Jerzy A. Sobański, MD-PhD

Faculty of Psychotherapy of the Jagiellonian University Medical College
Krzysztof Rutkowski, MD-PhD, Acting Head of Faculty



There are psychoactive, psychotropic and psychiatric drugs. All of them raise many doubts, cause uncertainty or bias and often become a source of mistaken convictions, such as the one that “every person taking psychiatric drugs is flaky, they do not know what they are doing, they are completely passive, etc.”

 

Psychoactive and psychiatric drugs: a simple general classification


Tranquilisers (sedatives)
This group includes, above all, benzodiazepines (such as well-known Alprazolam whose chemical equivalents are sold under the commercial names of Xanax, Alprox, Afobam, Zomiren, or clorazepate dipotassium sold under the names of  Cloranxen or Tranxene). Older drugs – barbiturates, practically went out of use. The same might happen to benzodiazepines, primarily because of the risk of addiction related to their very fast action (within minutes or quarters) and potent activity (they may put to sleep even very agitated patients). Currently, there is a trend of handing dosage control over to the patients affected by some illnesses (e.g. neurosis) or, more precisely, reducing the doses of tranquilisers when they are not needed and increasing (or even introducing the drug not used every day) the dose in more difficult moments – for example before a journey or other predictable situation causing the symptoms of anxiety (e.g. a walk in open space for agoraphobic patients, a public speaking occasion for those with a social phobia, etc.).


Hypnotics
Hypnotics are similar to sedatives. Their role is to put the patient to sleep and the most modern of them enable the patient uninterrupted functioning on the next day. These drugs raise many objections because of the possibility of addiction. Sometimes an evening dose is applied in order to make it easier for the patient to go to sleep. In such cases the drug plays a double role, it works as a hypnotic in the evening and as a sedative during the day. Examples include Zolopidem (Nasen, Zolpic) and Midazolam (Dormicum).


 
Antidepressants
Antidepressants are used not only in depressive disorders (affective disorder, unipolar or bipolar depression) but also in the pharmacotherapy of neurotic disorders, primarily anxiety. One of the latest and, at the same time, most popular groups of these drugs are selective serotonin reuptake inhibitors (abbreviated as SSRI), which include Fluoxetine (Prozac, Seronil, etc.), Paroxetine (Seroxat, Paxil, etc.), Sertraline (Zoloft, etc.). Because of the dynamic production of new drugs and the expiry of patent protection, the available drugs from this group and equivalent medications are countless. They share an important quality, i.e. slow action, as the full effect may appear as late as even after 2-3 weeks of treatment or after the dose increase. This is the reason (unjustified) why these drugs are rejected by patients expecting quick effects, which is the case for typical sedative drugs (benzodiazepin).

One important aspect should be noted here: not every drug is used following the indications in its description (in the information leaflet or other sources, e.g. the Internet). Fluoxetine is a good example (most commonly known as Prozac, other medications are called Seronil, Bioxetin etc.) of a typical modern antidepressant which may be administered to a patient with bulimia, too, because of its strong appetite suppression activity, which includes compulsive eating binges.


Antipsychotics (neuroleptics)

These drugs are prescribed to treat schizophrenia and similar disorders (and have excellent effects). But they are also used (in small doses) in the treatment aiming to sedate or reduce the impetuousness of patients who may become addicted to benzodiazepines and do not respond well to antidepressants. In large doses or in sensitive patients, however, they may cause many side effects. In principle, they are designed for long-term treatment lasting many months or even years (schizophrenia may be treated for many years), so they are not as potentially harmful as they may be burdensome. Their side effects are often mistaken by some, more sensitive patients, as the signs of alleged “poisoning”, which may be a confirmation of their delusions (often the symptoms of the condition). Some examples of neuroleptics include: Risperidone (Rispolept, Risperon, Risset), Olanzapine (Zyprexa, Zolafren, Olzapin), Haloperidol (Haldol) and Quetiapine (Seroquel, Ketilept).


Anti-epileptic drugs (anticonvulsants)

These neurological drugs are used in psychiatry as prophylactic medications to prevent the remission of depressive disorders and to stabilize the mood. Thus they do not have to be applied to treat epilepsy as the name might suggest.

 

Other drugs that may have side effects affecting the patient’s mental condition

The list of drugs and related substances may be never-ending, which is why only the ones most commonly applied will be discussed here due to limited space and very diverse patients’ response to them. Depending on the patient’s body condition, individual predilections and substance doses, all drugs may affect the human psyche in many different ways, starting from the most commonly used which may have adverse mental effects. Some blood pressure lowering drugs (hypertension medications) may lower concentration, cause drowsiness, apathy, restlessness and, by way of secondary side effects, lower self-esteem. Some hormonal drugs (e.g. contraceptives) may lower moods (deteriorate well-being, cause sadness and irritability). Some drugs prescribed by a GP, e.g. the ones lowering the concentration of blood lipids (fats, cholesterol) may cause despondence. Other drugs, e.g. weight-loss drugs (especially the unofficial drugs which are illegally imported, bought “under the counter”, e.g. in a fitness club) may cause inadequate mood swings. One of the principles that help to determine the influence of the drug upon the person is the occurrence of problems at the moment when a given medication starts to be used. But it should be remembered that its negative effects might be delayed (by days or even weeks) or occur when used in combination with other substances (ALCOHOL OR DRUGS) or psychophysical stress (effort, exam, the flue, a menstrual cycle phase, the loss of an important person or value, etc.).

 

Drug prices

Many psychoactive drugs are expensive, which may be explained by their on-going upgrade, which is costly, while maintaining high quality. Fortunately, in the most serious mental conditions (the ones listed as chronic conditions) most drugs, even the most expensive ones, are refunded to a large extent (the doctor marks the prescription with the letter “P”). The patient may always negotiate with the doctor to help him or her to choose a less expensive equivalent of a given drug or even ask for a change in pharmacotherapy because of financial constraints.

 

Unpleasant leaflets

Legal regulations, especially in the USA, require information on all known adverse effects, complications or discomfort be included in the medication information leaflet, even if they are very rare or their mechanism is not fully understood. When this model was adopted in the Polish system, a discrepancy arose: Polish doctors do not discuss such threats or mention them very sparingly while patients find out about them only when they read the leaflet. Half jokingly: the doctor himself or herself, when reading the information leaflet of a drug he or she is about to take or administer to a family member, may develop a (mistaken) impression that “such junk should never be taken”.

 

Collaboration and communication with a psychiatrist

A lot depends on the pattern of meetings with a psychiatrist and a sincere description of your condition as well as concerns related to pharmacotherapy and your experiences with doctors so far. The best is the solution when the frequency and additional dates of visits match the patient’s expectations, changes of his/her life situation and psychophysical burden (going home, exams, sports competition). Unfortunately, it is not always possible, sometimes when the patient’s visits are infrequent there is a problem of matching pharmacotherapy to the patient’s changing needs. For some drugs, it is often possible to achieve collaboration with the patient, so that the patient may change the dose or frequency of the drug administration on the basis of hisor her mental condition and general guidelines received from a psychiatrist.

 

Duration of the drug action

Some drugs work almost immediately, others achieve their full potency as late as after 2 or 3 weeks or even after the gradual reduction of the dose over the next weeks. Withdrawal may sometimes take as much time as introduction. Sometimes adverse effects precede benefits, which the patient should be informed about by his or her doctor.

 

Withdrawal of drugs

Planned withdrawal of most psychoactive drugs should be made in collaboration with the doctor, preferably a psychiatrist. Usually, when the patient is afraid of the change (and many people carry pills they do not use anymore, e.g., in their handbags, just in case, if they have an anxiety attack), it is possible, even if not recommended by the producer of this drug, to reduce the dose gradually. Other medications may be used to alleviate the symptoms of the withdrawal of more problematic drugs.

 

When you suddenly run out of pills

When you lose your pills or overlook the fact that you no longer have the supply needed, etc. then you may urgently consult your doctor (even before the date of the planned visit), or if the doctor is unavailable, the clinic that has the documentation concerning the type of the drug and its doses. If you run out of pills while, for example, in another city, or if your doctor or clinic is unavailable, you may go to any psychiatrist (the National Health Fund does not require a referral to book a visit to a psychiatrist) or if it happens at night, you may contact the nearest psychiatric hospital where there is at least one psychiatrist always available. After examination, he or she may prescribe the necessary medication.

 

Doctors of other specialisations vs. psychotropic drugs

Patients who consult doctors of other specialisations (neuropsychiatrists, e.g., neurologists) should remember that these specialists might prescribe specific psychiatric (and psychotropic) drugs because they do not have full knowledge about the drugs prescribed by this patient’s psychiatrist. This should not happen. In his or her best interest the patient should make sure that all his or her doctors are informed about the medications he or she is taking. The best way to do it is in writing on the patient’s discharge summary and an information card prepared by a doctor (hardly anyone remembers the exact names and doses of all their drugs). It may also be useful to retain medication packages with the dates of treatment written on them.

 

Interactions – conflicts between drugs

The more medications a patient takes, the more difficult is to control their interactions, especially if these drugs are prescribed by doctors of different specialisations. As it has already been mentioned, the safest way for the patient is to inform his or her every doctor about all drugs prescribed to him or her and agree on optional dose adjustment, for example some antipsychotic medications (neuroleptics) or tranquilisers (sedatives) may interact with hypotension drugs (lowering arterial blood pressure) and cause an even greater reduction of blood pressure and, as a result, problems with concentration, the patient’s physical function or even consciousness.

 

Trade names of drugs vs. chemical names

One of more serious practical problems in communication between patients and psychiatrists (and not only doctors of this specialisation) is the difficulty related to remembering the names of drugs, sometimes complicated ones, and recently increasingly more numerous, which describe the same chemical substance produced by several different companies (each of them under a different name, so the patient may be unaware of the fact of taking several identical medications of different names). Many legends have arisen around these different products made by different pharmaceutical companies. Advocates of some drugs claim that other drugs, despite the identical composition of the active substance, do not work or have more adverse effects and wear off faster. Nevertheless, it may be safely assumed that, as provided for by official medication attestation procedures, they differ in name only and contain the same amount of the active substance (just like sugar produced by different sugar refineries should be identical). Unfortunately, because of historical and business reasons, these drugs are sold under their own trade names while their proper chemical names (the equivalent of the information saying that it is sugar) are printed on packages using the smallest print and do not stay in the memory of the patient and many doctors. Still, in order to optimize your communication with doctors, you should remember or put down (exact) chemical names and doses and well as the time when the medication was taken (the real one, not the one recommended by doctors but not adhered to – because of shame or fear patients often fail to admit they have changed the dosing regimen themselves while true information about treatment will make it easier to select the right medication and dose).  

 

Do psychoactive drugs have gender?

The answer to this kind of a question should probably be negative but the patient’s gender should be taken into account because of several aspects. Women are usually much smaller in size than men (and than “typical patients” who weigh, e.g.,  60 kg) and female students may weigh much less than older women by several dozen percent (hence the need may arise to match the dose to the body mass), women may be pregnant (regardless of planning a pregnancy), may take hormonal contraception that impacts the mechanism of activity of other drugs and the mood (usually changing it towards despondence).

 

Contraception vs. drugs

Because of the burden that drugs are for the enzyme systems processing and removing them from the body, each drug combination (including hormonal contraceptives) potentially changes the activity of one substance or both. In practice, it means that it is necessary to discuss and check together with doctors whether there is an increased risk of unpredictable increase or decrease of activity of any substance.

 

Which drugs are safe in pregnancy?

There are no drugs (including non-psychiatric medications) that would be safe in pregnancy. Partially, it is so because of ethical rules and common sense as it is impossible to carry out studies to check the impact of drugs on pregnancy. The medications used during pregnancy are the ones that involve the least risk and, at the same time, are the most recommended for the patient and the foetus. Another issue is an unplanned pregnancy that occurs while the patient is on psychoactive medications. In this case, it is recommended to consult both the gynaecologist and the psychiatrist urgently.

 

Drugs from friends, neighbours, relatives

It is absolutely forbidden to take drugs (psychoactive or any other) obtained from anyone (friends, relatives) but the doctor or the pharmacist. Even if, often apparently, they have experienced similar disorders or are similar to you in some other respect, you may not rely on these analogies.

 

Drugs from the black market or the Internet may be fake

This kind of drugs purchased outside official distribution channels may have a good price or may be bought “without prescription”, but a large proportion of medications “brought from abroad” or “not needed any more” are falsified drugs. There have been incidents of selling sugar pills or unpolished pieces of painted concrete, etc. as drugs. The production of packages, which, to an untrained eye, look identical to the ones sold in a pharmacy, is not difficult, e.g. banknotes have been forged using home printers.

 

Drugs vs. psychotherapy

A common misunderstanding is pitting drugs against psychotherapy. Both methods of treatment may successfully complement each other. Sometimes drugs are introduced (or their dose is reduced) during intensive psychotherapy in order to facilitate the therapeutic process. It has also been proven that the effectiveness of pharmacotherapy in numerous mental disturbances may increase thanks to combining it with psychotherapy.

 

Drugs vs. studying

An especially important issue for the readers of this publication will be matching pharmacotherapy to the process of learning, in particular, taking exams. There might be many reasons why pharmacotherapy needs adjustment, ranging from the elimination of disturbing physical adverse effects such as excessive reduction of arterial blood pressure, headaches or nausea, through the selection of drugs without an excessive sedative effect, which do not slow the patient down, have less of a sleep-inducing effect during the day than at night, to the improvement of the student’s overall quality of life by avoiding the suppression of the sexual drive or regaining the sense of flavour or appetite. A correction of the drug-dosing regimen should especially be considered before an exam as sometimes the response of people who have not tried pharmacotherapy before may be excessive and, along with lower anxiety as planned, they may experience unexpected difficulty with concentration or drowsiness. Well-targeted drugs do not need to prevent studies or exams although their selection (and gradual improvement of the patient’s condition) may require time.

 

A date rape drug

What is especially important for women (not just them, but women more often fall victim to such crimes) is avoiding the consumption of all unknown substances, finishing drinks left unattended (or guarded by random friends), helping themselves to unknown dishes, chocolate, etc. These may often contain large doses of sedatives or hypnotics suppressing free will and decision-making, acting viciously and enabling rape or indecent acts. When you witness odd mental behaviour of a friend after taking an unknown substance, regardless of his/her condition, call an ambulance or even take him or her at night to the psychiatric hospital, an emergency or toxicology ward. Violent behaviour of the fight-or-flight type (attempts of jumping out of a car while being driven) should also be taken into account. All home-made methods of helping yourself,  such as ‘drinking milk, water, sleeping it off or marching” are not recommended if you have access to such achievements of the modern civilisation as qualified medical care, free of charge.

 

Drugs vs. alcohol

It is absolutely forbidden to combine psychoactive drugs with alcohol. If you plan to consume alcohol (patients often ask about “the planned consumption of alcohol at a wedding”) the break before and after alcohol consumption should enable you to eliminate the drug first and alcohol next, which often means that you should skip  more than just one daily dose. Of course, frequent discontinuation of pharmacotherapy in order to “consume alcohol in a safe way” is not recommended, either.

 

Drugs vs. driving

You should be cautious and very often abandon driving completely or at least consult this with a psychiatrist.

 

Final comments

This text is not personalised doctor’s recommendations as each patient needs to consult a psychiatrist in order to be directly examined and diagnosed. Even patients with what seems a similar problem might experience different disorders and need different medications and dosing regimens. Each doctor should give a comprehensive answer to the questions about drugs. Doctors are the ones responsible for giving competent answers to the patient’s questions, NOT pharmacists who, despite their knowledge about drugs, are not able to make a diagnosis and propose treatment. This is why the popular commercial slogan “consult a doctor or pharmacist” is largely dubious from the ethical and legal perspective with regard to its latter part. Remember, that a patient does not need a referral to see a psychiatrist and a visit to a clinic on a contract with the National Health Fund is free of charge (for those who pay health insurance but e.g. indispensible compulsory treatment for persons with mental disorders is free, too, even for the uninsured). It should be remembered that, most likely, a conversation with a psychiatrist will be much more pleasant than the patient might have expected and, above all, useful.