Picking the Right Medication Class, How to start. Q and A
Organizing symptoms, symptom clusters and disorders into medication responsive groups.
Are we starting with any assumptions?
This discussion is based on the assumption that environmental and general medical causes of the mental health problems are addressed or ruled out, and the psychology , attitude and mental mechanism of the patient and their family is at least conducive to medication management, and not so pathological that it would seriously interfere or prevent an adequate medication trial. If this is the case I proceed to make a provisional descriptive and brain chemistry diagnosis and fit it with a medication group and then specific medications based on the individuals needs.
How do you organize what you are hearing into useful information?
I take the problems and the symptoms, put them into clusters that may represent a possible diagnosis descriptively, than I think of the possible brain chemistry involved , in a sense a biochemical diagnosis, and what categories of psychiatric medications would be helpful.
What are these grouping of medications that represent biochemical diagnosis based on brain chemistry?
I start by considering seven types of possible brain chemistry problem presentations and their representative medication classes. I ask my self what can the patient and their problems benefit from biochemically? Is the kind of problem that requires mood stabilization, a neuroleptic, a SSRI type of med, a neurostimulants, some combination of these, or other medications not in these classes that can be used adjunctively.
1. Is the basic problem one of multiple brain chemistry problems leading to an overly excitable brain and needing Mood stabilizers of three classes? These are the atypical [ Risperdal, Zyprexa, Seroquel, Geodon, Abilify, Clozaril ]and typical neuroleptics,[ Trilifon, Thorazine, Mellaril, Moban, Haldol, Navane, and many others] the mood stabilizing anti convulsants, [ Depakote, Tegretol, Lamictal] and in a class by itself, Lithium as it carbonate salt. These problems are caused by an excitable brain with varying degrees of instability and disconnectedness of emotions, mood, thinking and behavior which is helped by these medications in varying degrees. These are broadly classified as Unstable Mood Disorders, including the Bipolar Spectrum, Atypical Moods, and serious Impulse Control and Anger Management problems.
2. Is the basic problem one of a serotonin- norepinephrine-dopamine [“SND” brain chemistry] mal function showing itself with a stable depressive mood disorders, as seen in Unipolar Depression, Atypical Stable Depression and its somatic equivalents like headaches, irritable bowel, and many other possible physical manifestations. The medicines of choice are called the SSRI/SSNRI/ NRI/DRI’s standing for selective serotonin/ norepinephrine/ dopamine re uptake inhibitors, that work by increasing these brain chemicals. These medicines include Prozac, Cymbalta, Welbutrin and others. The may indirectly temporarily stabilize in some parts of the brain , but may destabilize an excitable brain and should be used in caution if at all in this may be part of the problem.
3. Is it another problem with the, “SND” brain chemistry malfunction now showing itself primarily with one of the anxiety state? Seen in Panic Disorder, OCD or Obsessive Compulsive Disorder, Social, Phobic and Generalized Anxiety Disorders. The same medications are used but often in higher doses. The warnings mentioned above with the stable depression and the associated physical problems are the same.
4. Is it the brain chemistry of primarily of disconnected perception- thinking-emotions-behavior more pervasive , persistent and serious than seen in the unstable excitable brain? The symptom picture showing itself in sometimes very subtle forms of paranoia, misperceptions of thought like hallucinations, and disorganized , bizarre and illogical thinking. Clinically that may manifest in disorders of thinking, reality testing, and unusual relatedness, as seen in the Schizophreniform Spectrum disorders, some Psychotic disorders, and unpredictably and inconsistently in the person with Atypical Brain Chemistry. Any extreme state of anxiety, depression, or mood instability as seen in PTSD can result in these symptoms and problems. The medications that help this brain chemistry are the typical and Atypical neuroleptics as listed above.
5. is it the brain chemistry of the impulse motor movement disorders showing itself in classic involuntary motor movement or tic disorders, that can be exclusively having Motor movements, or Vocal that is some sort of sounds or having both called Tourette’s Disorder? These brain chemistry presentation is often missed or dismissed as being not significant, and because it comes and goes with its symptoms, is not even considered because some of its other associated problems may become the focus of attention because of their severity, such as “ADHD” like symptoms, but really isn’t ADHD, OCD type symptoms, that may qualify for true OCD but may not respond but get worse with the SSRI medications, and excitable and worried mental state easily confused with a Bipolar mood or severe anxiety states. The medications of choice are the atypical and typical neuroleptics, which can address the Tics and the other possible associated presentations.
6. Is it the brain chemistry of Classical Uncomplicated ADHD that is caused by a malfunction and possible deficiency of dopamine and norepinephrine, in certain parts of the brain and responds in a selective lock and key manner to neurostimulants medications? These medication all work biochemically the same but have different delivery systems that may have different effects on the individual, with the long acting usually being more beneficial but there is a select group of people who do much better on the short acting varieties. These medicines include Adderal, Ritalin, Dexedrine, Concerta, Metadate, Methylin, Focalin, Daytrana, Vyvanse. One must be sure that one has ruled out all the other biochemical causes of the core symptoms of hyperactivity, impulsivity and distractibility,[HID], that would be first better treated by the mood stabilizers, neuroleptics, and the SSRI type medications. The stimulant medications have non specific effects on HID and may help these symptoms while masking the underlying brain chemistry as it continues to fuel and drive the true underling brain chemistry problem, allowing it to progress and worse.
7. Is the unique and unpredictable brain chemistry that I call “Atypical Brain Chemistry” present? This clinically shows itself in and equally unique and unpredictable presentations I call the “Atypical Child or Person, who often gets put into one of the other diagnostic groups, yet doesn’t over time fit into any, over time having symptoms and clusters of more than one, sometimes only for a short time, and have unusual responses to medication treatments often overly responsive, too sensitive to the good and adverse or negative effects of the usual medications. Here more than any other place one must start very low with dosing medication, often using what I call micro dosing, and go very slow always looking with watchful caution that things may get worse rather than better. These people represent a challenge both diagnostically and therapeutically.
Is there any pearl , or words of wisdom when approaching this kind of descriptive and biochemical diagnosis?
1. It is best to assume at the onset that any symptom picture can represent any diagnosis that may have multiple treatments and then try to can clarify the actual diagnosis and its biochemical causation and its specific medication possible responsiveness before any medication trial is attempted.
2. Take as much time as needed to get history , history , and more history of the progression of the symptoms over time, in the individual and in the family, get a clear picture of the symptoms of emotion, mood, thinking, perception, and behavior as they are presenting that will be the focus of medication management.
3. Make these symptoms or problems measurable targets of the medication and if needed do multiple medication trials, to determine the individual response, and based on that response, to decide what changes have to made diagnostically and therapeutically.
4. Always try to treat the underlying brain chemistry not the outward symptom picture.
5. If at first there is not an adequate response try, try again using the above principles and always modifying diagnosis and treatment on the individuals unique needs and response.