence nor did they significantly improve quality of life. That many forms of mental illness had a treatable, biological cause was not seriously considered and the concept of an antidepressant, mood stabilizer, or antipsychotic medication did not exist.

This all began to change in 1952 with the fortuitous (though accidental) discovery that a medication used to treat symptoms related to stress during surgery had beneficial effects on the hallucinations and agitation of patients with schizophrenia. The drug was chlorpromazine (Thorazine®), the first antipsychotic. In many ways it ushered in the biological era of psychiatry. While researchers worked to find more effective and better-tolerated drugs to treat psychotic symptoms, another chance discovery in 1958 resulted in the first medication effective for symptoms of depression. This was imipramine (Tofranil®).

These early psychiatric medications served not only as clinical treatments, but were used as research “probes” to enhance our understanding of brain biology. If researchers could determine where and how these drugs caused their beneficial and adverse effects, they would also gain insight into brain function at the cellular and molecular (chemical) level. As a result, our understanding of brain function in both health and mental illness has increased tremendously during the last 50 years.

Also contributing to the search for better psychiatric medications are the advances in the way new drugs are developed. Researchers no longer rely on chance discovery to find new medications. Because we have a better understanding of where and how to target brain function at the molecular level, psychiatric medications are now designed with these desired brain targets and mechanisms in mind. This has resulted in medications that are not only effective, but safer and with fewer side effects when compared with the psychiatric medications of the 1950s, 60s, and 70s. These advances have also transformed psychiatric treatment from a solely psychological focus to treatments that encompass both a biological and psychological approach.

Today we have safer medications with fewer side effects. Ever-expanding drug treatment options means it is much more likely a medication or medication combination can be found that is not only effective, but also better tolerated. Many people have experienced a quality of life that is dramatically improved because of the medications now available. There are also those, however, who have not experienced the level of symptom improvement they had expected. This reflects, in part, that there is still a great deal we do not understand about the brain’s chemical messenger systems and the complex interactions between environment and these messenger systems. It is also likely that there are symptoms related to human thought, mood, and behavior that will not be improved with medications.

Those who believe that drug treatment for psychiatric illness is a toxic conspiracy perpetrated by the mainstream medical establishment and pharmaceutical companies are wrong. Equally misguided are those who believe that medications are a panacea, the treatment approach guaranteed effective for those tormented by thought, mood, and behavioral symptoms. In some people with psychiatric symptoms, medication treatment will lead to a dramatic improvement in their quality of life. Most people will experience improvement in many of their symptoms, but medication treatment alone is only partially effective. Then there are people for whom medication has no significant effect at all, or whatever modest symptom improvement they do experience is offset by medication side effects.

Biology of Psychiatric Symptoms:
Therapeutic Targets of Psychiatric Medications
The human brain is made up of billions of interconnecting brain cells (neurons) that communicate with each other by using chemical messengers. It is useful to think of the brain as a symphony orchestra, which has different instrumental sections such as strings, brass, woodwind, percussion, etc. The brain also has different areas that have specialized purposes. There are areas of the brain concerned with the senses: touch, smell, taste, sight, and hearing. Other areas of the brain are concerned with movement, speech, memory, emotions, and mood. There are brain areas concerned with planning, creativity, and social awareness. For the brain to function at an optimal level, each area needs to be aware of what the other areas are doing. Much like the various sections of an orchestra need to know what other sections are doing so the instruments start and stop playing at the proper time.

The way the various areas of the brain communicate with each other is through chemical messengers. You may be familiar with the names of some of these chemical systems: serotonin, dopamine, norepinepherine, acetlycholine, and there are many others. Psychiatric disorders such as depression, anxiety, mania, and psychosis occur when there is an imbalance or dysregulation of the chemical messenger systems the brain uses to communicate with itself. In cases such as depression, the problem may be a low functioning serotonin system. In disorders involving hallucinations and delusions, an overactive dopamine system is likely involved.

Psychiatric medications work by targeting one or more of the brain’s chemical messenger systems and correcting the imbalance. The chemical imbalances being treated are more complex than “not enough serotonin” or “too much dopamine.” There may be enough serotonin, but it may not be released in adequate amounts or at frequent enough intervals. The problem may not be with the chemical messenger at all but with the brain cell sites to which the chemical attaches (receptors). For our purposes in understanding how psychiatric medications work, think in terms of the brain chemical systems being overactive or underactive.

Further complicating this picture is that these brain chemical systems interact with each other and influence each other’s functioning. Using a medication to target the functioning of the serotonin system is also likely to have an indirect and important effect on other chemical systems that regulate mood, thought, and behavior.

The medications used in the treatment of psychiatric disorders can be divided into 5 main groups: 1) Antidepressants, 2) Antimanic Agents (a.k.a., Mood Stabilizers), 3) Antipsychotics (a.k.a., Neuroleptics), 4) Antianxiety and Hypnotics, and 5) Stimulants.

Important Facts About Treatment with Psychiatric Medications
It is important to keep in mind that, as with most medications, psychiatric drugs do not cure the illnesses they are intended to treat. A cure is a treatment that permanently corrects the underlying cause of a person’s symptoms. Except for antibiotics, some anticancer drugs, and antidotes or antitoxins, medications can reduce or eliminate the symptoms of a disease, but do not correct the underlying cause of an illness. Drugs reduce or eliminate symptoms and long-term consequences of disease. Symptom treatment is key, however, since symptoms are the body’s response to an underlying biological problem. It is the symptoms of an illness that adversely affect a person’s ability to function.

Psychiatric disorders can differ from chronic medical conditions in that some, such as depression, occur in episodes lasting several months after which there are long, symptom-free periods, or several months during which symptoms are less problematic. The answer to a common question: “How long will I have to take my medication(s)?” depends on the nature of the illness in an individual. If a person’s symptoms return soon after a course of effective treatment, then this indicates that medications should continue. On the other hand, should symptom-free periods last more than a year or two, then the psychiatric illness can be treated with medication when symptoms occur. Psychiatric disorders such as schizophrenia and the bipolar disorders usually require lifelong, continuous treatment because symptoms of these illnesses usually return within weeks or months after effective medications are discontinued. Major depression, although lifelong in most people, typically occurs in episodes separated by periods (years) with less severe or no symptoms.

Psychiatric disorders are similar to common medical conditions such as heart disease, high blood pressure, and diabetes in that 1) They have a biological cause (usually), 2) They are chronic, lifelong ailments, and 3) Medication treatment reduce and prevent symptom recurrence and improve quality of life, but do not cure (permanently correct the cause) these illnesses.

The leading cause of symptom relapse in people suffering from psychiatric disorders is non-adherence to the prescribed medication regimen, usually because of one or both of the following reasons: 1) Not understanding the goal of medication treatment, and 2) Discontinuing medications because of troublesome side effects.

It is important to emphasize that medications can only reduce or eliminate symptoms and prevent recurrence of symptoms, which is the goal of drug treatment. A common mistake people make is that they stop their medications as soon as their symptoms are reduced or eliminated. Nearly 50 years of research and experience tells us if we only administer medications until psychiatric symptoms are minimized or eliminated, the symptoms will return within days or weeks after effective medication treatment is stopped. With major depression, treatment is necessary for at least six months after a full therapeutic response before antidepressants should be discontinued. Because it takes anywhere from four to eight weeks for this optimal therapeutic response to be achieved, the typical course of drug treatment for a first or second episode of major depression lasts about one year.

Medication side effects are another reason patients stop their medications without advice from their physician. It is important to realize that all medications have the potential to cause side effects. What determines the type and severity of side effect a person experiences is the individual’s sensitivity to the side effect profile of a particular medication. While the majority of side effects are not life threatening, they can adversely affect a person’s ability to function. There are almost always steps that can be taken to minimize drug side effects. If a person taking psychiatric medication experiences troublesome side effects, he or she should contact the prescribing physician who can utilize a number of different strategies that can reduce or eliminate side effects without losing the therapeutic benefit of a medication.

1. Some side effects (for example, drowsiness) go away or minimize after several days of treatment because people develop a tolerance to the side effect. For some side effects your physician may advise you to “hang in there” until the side effect subsides.
2. Some side effects respond better when doses are slightly reduced and subsequent dosage increases are more gradual. This gives the patient more time to develop a tolerance to the medication side effects.
3. As a general rule, medications that cause drowsiness are dosed near the end of the day or at bedtime, while medications that are activating (stimulating) are dosed earlier in the day. However, there are always a small percentage of people that are affected by a typically sedating or activating medication in the opposite way. In these cases, the time of day the medication is taken can be changed. From a therapeutic standpoint it doesn’t matter what time of day most psychiatric medications are taken, as long as they are taken about the same time each day.
4. Should adjustments in dose or schedule of the medication fail to adequately reduce side effects, there are usually other therapeutic options available to your physician. These medications may have a side effect profile you find more tolerable.
5. Finally, there are side effects that can be best managed by the addition of a side effect medication.

Some people taking psychiatric medications will have to tolerate some side effects. However, the side effects caused by a medication should not significantly impair a person’s functioning, and should be offset by the therapeutic benefits received. If someone is experiencing troublesome side effects from a medication, he or she should not stop the medication but contact the prescribing physician to discuss options for reducing the side effects.

Ensuring Safe and Effective Medication Use
Research shows that up to 50 percent of prescription medications are not taken properly. By following these guidelines, you will increase the chances that your medication treatment will be both safe and effective.

Be Informed. Know About Your Medications.

Key questions to ask:

• What are the brand and generic names?
• What does it look like?
• Why am I taking it?
• How much should I take and how often?
• When is the best time to take it?
• How long will I need to take it?
• What side effects should I expect and what should I do if they happen?

What should I do if I miss a dose?

• Does this interact with my other medications or any food?
• Does this replace anything else I am taking?
• Where and how do I store it?

Make a Medication List.

Include prescription information:

• Name (brand name and generic name)
• Strength
• How much to take
• How often to take it
• Purpose

Include over-the-counter (non-prescription) and herbal medications.

Include allergies and adverse effects

• Name of drug and what happened

At the Pharmacy, Be a Partner in Your Care.

Tell the pharmacist about:

• Allergies
• Herbal therapies, vitamins, and nutritional supplements
• Over-the-counter medications
• Prescriptions you are using that they did not fill

Ask to speak to the pharmacist when you pick up a new prescription. Read written materials thoroughly and keep them for reference. Double-check the medication before you leave the pharmacy. Try to use a single pharmacy so that all your medication records are available in one place.

At the Doctor, Be a Partner in Your Care.

• Bring your medication list.
• Ask questions.
• Get the medication purpose written on prescriptions.
• If you get samples, make sure the doctor checked on drug interactions.

At the Hospital, Be a Partner in Your Care.

• Bring your medications, medication list, and list of allergies and adverse effects.
• Ask your doctor, nurse, or pharmacist about any new medications (name, reason).
• Look at all medications you take, ask questions.
• Make sure your hospital ID is checked every time you are given a medication.
• Question anything about your medication that doesn’t seem right.
• When discharged, go over each medication with a staff member.
• Update your medication list from home.
• If you are too ill, ask a friend or relative to help with the above.

Remember to ask your pharmacist, nurse, and physician questions about your medications.