Addiction Treatment Blog

Separation Liability

Liability for drug induced injuries did not become an issue of general concern until quite recently. However, a number of drug-induced problems from thalidomide in the 1960s to Opren and diethylstilbestrol in the 1970s have caused widespread public disquiet and led to increasing awareness of issues to do with liability. In psychiatry, concern in the UK focuses on the question of benzodiazepine prescribing, while in the US the paramount issue concerns the occurrence of tardive dyskinesia in individuals taking neuroleptics. The question has become an emotive one with some commentators who survey the problem referring to the appalling frequency of drug-induced injury, while others comment on its astonishing tray (1). Whatever the absolute frequencies, contrary probably to public belief, the evidence suggests that the larger the pharmaceutical company, the better its practice regarding drug safety is likely to be (2).

Drug-induced problems may stem from toxic effects of a drug, or toxic effects caused by an impure additive, or from allergic reactions to the drug or its additive. Problems may also stem from over prescribing. For instance, in the case of someone who dies from a resistant bacterial infection, a relative could claim that the subject’s death arose in part from the excessive prescription of antibiotics that in its own right brings about the production of resistant infections. In the case of neuroleptics, problems may be brought about by the overuse of these drugs but this overuse, far from being solely promoted by drug companies stems in part from the current politics of mental health – deaths have stemmed from rapid tranquillisation often by harassed staff in psychiatric units. Read more…

Dementia

Part of the problem in finding drugs which may be effective for dementia is that our ideas about what constitutes dementia have been undergoing radical change in recent years. It had been traditional to distinguish between Alzheimer’s dementia, or senile dementia of the Alzheimer’s type (SDAT) and multi-infarct dementia (MID), which is theoretically caused by small strokes which insidiously pick off brain tissue to the point where an individual’s cognitive function is compromised. Read more…

There are a number of steps that can be taken in the management of insomnia before resort is made in hypnotics. These include:

The elimination of all caffeine containing drinks

Such as tea, coffee, colas etc.

Ensuring quiet surrounds.

This is a particular problem for a shift worker, especially when he wants to burn the candle at both ends, or resents having to be on shift work. There are further shift work related difficulties – see point below on body awareness.

Relaxation exercises, in particular progressive muscular relaxation.

These are useful in their own right, but not particularly sleep inducing in the short term. They also require considerable patience and regular practice to master, as how they work depends on building up associations between relaxation and sleep. With regular practice, subjects find they drift off half way through their exercises. Cassette tapes or relaxation programmes promising sleep, however, rarely mention the fact that considerable hard work and patience is required. The failure of these methods to deliver, in the short term, seems to lead most subjects to feel frustrated or a failure and to abandon what is a useful skill. Read more…

5-HT Receptors and Drugs

The 1990s look like being the decade of the neurotransmitter 5-HT – otherwise called serotonin. This was first isolated in the intestine in 1933 and called enteramine. It was rediscovered in blood vessels in 1947 and found to cause them to constrict, which led to it being called serotonin. In 1949, it was established that the chemical structure of serotonin was 5-hydroxytryptamine or 5-HT for short. Both names, 5-HT and serotonin have remained in use. Serotonin survives partly because SmithKline Beecham stumbled on the marketing appeal of the acronym SSRI – selective serotonin reuptake inhibitor – as part of their marketing of paroxetine.

Serotonin was discovered in the brain in 1953. Shortly before in 1948, LSD had been discovered and it had been recognised that there were structural similarities between 5-HT and LSD. This led, at the beginning of the psychopharmacological era, to great interest in the role brain 5-HT might play in mental illness (1, 2, 3).

The initial biochemical observations on antidepressants were that these drugs had effects on the 5-HT system. But despite this, 5-HT more or less disappeared from view for over 20 years. One important reason for this was the emergence of the catecholamine hypothesis for depression. Although antidepressants affected both catecholamines and 5-HT, in 1965, Joseph Schildkraut proposed that the effects on catecholamines were more important. This led to a focusing of research on the catecholamine system and a virtual ignoring of the 5-HT system, at least in terms of depression (see All You Need To Know About Antidepressants). Read more…

In addition to the types of anxiety mentioned earlier, there are a number of different situations in which anxiety arises according to which it is categorised and treatment given. There are many different occasions of anxiety and in this article, you will find a detailed explanation to each of them in different subjects; such as Stage Fright Anxiety, Panic Disorder, Obsessive Compulsive Disorder, Generalised Anxiety Disorder (GAD), etc. Read more…

Stress Management

Five groups of drugs are used to manage anxiety

• The neuroleptics, particularly chlorpromazine, haloperidol, flupenthixol and thioridazine, which are dealt with in Management of Psychoses, The Neuroleptics, Side Effects of Neuroleptics, The Management of Side Effects, The Use of Psychostimulants in Schizophrenia.
• Tricyclic antidepressants, the MAOIs and the more recent 5-HT reuptake inhibitors, which are dealt with in Management of the Affective Disorders, All You Need To Know About Antidepressants, Side Effects of Antidepressants, The Management of Mania, All You Need To Know About Lithium.
• Minor tranquillisers of the benzodiazepine type, which will be covered later.
• Drugs active on the 5-HT system, which will be covered later.
• Beta-blockers, such as propanolol, which will be covered later.

Types of anxiety

To understand how any of these drugs may be useful, it is necessary to understand the various types of anxiety. The term anxiety covers four sets of experiences, one or other of which may be more prominent in any individual case.

There may be mental anxiety, which roughly translates as worry or a mental preoccupation with things that might go wrong. This may also include intrusive ideas or thoughts or impulses, which are of a distressing nature. This form of anxiety may be present without much in the line of physical symptoms such as increased muscular tension, increased heart rate, sweating or shaking of the hands. Read more…

Mania is for practical purposes the mirror image of depression. Approximately 50% of people affected present with an elated, euphoric mood. They may be grandiose in their attitudes and beliefs uninhibited in their behaviour. However, the remainder may be irritable and tetchy rather than elated and euphoric and paranoid rather than grandiose. Common to both groups is an increased level of activity, so that hyperactivity is perhaps the most consistent diagnostic feature of mania. In addition, there is typically an increase in appetite and a decrease in time spent asleep.

In 1853, Falret and Baillarger independently described a bipolar disorder, in which affected individuals cycled between periods of elation, or mania, and depression. This was variously called folie circulaire or folie à deux periodes. It forms the basis for what is now recognised as manic-depressive disorder. In 1896, Emil Kraepelin divided the major psychiatric illnesses into manic-depressive illness and schizophrenia. The former was primarily a disorder of mood, the latter a disturbance of cognitive functions. The former usually followed an episodic course with individuals recovering to normal between episodes. The latter was more likely to become a chronic illness with a majority of affected individuals not every fully recovering. These distinctions have broadly speaking held to this day. Read more…

As with almost any other pills, antidepressants has their own side effects.

For the first 2 weeks of taking an antidepressant, there may be little other than side effects. Generally, these will be mild. In some cases, however, they may be irritating or even intolerable. The first point to be made is that an antidepressant should only cause tolerable side effects. If treatment makes someone clearly worse, it should be stopped until advice has been sought and until that advice addresses the problem in hand.

Where side effects are more tolerable, there can be a great problem in distinguishing the effects of treatment from some of the symptoms of the illness. Both drugs and illness may cause a dry mouth, headache, indigestion, increased anxiety, sleeplessness or sedation for example.

There is a further unusual aspect to antidepressant side effects. When individuals are depressed, they are often much less sensitive to the effects of anything. They can’t smell, taste or hear as acutely before, for example. It is also common to find that sleeping pills don’t help the insomnia that goes with depression – even three to four times the recommended dose may not bring about sleep. After recovery, some people may be knocked by a low dose of the same sleeping pill that appeared inactive several weeks previously.

However, while some people are less sensitive to side effects when they are depressed, others seem more sensitive. It is very difficult, therefore, to predict the side effects that an antidepressant will have.

The side effects listed are typical. Some occur in everyone to some extent, depending on the particular compound, but they are usually mild and wear off after a few days. Even if they are severe, it should be noted that these side effects are reversible and will halt almost immediately on stopping the drugs.

As with the neuroleptics, there are two sorts of side effects to note. There are those which may feel like a worsening of the illness, like feeling more nervous, feeling strange or unreal, or even hearing voices. These latter side effects are the ones that need careful judgement. Read more…

There are seven major physical treatments for depression at present.

• Tricyclic Antidepressants (Table 1). These have until recently been by far the most widely used.
• The Monoamine Oxidase Inhibitors (MAOIs) (Table 2).
• Reversible Inhibitors of Monoamine Oxidase (RIMAs) (Table 3).
• 5-HT Reuptake Inhibitors (Table 4).
• Other Antidepressants (Table 5).
• Treatments for Bipolar Disorders or Prophylaxis of Recurrent Disorders (Table 6).
• Others (Table 7)

In the last category, a number of other treatments are marketed for or used for depression and they often work, but whether they are antidepressants in the same sense as electroconvulsive therapy (ECT), imipramine or phenelzine is a matter of dispute. The 5-HT-1a agonist, buspirone, has in addition been marketed as an antidepressant, and a further compound from this group, flesinoxan, looks as though it may also emerge as an antidepressant.

Finally, there is also ECT, the mechanism of action of which, and its use clinically will not be discussed at any length in this article. Its role when antidepressants fail to work and in cases of mania will be considered at a later stage. Read more…

Coping with stress can be hard at times.

The term ‘affective disorder‘ is sometimes taken to encompass both the mood and anxiety disorders. In this blog, it will be restricted to the former. Two disorders will be considered, depression and mania. Depression will be covered first followed by a consideration of mania and then the question of prophylaxis of recurrent episodes of a bipolar disorder, be they depressive or manic.

It is perhaps more difficult to specify exactly what antidepressants do than it is for any other drug that acts on the brain. In the following articles, I will employ an ulcer model of depression in an attempt to clarify the issues. This model, however, simplifies both ulcers and depression and this should be borne in mind. In clear cut cases of depression, an ulcer model performs passably. But in less clear-cut cases, the difficulty in pinpointing what it is that antidepressants do re-emerges.

Another way to consider the issues is by considering what the terms ‘mood’ and ‘emotion’ mean. These are notoriously difficult to define, but one way the problem has been approached is to define them in relation to each other – to compare, for instance, the relation of mood to emotions with the relation between climate and weather, or the relation between the pedal and the keys of the piano. Read more…