Addiction Treatment Blog

Over the past two decades there appears to have been a shift within health care from an expectation that patients with medical problems should entrust themselves passively to the care of physicians to an expectation that they should co-operate in their own care and indeed have some responsibility for the outcome of medical procedures they undergo. The changes are reflected in the terms we used; the word patient, which means someone who endures, is being replaced by terms such as client or consumer, which suggest a more active and discriminating participant in the medical process.

Nowhere is this shift more clear than when it comes to the question of what is known as informed consent. Informed consent was not an issue in medical practice 20 years ago. Today it forms a central issue in a number of ethical codes from the Nuremberg Code to the Helsinki Code as well as Codes originating from the Food and Drugs Administration (FDA) in the United States and the US Department of Health. Read more…

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 Treatment

It is not clear yet that damage to the cholinergic pathway is the central deficit in Alzheimer’s dementia. Indeed, it has recently become clear that a number of other neurotransmitters are affected in both Alzheimer’s and other cortical dementias. It is also clear that, because of the interactions between various neurotransmitter systems, it is almost impossible to manipulate one neurotransmitter systems, it is almost impossible to manipulate one neurotransmitter without affecting the others.

Finally, from the vantage point of the 1990s, it seems that many cortical dementias may involve cell protective mechanisms that have been thrown out of gear. Normally, there are a range of mechanisms within cells for neutralizing toxins of various sorts. These often involve the binding of a protein to the toxin, which labels it so that the cell’s own degredative processes destroy the offending agent. In the dementias, however, such mechanisms seem to have been stimulated to the point where the large amounts of cell-protective proteins are produced, to the point where large amounts of cell-protective proteins are produced, to the point that they themselves poison the cell. Whether the stimulus is genetic, viral, toxic (as in aluminium) or some combination of these and other factors is uncertain. The treatment options are to find compounds that will switch off the process or else compounds that will compensate for it. 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…

Insomnia itself can be difficult to manage and live with it.

An initial complaint of insomnia may refer to a number of different things, such as;

• An inability to get to sleep.
• An inability to stay asleep.
• Waking too early.
• Unsatisfying sleep.
• Tiredness during the day, which individuals assume is caused by inadequate sleep the previous night.

A range of underlying physical conditions can contribute to sleep disturbances, such as coughs, itches, pain, restlessness, frequency or urination and breathlessness. These may lead to any of the above complaints, and they need diagnosis and proper treatment.

There is a particular condition that deserves special notice. This is obstructive sleep apnoea, a condition commonest in middle aged men who are somewhat overweight, but who in particular have large necks. In a serious form, it may affect up to 3% of men. It involves the airway collapsing on attempted inhalation, which typically happens when sleeping at night lying on the back. Collapse of the airway leads to the individual stopping breathing until the respiratory drive becomes so intense that the airway is forced open – usually with a loud snort. The effort is so intense that individuals usually have their sleep disturbed, leading to poor quality sleep and hence tiredness next day. The snort is so dramatic and loud that bed partners are often woken. The diagnosis is therefore commonly made by interviewing the sleeping partner who complains about snoring, and will usually have noticed that their partner often appears to stop breathing for anything from 10-60 seconds. The significance of this condition for our purposes is that, because there is poor sleep and fatigue next day, the individual may come seeking something to improve his sleep, but treatment with hypnotics may be fatal. The condition can be treated very successfully with a method called CPAP (continuous positive airways pressure), which involves wearing a specially constructed device while asleep. 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…

Lithium Pellets

There are some suggestions from as early as the 2nd century AD that spring waters that were alkaline (which would be expected with a high concentration of lithium salts) were known to be of some use in the treatment of overactive states such as mania (1).

Lithium itself was isolated first by August Arfwedson in 1817. It was named lithium as it was found in stone – lithos being the Greek for stone. During the 1850s alkaline compounds, like lithium, were known to be of some use in preventing gout by interfering with the precipitation of uric acid in the blood and joints. At the time mania and melancholia were often seen as being part of the same family of diseases as gout and this led to the use of lithium for these conditions also. As early as 1880, the use of lithium in this manner led Carl Lange to suggest that it might have a role in preventing episodes of periodic depression.

Surprisingly, however, despite these discoveries and what would now appear to be correct hunches, lithium slipped out of use for mood disorders and had to be rediscovered in 1949. In part this was because of its side effects. In the middle of the 19th century, several investigators took lithium and noted that it caused increased urine flow, tremor of the hands and difficulties with memory or concentration, which led to wariness regarding its use. Later in the 1930s, it was used as part of a salt restriction diet in the United States and in many cases it caused such clear cut toxicity that its use was banned by the Foods and Drugs Administration (FDA). 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…