Wednesday, November 18, 2009


There has been a lot of concern recently about the 'metabolic' side effects of newer antipsychotic medications. These 'atypical' antipsychotics include the following medications, olanzepine (zyprexia), quietiapine (seroquel) , rispiridone (risperdal). They were called 'atypical's' because they worked on different receptors than the previous antipsychotics such as Chlorpromazine and Haldol.

These first line or original break through antipsychotics lead to the ability of many people to leave asylums and live independently in the community. Haldol specifically was amazing for stopping people from having auditory hallucinations. The problem with the original antipsychotics or major tranquillizers as they were also called was that they caused extra pyrimidal side effects which gave a person a 'parkinson's like' syndrome, examples being the 'thorazine shuffle', glazed eyes, muscle stiffness and tremor . Further they could lead eventually to a very unpleasant and potentially untreatable movement disorder called "tardive dyskenesia". This was most notably a restless movement of the tongue which aethetically was most unappealling There was also a sense of being controlled or somewhat restless creepy feelings for some.

It needs to be noted that the very vast majority of people had the most positive benefits from the medications. As with reporting of medication side effects in general it is only a small percentage of those who have a problem with the medication but it may be severe enough or frequent enough to warrant serious consideration. Many medications are used despite serious side effects because the disease warrants the cure. All the anti cancer drugs for instance do have serious side effects as do most of the cardiac and lung drugs. The whole idea is to balance the risk benefit and make adjustments and ameliorate the negatives while maximizing the positive benefit of the medications.

As one of many people said to me "when I didn't take my medication I was haunted by demons and so terrified I couldn't leave my room." "I couldn't talk to anyone because the voices were always interfering." "Thanks to the medication I can lead a normal life." This is what these medications achieve routinely. Peoples lives are restored and the medications that are used for mental illness have been as beneficial as the antibiotics or medications used for other diseases such as those of heart, kidneys or joints.

People too often forget the amazing progress that medications have brought for literally millions of sufferers of mental illness. Schizophrenia, schizoaffective disorders, manic depressive disorders, psychotic depressions, and borderline personality disorders all were conditions that only 50 years ago could mean a life in an asylum for those sufferers who would not be able to work or have normal relationships. These conditions were not a phenomena of the 'western world' but had been seen throughout history and had lead to horrible difficulties for so many in all the countries of the world. Roughly 1% were afflicted with these difficulties. Certainly some of those with hallucinations or delusions were having a religious experience or spiritual awakening or some situational psychologically complicated event but that was only at most a small percentage of the majority of cases who were more likely having the consequences of encephalitis, meningitis or traumatic brain injury. Increasing evidence from MRI studies shows that the most severe of these conditions have actual brain damage that may well have occurred intra uterine or as a result of a head injury or infection in childhood. It's not something that would just 'go' away on its own. It's a mental illness and not just a bad attitude or lack of will power.

Thanks to medications the asylums literally emptied. The problem today is that we need hospital beds for the mentally ill not because of the old mental illnesses but rather because of new mentall illness mostly associated with drug and alcohol abuse and traumatic brain injury and post traumatic stress disorders. Those with schizophrenia and the other severe mental illnesses are mostly able to live in the community thanks to medication but they do need respite care in hospital at times. The lack of resources often makes this otherwise treatable illness a nightmare. These individuals who once needed to be a lifetime in hospital now will have months or at most a year of their life in hospital however they still need those hospital beds for these periods of illness severity no different than people with heart disease who experience periods of angina and have mild heart attacks. The very success of the antipsychotic medications cost the mentally ill patients the government funding and hospital beds that were once always necessary.

As to the atypical medications, these were a god send to the patients collectively because they didn't have the extra parimidal side effects and didn't have the danger of tardive dyskenesia. They were pleasant to take compared to the original medications for so many. Unfortunately they came with their own side effects which is simply the way of life, there is no 'free lunch'. All treatments come with costs. For most these new side effects are not a problem. The risk is small compared to the overall benefits of the drugs and there are indeed ways of treating the side effects.

The greatest concern is weight gain with associated diabetes. Zyprexia (olanzepine) was an amazingly appreciated medication but had a seriously concerning tendency with increasing dosage to cause weight gain. Alot of the metabolic side effects for all these medications were indeed dose related. A medication that caused no problem at low dose caused problems at higher dosage. Aspirin is like this. One or two pills cause little effect on platelets but more will increasing the tendency for a persons platelet system to not be able to stop bleeding if one has a cut.

One of the problems of patients looking up side effects of medications on the internet is that the side effects listed commonly come from the pharmaceutical companies necessary list of "medical disclaimer side effects". This means that the side effect is listed if it ever occurred even if it is rare and even if it was taken improperly or with other medications by the elderly or dying and in large dosage. It's like saying that planes wings fall off without listing the speed at which the plane was going of that the plane had had it's wings shot up by an enemy plane before the wings fell off later. In contrast the medical and psychiatric community utilized actual clinical resources and clinicians have experience of the medications and use them in a way which will be individualized and result in the least possible side effects. The 'studies' in the individual research papers which doctors read tell the ages and weights and races and other medical conditions which might have been present when a medication was used and then if it worked. Further these studies list whether the research information was randomized or controlled or subject to bias. Too much of the information listed on the internet is for legal purposes, to protect someone from legal assault, or simply a personal account. Too often critical information is missing.

That said, Ziprasidone or Zeldox (Pfizor Pharmaceuticals) is a new class of medication which has all the benefits of the original antipsychotics and the atypicals but in addition is energizing and doesn't lead to weight gain or cause metabolic side effects. It's been a relative breakthrough in the psychiatric medication armamentarium. No doubt it will eventually be seen to have it's limitations. Even the God send Penicillin caused allergies in many while it saved the lives of millions. Ziprasidone for now is working very well for those who need a major antianxiety medication but won't cause the other serious side effects. It's proving highly beneficial in the treatment of schizophrenia but is also very helpful in the treatment of anxiety disorders and mood disorders.

I'm thankful to the pharmaceutical companies for the work they have put into providing yet another medication that will help patients live independent lives to their greatest satisfaction without the nightmares of mental illness destroying their hopes and dreams.

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