Treatment

Treatment

The Emergence of Dual Recovery Treatment

The setting was a psychiatric hospital during a group therapy session. Suddenly, Karen* stood up, opened the Alcoholics Anonymous Big Book to page 58, and read, “Those who do not recover are people who cannot or will not completely give themselves to this simple program, usually men and women who are constitutionally incapable of being honest with themselves. There are such unfortunates.”

“That’s me,” she said. ‘I’ll never recover. I’m doomed.” And she meant it. She, like others, had tried many treatment programs with little success. Over and over, she’d relapse. She just couldn’t quit drinking. Karen also struggled with debilitating depression a result of her uncle sexually abusing her for three years when she was a child. Her repeated suicide attempts had led to several psychiatric hospitalizations. Despair she knew well and voiced it angrily in group.

People who have concurrent mental health’ and substance abuse disorders often called “dual disorders” or “dual diagnosis” face a difficult path. There are many reasons for the challenges they confront.

One of these is that treatment programs historically have not addressed both disorders at the same time. When Karen received inpatient psychiatric treatment, many times her treatment team didn’t even address her alcohol problem as part of the treatment plan. However, it was a treatment issue. By ignoring it, the team made it worse. They actually enabled her drinking by not dealing with it.

Conversely, when Karen was in substance abuse treatment, her treaters ignored her severe depression. They told her she wasn’t successful because she didn’t “work the program” hard enough. In other words, if she were truly following the 12-step program, she’d be able to stop drinking. The treaters blamed Karen’s inability to work the program for her chronic relapses, rather than addressing her depression with treatment that included medications and psychotherapy.

Part of the reason mental health and substance abuse disorder treatments have been separate is that treatment for each is different.

Psychiatric treatment’s goal is symptom relief or resolution of the disorder. Symptom relief would mean a person with bipolar disorder no longer experiences wide mood swings, and resolution would mean a person with a panic disorders would no longer have panic attacks/ People with mental disorders receive treatment in supportive environments that build patients up so they can effectively deal with their problem. Medication is often essential, and the doctor/psychiatrist controls treatment in the medical model.

In contrast, substance abuse treatment’s goal is sobriety or recovery. This means the person would not only be abstinent from the substance, but would be developing positive, non-addictive coping skills, growing interpersonally, and rebuilding a sobriety-centered value system. Treatment can be confrontational to break down people’s denial system so they admit they have a problem, accept their powerlessness over their substance, and learn to work the 12 steps developed by Alcoholics Anonymous. A team of substance abuse counselors, many of whom are successful at recovery themselves, make treatment decisions.

These contrasts long led to separation. People with a dual diagnosis typically bounced back and forth between treatments, never addressing both problems at once. It could become the typical “vicious cycle.”

Fortunately, in the last two decades, there has been a movement to integrate psychiatric and substance abuse treatment. This has been challenging, but fruitful. Programs in mental health and substance abuse are tackling both problems from a dual perspective. Some of the key issues that integrated programs address include the use of medication, spirituality, powerlessness versus empowerment, and confrontation versus supportive styles. It’s not surprising that research shows the programs that treat both disorders are more effective than separate programs.

Yet, there are few dual programs. Why? The reasons are many: separate funding streams, lack of cross-trained professionals, continued differing treatment philosophies, and lack of political will to make changes in the structure and financing of treatment systems. For example, until recently in Michigan, mental health treatment fell under the auspices of the Department of Mental Health while substance abuse treatment fell under the Department of Public Health. Now they are both under the Department of Community Health, which hopefully will help dual people. Despite these hurdles, some facilities are developing integrated approaches. Even within the self-help movement, there is now Dual Recovery Anonymous for people with dual disorders.

Ironically, given the historical differences in treatment, the disorders themselves have many similarities that lend themselves to integrated treatment. Successful dual programs emphasize the parallels between mental health and substance abuse disorders, rather than the differences.

A major similarity is there is no one cause for either of these disorders. Heredity and life circumstances (such as stress) often play a role in producing either a substance abuse problem or a mental health problem.

The disorders can affect every aspect of a person’s life.
Both disorders can be progressive. Examples are people who start out as social drinkers and whose addiction grad-ually develops and people who may have periodic “blue” or down periods that get worse each time until they are in a clinical depression. For both, the progress of the disorder can be slow or fast. Without help, the disorders tend to progress and create crises, loss of relationships and jobs, and financial and/or legal problems.

At this time, there is no cure for either a mental health or substance abuse disorder. Even if symptoms are gone for a long time, the potential for relapse is generally always there. People with addictions can never use their substance of abuse again even in small quantities. People with mental health disorders may-have to stay on medication, continue psychotherapy, or make permanent lifestyle changes to avoid the stress that could trigger a relapse. People with dual diagnosis have difficulty with those words “no cure.” Someday, we may conquer these disorders. Bill W., a founder of AA, recognized that if alcoholism was ever cured, it would be through the medical community. There is always hope.

Denial is strongly characteristic to both disorders. Clinicians cite denial of alcohol abuse/dependency as the most difficult problem. Why? It means facing the loss of the substance, coping with feelings of guilt and failure, dealing with the stigma of having an “addiction” or “mental illness,” and perhaps facing underlying wounds from childhood.

The primary aspect of both disorders is loss of control. In chemical depen-dency, it’s the loss of control over one or more substances. It means either people cannot control their use once they start or have no ability to abstain. In mental health disorders, the loss of control is more varied. In depression, it could be when people lose so much energy, they can’t take care of themselves. Or they’re in such despondency and despair, they become suicidal, losing the ability to see any other options. With anxiety, the loss of control can take the form of the person experiencing extreme moments of panic for no obvious reasons. With a bipolar disorder, some people lose control of their moods, experiencing severe mood swings. And with psychotic disorders, people may lose a sense of reality by experiencing hallucinations, delusions, or confusion.

The impact on the whole family is significant for both disorders. Families experience disruption because other members don’t understand the disorders and the effects the disorders can have on them. Enabling, blaming, and conflicts are common. Education and family treatment are important components of the family’s recovery. Many families receive support from self-help groups like Alanon, which is for friends and family members of a loved one with alcoholism.

With all these factors, people with dual disorders can be easily overwhelmed and tend to experience significant powerlessness. They need powder to manage their symptoms, to treat these disorders, and to prevent the harmful consequences their disorders cause their families, friends, and themselves. When they can’t control the disorders by themselves, they can equate powerlessness with hopelessness. That’s what Karen was feeling.

The paradox facing people in dual recovery is they must accept the powerlessness over both disorders as they empower themselves with help from others to manage the disorders and live stable, sober, fulfilling, healthy lifestyles. This is exactly where the 12 steps start, with the First Step, the explicit concept of powerlessness and the implicit need to humbly reach out by asking for help from fellows and our higher power.

This can be difficult for people just starting in recovery. One key is to embrace the powerful slogan: KEEP IT SIMPLE. There are so many issues in early recovery, so many losses, so many big lifestyle changes, it can be overwhelming. People have to make sure they don’t take on too much. The other disordered aspects of their lives will gradually fall into place, but they can’t expect to fix everything at once. They need to focus on just staying stable and abstinent.

When Karen shared her despair, she received some honest feedback from another group member, Juanita. First. Juanita told Karen that Karen had taken the quote out of context. The Big Book goes on to say, “There are those, too, who suffer from grave emotional and mental disorders, but many of them do recover if they have the capacity to be honest.”

Juanita said, “What works for me is M&Ms. No, not candy. My 12-step meetings and my medications.” Juanita kept it simple. And she was right. Karen, however, had never consistently followed a 12-step program, stayed abstinent, and followed through with mental health treatment for any period of time. Listening to Juanita’s success gave Karen what she needed hope.

Dual recovery for people with dual disorders is possible. Powerlessness does not mean hopelessness and despair. Powerlessness can, instead, mean the first step to a new, empowering life. But like anything worthwhile, it’s doesn’t come easily. It’s a lot of hard work for the people and their families. Slogans like “Keep it simple” and “Remember your M&Ms” give focus to day-to-day living and goal-setting.

Joseph Koblev, M.S.W., Coordinator of Dual Diagnosis Semices, has worked at Pine Rest since 1995. He provides psychotherapy with patients, develops programming, trains and consults with staff, and sewes as liaison with community substance abuse programs. He earned his B.A. at Aquinas College, attended Catholic seminar]’, and graduated from Grand Valley State University with his masters degree is social work.
Names find circumstances of people have been changed to protect confidentialitv.

Pharmacology and Medication Issues in Dual Diagnosis

We’re a society of pill-poppers. Headache? Stomachache? Can’t sleep? Runny nose? Carsick? Any time we don’t feel just right, we can go to the local drugstore and buy from countless over-the-counter medications. And that doesn’t begin to address the pills available through prescriptions. There is a pill for almost anything that ails us.

Unfortunately, this pill-popping attitude can lead to problems for some people. Have you ever had a sore throat, figured it was strep and used some of the medication left over from the last time your child had strep? While that may be a minor example, it does illustrate our tendency to self-medicate. We give ourselves the medication we need.

For some people, that “medication” takes the form of alcohol, cocaine, or other substance. If they become addicted to the substance, it complicates their use of other medications. This can especially be a problem if they become clinically depressed or suffer from an anxiety disorder or another psychiatric issue. Whether they’re addicted or recovering, whether the medication is over- the-counter or prescription only, people with a dual diagnosis need to know how medications can potentially affect them.

Dr. Gregg Miklashek, addiction specialist, and psychiatrist, addresses some of the medication issues facing people with a dual diagnosis.

There are many over the counter drugs that recovering alcoholics have to avoid.

What advice about medications would you give to someone who struggles with both an addiction problem and a psychiatric issue?

Whether you’re addicted or not, it’s important that you’re educated. For years, people blindly trusted their physicians and didn’t ask questions. On the other hand, physicians or psychiatrists can only help if they’re informed. For example, people who hide a drinking problem from their doctors may get medications that are harmful.

The recovery community has known for a long time that many anti-anxiety agents, or minor tranquilizers, can destroy the sobriety of recovering alcoholics. Benzocliazepines Valium, Librium, Tranxene, Ativan, Xanax are the pharmacological descendants of barbiturates. They use the same receptor sites in the brain. Literally, the brain doesn’t know whether it’s being calmed by a dose of alcohol or a close of benzocliazepine.

Let’s look at recovering alcoholics trying to get through the day-to-day travails of their life without depending on alcohol to calm, sedate, anesthetize, or inebriate their emotional state. They go to their physicians, don’t say they’re in recovery, and ask for something to help their anxiety. Well-meaning physicians may prescribe the only FDA-approved benzocliaxepine for anxiety disorders, Xanax. The result is they receive a drug that stimulates the biochemical craving in the brain for alcohol. The medical community and the recovery community have to be knowledgeable about what is and isn’t safe. It’s the only want to really benefit the addicted population.

What kinds of drugs are “safe” in that they don’t contribute to relapse for the recovering alcoholic?
The anticlepressants are safe for dealing with depression and anxiety disorders. They’re typically the drugs of choice and should be the first-line drugs for chronic treatment of an anxiety disorder in a recovering person. There doesn’t seem to be any correlation with any kind of drug of abuse, including alcohol, in the use of anti-depressants. Very small closes of some antipsychotic agents (Thorazine or Mellaril) also work for anxiety disorders. The mood stabilizer Lithium Carbonate also is safe.

What kinds of drugs are dangerous?
Since alcohol is a sedative, sedatives can be dangerous. There are many over-the-counter drugs that recovering alcoholics have to avoid. When people have colds or it’s allergy season, they often take antihistamines. People in recovery may end up drinking again because antihistamines are sedatives. Sleep aids are dangerous, too. Once a person is in recovery, he or she has to become educated about many medications that the general public gives little or no thought to. One of the advantages of attending AA [Alcoholics Anonymous! is that often the recovery community is knowledgeable about which over-the-counter medicines are safe. People who have had bad experiences learn from their mistakes and pass that information on in AA meetings.

Are different kinds of drugs dangerous for someone with a different addiction for example, cocaine?
Not in the same way that antihistamines or benzocliazophines are for the recovering alcoholic. Cocaine addiction is similar and different. The similarities are that alcohol and cocaine are primarily pharmacologically anesthetic agents. They’re both pain killers. That has everything to do with the general psychology of addiction. All the drugs of addiction are pain killers. So what does that mean about the people using them? They’re trying to kill pain. In that regard, alcohol and cocaine are identical.

However, cocaine’s mechanism of action is very different. Cocaine is an anti depressant. It deals with the brain neuro transmitter “clopamine.” One of the anticlepressant medications available, Wellbutrin, is similar, but much weaker. Cocaine is such an incredibly powerful antidepressant that it literally empties out the brain’s reserves of dopamine in a week or two. It takes Wellbutrin 2years.

Needless to say, there are a lot of people with chronic depression who end up being addicted to cocaine. Even people who weren’t depressed before using cocaine will be depressed when they stop using it. The nature of the drug is to simply wipe out your supplies of dopamine and probably other neurotransmitters.

The brain can replenish this, but it takes months. That’s why cocaine addicts have their highest incidence of relapse at six weeks after the last usage. The effect of the drug has worn off, the fear of the consequences of renewed drug use has worn off, and the craving because of the depletion of the dopamine supplies is extremely high. Even a person who only used cocaine a few days will experience this depletion and craving.

How do we begin treating dual diagnosis?
The first step is to make sure it IS a dual diagnosis problem. This is complicated because it’s impossible to make a good psychiatric evaluation and diagnosis of someone who has just recently stopped using chemicals in an abusive way for any length of time. The abuse totally distorts the psychological and psychiatric picture.

People need to have 6-12 months of sobriety before psychiatry can really deal with them well. If someone is addicted and depressed, we provide supportive care. If someone has been using cocaine heavily for any length of time, no dopaminergic antidepressant will work for them because their central supplies of dopamine are gone. We can only offer supportive care until the brain heals. Some treatment centers offer vitamins that include amino acids to help the brain rebuild these supplies. And there has been some success with norepinephrinergic antidepressants like Norpramin.

It is possible to make psychiatric diagnoses from an historical record. However, it can be difficult. Usually people have a life story of using chemicals of abuse for twenty years during the entire course of their alleged mental illness. Who knows what came first? Until the substances of abuse are removed from the picture, there’s no way to tell.

People have to be clean and sober for some time before they’re going to get good psychiatric care. They need to understand their illness, the medications being used, and their side effects. To treat people psychiatrically with a dual diagnosis problem, I insist on a good, sustained recovery. If I’m going to prescribe medications, they have to insure me they’re substance free. If they can’t do that, I’ll see them and provide supportive psychotherapy, but I won’t prescribe medications. They’re unreliable and potentially self-harmful if they’re continuing to use substances of abuse. I’m not saying that newly recovered people shouldn’t be medicated, but I’m extremely cautious.

The vast majority of depressed alcoholics aren’t depressed any more six months into sobriety because alcohol abuse induces many different mood disorders. Every freshly recovering, newly withdrawn alcoholic is depressed. Often their health is poor. They may have lost a job or damaged their marriage. Their brain is depleted of important, mood-stabilizing chemicals. Most of them will no longer be depressed after six months of abstinence, good diet, supportive care (including psychotherapy), and immersion in a 12-step recovery program.

The supportive care helps those with true psychiatric problems get through until they can start aggressive treatment.

Is it difficult for a person in recovery to take medications for their psychiatric problems?
For an individual to have to depend on a medication to make themselves function or feel OK inside is a powerful event in a person’s life. We need to focus more attention on the psychology of medicines because all the medications that psychiatrists prescribe are mood-altering substances. Being put on a medication is a profound issue, especially for recovering people. Some may view this as trading one addiction for another, however, there is a big difference.

One of the most basic psychological issues of addicts is whether an individual is self medicating or granting control of medications to someone else. If a person is giving me as their treating physician the privilege and responsibility of prescribing medication to them, then they’re giving up control over the medication to me. They should ask all kinds of questions about it, but the bottom line is I write the prescription, not them. The pharmacist fills it, not them. It’s a different process psychologically than addiction.

Addiction starts when someone thinks, “1 don’t feel quite right inside. I’ll go down to the drugstore or to the liquor store and pick something to fix myself. I’ll self medicate.” While those words don’t actually go through people’s minds, that is, essentially, the subconscious process. By handing control to someone else, that’s the first big step in recovery.

Yet, they are in some sense addicted to something. In AA, the phrase is “Once a cucumber becomes a pickle, it can’t become a cucumber again.” There’s some biochemical truth in that for addicts. Many people in the recovery community think of themselves as cross-addicted. We have the potential for addiction to anything. It’s ironic that the founder of AA, Bill Wilson, a God-sent man, died of emphysema because he was addicted to cigarettes and nicotine and unable to over come that addiction like he overcame his alcohol addiction.

So some people are reluctant to comply with their medication because they believe it’s trading one addiction for another. This is an issue they and their physician must deal with. Recovering people may not be comfortable taking medication, and doctors must be sensitive to that to insure compliance. It’s important for the medical profession to support the recovery of addicted people. There’s an ever-larger population of recovering people, and they make up an increasing proportion of the patient population that every physician sees. To recovering people, it’s terribly important and a major issue to be taking any kind of medication particularly if it’s mood-altering.

As a recovering alcoholic, I sometimes talk in meetings about how difficult it is for me to prescribe medications to recovering people. It’s a huge responsibility because the last thing I want to do is create an addict or lead someone back to drinking. It’s something physician and patient alike must take seriously.

Psychiatric Medications

Mental illnesses are among the most common conditions affecting health today: One in five American adults suffers a diagnosable mental illness in any six-month period. According to the National Institute of Mental Health, though, some 90 percent of these people will improve or recover if they get treatment. Psychiatrists and other physicians treating mental illnesses have a wide variety of treatments available today to help them help their patients. Most often, psychiatrists will work with a new patient to construct a treatment plan that includes both psychotherapy and a psychiatric medication. These medications, combined with other treatments such as individual psychotherapy, group therapy, behavioral therapy or self-help groups, help millions each year to return to normal, productive lives in their communities, living at home with loved ones and continuing their work.

Mental Illnesses and Medications

Psychiatric researchers believe that many people suffering from mental illnesses have imbalances in the way their brain metabolizes certain chemicals, called neurotransmitters. Because neurotransmitters are the messengers the nerve cells use to communicate with one another, these imbalances may result in the emotional, physical and intellectual problems that mentally ill people suffer. New knowledge about how the brain functions has permitted psychiatric researchers to develop medications that can alter the way in which the brain produces, stores and releases these neurotransmitter chemicals, alleviating the symptoms of the illness.

Psychiatric Medications

Psychiatric medications are like any other medicine your doctor would prescribe. They are formulated to treat specific conditions, and they must be monitored by a physician, such as a psychiatrist, who is skilled in treating your illness. Like most medications, psychiatric prescriptions may take a few days or a few weeks to become fully effective.

All medicines have positive and negative effects. Antibiotics, which cure potentially serious bacterial infections, can cause nausea. Heart disease medication can cause low blood pressure. Even over-the-counter drugs such as cold remedies can cause drowsiness, while aspirin can cause stomach problems, bleeding and allergic reactions. The same principle applies to psychiatric medications. While very effective in controlling painful emotional and mental symptoms, psychiatric medications can produce unwanted side effects. People suffering from mental illness should work closely with their physicians to understand what medications they are taking, why they are taking them, how to take them and what side effects to watch for.

Before deciding whether or not to prescribe a psychiatric medication, psychiatrists either conduct or order a thorough psychological and medical evaluation, which may include laboratory tests. After a patient has begun taking a medication, the psychiatrist closely monitors his or her patient’s health throughout the time the patient is taking the medicine. Often, the side effects disappear after several days on the medication; if they don’t, the psychiatrist may change the dose or switch to another medication that maintains the benefits but reduces the side effects. The psychiatrist may also prescribe a different medication if the first one does not alleviate symptoms within a reasonable period of time.

Classes of Medications

Antidepressant medications

Depression, which afflicts 9.4 million Americans in any six-month period, is the most common form of mental illness. Far different from the normal mood shifts everyone feels on occasion, depression causes a profound and unremitting sense of sadness, hopelessness, helplessness, guilt and fatigue. People suffering from depression find no happiness or joy in activities once enjoyed or in being with family and friends. They may be irritable and develop sleeping and eating problems. Unrecognized and untreated, depression can kill, as those with depression are at high risk for suicide.

However, up to 80 percent of people suffering from major depressive disorder, bipolar disorder (manic-depression), and other forms of this illness respond very well to treatment. Generally treatment will include some form of psychotherapy and, often, a medication that relieves the excruciating symptoms of depression. Because people suffering from depression are likely to have a relapse, psychiatrists may prescribe antidepressant medications for six months or longer, even if the symptoms disappear.

Types of antidepressant medications

Three classes of medication are used as anti-depressants: heterocyclic antidepressants (formerly called tricyclics), monoamine oxidase inhibitors (MAOIs) and serotonin-specific agents. A fourth medication,the mineral salt lithium, works with bipolar disorder. The ben-zodiazepine alprazolam is sometimes used with depressed patients who also have an anxiety disorder (see section on anxiety disorder medications).

Taken as prescribed, these medications can mean the difference between life and death for many patients. Antidepressant medications alleviate the terrible emotional suffering and give people a chance to benefit from the non-drug therapies that enable them to deal with the psychological issues that may also be part of their depression.

Heterocyclic antidepressants:

This group of antidepressants comprises amitriptyline, amoxapine, desipramine, doxepin, imipra-mine, maprotiline, nortriptyline, protriptyline, and trimipramine. They are safe and effective for up to 80 percent of all people with depression who take them.

At first, heterocyclics may cause blurred vision, constipation, a feeling of light-headed-ness when standing or sitting up suddenly, a dry mouth, retention of urine or feelings of confusion. A small percentage of people will have other side effects such as sweating, a racing heartbeat, low blood pressure, allergic skin reactions or sensitivity to the sun. Though bothersome, these side effects can be lessened with practical suggestions such as increasing fiber in the diet, sipping water, and getting up from a seat more slowly. Side effects generally disappear after a few weeks, when the therapeutic effects of the medication take hold.

More serious side effects are extremely rare. However, a very small percentage of people being treated with these medications have aggravation of narrow-angle glaucoma and seizures.

As the bothersome side effects clear, the benefits of these medications take hold. Gradually insomnia clears up and energy returns. The person’s self-esteem improves, and the feelings of hopelessness, helplessness and sadness ease.

MAOIs: Though they are as effective as het-erocyclic medications, MAOIs such as isocar-boxazid, phenelzine, and tranylcypromine, are prescribed less frequently because of the dietary restrictions their use requires. Psychiatrists will sometimes turn to these medications when a person hasn’t responded to other anti-depressants. MAOIs also help depressed people whose health conditions, such as heart problems or glaucoma, prevent them from taking other types of medications.

People who take MAOIs should not eat foods, such as cheese, beans, coffee, chocolate or other items, that contain the amino acid tyramine. This amino acid interacts with MAOIs and causes a severe and life-threatening increase in blood pressure. MAOIs also interact with decongestants and several prescription medications. People using these antidepressants should always consult their physicians before taking any other drug, and should rigorously follow dietary instructions.

Serotonin-specific agents:

Serotonin-specific medicines, such as fluoxetine and sertraline, represent the newest class of medication for people suffering from depression. These medications have less effect on the cardiovascular system and therefore are helpful for depressed people who have had a stroke or heart disease. They generally have fewer side effects than other classes of anti-depressants.

However, during the first few days of taking them, patients may feel anxious or nervous and may have sleep disturbances, stomach cramps, nausea, skin rash and, rarely, sleepiness. In extremely rare cases, a person may develop a seizure.

A few patients reported that, though they had had no suicidal thoughts before taking fluoxetine, they developed a preoccupation with suicide after medication began. There have also been some reports that a very few patients developed violent behavior after beginning to take fluoxetine. Scientific data do not support these claims, however. No studies have shown that the medication itself caused these preoccupations or behaviors, which are also symptoms of depression.

Bipolar medications

People suffering from bipolar disorder go through phases of severe depression that alternate with periods of feeling normal and/or “periods of excessive excitement and activity known as mania. During the manic phase, people have extremely high energy, develop grandiose and unrealistic ideas about their abilities, and commit themselves to unrealistic projects. They may go on spending sprees, for example, buying several luxury cars despite moderate income. They may go for days without sleeping. Their thoughts become increas-ingly chaotic; they speak rapidly and they may become quite angry if interrupted.

Lithium

The medication of first choice for bipolar illness is lithium, which both treats the manic symptoms in seven to ten days and reduces depressive symptoms if they develop.

Though it is very effective in controlling the wild thoughts and behaviors of mania, lithium does have some side effects, including tremor, weight gain, nausea, mild diarrhea, and skin rashes. People taking lithium should drink 10 to 12 glasses of water a day to avoid dehydration. Adverse reactions that may develop in a small number of people include confusion, slurred speech, extreme fatigue or excitement, muscle weakness, dizziness, difficulty in walking or sleep disturbances.

Physicians also sometimes prescribe anticon-vulsant drugs such as carbamazepine or val-proate for people with bipolar disorder, though the FDA has not yet approved them for this purpose. They have been known to cause potentially serious blood disorders in a minority of cases.

Anti-anxiety medications

Anxiety disorders, in addition to generalized anxiety, include such disorders as phobias, panic disorder, obsessive-compulsive disorder, and post-traumatic stress disorder. Studies indicate that 8 percent of all adults have suffered from a phobia, panic disorder or other anxiety disorder during the preceding six months. For millions of Americans, anxiety disorders are disruptive, debilitating and often the reason for loss of job and serious problems in family relationships.

Often an anxiety disorder, such as a simple phobia or post-traumatic stress disorder, responds well to psychotherapy, support groups and other non-medication treatments. But in severe cases, or with certain diagnoses, a person may require medication to control the unrelenting and uncontrollable tension and fear that rule their lives.

Psychiatrists can prescribe highly effective medications that relieve the fear, help end the physical symptoms such as pounding heart and shortness of breath, and give people a greater sense of control. Psychiatrists often prescribe one of the benzodiazepines, a group of tranquilizers that can reduce debilitating symptoms and enable a person to concentrate on coping with his or her illness. With a greater sense of control, the person can learn how to reduce the stress that can trigger anxiety, developing new behaviors that will lessen the effects of the anxiety disorder.

Benzodiazepines, such as chlordiazepoxide and diazepam, and several other medications effectively treat mild to moderate anxiety, but these medications should be taken only for short periods. Side effects can include drowsiness, impaired coordination, muscular weakness, impaired memory and concentration, and dependence after long-term use.

Alprazolam, which is a high-potency benzo-diazepine, is effective against anxiety disorders that are complicated by depression. People with this combination of symptoms who begin treatment may find that their anxiety symptoms worsen when they begin antide-pressant medication. Alprazolam helps control those anxiety problems until the anti-depressant takes effect. Though alprazolam works quickly and has fewer side effects than antidepressants, it is rarely the medication of first choice because it has a high potential for dependency. Its side effects include drowsi-ness, impaired coordination, impaired memory and concentration, and muscular weakness.

Another anti-anxiety medication, buspirone, has different side effects than those sometimes caused by benzodiazepines. Though it has little potential for dependency and doesn’t cause drowsiness or impair coordination or memory, buspirone can cause insomnia, nervousness, light-headedness, upset stomach, nausea, diarrhea, and headaches.

Medications for obsessive-compulsive disorder

Obsessive-compulsive disorder, which causes repeated, unwanted and often very disturbing thoughts and compels repetition of certain ritualistic behaviors, is a painful and debilitating mental illness. A person with obsessive-compulsive disorder might, for instance, develop a fear of germs that compels him or her to wash his or her hands so often that they continually bleed.

Though obsessive-compulsive disorders are officially classified as anxiety disorders, they respond best to antidepressant medications. In February 1990, the U.S. Food and Drug Administration (FDA) approved clomipramine, a heterocyclic antidepressant, for use against obsessive-compulsive disorder. This medicine acts on serotonin, a neurotransmitter thought to affect mood and alertness. Though this medicine may not take full effect for two or three weeks, it is effective in reducing the uncontrollable thoughts and behaviors and the devastating disruptions they cause in a person’s life.

Clomipramine’s side effects, like those of all heterocyclic antidepressants, may include drowsiness, hand tremors, dry mouth, dizziness, constipation, headache, and insomnia. While its use in treating anxiety disorders has not yet been approved by the FDA, fluoxetine has shown some promise in research.

Anti-panic medications

Like other anxiety illnesses, panic disorder has both physical and mental symptoms. People suffering from a panic attack often think they are having a heart attack: their heart pounds; their chest is tight; they sweat profusely, feel they are choking or smothering, have numbness or tingling around their lips or their fingers and toes, and may be nauseated and chilled. Panic attacks are so terrifying and unpredictable that many who have them may begin to avoid places and situations that remind them of those under which previous panic attacks occurred. Over time those suf-fering from panic attacks may even refuse to leave home.

Currently, many psychiatrists may prescribe al-prazolam for people with panic attacks. However, as already stated, this medication can cause dependency when used for an extended period. Once an antidepressant has taken effect, physicians treating panic with alprazolam and an antidepressant in tandem will usually reduce the alprazolam dosage slowly.

Learning new ways of thinking, modifying behavior, learning relaxation techniques and participating in support groups are among the non-medication treatments that are also important parts of the overall treatment plan for panic disorder.

While alprazolam is the only medication the FDA has approved for treatment of panic disorder, research continues into the positive effects of other medications as well.

In clinical trials, panic disorder has responded well to heterocyclic antidepressant medications. In fact, antidepressant medications such as imipramine have been effective in reducing panic symptoms in 50 to 90 percent of the patients studied. When combined with psychological and behavioral treatments, the effectiveness of the medications increases. When the panic symptoms lessen, the patient can begin working with the psychiatrist in understanding his or her illness and coping with its effects on daily life.

Likewise, studies have suggested that MAOIs such as phenelzine or tranylcypromine can be as effective as heterocyclic antidepressants in the treatment of panic.

Fluoxetine, which is also awaiting FDA approval for treatment of panic, has had promising results in tests of its effects on panic.

Anti-psychotic medications

Psychosis is a symptom, not a disease. It can be part of several mental illnesses, such as schizophrenia, bipolar disorder, or major depression. It also can be a symptom of physical illnesses such as brain tumors, of drug interactions, of substance abuse, or of other physical conditions.

Psychosis alters a person’s ability to test reality. A person may suffer from hallucinations, which are sensations that he or she thinks are real but don’t exist; delusions, which are ideas that he or she believes despite all proof that they are false; and thought disorders, in which his or her thought processes are chaotic and il-logical.

Schizophrenia is the mental illness most often associated with psychosis. Researchers do not know the specific causes of schizophrenia, though most believe that it is primarily a physical brain disease. Some believe that the neurotransmitter dopamine is involved with the hallucinations, delusions, thought disorders and blunted emotional responses of this mental illness. Most medications prescribed for schizophrenia affect the dopamine levels in the brain at the same time they reduce the extremely painful mental and emotional symptoms.

Anti-psychotic medications—acetophenazine, chlorpromazine, chlorprothixene, clozapine, fluphenazine, haloperidol, loxapine, mesori-dazine, molindone, perphenazine, pimozide, piperacetazine, trifluoperazine, triflupro-mazine, thioridazine, and thiothixene—lessen the psychotic symptoms and allow the person to participate more fully in life.

Anti-psychotic medications do have side effects. They include dry mouth, blurred vision, constipation, and drowsiness. Some people taking the medications can experience a difficulty in urinating that ranges from mild problems in beginning urination to complete inability to urinate, a condition that requires prompt medical attention.

For many, these side effects lessen over several weeks as their bodies adapt to the medication. To lessen constipation, people taking antipsychotic medications can eat more fruits and vegetables and drink at least eight glasses of water per day.

Other side effects include greater risk of sunburn, changes in white blood cell count (with clozapine), low blood pressure when standing or sitting up, akathisia, dystonia, parkinson-ism, and tardive dyskinesia.

Patients with akathisia (which to some degree affects up to 75 percent of those treated with anti-psychotic medications) feel restless or unable to sit still. While this side effect is difficult to treat, some medications, among them propranolol, clonidine, lorazepam and diaze-pam, can help. Those with dystonia (between 1 and 8 percent of patients taking anti-psychotic medications) feel painful, tightening spasms of the muscles, particularly those in the face and neck/This side effect is also treatable with other medications, including benz-tropine, trihexyphenidyl, procyclidine, and diphenhydramine, that act as antidotes. Park-insonism is a group of symptoms that resemble those brought on by Parkinson’s disease, including loss of facial expression, slowed movements, rigidity in arms and legs, drooling, and/or shuffling gait. It affects up to one-third of those taking anti-psychotic medications, and is also treatable with the medications mentioned for treatment of dystonia, with the exception of diphenhydramine. Tardive dyskinesia is one of the most serious side effects of anti-psychotic medications. This condition affects between 20 and 25 percent of persons taking antipsychotic drugs. Tardive dyskinesia causes involuntary muscular movements, and though it can affect any muscle group, it often affects facial muscles. There is no known cure for these involuntary movements (though some drugs, including reserpine and levodopa, may help), and tardive dyskinesia may be permanent unless its onset is detected early. Psychiatrists emphasize that patients and their family members should watch closely for any signs of this condition. If it begins to develop, the physician can discontinue the medication.

Clozapine, which the FDA approved for prescription in 1990, now offers hope to patients who, because they suffer from so-called “treatment-resistant” schizophrenia, could not be helped before by anti-psychotic medications. Though clozapine has not been associated with tardive dyskinesia, this anti-psychotic medication does cause a serious side effect in 1 to 2 percent of the people who take it. This side effect, a blood disorder called agranulocy-tosis, is potentially fatal because it means the body has stopped producing the white blood cells vital to its protection from infections. To guard against development of this condition, the medication’s manufacturer requires weekly monitoring of the white blood cell count of each person taking the medication. As a result, use of clozapine and its accompa-nying monitoring system can be expensive.

Though anti-psychotic medications have side effects, they offer benefits that far outweigh the risks. The hallucinations and delusions of psychosis can be so terrifying that some people are willing to endure their side effects for relief from the terrors of the illness. The thought disorders can be so confusing and frightening, they isolate those afflicted with them in a lonely world from which no escape seems possible. Unable to know whether the insects they see crawling on their bodies are real, unable to control the voices that harass and degrade them, unable to express their thoughts so others can understand them, people suffering from psychotic symptoms lose their jobs, their friends and their families. Cast into a hostile world of people who are afraid of or unable to understand their disease, these people often become suicidal.

Conclusion

No medication, whether an over-the-counter drug such as aspirin or a carefully prescribed psychiatric medication, is without side effects. But just as relief from the pain and discomfort of a cold is worth the potential side effects, so is the relief from the excruciating and potentially fatal symptoms of mental illnesses. Psychiatrists are trained to carefully weigh the benefits and risks of prescribing these medications.

No one should fear taking a psychiatric medication if he or she has received a complete medical and physical examination and is properly monitored for both the medicine’s benefit and its side effects. Not only do psychiatric medications offer relief from the terror, loneliness, and sorrow that accompany untreated mental illnesses, but they enable people to take advantage of the psychotherapy (which psychiatrists usually prescribe in tandem with medication), self-help groups, and supportive services available through their psychiatrist. Better, these medications and the other services available through mental health care enable people who have mental illness to enjoy their lives, their families and their work.