Significant others, medications

Some studies have involved a spouse or significant other in observing medication ingestion. In a 6-month study, patients who consumed disulfiram (200 mg/day) under observation of a significant other significantly increased the number of abstinent days and decreased the total number of drinks, relative to patients who received placebo under observation (Chick et al. 1992). 

Probably the greatest advances in psychiatric medications of the last 15 years have involved the neurotransmitter serotonin. First was the arrival of serotonin-specific antidepressants with fewer side effects and greater safety than their predecessors. More recently, atypical antipsychotics have highlighted the importance of serotonin-dopamine interactions in the optimal treatment of schizophrenia and other psychotic disorders. While these are indeed significant advances, medications that alter serotonin activity are not without their own side effect burden. 

As noted in Chapter 2, the medical literature on patient compliance with medication is enormous. The assumption underlying much of the discussion is that if only doctors could better communicate to patients the necessity of following a medication regimen, compliance would increase. This may be so. However, medical treatment built on the presumption of a two-person social system-doctor and patient—misses the way each of us is embedded in a network of significant others. As the accounts in this section demonstrate, people s attitudes toward psychotropic drug use are inseparable from the perspectives and concerns of those with whom they wish to build... 

This chapter describes the structure and neurochemical function of TCAs, metabolism and significant interactions with other medications, side effects, and specific recommendations for monitoring of side effects in children and adolescents. Because of the recent concern regarding the sudden deaths of children stabilized on TCAs, particular attention will be paid to the potential cardiovascular effects of these medications. The chapter will focus on the five TCA medications that have been most widely used in children amitriptyline (AMI), nortriptyline (NT), imipramine (IMI), desipratnine (DMI), and clomipramine (CMI). 

Chart reviews and open trials of outpatients with bipolar disorder and bipolar spectrum disorder have been published for 28 risperidone- and 23 olanzapine-treated treated children and adolescents (Frazier et ah, 1999 2001). Significant decreases in mania, depression, and aggression ratings occurred over the course of treatment however, other medications were also used simultaneously. Additional anecdotal information exists for olanzapine (Soutullo et ah, 1999 Chang and Ketter, 2000), quetiapine (Schaller and Behar, 1999), and clozapine (Fuchs, 1994). 

Carbamazepine induces hepatic cytochrome P450 (CYP) enzymes, which may reduce levels of other medications. Through the mechanism of hepatic enzyme induction, carbamazepine therapy can lead to oral contraceptive failure therefore, women should be advised to consider alternative forms of birth control while taking carbamazepine. Similarly, use of medications or substances that inhibit CYP 3A3/4 (discussed in Chapter 1) may result in significant increases in plasma carbamazepine levels. 

Memantine is not a major substrate for hepatic cytochrome P450 isoenzymes and has not been shown to significantly inhibit or induce these enzymes. However, memantine is partially excreted by renal tubular secretion. Thus, concomitant use of other medications that use the same renal system (i.e., triampterene, hydrochlorothiazide, digoxin, cimetidine, ranitidine, metformin, and quinidine) may affect plasma levels of both drugs (Namenda 2005). Memantine should not be used in combination with other NMDA receptor antagonists, such as amantadine or dextromethorphan, because these combinations have not been formally studied. The clearance of memantine can be reduced when the urine is alkalinized, such as with the concomitant use of sodium bicarbonate or carbonic anhy-... 

As far as possible, methadone treatment should mean just that, not methadone plus other medications of potential misuse. The theoretical footing for this is that the majority of the positive evidence for effectiveness relates to methadone alone, although we noted earlier that the main studies did not include individuals who were significant users of non-opiate drugs. 

Interest in the neurobiological substrates of psychiatric disorders has paralleled the increase in effective somatic therapies, which, in turn, have extended the laboratory s role in evaluating patients. Although the laboratory can never replace clinical acumen in psychiatry, or in any other medical specialty, it can play a significant role in ... 

A long list of adverse effects may imply that most patients experience many of them to a significant degree. In fact, although almost all patients will experience some mild side effects with these drugs, such as dry mouth or tremor, they are usually transitory and disappear with time, medication reduction, or discontinuation. Fortunately, these effects are rarely serious or irreversible, and on average, the typical complications with antipsychotics are no worse than with medications prescribed for other medical disorders. 

The primary indication for antidepressant agents is the treatment of MDD. Major depression, with a lifetime prevalence of around 17% in the USA and a point prevalence of 5%, is associated with substantial morbidity and mortality. MDD represents one of the most common causes of disability in the developed world. In addition, major depression is commonly associated with a variety of medical conditions—from chronic pain to coronary artery disease. When depression coexists with other medical conditions, the patient s disease burden increases, and the quality of life—and often the prognosis for effective treatment—decreases significantly. 

---