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Mental Disorders and Psychiatric Medications (page 3)

— National Institute of Mental Health
Updated on Jul 26, 2007

Antianxiety Medications

Everyone experiences anxiety at one time or another—"butterflies in the stomach" before giving a speech or sweaty palms during a job interview are common symptoms. Other symptoms include irritability, uneasiness, jumpiness, feelings of apprehension, rapid or irregular heartbeat, stomachache, nausea, faintness, and breathing problems.

Anxiety is often manageable and mild, but sometimes it can present serious problems. A high level or prolonged state of anxiety can make the activities of daily life difficult or impossible. People may have generalized anxiety disorder (GAD) or more specific anxiety disorders such as panic, phobias, obsessive-compulsive disorder (OCD), or post-traumatic stress disorder (PTSD).

Both antidepressants and antianxiety medications are used to treat anxiety disorders. The broad-spectrum activity of most antidepressants provides effectiveness in anxiety disorders as well as depression. The first medication specifically approved for use in the treatment of OCD was the tricyclic antidepressant clomipramine (Anafranil). The SSRIs, fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), and sertraline (Zoloft) have now been approved for use with OCD. Paroxetine has also been approved for social anxiety disorder (social phobia), GAD, and panic disorder; and sertraline is approved for panic disorder and PTSD. Venlafaxine (Effexor) has been approved for GAD.

Antianxiety medications include the benzodiazepines, which can relieve symptoms within a short time. They have relatively few side effects: drowsiness and loss of coordination are most common; fatigue and mental slowing or confusion can also occur. These effects make it dangerous for people taking benzodiazepines to drive or operate some machinery. Other side effects are rare.

Benzodiazepines vary in duration of action in different people; they may be taken two or three times a day, sometimes only once a day, or just on an "as-needed" basis. Dosage is generally started at a low level and gradually raised until symptoms are diminished or removed. The dosage will vary a great deal depending on the symptoms and the individual's body chemistry.

It is wise to abstain from alcohol when taking benzodiazepines, because the interaction between benzodiazepines and alcohol can lead to serious and possibly life-threatening complications. It is also important to tell the doctor about other medications being taken.

People taking benzodiazepines for weeks or months may develop tolerance for and dependence on these drugs. Abuse and withdrawal reactions are also possible. For these reasons, the medications are generally prescribed for brief periods of time—days or weeks—and sometimes just for stressful situations or anxiety attacks. However, some patients may need long-term treatment.

It is essential to talk with the doctor before discontinuing a benzodiazepine. A withdrawal reaction may occur if the treatment is stopped abruptly. Symptoms may include anxiety, shakiness, headache, dizziness, sleeplessness, loss of appetite, or in extreme cases, seizures. A withdrawal reaction may be mistaken for a return of the anxiety because many of the symptoms are similar. After a person has taken benzodiazepines for an extended period, the dosage is gradually reduced before it is stopped completely. Commonly used benzodiazepines include clonazepam (Klonopin), alprazolam (Xanax), diazepam (Valium), and lorazepam (Ativan).

The only medication specifically for anxiety disorders other than the benzodiazepines is buspirone (BuSpar). Unlike the benzodiazepines, buspirone must be taken consistently for at least 2 weeks to achieve an antianxiety effect and therefore cannot be used on an "as-needed" basis.

Beta blockers, medications often used to treat heart conditions and high blood pressure, are sometimes used to control "performance anxiety" when the individual must face a specific stressful situation—a speech, a presentation in class, or an important meeting. Propranolol (Inderal, Inderide) is a commonly used beta blocker.

Medications for Special Groups

Children, the elderly, and pregnant and nursing women have special concerns and needs when taking psychotherapeutic medications. Some effects of medications on the growing body, the aging body, and the childbearing body are known, but much remains to be learned. Research in these areas is ongoing.

In general, the information throughout this booklet applies to these groups, but the following are a few special points to keep in mind.

Children

The 1999 MECA Study (Methodology for Epidemiology of Mental Disorders in Children and Adolescents) estimated that almost 21 percent of U.S. children ages 9 to 17 had a diagnosable mental or addictive disorder that caused at least some impairment. When diagnostic criteria were limited to significant functional impairment, the estimate dropped to 11 percent, for a total of 4 million children who suffer from a psychiatric disorder that limits their ability to function.6

It is easy to overlook the seriousness of childhood mental disorders. In children, these disorders may present symptoms that are different from or less clear-cut than the same disorders in adults. Younger children, especially, and sometimes older children as well, may not talk about what is bothering them. For this reason, it is important to have a doctor, another mental health professional, or a psychiatric team examine the child.

Many treatments are available to help these children. The treatments include both medications and psychotherapy—behavioral therapy, treatment of impaired social skills, parental and family therapy, and group therapy. The therapy used is based on the child's diagnosis and individual needs.

When the decision is reached that a child should take medication, active monitoring by all caretakers (parents, teachers, and others who have charge of the child) is essential. Children should be watched and questioned for side effects because many children, especially younger ones, do not volunteer information. They should also be monitored to see that they are actually taking the medication and taking the proper dosage on the correct schedule.

Childhood-onset depression and anxiety are increasingly recognized and treated. However, the best-known and most-treated childhood-onset mental disorder is attention deficit hyperactivity disorder (ADHD). Children with ADHD exhibit symptoms such as short attention span, excessive motor activity, and impulsivity which interfere with their ability to function especially at school. The medications most commonly prescribed for ADHD are called stimulants. These include methylphenidate (Ritalin, Metadate, Concerta), amphetamine (Adderall), dextroamphetamine (Dexedrine, Dextrostat), and pemoline (Cylert). Because of its potential for serious side effects on the liver, pemoline is not ordinarily used as a first-line therapy for ADHD. Some antidepressants such as bupropion (Wellbutrin) are often used as alternative medications for ADHD for children who do not respond to or tolerate stimulants.

Based on clinical experience and medication knowledge, a physician may prescribe to young children a medication that has been approved by the FDA for use in adults or older children. This use of the medication is called "off-label." Most medications prescribed for childhood mental disorders, including many of the newer medications that are proving helpful, are prescribed off-label because only a few of them have been systematically studied for safety and efficacy in children. Medications that have not undergone such testing are dispensed with the statement that "safety and efficacy have not been established in pediatric patients." The FDA has been urging that products be appropriately studied in children and has offered incentives to drug manufacturers to carry out such testing. The National Institutes of Health and the FDA are examining the issue of medication research in children and are developing new research approaches.

The use of the other medications described in this booklet is more limited with children than with adults. Therefore, a special list of medications for children, with the ages approved for their use, appears immediately after the general list of medications. Also listed are NIMH publications with more information on the treatment of both children and adults with mental disorders.

The Elderly

Persons over the age of 65 make up almost 13 percent of the population of the United States, but they receive 30 percent of prescriptions filled. The elderly generally have more medical problems, and many of them are taking medications for more than one of these conditions. In addition, they tend to be more sensitive to medications. Even healthy older people eliminate some medications from the body more slowly than younger persons and therefore require a lower or less frequent dosage to maintain an effective level of medication.

The elderly are also more likely to take too much of a medication accidentally because they forget that they have taken a dose and take another one. The use of a 7-day pill-box, as described earlier in this brochure, can be especially helpful for an elderly person.

The elderly and those close to them—friends, relatives, caretakers—need to pay special attention and watch for adverse (negative) physical and psychological responses to medication. Because they often take more medications—not only those prescribed but also over-the-counter preparations and home, folk, or herbal remedies—the possibility of adverse drug interactions is high.

Women During the Childbearing Years

Because there is a risk of birth defects with some psychotropic medications during early pregnancy, a woman who is taking such medication and wishes to become pregnant should discuss her plans with her doctor. In general, it is desirable to minimize or avoid the use of medication during early pregnancy. If a woman on medication discovers that she is pregnant, she should contact her doctor immediately. She and the doctor can decide how best to handle her therapy during and following the pregnancy. Some precautions that should be taken are:7

  • If possible, lithium should be discontinued during the first trimester (first 3 months of pregnancy) because of an increased risk of birth defects.
  • If the patient has been taking an anticonvulsant such as carbamazepine (Tegretol) or valproic acid (Depakote)—both of which have a somewhat higher risk than lithium—an alternate treatment should be used if at all possible. The risks of two other anticonvulsants, lamotrigine (Lamictal) and gabapentin (Neurontin) are unknown. An alternative medication for any of the anticonvulsants might be a conventional antipsychotic or an antidepressant, usually an SSRI. If essential to the patient's health, an anticonvulsant should be given at the lowest dose possible. It is especially important when taking an anticonvulsant to take a recommended dosage of folic acid during the first trimester.
  • Benzodiazepines are not recommended during the first trimester.

The decision to use a psychotropic medication should be made only after a careful discussion between the woman, her partner, and her doctor about the risks and benefits to her and the baby. If, after discussion, they agree it best to continue medication, the lowest effective dosage should be used, or the medication can be changed. For a woman with an anxiety disorder, a change from a benzodiazepine to an antidepressant might be considered. Cognitive-behavioral therapy may be beneficial in helping an anxious or depressed person to lower medication requirements. For women with severe mood disorders, a course of electroconvulsive therapy (ECT) is sometimes recommended during pregnancy as a means of minimizing exposure to riskier treatments.

After the baby is born, there are other considerations. Women with bipolar disorder are at particularly high risk for a postpartum episode. If they have stopped medication during pregnancy, they may want to resume their medication just prior to delivery or shortly thereafter. They will also need to be especially careful to maintain their normal sleep-wake cycle. Women who have histories of depression should be checked for recurrent depression or postpartum depression during the months after the birth of a child.

Women who are planning to breastfeed should be aware that small amounts of medication pass into the breast milk. In some cases, steps can be taken to reduce the exposure of the nursing infant to the mother's medication, for instance, by timing doses to post-feeding sleep periods. The potential benefits and risks of breastfeeding by a woman taking psychotropic medication should be discussed and carefully weighed by the patient and her physician.

A woman who is taking birth control pills should be sure that her doctor knows this. The estrogen in these pills may affect the breakdown of medications by the body—for example, increasing side effects of some antianxiety medications or reducing their ability to relieve symptoms of anxiety. Also, some medications, including carbamazepine and some antibiotics, and an herbal supplement, St. John's wort, can cause an oral contraceptive to be ineffective.

Index of Medications

To find the section of the text that describes a particular medication in the lists below, find the generic (chemical) name and look it up on the first list or find the trade (brand) name and look it up on the second list. If the name of the medication does not appear on the prescription label, ask the doctor or pharmacist for it. (Note: Some drugs are marketed under numerous trade names, not all of which can be listed in a short publication like this one. If your medication's trade name does not appear in the list—and some older medicines are no longer listed by trade names—look it up by its generic name or ask your doctor or pharmacist for more information. Stimulant medications that are used by both children and adults with ADHD are listed in the children's medications chart).

Alphabetical List of Medications by Generic Name8

Generic Name
Trade Name
Combination Antipsychotic and Antidepressant Medication
Symbyax (Prozac & Zyprexa) fluoxetine & olanzapine
Antipsychotic Medications
aripiprazole Abilify
chlorpromazine Thorazine
chlorprothixene Taractan
clozapine Clozaril
fluphenazine Permitil, Prolixin
haloperidol Haldol
loxapine Loxitane
mesoridazine Serentil
molindone Lidone, Moban
olanzapine Zyprexa
perphenazine Trilafon
pimozide (for Tourette's syndrome) Orap
quetiapine Seroquel
risperidone Risperdal
thioridazine Mellaril
thiothixene Navane
trifluoperazine Stelazine
trifluopromazine Vesprin
ziprasidone Geodon
Antimanic Medications
carbamazepine Tegretol
divalproex sodium (valproic acid) Depakote
gabapentin Neurontin
lamotrigine Lamictal
lithium carbonate Eskalith, Lithane, Lithobid
lithium citrate Cibalith-S
topimarate Topamax
Antidepressant Medications
amitriptyline Elavil
amoxapine Asendin
bupropion Wellbutrin
citalopram (SSRI) Celexa
clomipramine Anafranil
desipramine Norpramin, Pertofrane
doxepin Adapin, Sinequan
escitalopram (SSRI) Lexapro
fluvoxamine (SSRI) Luvox
fluoxetine (SSRI) Prozac
imipramine Tofranil
isocarboxazid (MAOI) Marplan
maprotiline Ludiomil
mirtazapine Remeron
nefazodone Serzone
nortriptyline Aventyl, Pamelor
paroxetine (SSRI) Paxil
phenelzine (MAOI) Nardil
protriptyline Vivactil
sertraline (SSRI) Zoloft
tranylcypromine (MAOI) Parnate
trazodone Desyrel
trimipramine Surmontil
venlafaxine Effexor
Antianxiety Medications
(All of these antianxiety medications except buspirone are benzodiazepines)
alprazolam Xanax
buspirone BuSpar
chlordiazepoxide Librax, Libritabs, Librium
clonazepam Klonopin
clorazepate Azene, Tranxene
diazepam Valium
halazepam Paxipam
lorazepam Ativan
oxazepam Serax
prazepam Centrax

Alphabetical List of Medications by Trade Name

TRADE NAME GENERIC NAME
Combination Antipsychotic and Antidepressant Medication
fluoxetine & olanzapine Symbyax (Prozac & Zyprexa)
 
Antipsychotic Medications
Abilify aripiprazole
Clozaril clozapine
Geodon ziprasidone
Haldol haloperidol
Lidone molindone
Loxitane loxapine
Mellaril thioridazine
Moban molindone
Navane thiothixene
Orap (for Tourette's syndrome) pimozide
Permitil fluphenazine
Prolixin fluphenazine
Risperdal risperidone
Serentil mesoridazine
Seroquel quetiapine
Stelazine trifluoperazine
Taractan chlorprothixene
Thorazine chlorpromazine
Trilafon perphenazine
Vesprin trifluopromazine
Zyprexa olanzapine
Antimanic Medications
Cibalith-S lithium citrate
Depakote valproic acid, divalproex sodium
Eskalith lithium carbonate
Lamictal lamotrigine
Lithane lithium carbonate
Lithobid lithium carbonate
Neurontin gabapentin
Tegretol carbamazepine
Topamax topiramate
Antidepressant Medications
Adapin doxepin
Anafranil clomipramine
Asendin amoxapine
Aventyl nortriptyline
Celexa (SSRI) citalopram
Desyrel trazodone
Effexor venlafaxine
Elavil amitriptyline
Lexapro (SSRI) escitalopram
Ludiomil maprotiline
Luvox (SSRI) fluvoxamine
Marplan (MAOI) isocarboxazid
Nardil (MAOI) phenelzine
Norpramin desipramine
Pamelor nortriptyline
Parnate (MAOI) tranylcypromine
Paxil (SSRI) paroxetine
Pertofrane desipramine
Prozac (SSRI) fluoxetine
Remeron mirtazapine
Serzone nefazodone
Sinequan doxepin
Surmontil trimipramine
Tofranil imipramine
Vivactil protriptyline
Wellbutrin bupropion
Zoloft (SSRI) sertraline
Antianxiety Medications
(All of these antianxiety medications except BuSpar are benzodiazepines)
Ativan lorazepam
Azene clorazepate
BuSpar buspirone
Centrax prazepam
Librax, Libritabs, Librium chlordiazepoxide
Klonopin clonazepam
Paxipam halazepam
Serax oxazepam
Tranxene clorazepate
Valium diazepam
Xanax alprazolam

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