Medication Management
Psychiatric medications can be prescribed only by a physician. They can be helpful in many situations; and in some cases, the proper medication can alter a person’s life. Dr. Turecki uses medication regularly in his practice, but he tends to be conservative, especially when prescribing for a child. He almost always combines medication management with other treatment recommendations. Dr. Turecki will recommend a medication only after conducting a Comprehensive Evaluation. He will raise the dose slowly, carefully monitor the medication to see if it is helping, be on the lookout for side effects and slowly discontinue any medication to avoid withdrawal symptoms.
How Do Medications Work?
Psychiatric medications change the function or chemistry in certain areas of the brain by correcting a “chemical imbalance.” They work mainly by raising or lowering the levels of certain chemical messengers (neurotransmitters) in the spaces (synapses) between brain cells (neurons).
What Are the Different Types of Medication?
There are many psychiatric medications. Some are approved by the Food and Drug Administration (FDA) for specific conditions, but often a medication is used, perfectly legitimately, “off-label.” Generic versions are much more affordable and generally just as effective. However, brand name drugs are more easily recognized. Psychiatric medications can be classified according to the problems they are designed to treat.
Anti-Depressants. The best-known anti-depressants are the SSRIs (Selective Serotonin Reuptake Inhibitors), which increase serotonin levels in the spaces between brain cells. SSRIs include Prozac, Lexapro and Zoloft. These medications are effective in the treatment of depression, anxiety and OCD (Obsessive-Compulsive Disorder). Other anti-depressants raise the levels of different chemical messengers.
Anti-Anxiety Medications. These include the benzodiazepines such as Klonopin, Ativan and Xanax. They act by increasing the levels of the chemical messenger GABA. The medication can be taken at regular intervals to achieve a “steady state” or they can be used as needed for spikes of anxiety. Benzodiazepines are also used in the treatment of insomnia.
Atypical Anti-Psychotics. The name “anti-psychotic” is deceptive because these medications are very useful in several conditions that do not present with psychotic symptoms, such as severe behavior disorders in children and adolescents, or bipolar disorder. Examples of atypical anti-psychotics include Risperdal, Seroquel and Abilify. These medications act by reducing the levels of the chemical messenger dopamine.
Mood Stabilizers. As the name implies, these medications are used to even out the mood swings seen in adult and childhood bipolar disorder, and to reduce the rages in certain conditions in children. The best-known mood stabilizers are Lithium (a salt), and Depakote and Lamictal (anti-convulsants). The blood levels of all three can be measured to make sure that the correct dose is being given.
Stimulants. Stimulants are the treatment of choice for ADHD. They improve focus by increasing the levels of the chemical messenger dopamine, and they also reduce hyperactivity and impulsivity. Unfortunately, if not carefully monitored, they can be abused by high-school and college students, and by adults with demanding jobs. Stimulants can be short-acting (Ritalin, Adderall) or long-acting (Vyvanse, Concerta, Ritalin LA).
Sleep Aids. Ambien and Sonata help adults fall asleep. A long-acting form of Ambien can help the person sleep through the night. Benzodiazepines are also effective in the treatment of insomnia. Melatonin, a natural hormone, does not need a prescription. It is very effective in children and in many sleep-deprived adults.
The Future
Neuroimaging studies can pinpoint impaired function or structure in specific areas of the brain. However, these techniques are not yet clinically useful as diagnostic tools, nor can they match a specific medication to a specific disorder.
Pharmacogenetics, the study of how genetic factors affect responses to drugs, will one day allow physicians to choose specific medications based on genetic studies.
Neuroinflammation. A link may exist between low-grade inflammation in the gut and some cases of depression. Microbes normally found in the gut can cross the blood-brain barrier, and high levels of inflammatory markers (cytokines) are being found in some people with depressive symptoms. These findings open up the exciting future possibility that such cases of depression can be treated with anti-inflammatory agents.
Ketamine. Used for many years as an anesthetic, Ketamine has been developed as a therapy for treatment-resistant depression. The FDA has recently approved Esketamine, a fast-acting nasal spray, to be used in conjunction with a traditional anti-depressant. If the nasal spray proves to be safe and effective, it would be the first really innovative treatment for depression in over 20 years.