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
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.
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
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
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
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.)
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
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
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.)
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.
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.
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
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
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.
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.
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.
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.
126.96.36.199 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
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.)
- High levels of thyroid hormones. Hyperthyroidism causes many
problems, including weight loss, extreme appetite, weakness, loss of
libido, apathy, irritability, depression, and other symptoms.
- 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.
- 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.
- 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.
- 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.
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
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.
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.
- The best predictor of success in therapy is the rapport, or
quality of the relationship, between the therapist and patient. It is
important to find a therapist with whom you can have a good working
relationship.1 Keep this fact in mind when you interview therapists, and be prepared to interview several until you find one you like.
- Therapy can be useful for people with depression, bipolar
disorder, and schizophrenia, but while some (not all) cases of
depression can be resolved through therapy alone, medication is
normally required to treat bipolar disorder and schizophrenia. Bipolar
disorder and schizophrenia are believed to arise from neurological
abnormalities; while they may be worsened by stress of various kinds,
they cannot be resolved solely by addressing factors that cause stress.
Depression, on the other hand, can sometimes arise entirely as a
response to stress, and fade away as the stressful problems are
resolved. More often, though, it appears to arise from a combination of
neurological factors and external factors (life situation and
relationships). Medication can address the former, but not the latter.
For these reasons, depression is more likely to be resolved by a
combination of therapy and medication.
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
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:
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
- 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).
- When medications have proven ineffective, and symptoms remain severe.
- 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
- For patients with catatonia, a dangerous condition that is often resistant to medication.
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
- Practical Difficulties. Access to ECT may be difficult,
as it is not a common treatment. Also, the expense, and the overhead in
terms of time and care that the treatment entails, make it burdensome.
- Short-term memory loss. ECT typically causes short-term memory loss, and possibly some temporary impairment of ability to think clearly.
- Possible long-term deficits. There are many anecdotal
accounts of long-term, even permanent, impairment of memory, ability to
think, and ability to experience the normal range of human emotion.
These claims have not been confirmed by clinical studies to date. Those
who assert the truth of these claims explain this discrepancy by saying
that the studies do not measure these types of deficits. As of this
writing, no conclusive evidence exists to settle the debate.
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
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
- The introduction of quantitative measurements for use in treating mental illness
- Reliance on correlation between measurement, outcome, and treatment type
- The deprecation or elimination of diagnosis as a requirement for treatment
188.8.131.52 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.
184.108.40.206 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.
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.
220.127.116.11 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
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
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
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
18.104.22.168 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.
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.
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.
- Investigate medication and therapy with an open mind. You may
need either or both. Only you can decide, but you need to be honest
with yourself about what your problems really are.
- Find a good doctor. A psychiatrist is generally a better choice
than a general practitioner, and a psychiatrist who specializes in
psychopharmacology is a better choice still. Therapy can be very
useful, but is often insufficient by itself. Medication is often
- Find a good therapist. The likelihood of success in the
treatment of mental illness is greater when you get help from both
therapy and medication. Medication can reduce the suffering, but
therapy is often necessary to make changes in your life and behavior to
solve the problems that cause or contribute to your condition.
- Be honest with your doctor and therapist about what is troubling
you. Don't play games or hide the truth (or why bother talking to him
in the first place?).
- Don't let an understandable reluctance to try medication that
affects the functioning of your brain get in the way of your mental
health. A bias against medication will not help you.
- If you read of a medication that seems particularly appropriate for your situation, discuss it with your doctor.
- If medication has not improved your mental health dramatically
within twelve months (and you haven't been sabotaging yourself), get a
second opinion from another doctor, preferably one who knows more than
the one you've been seeing. It may be worth driving or flying 1000
miles to see a "high-powered" specialist for two hours, if you return
home with new avenues to try that your physician hadn't thought of.
- If you don't have confidence in your doctor or therapist, find another one.