Psychiatric disorders. See

Figure 30-33 Some drugs used to treat psychiatric disorders. See also Figs. 30-25 and 30-28.

The short-acting clomethia2ole [533-45-9] (1), sometimes used as therapy for sleep disorders ia older patients, shares with barbiturates a risk of overdose and dependence. Antihistamines, such as hydroxy2iae [68-88-2] (2), are also sometimes used as mild sedatives (see HiSTAMlNES AND HISTAMINE antagonists). Antidepressants and antipsychotics which have sedative effects are used to treat insomnia when the sleep disorder is a symptom of some underlyiag psychiatric disorder. 

In summary, research on the use of antidepressants to treat cannabis dependence, particularly among individuals with comorbid major depressive disorder, although limited, offers a promising avenue for the development of pharmacological aids to assist in the treatment of cannabis withdrawal. There are clear parallels between this literature and the existing research on the use of antidepressants in the treatment of alcohol dependence comorbid with major depressive disorder (see Chapter 1, Medications to Treat Co-occurring Psychiatric Symptoms or Disorders in Alcoholic Patients). 

For years, psychiatric and drug abuse disorders were not even treated together. Now we know they commonly co-occur, which means for many years clients were getting only partial treatment. Even today we are still not sure how to treat these co-occurring conditions simultaneously in a consistently effective way with both psychotherapy and pharmacotherapy (see Chapter 5). The next century is likely to see many advances in both pharmacotherapy and psychotherapy to treat co-occurring conditions. There are effective methods to treat drug abuse and to treat other co-occurring psychiatric disorders. The next frontier in research is to learn how to combine these approaches in a way that can treat multiple disorders at once ... 

Medications can play a prominent role in the treatment of alcohol use disorders (see Table 6.4). As noted earlier, they are widely used during the initial detoxification phase of treatment. In recent years, psychiatric medications have taken on a more prominent role during the rehabilitation phase of treatment. 

Psychiatric medications do not currently play a prominent role in the treatment of cocaine-dependent patients (see Table 6.4). Although researchers have labored to find medications to treat cocaine addiction, there have not been any notable breakthroughs. As with other substance use disorders, the presence of a psychiatric disorder for which medication is indicated (i.e., depression, anxiety disorders, bipolar affective disorder, or schizophrenia) should prompt appropriate treatment. Similar to the presence of alcohol intoxication, deferring a diagnosis for a day or two in a new patient with no past history is often the more prudent course. 

Suicidality in children and adolescents Antidepressants increased the risk of suicidal thinking and behavior (suicidality) in short-term studies in children and adolescents with major depressive disorder (MDD) and other psychiatric disorders. Anyone considering the use of trazodone or any other antidepressant in a child or adolescent must balance this risk with the clinical need. Patients who are started on therapy should be observed closely for clinical worsening, suicidality, or unusual changes in behavior. Families and caregivers should be advised of the need for close observation and communication with the prescriber. Trazodone not approved for use in pediatric patients (see Clinical worsening and suicide risk and Children sections in Warnings). 

A review of effective pharmacological treatments for each psychiatric disorder can be found in chapters elsewhere in this volume. Medications that have been evaluated in open and double-blind studies for the behavioral management of aggression in children and adolescents are outlined below (see Table 50.3). 

Anticonvulsants. The plasma levels of anticonvulsants that are optimally therapeutic for psychiatric disorders have not been clearly established. Because there are data on their usefulness to treat seizure disorders, monitoring of blood levels has increased the safety of anticonvulsants (and indirectly their efficacy), while also verifying compliance and determining the cause of toxicity when more than one medication is concurrently administered (see the section Alternative Treatment Strategies in Chapter 10). 

Kessler RC, Walter SEE, Forthofer MS. The social consequences of psychiatric disorders, III probability of marital stability. Am J Psychiatry 1998 155 1092-1096. 

The adverse effects of SSRIs, venlafaxine, and nefazodone in children and adolescents are comparable with those in adults (see Chapter 7) and have been documented in both clinical trials and practice ( 35, 36, 119, 120 and 121 123). As in adults, isolated case reports have described behavioral activation in children and adolescents given SSRIs (133, 134). The significance of such reports in terms of a causal link to the drug is difficult because of their rare and anecdotal nature and because the patients are at increased risk for such behavioral disturbances relative to the general population as a result of their underlying psychiatric disorder. 

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