References for further reading that are oriented toward utility in clinical practice. Antiepileptic Drugs: A Clinician's Manual fills an unmet need as a practical, patient-oriented reference and leads to improved patient care. Supported by practical, clinical knowledge and experience, this is the perfect guide for physicians looking to ensure safe practices in antiepileptic drug therapy. Bloggat om Antiepileptic Drugs. That is, initially reaching a high but tolerable dose and staying with that dose for 12 months may continue to yield ever-increasing improvement with a plateau being reached by 12 months.
Anafranil has significant side effects and thus is generally a second line treatment, although it has the most robust efficacy of all antidepressants in the treatment of OCD. A common practice is to start with an SSRI and if there is only partial improvement, augment with low doses of Anafranil e. This strategy is often effective in providing additional symptomatic improvement. Acute treatment of PTSD or Acute Stress Disorder is best accomplished by the use of clonidine or beta blockers which rapidly decrease anxiety symptoms.
Traditionally benzodiazepines have been used, but several studies have actually shown that chronic treatment with tranquilizers can produce poor outcomes. Thus, use of benzodiazepines should be limited to very brief treatment one or two days. The down side of SSRI use is that it requires weeks of treatment before symptom reduction is noticed and can, in some individuals cause initial activation i. These medications reduce intrusive symptoms, hyperarousal and, interestingly, dissociation and numbing symptoms. As with OCD, sometimes relatively low doses may be effective, but more often the dose of antidepressants needed to provide symptomatic relief needs to be high.
Although anxiety can be pronounced with PTSD, generally benzodiazepines are not recommended for longer-term treatment and may in fact complicate recovery. If transient psychotic symptoms are evident, low doses of atypical antipsychotics may be helpful e. Generally, the use of antipsychotics can be of relatively short duration. Experimental drugs that may be effective in treating PTSD-related anxiety are beta blockers e. Inderal , clonidine Catapres; Kapvay , guanfacine Tenex; Intuniv and for treatment of nightmares, prazosin Minipress.
Prazosin is also being used to treat daytime anxiety in those suffering with PTSD.
In most cases the best strategy is to treat the medical disorder or resolve substance use and not use psychiatric drugs to treat these conditions. However, in some instances the use of antidepressants or benzodiazepines may be indicated. The anticonvulsant, Neurontin gabapentin, daily doses: mg. It has the further benefit of being non-habit-forming and effective in relieving some types of chronic pain especially neuropathic pain.
Additionally, antidepressants may exacerbate bipolar disorder. Rates of co-occurring bipolar and anxiety disorders are high. Therefor gabapentin may be an alternative. Finally, the drug Lyrica is approved to treat anxiety in Great Britain, and is sometimes used in the USA to treat anxiety, off- label.
The over-the-counter product, Kava Kava has antianxiety properties however it has been associated with cases of liver toxicity and is not recommended for safety reasons. Transcranial magnetic stimulation with low frequency stimulation over the right frontal lobe has been used experimentally to treat PTSD and may be an option for other types of anxiety disorders. Finally, exercise therapy has a proven track record of effectiveness in treating most forms of anxiety disorder.
Two thirds experience ongoing symptoms throughout life. It is very important to emphasize that most psychiatric disorders in childhood present with some degree of motoric restlessness and inattention. These outwardly observable behaviors absolutely do not automatically lead to a diagnosis of ADHD. The box below lists those disorders that must be considered in any comprehensive evaluation of children or adolescents with hyperactivity and inattention.
The diagnosis of ADHD is based largely on three sources of data: family history since ADHD is considered to be a genetically transmitted disorder and thus often runs in families , a very careful history detailing the nature and onset of behavioral symptoms, and a description of current symptoms especially as they vary across situations.
It is also a diagnosis of exclusion one must always first rule out those disorders listed above. The most common presentation for ADHD is an early onset often present in infancy of restlessness, unstable sleep patterns, affective lability especially, crying a lot and difficulty in being soothed. Most true ADHD children are identified in preschool when they have their first sustained contact with other children and encounter social standards expectations to control behavior, follow rules, and stay on task in age appropriate ways.
There is some controversy among experts, but general agreement that this very early onset of significant behavioral problems is very characteristic of ADHD. However, there is emerging data to suggest that some children destined to have bipolar disorder may show early-onset behaviors that are ADHD-like i. During childhood the following symptoms predominate: hyperactivity, impulsivity, impaired self-control, difficulties staying on-task and limited ability for intrinsic motivation e.
Such symptoms are often highly context-dependent; that is: most noticeable in situations requiring that the child remain still and quiet e. With adolescence, as noted above, motoric hyperactivity often is reduced, but core symptoms remain. This fundamental difference is also underscored by the failure of stimulants to effectively treat the inattentive subtype it should be noted that most people without ADHD when given stimulants do show a degree of enhanced abilities to maintain attention…this can occur to a limited degree when used with children with the inattentive specifier, but the results are nowhere near as robust as seen in typical ADHD.
Second-generation antiepileptic drugs and pregnancy: a guide for clinicians. - Semantic Scholar
Currently there are no effective medication treatments for those suffering with the inattentive version of ADHD. Numerous studies suggest impaired frontal lobe functioning in people suffering from ADHD evident in studies of metabolic functioning: e.
In addition, abnormalities have been shown in the dopamine neurotransmitter system. Likewise, dopamine agonists e. Minor structural abnormalities have also been found in the brains of ADHD subjects e. Appropriate treatment with stimulants may not only reduce symptoms, but also may also normalize the chemical microenvironment of the developing brain, and ensure more normal brain maturation. Castellanos, et al. The degree of reduction in frontal, temporal, cerebellar, and white matter volumes correlated significantly with parent and teacher ratings of ADHD symptom severity.
Unmedicated ADHD subjects exhibited strikingly smaller white matter volumes compared to both controls and medicated ADHD children treated with stimulants. This suggests that appropriate treatment may be neuroprotective. There are three classes of medications with empirical support of efficacy in the treatment of ADHD: stimulants, certain antidepressants and a-2 adrenergic agonists. The mechanism of action of stimulants is inhibition of dopamine reuptake additionally, amphetamines promote increased release of dopamine from vesicles.
Listed below are the currently available stimulants. There are different ways to categorize stimulants, either by the onset of action or duration of action. In general, most of these agents have a moderately rapid onset, with symptom reduction occurring minutes after ingestion, and a duration of action ranging from hours.
Depending on the formulation, dosing is two to three times daily, with some long acting products providing once daily dosing. What is most important is to find the best possible dose and dosing schedule for a given patient. In the past few years there has been an explosion of various drugs that have received FDA approval, most of which are versions of methylphenidate. Listed below are those in most commonly in use. There are over well-controlled studies of stimulant use and outcomes are significantly positive. Although the stimulants are similar, there are differences.
Thus, if a trial with one stimulant e. Across studies effect sizes are quite high, ranging from 0. Failure to accurately diagnose and then to mistreat with stimulants can have very adverse consequences see table below. Consequences of Misdiagnosis and Stimulant Treatment.
Second-generation antiepileptic drugs and pregnancy: a guide for clinicians.
Clonidine Catapres; Kapvay and guanfacine Tenex; Intuniv may be used to treat core ADHD symptoms see figure below , however they are most effective in reducing irritability, aggression, and impulsivity, and promoting sedation to treat initial insomnia. Alpha-2 agonists are also the treatment of choice for comorbid tics.
However, the FDA has conducted an investigation and failed to find any significant cause for concern in co-administering these drugs. The deaths seen, as determined upon autopsy, occurred in children who had evidence of pre-existing, yet un-diagnosed significant cardiac disease. It is prudent to do cardiac screening on all subjects prior to administering the medications, including a family history of early heart disease, sudden infant death syndrome, a history of fetal alcohol exposure, or any of the following symptoms: sudden, unexplained loss of consciousness; dizziness; tachycardia; or, chest pain.
Should any of these exist it is recommended that the child be given a pre-treatment EKG. Antidepressants certainly may be helpful in reducing mood symptoms. However, beyond this use of antidepressants, certain classes of antidepressants have been shown to have positive effects on core ADHD symptoms. Not all antidepressants treat ADHD; only those that increase the availability of dopamine or norepinephrine thus SSRIs, although often a good adjunct for treating anxiety or depression, are not effective in treating core ADHD symptoms. Antidepressants that have evidence of efficacy in treating ADHD are listed below.
Treatment outcomes with antidepressants are not as robust as that seen with stimulants, however they afford several advantages:. To keep up-to-date with new medications, click on my website www. This appendix may be copied and given to patients who desire detailed information regarding their medications. Note: To the best of our knowledge doses and side effects listed in the Quick Reference Guide, linked to below, are accurate. However, this is meant as a general reference only and should not serve as a guideline for prescribing medications.
Brand names are registered trademarks. Uses: Treats mania, bipolar depression and is used to reduce recurrences of mania and depression. Used to augment antidepressants in treating major depression.