Psychotherapy

Antipsychotic agents

The advent of antipsychotic, or neuroleptic, drugs such as chlorpromazine enabled many patients to leave mental hospitals and function in society. The primary indication for the use of antipsychotics is schizophrenia, a severe mental disorder characterized by delusions, hallucinations, and sometimes unusual behaviour. One form, paranoid schizophrenia, is marked by delusions that are centred around a single theme, often accompanied by hallucinations. The most effective drug to use may depend on an individual patient’s metabolism of the drug or the severity and nature of the side effects.

Antianxiety agents

Drugs that combat anxiety, also known as anxiolytics or minor tranquilizers, enable otherwise dysfunctional patients to cope more effectively with the environmental or personal factors that trigger symptoms. This class of drugs includes the barbiturates, benzodiazepines, nonbenzodiazepine-nonbarbiturates, and hypnotics. The barbiturates phenobarbital, amobarbital, pentobarbital, and secobarbital have been around the longest and are used primarily as sedatives or for seizure disorders (phenobarbital).

The benzodiazepines have become the drugs of choice for acute anxiety. The first to be discovered was chlordiazepoxide (Librium), in 1959. The development of chlordiazepoxide was followed by a large variety of benzodiazepines, each with slightly different properties. Some are used primarily as sleeping pills (hypnotics) to treat insomnia. Before the development of the benzodiazepines, the only available antianxiety drugs were the barbiturates and meprobamate. The benzodiazepines have fewer unfavourable side effects and less abuse potential and have replaced barbiturates and meprobamate in the treatment of anxiety. They also are useful in treating alcohol withdrawal, calming muscle spasm, and preparing a patient for anesthesia. Drug dependency is a potential problem, however, especially in persons with a history of dependence on alcohol or other psychoactive drugs. Meprobamate is an example of a nonbenzodiazepine-nonbarbiturate drug. It is rarely used today, however, since benzodiazepines are more effective and safer.

Other agents include the azaspirodecanediones (e.g., buspirone), which have a relatively low potential for abuse, rendering them safer than other anxiolytics in the long-term treatment of chronic problems such as generalized anxiety disorder. They also have no sedative effects and thus are safe for patients to use when driving or operating machinery.

Hypnotic agents (nonbenzodiazepines) include chloral hydrate, some sedating antidepressants, and sedating antihistamines, such as diphenhydramine (Benadryl) and hydroxyzine (Atarax). These tend to be used less frequently than the benzodiazepine hypnotics because of an increased morning hangover effect and other side effects. The distinction between antianxiety drugs and hypnotics is not clear, because many can serve both functions. Small doses of hypnotic benzodiazepines are effective antianxiety agents, and in many persons, especially the elderly, antianxiety benzodiazepines can induce sleep.

Antidepressant drugs

Depression, a common mental disorder, is classified as an affective disorder (also called mood disorders). Many drugs are available to treat depression effectively. One is selected over another based on side effects or safety. The main classes of antidepressants are the tricyclics, selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs), and others that are often called heterocyclics (e.g., trazodone, bupropion). The SSRIs, such as fluoxetine (Prozac), sertraline, and paroxetine, have no sedating effect, anticholinergic activity, associated weight gain, or cardiac toxicity, but they can cause nervousness.

The oldest and best-studied class is the tricyclic antidepressants, which are divided into tertiary amines and secondary amines. Most tricyclics have a sedating effect, cardiac toxicity, and varying degrees of anticholinergic side effects, which some individuals, especially the elderly, have difficulty tolerating. Anticholinergic effects, which result from the blockage of parasympathetic nerve impulses, include dry mouth, constipation, difficulty urinating, and confusion. MAOIs have the potential to produce dangerous drug interactions. This is especially true of tyramine, which can cause hypertension and severe headache. Tyramine is found in many foods, which forces patients who take it to adhere to a specific diet.

Bipolar disorder is characterized by severe mood swings, from excessive elation and talkativeness to severe depression. The predominantly favoured mood-stabilizing drug is lithium, which requires regular monitoring of blood concentrations to achieve optimum effect. If the patient experiences episodes of mania or depression while taking lithium, additional drugs, such as anticonvulsants (e.g., carbamazepine and lamotrigine), may be necessary.