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Chapter 1
Introduction

Psychotropic medications affect the functioning of the brain, usually by modifying neurotransmitter chemistry. They are prescribed for a variety of mental illnesses, such as depression, bipolar disorder, anxiety, and schizophrenia.
The number of psychotropic medications is large and growing, so much so that physicians who specialize in the field have difficulty keeping up with developments. In fact, relatively few physicians, even among psychiatrists, can be considered highly knowledgeable in this area, and it is unlikely that any one psychiatrist is well acquainted with all of the available medications. Unfortunately, this is an area where ignorance comes with a cost, in the form of missed opportunities, and dangerous reactions.
The average person who needs medication for a psychiatric disorder is unlikely to know anything about the field, and is often in such a distressed state that research is impossible. Yet the sick person, above all, cares more about the effectiveness and safety of his medication than anyone else.
If the people who care the most about treatment for mental illness know the least, and the people who know the most seldom know enough, then there is a serious need for information on the subject at a level that both the sick and their healers can understand.
This book was written to provide information about the medical treatment of depression, bipolar disorder, schizophrenia, and sexual dysfunction. It was written primarily to assist the sick and suffering in understanding what their medications do, and what their treatment options are. It covers virtually all medications in use at the time of writing, and is organized in a manner that allows the casual reader to skip the technical details, and quickly learn the basics about the medications he needs, or is taking.
At the same time, this book contains enough technical information to be useful for medical practioners and educated laypeople who wish to understand how these medications work. Nurses and general practitioners, who do not specialize in treating psychiatric disorders, should find it a convenient guide to the available treatments, and a good reference to provide to their patients.
The document is organized by the illness for which the medications are most often prescribed. Each section contains a list of categories of medications and their acronyms. The general properties of each category are described, and a list of individual medications follows. Note that a particular medication, though listed as prescribed for one illness, may be useful and prescribed for others as well.
The remainder of this chapter introduces some basic concepts about how the brain functions, and how mental illnesses are diagnosed and treated. The following chapters focus on specific types of disorder, namely depression, bipolar disorder, schizophrenia, and sexual dysfunction. Chapters and sections may be read (or skipped) in any order, to suit the reader.
Finally, additional information about the medications listed in this book may be found on the author's Web site, at www.mentalmeds.org. The site is designed to be a companion to this book, and it provides detailed prescribing information about each medication, along with additional information and services.

1.1  Sources

Most of the information in this document is generally available from a large number of sources, in which case no specific sources are given. (Specific references are cited for quoted material.) Some resources of particular interest are listed below.
www.crazymeds.us Quirky, but good medication info and forums
www.driesen.com/index.html Medication and neurological info
www.pdrhealth.com/index.html Physician's Desk Reference-very useful
www.nami.org Self-help, support, and advocacy group
google.fda.gov US Food and Drug Administration (FDA) Web site
www.mentalhealth.com Lots of medication information
www.biopsychiatry.com Odd, but lots of med data, often technical
www.rxmed.com Good medication database
www.emedicine.com/rc/depression.asp Good medication database
www.coreynahman.com Information for the pharmaceutical trade
www.dr-bob.org Message boards, FAQs, links, and miscellany
www.psycom.net/depression.central.html Huge site with lots of links
www.needymeds.com Med suppliers, discount med programs
www.lorenbennett.org/freemeds.htm Free meds for those with low incomes
home.avvanta.com/~charlatn/depression/tricyclic.faq.html Good tricyclics info
www.preskorn.com Good, rather technical information about medications
www.psychopharminfo.com Current news about medications
www.wholehealthmd.com Drugs, vitamins, alternative medicine
www.erowid.org/chemicals/maois/maois.shtml Odd site with MAOI info
www.currentpsychiatry.com/images/pdf/cp0602/CP0602TricyclicTable2.pdf Reuptake inhibition
sl.schofield3.home.att.net/medicine/psychiatric_drugs_chart.html Chemistry
redpoll.pharmacy.ualberta.ca/drugbank Exhaustive technical medication database
www.drugguide.com Good database for medications in general
emc.medicines.org.uk Medications available in the UK

1.2  Answers to Common Questions about this Book

What Do All the Big Words Mean?
It is impossible to describe how medications and other treatments work, and what we know about mental illness, without using some terms that are not familiar to most readers. If you do not know what a technical word means, consult the glossary of Chapter 6. The glossary is very complete, and should contain all the definitions you need to understand the main text.
Isn't this Book Obsolete?
Yes, it probably is, if it is more than two years old. Medical science progresses rapidly, and new treatments appear every year. Over time, the information in this book will become increasingly incomplete. While it is not possible to update the print in this copy, it is possible to produce new editions that contain the new information.
The newest edition will always be available from www.mentalmeds.org, so look there for updates. The best way to keep up to date is to visit the site, and register to be notified when a new edition is available.
Don't You Need a Medical Degree to Write about Medicine?
No. A medical degree (M.D.) provides assurance that a physician is competent to treat his patient's common health problems. By itself, it does not turn a physician into a scientist (few medical doctors perform medical research), nor does it guarantee a deep knowledge of psychotropic medications (few medical doctors specialize in this area, and even among psychiatrists, few perform research).
What is necessary to write a book like this is a basic understanding of brain chemistry, and how medications affect it. This information is readily available for anyone who knows where to look, but is not easy for most people to understand. However, it is comprehensible to anyone with a background in physical science who takes the time to study the subject.
In short, all that is necessary to write a useful book about medicine is an understanding of the subject.

1.3  The Chemicals at the Heart of the Brain

Neurotransmitters are chemicals that are used by neurons (brain cells, or cells in the nervous system) to send signals to each other. A neuron emits a pulse (a "squirt") of a particular neurotransmitter from a vesicle (storage chamber) into the synapse, or synaptic gap, between it and an adjacent neuron. The receptors on the receiving neuron detect the sudden increase in concentration of the emitted neurotransmitter when molecules of the latter "bind," or attach, to them.
If the number of receptors on the receiving neuron that register the increase in neurotransmitter concentration exceeds a threshold, the neuron registers a signal, and takes some action in response (which typically involves sending a signal of its own to its neighbors); otherwise, the neuron ignores the change in neurotransmitter concentration.
Once the concentration of emitted neurotransmitter molecules has exceeded the receving neuron's detection threshold, the neurotransmitter molecules must be removed from the synapse in order to allow for a subsequent signal. Otherwise, the receiving neuron's receptors would quickly be saturated, and cease to function.
The sending neuron has a "reuptake system," a mechanism to absorb the emitted neurotransmitter molecules. Some of the emitted molecules are sucked back in to storage vesicles for re-use, while others are metabolized (destroyed) by the Monoamine Oxidase enzymes. These two mechanisms (reuptake into storage, and metabolization) clear the emitted neurotransmitter molecules from the synapse and prepare it for the next signal.
There are many different types of receptors, and many (over one hundred) known neurotransmitters. The plethora of neurotransmitter and receptor types leads to extremely complex behavior in the brain.
Neurotransmitters commonly affected by psychotropic medications include serotonin, norepinephrine, dopamine, and GABA (gamma-aminobutyric acid). The sequence of chemical reactions involving neurotransmitters is complex and interconnected; as a result, medications that directly affect the chemistry of one neurotransmitter (say, serotonin) do not affect it alone, but others as well. Thus it is a mistake to assume that taking a medication that increases serotonin concentration has no effect on other neurotransmitters, because, in general, it does.
The complexity of brain chemistry, and the complexity of subjective human experience, make it impossible to identify a straightforward connection between a specific neurotransmitter and a particular emotional state, or a particular emotional problem. Nevertheless, some trends can be identified, and are discussed below. (Just bear in mind that all statements about what a particular neurotransmitter does are incomplete, and very rough approximations.)

1.3.1  Dopamine

Dopamine is typically identified as the neurotransmitter most directly associated with pleasure. "Pleasure" includes emotions such as joy, and more physically-oriented sensations such as sensuality, libido, and sexual pleasure. Problems involving dopamine chemistry may reduce or eliminate the capacities for pleasure and libido (sexual desire). People who suffer from an inability to have pleasant feelings (as opposed to having too much in the way of unpleasant feelings) are particularly likely to benefit from increases in dopamine concentration.
Medications (such as amphetamines) that raise dopamine levels often increase energy level as well. This makes sense, as dopamine is a precursor to norepinephrine. Any increase in dopamine concentration can be expected to cause an increase in norepinephrine concentration as well.

1.3.2  Gamma-Aminobutyric Acid (GABA)

GABA, discovered in the 1950s, is a "message-altering" neurotransmitter. It is the major inhibitory neurotransmitter in the central nervous system, and regulates the transmission of signals in the brain.
Neurons receive signals from other neurons in the form of "squirts," or pulses, of neurotransmitters. If a neuron's receptors receive a sufficiently large pulse of neurotransmitters, it registers this pulse as a signal, to be acted on. The neuron's action will very often involve forwarding that signal to adjacent neurons in the same fashion.
The higher the GABA concentration, the less often neurons forward signals to other neurons. Thus GABA has a dampening effect on neural-signal propagation. Too much GABA retards propagation, while too little allows too much propagation. It seems likely that an insufficiency of GABA results in too much signal propagation, which in turn leads to seizures and mania. (See Section 3.2 for more information.)

1.3.3  Glutamate

Glutamate is the most common neurotransmitter in the brain. It's function is roughly the opposite of GABA's, in that it is an excitatory neurotransmitter. The higher the glutamate concentration, the greater the sensitivity of neurons to signals conveyed by other neurotransmitters.

1.3.4  Norepinephrine

Norepinephrine is typically identified as a neurotransmitter most directly associated with energy, meaning the feeling of vigor, and capacity for physical labor. It is also associated with the ability to concentrate. Problems involving norephinephrine chemistry may impair the ability to concentrate, and sap one's energy, leading to fatigue that can become life-threatening if severe enough.
Norepinephrine concentration can be increased by changing how norepinephrine is processed, or by increasing the concentration of dopamine, as dopamine is a precursor to norepinephrine (or, equivalently, norepinephrine is a metabolite of dopamine).
Given the link between norepinephrine and the ability to concentrate, it is not surprising that treatments for Attention Deficity-Hyperactivity Disorder boost norepinephrine levels.

1.3.5  Serotonin

Serotonin is typically identified as the neurotransmitter most directly associated with calmness and general feelings of well-being. Problems involving serotonin chemistry may cause severe emotional disturbance, such as dramatic over-sensitivity to disappointment, extreme melancholia (sadness, e.g., characterized by crying spells), and feelings of worthlessness. Medications that raise serotonin levels often alleviate these symptoms. Unfortunately, increases in serotonin concentration tend to impair libido and sexual function, an effect for which SSRI medications are notorious (though one not limited to them). However, strategies do exist to alleviate these serotonin-induced impairments, for those who require serotonin enhancement to treat their depression.

1.4  The Bad Things that Happen with Good Medications

Few things are as dismaying as taking medication for a mental illness and discovering that you are getting worse, rather than better. There are a variety of reasons why medicines can produce unpleasant results, the most common being that the medication isn't appropriate for the condition. Unfortunately, it is not possible to know in advance which medication will work for a particular person, because individual responses vary so widely. Thus doctors, and patients, must put up with a certain amount of trial and error before finding the right medication. Unfortunately, and by definition, the "wrong" medications will either have no effect, or produce unpleasant effects. This is simply one of the facts of life in the treatment of mental illness as it is today. The wise patient will realize that a degree of patience and stoicism is appropriate when seeking medical treatment.
The following sections describe some of the ways in which medications can cause trouble. The bad news is that there are many opportunities for problems. The good news is that the problems can usually be resolved.

1.4.1  Side Effects and Withdrawal Effects

All medications have the potential for unwanted, unpleasant, or dangerous side effects. This is true whether the medications are prescription drugs, over-the-counter drugs, or herbal products (such as St. John's Wort). Unfortunately, in the case of psychotropic medications, the potential for unwanted side effects approaches certainty. Antidepressant medications that increase serotonin concentration, for example (such as Prozac), are almost guaranteed to suppress libido and sexual function in men and women to some extent. (Methods for alleviating sexual dysfunction are discussed in Section 5.)
The challenge for the physician and patient is to find the medications that provide the greatest benefit with the least negative impact due to side effects. Some people are fortunate, and find medications that completely eliminate their symptoms while having no negative effects. A small number are very unfortunate, and find little or no benefit from existing medications, while experiencing highly unpleasant or even fatal reactions to them. Most are in the middle somewhere, finding substantial benefits while having to find ways to alleviate some degree of side effects.
While the side effects of psychotropic medications are unwanted and occasionally quite unpleasant, they are often transient, disappearing within a couple of weeks of starting the medication. If the effects continue, and are sufficiently unpleasant (or the medication isn't working), the patient will usually stop the medication and try a different one. (Note: Never stop taking one of these medications without consulting with your physician first! Read on to see why this is important.)
Unfortunately, new and unpleasant effects, called withdrawal effects, may appear when a medication is stopped. The good news is that withdrawal effects fade away in time. "In time" may be a few days, a few weeks, or, less commonly, a few months. Some medications generally produce negligible withdrawal effects, while others may produce dramatically unpleasant effects. Withdrawal effects are similar to the benefits of the medication in that they vary widely from person to person, as well as from medication to medication. It is very important to discuss how to stop a medication with your doctor before doing so, as some medications require a careful tapering process (i.e., gradual reduction in dose) in order to avoid unpleasant or dangerous effects.
There are exceptions to the rule that side- and withdrawal effects are temporary. In some cases, they can be permanent, or cause physical damage. As is the case with many drugs, some patients may have drastic reactions to a psychotropic medication (such as liver damage) that may not go away when the medication is stopped. Thus it is always wise to discuss possible dangerous reactions with your physician before trying a medication, and take careful note of any side effects that may foreshadow serious complications. In the case of drugs known to cause liver damage in some people (one of the most common serious dangers for all medications, psychotropic and otherwise), the physician may order routine blood tests to check liver function and detect incipient problems before they become serious.
Medications for psychosis (anti-psychotic, or neuroleptic, drugs) are a special category and have special risks. These medications can cause serious, sometimes permanent, and even fatal conditions called Tardive Dyskinesia and Neuroleptic Malignant Syndrome. For these reasons, the use of anti-psychotic medications must be carefully controlled, and the potentially serious risks weighed against the possible benefits. For some people, the decision may come down to a choice between Tardive Dyskinesia or psychosis, a decidedly unfortunate choice. These problems are a major factor in the drive to find safer medications for the treatment of psychosis, an effort which has produced safer drugs, if not yet as safe as one would wish.

1.4.2  When Antidepressants Drive You Crazy

That psychotropic medications may have undesirable physical side effects is not in dispute, but the extent to which they may have undesirable mental (cognitive or emotional) side effects is a murkier subject. Some such effects are discussed below.

1.4.2.1  Mania

There is one situation in which an antidepressant can almost literally "drive you crazy." Serotonergic medications (such as the SSRI, SNRI, and MAOIs) can trigger manic states in people who have Bipolar Disorder (see Chapter 3). This is a counterintuitive result, but a well-established one. Thus it is very important to monitor the reaction to these medications for signs of mania. If mania does occur, the patient will require treatment for Bipolar Disorder, not for depression alone.

1.4.2.2  Suicide

The question as to whether antidepressants increase the risk of suicide, especially among teenagers, has been hotly debated. There is some evidence that the rate of attempted suicide among teenagers who take antidepressants is higher than among their peers who do not, but it is not clear whether the difference is due to downswings in mood caused by the medication, or if the medication sometimes improves energy before mood, so that some depressed but energized teens find their suicidal impulses unimpaired by lethargy.
Most depressed teenagers who take an antidepressant are not likely to attempt suicide as a result. However, anyone who is being treated for depression, whether teenaged or not, should be monitored for suicidal tendencies as a matter of course, given that depression by itself is the major cause for suicide. Monitoring for suicidal tendencies should be a standard element of any treatment program, whether medication is involved or not.

1.4.2.3  Anxiety

The neurotransmitter norepinephrine is associated with heightened arousal. At normal levels, it provides an appropriate degree of energy and ability to concentrate. At high levels, it can cause feelings of panic and dread, and physical responses such as elevated heart rate and blood pressure. Elevated levels of norepinephrine are appropriate for "fight or flight" reactions to threats, but not for daily living.
Some people are prone to frequent, even constant, feelings of anxiety. For these people, taking a medication that increases norepinephrine may trigger or worsen these feelings. Thus those who suffer from anxiety disorders should generally avoid noradrenergic medications such as the SNRI, NRI NDRI, and MAOI categories.

1.4.2.4  Emotional Flattening

Serotonergic antidepressants (such as the SSRIs) sometimes "flatten" emotional responses to the point where one feels numb and unresponsive to external events, interactions with people, and so forth. Similarly, medications that blockade (inhibit) dopamine (i.e., the antipsychotics) can suppress the ability to feel pleasure (a condition called "anhedonia"), removing the joy from life.
In the case of serotonergic antidepressants, simply switching to a different medication in the same category often suffices to fix the problem. Unfortunately, the anhedonic response to antipsychotic medications is generally more difficult to address via medication or dose changes, and sometimes cannot be resolved.

1.5  Important: Hormones and Endocrine Disorders

If you have been suffering from fatigue and listlessness, and generally feeling down, you may be able to stop after reading this section. You may be suffering from an endocrine (hormonal) disorder, rather than depression per se.
An endocrine disorder is any health problem that arises from having too little, or too much, of any hormone. (Problems with the thyroid hormones, triiodothyronine, or T3, and levothyroxine, or T4, are particularly common.) Typical endocrine problems include
Hyperthyroidism.
High levels of thyroid hormones. Hyperthyroidism causes many problems, including weight loss, extreme appetite, weakness, loss of libido, apathy, irritability, depression, and other symptoms.
Hypothyroidism.
Low levels of thyroid hormones. Hypothyroidism causes many problems, including fatigue, impaired memory and alertness, difficulty thinking, slowed metabolism, weight gain, loss of libido, anxiety, depression, and other symptoms.
Hashimoto's thyroiditis.
An autoimmune disease, in which the body's immune system produces antibodies that attack the cells of the thyroid gland. This illness causes hypothyroidism, and all the symptoms of hypothyroidism, along with swelling and pain in the thyroid gland (in the neck), and flu-like symptoms that are characteristic of autoimmune diseases.
Hypogonadism.
Low levels of reproductive hormones, namely testosterone in men, and estradiol and progesterone in women (although women can suffer from too-low levels of testerone as well, which can impair libido). Symptoms of hypogonadism include loss of energy and libido, fatigue, deterioration of mental faculties, and depression.
Hyperprolactinemia.
High levels of prolactin. Symptoms of hyperprolactinemia include loss of libido, sexual dysfunction, and depression, in both men and women. Women may suffer from menstrual problems, infertility, hirsutism, or obesity. Sperm production in men may be reduced or absent.
Hypopituitarism.
Low levels of hormones produced by the pituitary gland: prolactin, somatropin (growth hormone, or GH), luteinizing hormone (LH), follicle stimulate hormone (FSH), thyroid stimulating hormone (TSH), and adrenocorticotropic hormone (ACTH). Low levels of somatropin and TSH can produce marked energy loss, and deterioration of mood and mental function, similar to hypothyroidism.
The above list is not exhaustive, as many other endocrine disorders exist, but it does capture some of the more common ones that can produce depression symptoms.
As endocrine disorders can cause many of the symptoms of emotional illness, it is important to have a thorough checkout of possible hormonal problems before concluding that the problem is in the brain, rather than the endocrine system. Antidepressant medication will not solve hormonal problems! Fortunately, most common endocrine problems (other than diabetes) can be treated easily. Discuss the possibility of endocrine problems with your doctor. (If possible, seen an Endocrinologist, rather than a General Practitioner or family doctor, for this purpose.)

1.6  Diagnosis and Treatment of Mental Illness

The classic approach to treating mental illness is the same as for treating any illness: First, diagnose the illness, and second, prescribe a type of treatment (medication or otherwise) known to be effective for treating that illness.
Unfortunately, treating mental illness is more difficult than treating a physical illness, such as a bacterial infection, for two reasons: We do not understand the mechanism of the illness, and we lack objective tests useful in the diagnosis and treatment of the illness.
The mechanism problem is a serious one, which affects the treatment process from beginning to end. Because we do not know what causes the various mental illnesses, we cannot even identify them by their cause, but only by their symptoms. A diagnosis such as Major Depressive Disorder is simply a name for a list of symptoms. It is quite possible that such a diagnosis applies to several different illnesses, which operate by different mechanisms, but produce similar symptoms. Thus a medication that, by chance, happens to work well for one of the unidentified illnesses, may not work at all for another. The result is that the medication is described as having a success reate of, say 30%, in treating Major Depressive Disorder, while in fact it works at close to 100% for one of the illnesses, and not at all for the others.
Another problem that stems from a lack of understanding of the mechanism of mental illness is that it is impossible to design a treatment for an illness when one does not know what the illness does. Thus the current treatments for mental illnesses represent many years of trial and error, rather than targeted design. When a medication is discovered that has some benefits, researchers study its effects, and experiment with medications that have similar, but not identical, mechanisms. This type of experimentation helps not only to identify better medications, but to uncover some information about the mechanisms that are involved in the illness. This type of experimentation is responsible for much of our understanding of mental illness, such as it is.
The lack of objective tests is another serious problem. Physicians diagnose mental illness based on the evidence. However, physical illnesses produce not only subjective symptoms (i.e., how the patient feels), but also objective indications that can be observed and measured (e.g., fever, swelling, and bacteria that can be cultured and identified). In contrast, physicians have had to rely entirely on subjective symptoms to diagnose mental illness. Once again, the subjective reports of symptoms cannot reliably distinguish between cases of mental illness with similar symptoms but different origina, and provide a decidely imperfect guide to useful diagnosis.
The limitations on current abilities to diagnose and treat mental illness should not be disheartening. Psychiatry has come a very long way in the last fifty years, and medical treatment of mental illness will continue to improve. Even now, millions of people find relief from the crushing burden of mental illnesses that would have doomed them to misery and early death only fifty years ago. The majority of people who seek treatment for depression and bipolar disorder do so successfully, provided they are willing to invest the time and effort required to find the best medications for them. Even schizophrenia has yielded, albeit imperfectly, to the advance of medical science.
Over time, scientific research will cast more and more light onto the functioning of the brain, and onto the causes and treatment of mental illness.

1.7  Standard Treatments for Mental Illness

Few types of treatment work for a wide variety of mental illnesses. Most are specific to particular illnesses, such as depression, bipolar disorder, and schizophrenia. A few, however, are broadly applicable across multiple types of illness, and are discussed here.

1.7.1  Therapy

Therapeutic approaches may be useful in situations where the depression arises solely from behavioral or situational factors that can be improved by changes in thought patterns and behavior. Therapy may also be useful in conjunction with medical treatment, especially when adjustment to an improved mood presents new challenges to the individual. Therapy, especially cognitive-behavioral therapy (which focuses on improving thought patterns and behavior), is often recommended in conjunction with medication.
The range of available therapies is almost limitless. Examples of different schools of therapy include psychoanalysis, psychodynamic therapy, Jungian therapy, cognitive behavioral therapy (CBT), gestalt therapy, humanistic therapy, dialectical behavior therapy (DBT), rational emotive therapy, exposure therapy, interpersonal therapy, play therapy, and so on. There are also a variety of techniques that can be used to bring about specific results within the context of therapy, such as neuro-linguistic programming (NLP), hypnotherapy, and eye movement desensitization reprocessing (EMDR).
In practice, most therapists draw on several schools of therapy, blending approaches to suit their own preferences and their patients' needs. This approach is an eclectic one, and is often referred to as eclectic therapy.
There are really just a few things one should know about therapy as an approach to treating mental illness.

1.7.2  Electro-Convulsive Therapy (ECT)

Electroconvulsive Therapy (ECT) is an electrical-stimulation technique used to treat severe depression, bipolar disorder, schizophrenia and psychosis, and catatonia. It is a remarkable fact that ECT is an effective treatment for so many apparently unrelated types of mental illness. It is perhaps equally remarkable that so little is known about why it works, beyond the consensus that it is the seizure induced by ECT that leads to the benefits.
During an ECT session, the patient is given a general anesthetic to induce brief unconsciousness, and then a voltage is applied to cause an electric current to flow through one (right lateral) or both (bilateral) sides of the brain, inducing a seizure. For reasons that are not well understood, this electrically-induced seizure can dramatically alleviate depression.
Bilateral treament acts more rapidly than unilateral treatment, but has more severe side effects. Right unilateral treatment produces less severe memory loss, and is preferred for depression. Bilateral treatment is generally restricted to emergency situations involving severe depression with psychosis, severe manic episodes, severe psychotic episodes, and catatonia.
ECT is typically used in these circumstances:
  1. When it is essential to provide the fastest-possible relief for depression, mania, or psychosis (for example, in the case of someone who is suicidal).
  2. When medications have proven ineffective, and symptoms remain severe.
  3. For patients with bipolar disorder who need immediate stabilization of their condition, or who are experiencing severe manic episodes. ECT helps both the manic and depressive aspects of this disorder, something that is not normally true for individual medications.
  4. For patients with catatonia, a dangerous condition that is often resistant to medication.
ECT is a proven technique. It does not always work, but it works more often than medication for severe depression, and generally as well as medications for bipolar disorder and schizophrenia. It often is the only treatment that works for catatonia.
There are a number of drawbacks to ECT, including
It should also be said that some people not only respond well to ECT, but do so without experiencing significant deficits. For these people, most of whom have exhausted the set of available medications, ECT is very much a life saver.
These drawbacks, plus a somewhat sensational and checkered history of past abuse, has led physicians and possible candidates to shy away from ECT. However, ECT should be considered for the circumstances described above.

1.7.3  Medication

While no one medication is effective at treating all types of mental illness, the general strategy of medication applies to more types of mental illness than any other.2 Medication has eclipsed all other forms of treatment for mental illness by any measure. The success of medication as a strategy is very much a function of its effectiveness, its accessibility, and its relatively low cost compared to the alternatives (where alternatives exist, which is not always the case).
The combination of effectiveness and cost-effectiveness has resulted in a steady migration towards medication, and a steady erosion of access to alternatives (such as therapy and ECT). This trend is particularly evident when one considers that health insurance plans typically pay for medications without limit, but place caps on payments for therapy.
Further details about the use of medication in treating mental illness may be found in the following chapters, as the subject is the main focus of this book. However, the focus on medication should not mislead the reader into thinking that other strategies are without value, when, in fact, they may have great value. What matters in the end is not the path to success, but its achievement. The ultimate criterion for judging treatments of mental illness is effectiveness. The best strategy is always the one that gives the best results.

1.8  Looking to the Future

For the most part, this text focuses on standard medical treatments for mental illness, meaning treatments that have been approved by the US Food and Drug Administration, better known as the FDA. However, the state of the art in medical treatment outpaces the imprimatur of the FDA, as anecdotal evidence accumulates regarding new and effective uses of existing prescription medications. It is for this reason that known uses of these medications is divided into FDA-approved on-label and unapproved off-label uses throughout.
All existing treatments for mental illness have limitations. These limitations are felt most painfully by those whom they do not help, or for whom they are too expensive, or simply unavailable. Thus it is worth considering some of the novel treatment methods which are becoming available. These methods are not well known, and are not widely accepted by the medical community. However, lack of wide acceptance is typical for new treatments, and by itself says nothing about their usefulness.
Some of these new treatments are described in the following sections. They must be regarded as experimental at this point, and their appearance in this text should not be taken as an endorsement. How well these treatments work remains to be seen, but the effort to generate new paradigms for the treatment of mental illness should be applauded.

1.8.1  Correlation Methods

The standard paradigm of "diagnose and treat" relies strongly on the concept of diagnosis as an organizing principle, around which the conceptual framework of illness and treatment is constructed. It is worth keeping in mind that the notion of diagnosis is a human concept, not a natural phenomenon. Likewise, diagnosis is important to the patient primarily as a stepping stone on the way to recovery, not as something of value in itself (though it should be said that much comfort can indeed come from knowing what to expect of an illness, which is part of what follows from a diagnosis).
The concept of diagnosis may not be nearly as useful for mental illness as for physical illness. It may be that the underlying mechanisms of both illness and its treatment are so varied, with no firm boundaries between disorders at the level of mechanism, that diagnostic categories will ultimately prove less useful than alternative paradigms for organizing information.
One alternative to the classic paradigm of "diagnose and treat" is a new one, which might be described as "correlate and treat." Correlation methods either reduce the significance of diagnosis, or omit the diagnostic stage entirely, and instead focus on the statistical correlation between quantitative measurements, treatments, and outcome.
The novel aspects of the correlation paradigm are
  1. The introduction of quantitative measurements for use in treating mental illness
  2. Reliance on correlation between measurement, outcome, and treatment type
  3. The deprecation or elimination of diagnosis as a requirement for treatment

1.8.1.1  The Referenced EEG Method (rEEG)

The Referenced EEG method (rEEG) is an approach developed by a company named CNS Response (www.cnsresponse.com). It is based on the premise that mental illnesses are associated with abnormal brain activity, and that the abnormal brain activity produces measurable deviations from the norm in electroencephalogram (EEG) recordings. The company maintains a database of normal and abnormal EEG measurements, as well as EEG measurements for people who have taken psychotropic medications of different kinds.
Statistical analysis is then used to predict how an individual with a particular set of abnormal measurements will respond to the medications in the database. Medications are ranked by effectiveness at restoring normal activity. The result of the process is a recommendation for one or more medications predicted to be most effective for the patient.

1.8.1.2  Neurotransmitter Assessment

The premise behind neurotransmitter assessment is that it is possible to measure neurotransmitter levels for an individual to a useful degree of accuracy, to identify deficiencies or excesses of neurotranmsitters, and to restore the proper levels of neurotransmitters through the use of the appropriate chemicals.
While "appropriate chemicals" could include both prescription and non-prescription substances, a company named NeuroScience, Inc. currently recommends non-prescription amino-acid supplements. NeuroScience (www.neurorelief.com) measures neurotransmitter and hormone concentrations in saliva, urine, or blood, and analyzes deviations from the norm. The company then identifies a set of amino-acid supplements whose purpose is to restore concentrations of neurotransmitters and hormones to normal levels.

1.8.1.3  Comparison of rEEG and Neurotransmitter Assessment

It is impossible to compare the effectiveness of these two techniques, as the necessary studies have not been done. However, one can compare and contrast them in terms of science and philosophy.
CNS Response uses a standard diagnostic tool, the EEG, in a new way. The rEEG correlation method tries to identify the best medications to treat an illness. The means by which the identification is made is novel, as is the use of any quantitative measurement in psychiatry, but the philosophy of ordering a laboratory test and then prescribing medication is very much in the mainstream of standard medical practice. It requires no stretch of the imagination to picture psychiatrists ordering this type of test routinely in a few years, much as an endocrinologist would order tests for hormone levels.
The hurdles to be overcome for the rEEG correlation method include acquiring the imprimatur of successful clinical tests, and the culture change (specific to psychiatry) of never ordering lab tests because none have ever been available.
NeuroScience, Inc. uses classic chemical-assay techniques on standard types of laboratory samples (urine, saliva, and blood). It is true that the specific measurements made are not standard, and their use in identifying neurotransmitter problems is new, but where the company most clearly departs from standard medical practice is in recommending amino-acid supplements instead of prescription medications.
This strategy bypasses the bottleneck of traditionally conservative physicians, and the burdensome requirements for FDA approval. The tests and supplements can be supplied by any type of healthcare practitioner, as neither requires a doctor to write a prescription.3
The hurdles to be overcome for the neurotransmitter-assessment method include market acceptance by non-physician healthcare practitioners and their patients, and avoidance of regulatory intervention by the FDA. Should the company decide to woo physicians, it will have to face the same hurdles as the rEEG method, as well as possible stigma and hostility from the medical establishment resulting from its initial strategy.

1.8.2  Neurotherapy

Neurotherapy for the brain and nervous system is analogous to physical therapy for the body. The premise behind neurotherapy methods is that the behavior of the brain and nervous system can be modified in beneficial ways by exposing the patient to suitable stimuli and activities.
These therapies do not rely on, or prescribe, medications, but also do not conflict with the use of medications. There is no need for a patient to stop his medication in order to take advantage of these techniques (nor should he, without consulting the prescribing physician).

1.8.2.1  Chiropractic Neurology

Chiropractic Neurology is an outgrowth of the chiropractic approach to treating musculoskeletal disorders, but oriented towards the brain and nervous system. (For accreditation information, see www.acnb.org. Information about the treatment process is available at www.carrickinstitute.org). This specialty focuses on treating nervous-system disorders such as pain, sensory disorders, learning disorders, Tourette's Disorder, Attention Deficit-Hyperactivity Disorder, migraines, and mood disorders such as depression.
Assessment of the patient's condition is made by performing a variety of non-invasive tests of sensory function, blood pressure, coordination, sense of balance, and other functions. Treatment consists of numerous physical techniques (similar to physical therapy), sensory techniques (periodic exposure to selected visual, auditory, and other stimuli), and so forth.

1.8.2.2  Neurofeedback

Neurofeedback is another neurotherapeutic approach. It is very similar in philosophy, and in the problems it treats, to chiropractic neurology (see www.eegspectrum.com). Assessment of the patient's condition is made largely through the use of electroencephalogram (EEG) recordings.
During treatment, the practitioner observe's the patient's responses with a real-time EEG display. The treatment uses a computer monitor to present games that encourage certain responses in the patient's brain. What the patient sees and does is influenced by the EEG signals, and vice versa (which is why this is a feedback technique). As the patient works to achieve certain goals in the game, he is also training his brain and nervous system to change in beneficial ways.

1.8.3  Conclusion

How these treatment strategies will play out over time is unknown. Neither correlation methods nor neurotherapy methods have yet been subjected to the level of clinical studies necessary to confirm how well they work. Until this type of scrutiny has been applied, an individual is left with at most anecdotal reports of success, and descriptions of underlying theory, as guides to evaluation.
The good news is that new strategies are becoming available to the people who have found the old strategies inadequate. There are times when necessity compels one to experiment with methods that have not been proven, because the alternative is unacceptable. At least these new methods are no more dangerous than current FDA-approved ones, and they show that new ideas are still appearing on the horizon.

1.9  Advice for the Patient (and Impatient)

The purpose of this book is to provide useful information, not to make recommendations for treatment. The only recommendations made here, for those who are suffering from mental illness, are these:
Above all else, perservere, educate yourself, and read on.
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