PSYCHOTROPIC MEDICATIONS
The field of psychopharmacology is vast and growing. This is a particularly exciting time for professionals in the mental health field to utilize medications which have the potential to help patients with mental illness challenges. Research is expanding to genetically and immunologically based strategies which promise to expand our armamentarium and enable us to provide medication interventions which are more specific and personalized. In the future, it is likely that a broadening recognition that mental health challenges are present in virtually all of us, the treatment of these challenges will be even further destigmatized and allow for increasing numbers of individuals to recognize that they can address their challenges and enhance the quality of their lives.
Psychotropic medications are primarily the purview of the psychiatrist and psychiatric nurse practitioner. Other clinicians appropriately prescribe some of the most common psychotropic medications. Many psychotropic medications are relatively safe, and it is important to make them easily accessible to patients. If a patient is not responding well, it may be prudent to refer the patient to a psychiatrist for more complex considerations. Many psychotropic medications have multiple uses. They may be used by psychiatrists for one purpose, and by other specialists for other indications. Therefore, a clinician may prescribe these medications in the hope that they may have multiple benefits. Potential benefits, side effects and interactions with other medications vary considerably between individual patients. As a result, decision making regarding treatment options benefits from a close collaboration between the patient and the provider.
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Psychotropic medications can be divided into at least seven major classes, as follows:
1. Antidepressents
These agents have many potential benefits. In addition to treating depression and anxiety. They can be used to treat conditions such as Panic Disorder, Obsessive-Compulsive Disorder, Attention Deficit Disorder, eating disorders, pain syndromes, weight loss or weight gain, Irritable Bowel Syndrome, Fibromyalgia, Chronic Fatigue Syndrome, insomnia, urinary frequency and incontinence. They can be divided into newer (often with a lower side effect profile, but more expensive) and older agents. They can also be characterized by their specific chemical actions, which contribute to benefits and side effects. For example, SSRI antidepressants can be particularly helpful in decreasing stress and worry, presumably due to their specific interactions with serotonin.
2. Mood Stabilizers
These agents are often used to treat mood disorders, such as Bipolar Disorder (Manic-Depressive Disorder). They can also be used to treat conditions such as agitation, irritability, disinhibition and aggression (often in the elderly, with dementia or other brain disorders). They can be effective in treating various forms of verbal and physical aggression, including screaming, cursing, combativeness and hypersexuality. Many of the agents in this class are also used to treat seizure disorders and pain (particularly fibromyalgia, neuropathy, neuralgia and migraine). Other (some off-label) indications include eating disorders, tremor, substance overuse/dependence and PTSD. The original mood stabilizer, Lithium, is used less frequently these days. It works very differently than the other agents in this class. However, Lithium can be very effective in some patients and has been found to be particularly useful in treating suicidal patients.
3. Major Tranquilizers (Also called antipsychotics or neuroleptics).
These medications have been traditionally used to treat psychosis, in patients with schizophrenia and severe mood disorders. However, the newer generations of this class of medications are frequently used to treat non-psychotic illnesses, including Bipolar Disorder and Major Depression. The newer agents generally have considerably fewer serious side effects. They can be used for anxiety, insomnia, tic disorders, stuttering and other off-label indications.
4. Anti-anxiety (anxiolytic) agents.
Most of the medications in this class are chemically related compounds called Benzodiazepines. These medications may be very
effective in decreasing anxiety (particularly severe anxiety, such as panic attacks) on an “as-needed” basis. They work quickly and are useful when trying to address the type of anxiety which onsets quickly and unpredictively. However, they are habit-forming when
they are used daily, leading to tolerance (loss of effectiveness) and withdrawal when they are discontinued. They have numerous problematic side effects, particularly in patients who are already confused. These side effects include worsening confusion,
unstable gait and possible fall risk, disinhibition and aggression. Therefore, they are rarely good agents to use in cognitively impaired patients. There are a few non- benzodiazepines which are useful in treating anxiety, but not depression, and which
have a lower side effect profile than benzodiazepines.
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As noted, some antidepressants are very effective in treating anxiety and may be the first choice for many patients. They are usually preferable if the patient requires help with their anxiety on a daily basis. First, they are not habit-forming in the traditional sense. Second, they can reset a patient’s brain chemistry, which can lead to a lasting improvement in anxiety. This benefit may enable the patient to eventually stop taking the medication and remain relatively free of excessive anxiety for an indefinite period of time.
In contrast, benzodiazepines, taken daily, do not reset a patient’s brain chemistry in a positive fashion. In fact, when taken daily, they can lead to a vicious cycle of needing to take the medication partially to diminish the anxiety which emerges when the
patient hasn’t taken the medication for a while. On the other hand, antidepressants may take 2 to 6 weeks before the anti-anxiety effect is first notable. Therefore, the patient and clinician need to engage
5. Hypnotic (sleep-inducing) agents:
Most of the agents in this class are also Benzodiazepines, or related medications. As previously indicated, the Benzodiazepines
must be used judiciously, due to problems with dependency in patients using them regularly and potentially side effects. There are many other non-Benzodiapine medications available to help with insomnia. Homeopathic remedies are usually the first-line option. Calming antidepressants, mood stabilizers and occasionally major tranquilizers are also utilized.
6. Memory-enhancing agents:
The medications which are available to treat memory and other cognitive impairments are often specific to the cause of the memory
problems. Normal Age-Associated Memory Decline is extremely common, though it frequently causes concerns for the patient and/or their family. Generally, the best approach is non-pharmacological, though there is limited evidence suggesting homeopathic medications can be helpful for some patients. Non-pharmacological approaches include formal cognitive training regimens, other cognitively challenging activities, physical exercise and healthy diets. For Alzheimer’s Disease, the standard pharmacological approach has been the use of Cholinesterase Inhibitors and/or NMDA (Glutamate) Receptor Antagonists. Recently, several novel, potentially disease- modifying agents have been approved to treat mild-moderate stages of Alzheimer’s Disease. These agents have the potential to change the course of Alzheimer’s Disease as opposed to the previous agents which are unlikely to achieve more than slowing the progress of the illness. These agents immunologically target the amyloid plaques which are associated with an underlying disease process of Alzheimer’s Disease. They are Lecanemab (Leqembi) and Donanemab (Kisunia). Other promising medications are under development which also offer hope to those who are suffering from this illness.
7. Stimulants/ Related agents:
Stimulants are typically used for children, adolescents and young adults who have Attention Deficit Disorder (ADD). Many of these patients continue to struggle with ADD later in life. Stimulants also have some utility in treating patients with severe deficits of energy, initiative and motivation. However, they have a number of serious potential side effects, including cardiac problems, anxiety and
anorexia. Patients can develop dependency and they are frequently misused by students and others who do not have ADD. Several other agents, which are not traditional stimulants, have been utilized for alerting individuals with conditions such as Narcolepsy, Circadian Rhythm Sleep Disorders, Obstructive Sleep Apnea and shift work sleep disorder. There are also several medications which are used for ADD which are not stimulants, but are effective for some patients.
8. Other
A number of other medications are under the purview of psychiatrists. They include agents which mitigate side effects of other medications, improve appetite, provide alternative chemical approaches to treating conditions like depression (e.g. hallucinogens) and others which approach psychiatric illnesses in innovative ways. Of course, the use of other approaches to treating mental illness in non-pharmacological ways is beyond the scope of this discussion. Nevertheless, it is important for patients to be aware of the growing number of strategies (e.g. transcranial magnetic stimulation, electroconvulsive therapy, deep brain stimulation) which are available for treating patients who have not responded well to medications or prefer to avoid taking medication.
DEMENTIA
What is Dementia?
Dementia is a condition in which a patient has experienced a deficit in cognitive abilities, which may include memory, language or other higher intellectual functions. It is also important to establish that the deficits represent a significant decline from the patients’
previous abilities. Dementia is now referred to in professional terminology as a Major Neurocognitive Disorder. However, the word “dementia” is still the primary term to describe this condition within the medical community and with the public. Therefore, we will be using “dementia” for the purposes of this discussion. It is important to clarify that all adults experience memory and other forms of cognitive (intellectual) decline as they age. This decline can be entirely normal and is called “Age-Associated Cognitive Impairment”. Seniors are often concerned that the cognitive impairments they are experiencing are premonitory signs of a more serious condition. It can be very reassuring to find out that one’s cognitive challenges are normative. We seniors might also be consoled by the fact that we are frequently superior to younger folks with respect to certain cognitive realms. These realms may contribute to the “wisdom” that seniors often possess. They include functions which rely on knowledge derived from living longer, including decision-making and conflict resolution. Seniors may have a more balanced view when it comes to matters which younger people find stressful or distressing, because they are better at seeing events from a larger perspective and assigning priorities more realistically and in an emotionally healthier fashion. When an individual’s cognitive functioning is impaired beyond the level expected for their age and education (but not sufficiently impaired to meet criteria for dementia) they may be diagnosed with Mild Cognitive Impairment (now called Mild Neurocognitive Disorder). Some of these patients will progress to dementia, and it is important for them to be monitored over time. Other patients will remain mildly impaired and not progress to dementia. Still others will improve to the point that they no longer have Mild Cognitive Impairment. It is particularly important that the patient follows a treatment course
designed to mitigate risk factors and maintain good brain health. It has been shown that good nutrition, physical exercise and engagement with mentally challenging activities can all be effective in preventing and treating cognitive decline.
There are many possible causes of dementia, including Alzheimer’s Disease, which is the most common cause. Some causes of dementia are easier to treat. In some cases, the dementia can be completely reversed. It is important to understand that the presenting problems of various dementias can be similar, and difficult to distinguish unless a more extensive diagnostic evaluation is
is performed. Patients and families often ask a reasonable question; why would I want to undergo an evaluation if there is nothing that can be done about the progress of the dementia if the cause is discovered? Historically, one answer has been that prognostic information can be valuable in future planning. Developments in understanding the genetic contributions to some dementias can also offer family members the option to pursue their own genetic testing. Genetic testing can inform cognitively-normal individuals as to whether they are at greater or lesser risk for future cognitive decline than the general population. The memory medications we have been using for some time can slow the course of dementia and manage symptoms in some patients. Geriatric psychiatrists and psychiatric nurse practitioners are experts in treating the psychiatric symptoms which frequently accompany dementia. These symptoms include depression, anxiety, apathy, agitation, insomnia, weight loss, aggression, delusions and hallucinations.
An important caveat is that there is another domain of illnesses which can be difficult to differentiate from dementia. This domain is called delirium. The delirious patient can become very confused, agitated or withdrawn, aggressive or psychotic. A delirium is
almost always due to an underlying medical condition. In fact, the sudden onset of confusion and altered behavior is sometimes the first sign that a patient is experiencing a delirium. It is critical to determine if a delirium is present, because when the medical cause is identified and treated, the patient’s cognitive problems often revert to their baseline cognitive functioning prior to the onset of the delirium. It is beyond the scope of this discussion to comment further on delirium.
​Causes of Dementia:
​​The cause of dementia can be divided into a number of categories. To begin, it should be noted that it is not possible to determine the cause of an individual’s dementia in some cases. It is certainly possible that an individual’s dementia is due to multiple causes.
The most common categories of dementia are:
1. Primary Degenerative Dementias; Alzheimer’s Disease, Pick’s Disease, Frontotemporal Dementia, Diffuse Lewy Body Disease, and L.A.T.E. (Limbic Predominant Age-related TDP-43 Encephalopathy. New types of primary degenerative dementias are likely to be identified and differentiated from Alzheimer’s Disease, based on genetic, chemical and anatomical differences.
2. Vascular Dementias. These dementias are due to strokes (also called CVA’s or Cerebral Vascular Accidents) of different sizes. They can present with markedly different symptoms, depending on where the stroke took place. The accumulation of extremely small
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strokes can also lead to dementia. It is important to note that a stroke is not the same as a TIA (Transient Ischemic Attack). A TIA is a warning sign that a stroke might occur, but no brain tissue is actually damaged. Comparing a TIA to a stroke is like comparing angina to a heart attack.
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3. Subcortical Dementias; Parkinson’s Disease, Huntington’s Disease, Progressive Supranuclear Palsy.
4. Infectious causes; AIDS, Syphilis, Herpes, Encephalitis and others.
5. Vitamin Deficiencies; B12, Folate and Thiamine.
6. Alcohol and other substance abuse, in vulnerable individuals. With respect to alcohol, the dementia may be called Wernicke-Korsakoff Syndrome (WKS). WKS is due to a Thiamine deficiency, which is associated with the alcohol toxicity.
7. Brain Trauma; Brain damage can result from many kinds of trauma. For example, a fall does not have to be particularly hard to cause brain damage, particularly in seniors. For example, a Subdural Hemorrhage (SDH) can develop after a relatively mild head
injury. Intracranial hemorrhages can be due to a burst intracranial aneurysm. Concussions, including multiple apparently mild concussions, can result in significant degrees of brain trauma. These concussions are often suffered in high contact sports, such as boxing and football.
8. Hormonal and metabolic disturbances; thyroid disease, kidney disease, liver disease and others.
9) Cancer and other brain tumors.
10) Hydrocephalus (water on the brain), which can be due to a tumor or another physical obstruction to the normal flow of cerebrospinal fluid. It can also be a result of a condition called Normal Pressure Hydrocephalus, which may result from impaired
reabsorption of cerebrospinal fluid.
​11) Depression. It is important to recognize that a person with depression often develops problems with their memory and concentration. In some patients, (particularly elderly individuals or those who already have another cause of dementia) depression
can lead to serious cognitive problems, which can be difficult to differentiate from other causes of dementia. Fortunately, treatment of the depression can lead to a complete resolution of the new cognitive impairments.
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Dementia Evaluation:
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Therefore, it is important to determine the cause of an individual’s cognitive decline, when it appears to be beyond that which is expected, given the patient's age and educational background. Some causes of dementia can be entirely treated and at least
partially reversed. Other causes can be contained with interventions which are optimally undertaken early in the course of the condition. A standard dementia evaluation is usually performed in the office of a specialist in the field, such as a neurologist, geriatric psychiatrist or a geriatrician. The evaluation consists of a thorough history, examination of the patient (including an assessment of cognitive functioning), blood tests and brain imaging. A separate, comprehensive Neuropsychological evaluation can provide important additional information which can help differentiate between the presence and possible causes of Normal Age-Associated Cognitive Impairment, Mild Cognitive Impairment and Dementia. The brain imaging tests we may perform include an anatomical scan (examining the physical structure of the brain), such as an MRI or a CT scan. They also often include a functional scan (examining the way the brain is working), such as a PET or a functional MRI scan. Other tests might include genetic
testing, analysis of the patient's cerebrospinal fluid and additional blood studies.