The Practitioner’s Guide to Psychoactive Drugs PDF
Preview The Practitioner’s Guide to Psychoactive Drugs
The Practitioner's Guideto Psychoactive Drugs THIRD EDITION The Practitioner's Guideto Psychoactive Drugs THIRD EDITION Edited by Alan J. Gelenberg, M.D. University 01 Arizona Health Sciences Center Tueson, Arizona Ellen L. Bassuk, M.D. The Better Hornes Foundation Newton Centre, Massachusetts and Harvard Medical School Boston, Massachusetts and Stephen C. Schoonover, M.D. Schoonover Associates Newton Centre, Massachusetts Springer Science+Business Media, LLC L1brary of Congress Catalog1ng-1n-PubI1cat1on Data The Pract1tioner's guide to psychcaetive drugs I ed1ted by Alan J. Gelenberg. Ellen L. Bassuk, and Stephen C. Schoonover. -- 3rd ed. p. cm. Includes bibliographieal referenees and index. 1. Psychopharmacology. 2. Psychoaetive drugs. I. Gelenberg, Alan J, II. Bassuk, Ellen L., 1945- III. Schoonover, Stephen C., 1947- [DNLM, 1. Psychotrop i c Drugs. av 77 P8952] RC483.P726 1990 615'.78--dc20 DNLM/DLC for Library of Congress 90-14325 CIP ISBN 978-1-4757-1139-4 ISBN 978-1-4757-1137-0 (eBook) DOI 10.1007/978-1-4757-1137-0 First Printing-January 1991 Second Printing-November 1991 © 1991, 1983, 1977 Springer Science+Business Media New York Originally published by Plenum Publishing Corporation in 1977 All rights reserved No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the Publisher To Sherry Gelenberg -AJG In memory of Molly Bassuk and to Sarah and Danny Schoonover ses -ELB & Contributors Joseph Biederman, M.D. Associate Professor of Psychiatry, Department of Psychi- atry, Harvard Medical School, Boston, Massachusetts 02115; Director, Psycho pharmacology Unit, Massachusetts General Hospital, Boston, Massachusetts 02114 Andrew W. Brotman, M.D. Director, Social and Community Psychiatry, Massachu- setts General Hospital, Boston, Massachusetts 02114; Department of Psychia try, Harvard Medical School, Boston, Massachusetts 02115; Director, Outpa tient Services, Erich Lindemann Mental Health Center, Boston, Massachusetts 02114 Lee S. Cohen, M.D. Attending Psychiatrist, Pregnancy Consultation Service, Clinical Psychopharmacology Unit, Massachusetts General Hospital, Boston, Massachusetts 02114; Assistant Professor of Psychiatry, Harvard Medical School, Boston, Massachusetts 02115 Alan J. Gelenberg, M.D. Professor and Head, Department of Psychiatry, Univer- sity of Arizona Health Sciences Center, Tucson, Arizona 85724 Shelly F. Greenfield, M.D. Resident in Adult Psychiatry, McLean Hospital, Bel- mont, Massachusetts 02178; Department of Psychiatry, Harvard Medical School, Boston, Massachusetts 02115 Thomas G. Gutheil, M.D. Associate Professor of Psychiatry, Department of Psychi- atry, Harvard Medical School, Boston, Massachusetts 02115; Program in Psy chiatry and the Law, Massachusetts Mental Health Center, Boston, Massachu setts 02115 Vicki L. Heller, M.D. Attending Obstetrician, Department of Obstetrics and Gynecology, Beth Israel Hospital, Boston, Massachusetts 02215; Instructor in Obstetrics and Gynecology, Harvard Medical School, Boston, Massachusetts 02115 vii viii Contributors David B. Herzog, M.D. Director, Eating Disorders Clinic, Massachusetts General Hospital, Boston, Massachusetts 02114; Associate Professor of Psychiatry, De partment of Psychiatry, Harvard Medical School, Boston, Massachusetts 02115 Steven M. Mirin, M.D. Acting General Director and Psychiatrist in Chief, McLean Hospital, Belmont, Massachusetts 02178; Associate Professor of Psychiatry, Department of Psychiatry, Harvard Medical School, Boston, Massachusetts 02115 George B. Murray, M.D. Director, Private Consultation Service, Assistant Pro- fessor of Psychiatry, Harvard Medical School, Boston, Massachusetts 02115 Jerrold F. Rosenbaum, M.D. Chief, Clinical Psychopharmacology Unit, Massa- chusetts General Hospital, Boston, Massachusetts 02114; Associate Professor of Psychiatry, Harvard Medical School, Boston, Massachusetts 02115 Carl Salzman, M.D. Associate Professor of Psychiatry, Harvard Medical School, Boston, Massachusetts 02115; Director of Psychopharmacology, Massachusetts Mental Health Center, Boston, Massachusetts 02115 Stephen C. Schoonover, M.D. President, Schoonover Associates, Newton Centre, Massachusetts 02159 Paul H. Soloff, M.D. Associate Professor of Psychiatry, University of Pittsburgh, Western Psychiatrie Institute and Clinic, Pittsburgh, Pennsylvania 15213 Ronald Steingard, M.D. Assistant Director, Pediatric Psychopharmacology Unit, Child Psychiatry Service, Massachusetts General Hospital, Boston, Massachu setts 02114; Instructor in Psychiatry, Harvard Medical School, Boston, Massa chusetts 02115 Jeffrey B. Weilburg, M.D. Director, Neuropsychiatry Section, Psychopharmacol- ogy Unit, Massachusetts General Hospital, Boston, Massachusetts 02114; As sistant Professor of Psychiatry, Harvard Medical School, Boston, Massachusetts 02115 Roger D. Weiss, M.D. Clinical Director, A1cohol and Drug Abuse Program, McLean Hospital, Belmont, Massachusetts 02178; Assistant Professor of Psy chiatry, Department of Psychiatry, Harvard Medical School, Boston, Massachu setts 02115 Foreword In the eight years since the publication of the second edition of this Guide, psycho phannacotherapy has made many advances not only through the discovery of new medications but by the effective directing of their use to an ever-increasing variety of clinical disorders. These welcome developments are reflected in the concurrent growth and development of the Guide itself, which now enters adulthood with renewed vigor. Under the thoughtful and scholarly leadership of Dr. Alan Gelenberg, the third edition has undergone a significant transformation designed to meet the needs of the modem clinician. The panel of contributors is nearly double that of the former edition with the addition of nine new authors, who have helped in the major revision and rewriting of the text and in a broadening of the topics included. As a conse quence, the reader is assured of a thorough and thoroughly up-to-date coverage of current psychopharmacology that is both accurate and aimed at clinical utility. Having reached maturity, the third edition, while maintaining the lineaments of its earlier versions, is a considerably expanded and strengthened guide to treatment. Although now more encyclopedic in content, the new Practitioner' s Guide to Psy choactive Drugs retains the virtues of a clinical vade mecum that informed its predecessors and have eamed it a place by the patient's bedside for weIl over a decade. One may confidently anticipate its long and flourishing career in the years ahead. John C. Nemiah, M.D. Boston ix Preface Since its birth four decades ago, the field of psychopharmacology continues to mature. Born with aseries of serendipitous, heady, and dramatic breakthroughs in the 1950s, the field has become more sophisticated and has expanded to offer many more options to patients who suffer from medication-responsive psychiatrie ill nesses. But recent years have brought disappointments as weIl as the developments. The earliest of the "newer" antidepressants proved to be less effective and more toxic than originally hoped. Nomifensine and bupropion were withdrawn from clinical use [although bupropion (Wellbutrin®) was recently reintroduced in the United States]. Psychopharmacologists continue to search for the ever-elusive bio logical tests that will help tailor therapy to specific syndromes; the dexamethasone suppression test and other neuroendocrine assays have failed to live up to their earlier promises . Despite these disappointments, psychopharmacology greets the 1990s with more therapeutic options than it did 10 years ago. Recently introduced for general use within the United States, clozapine (Clozaril®) holds promise for some schizo phrenie patients previously refractory to standard medication. Fluoxetine (Prozac®) has become a widely used antidepressant, largely because of its efficacy and differ ent side effects. Clomipramine and several other new antidepressants bring at least partial relief to those suffering from obsessive compulsive disorder. Practitioners are increasingly exploiting psychopharmacologic assistance for patients with other mental disorders. Clinicians now recognize the distinction be tween panic and generalized anxiety disorders, and through clinical research are determining appropriate roles for high-potency benzodiazepines and antidepressants in panic disorders. Buspirone (BuSpar®) appears to be a non-benzodiazepine alter native for generalized anxiety, although its place in our therapeutic guide remains unclear as of this writing. Although less dramatic than the discovery of new landmark drugs, studies of dose-response relationships among older agents allow physicians to extend their benefits to previously untreated patients. For example, lower doses of antipsychotic xi xii Preface agents, for both the acute phases of psychosis and for maintenance treatment, afford comparable efficacy and are less toxic. At the same time, higher doses of tricyclic antidepressants can relieve previously resistant patients. Maintenance lithium for bipolar patients is more effective when higher blood levels are achieved. For newer agents, such as fluoxetine, numerous dose-response relationships are being ex plored. The previous two editions of the Practitioner' s Guide have been widely re ferred to and read. The third edition's two older siblings adom the desks and bookshelves of students, residents, other trainees, and a wide range of medical and mental health practitioners. The books tend to be well-thumbed, and thus not only is it now time to update information, but many readers need a clean copy. We have maintained the format and emphasis that have contributed to the popularity of the earlier editions. The book's organization is essentially the same. We have added sections on the use of medications in patients with borderline personality disorder and eating disorders. As drugs and a1cohol ravage our population-disproportionately afflicting the young, the poor, and the mentally ill-psychopharmacologic approaches are being studied and applied in attempts to block the craving for these chemicals. These approaches are reflected in an ex panded section on substance abuse. Since publication of the last edition, Dr. Gelenberg has moved from Boston, Massachusetts to Tucson, Arizona to become Professor and Head of the Department of Psychiatry at the University of Arizona Health Sciences Center. In addition to his involvement with administration, teaching, research, and clinical practice, he con tinues to write the Biological Therapies in Psychiatry newsletter; he is also Editor in-Chief of the Journal of C linical Psychiatry. Dr. Gelenberg expresses his gratitude and appreciation to the many colleagues in Boston who have contributed to this book and who have been sources of support, stimulation, and friendship throughout his career. He particularly wishes to acknowledge the love and encouragement of his wife, which have provided the bedrock on which his professional activities proceed. Drs. Bassuk and Schoonover have also changed their career paths. Dr. Bassuk has become president of the Better Hornes Foundation, anational nonprofit organi zation that serves homeless families. Dr. Schoonover has become president of a management consulting firm. We hope that the third edition of the Practitioner' s Guide will continue to provide, in an easy, accessible manner, the most up-to-date information on psycho active drugs and that its application will mitigate the suffering of many patients. A.J.G. E.L.B. S.C.S. Tucson and Boston Contents I. State of the Art 1. Introduction: The Practice of Pharmacotherapy Stephen C. Schoonover, M.D. I. Historical Perspective .................................... 3 11. Current Trends in Psychopharmacology ..................... 6 A. Definition of Clinical Syndromes ....................... 6 B. Development of Brain Chemistry Models and New Pharmacological Agents ................. , . . . . . . . . . . . . . 6 C. Pharmacokinetics .................................... 6 D. Design of Drug Studies ............................... 7 III. Perspectives on Clinical Practice ........................... 7 A. Matching Medications with Drug-Responsive Syndromes ... 8 B. Properties of Medication .............................. 8 C. Attributes of the Clinician ............................. 8 D. Attributes of the Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 E. Pharmacotherapy and Psychotherapy .................... 9 IV. General Clinical Guidelines ............................... 11 A. Patient Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 B. Principles of Drug Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 1. Use Nonbiological Treatments When They Are as Effective as Pharmacotherapy . . . . . . . . . . . . . . . . . . . . . . . 12 2. Do Not Deny a Patient Appropriate Medication . . . . . . . . 14 3. Choose the Drug with the Best Risk/Benefit Ratio ..... 14 4. Understand the Pharmacokinetics of Psychotropic Agents ............................ 14 5. Leam the Differences between Preparations ........... 16 6. Prescribe the Simplest Drug Regimen to Increase Compliance ..................................... 16 7. Avoid Polypharmacy Whenever Possible ............. 16 xiii
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