Psychopharmacotherapy in pregnancy and breast feeding

The primary purpose of this article is to review critically the literature on the use of psychotropic medications in pregnancy and during breast feeding in order to suggest strategies for the clinical management of these periods. Use of psychotropic medications during pregnancy may cause three complications: 1. teratogenicity, 2. perinatal syndromes (neonatal toxicity), and 3. postnatal behavioural sequelae (behavioural toxicity). The literature features few well-controlled studies concerning these points, so that the available information allows only few conclusions. Exposure to certain psychotropic drugs in utero may increase the risk for some specific congenital anomalies; there is mostly no strong evidence for behavioural toxicity in children exposed to psychotropic medications. Use of psychotropic drugs during pregnancy and breast feeding may be appropriate in many clinical situations and should include thoughtful weighing of risk of pre- and postnatal exposure versus risk of relapse following drug discontinuation. The authors try to present disorder-based guidelines for psychotropic drug use during pregnancy and breast feeding and for psychiatrically ill women who wish to conceive.     

Psychotropic drugs and behavior

Behavioural modifications induced by psychotropic drugs results primarily from their pharmacological properties. According to classification of psychotropic drugs, sedative compounds contrast with psychostimulating medications. Behavioural effects of psychotropic drugs depend on dosing, subject's status (patient or healthy volunteer), acute or chronic administration, and environment. Some psychotropic compounds, particularly sedative drugs, decrease the level of mental alertness and cognitive functioning. But those deleterious effects tend to disappear during the course of a repeated administration. Some psychotropic drugs, especially benzodiazepines, induce a tolerance effect, eventually a psychic or a physiological dependence state evidenced by withdrawal reactions. Such similar dependence processes have been reported with other psychotropic drugs. Forensic problems have been attributed to some psychotropic compounds, like benzodiazepines: paradoxical aggressive reactions, psychomotor automatism; Psychotropic drugs usually can confer a positive effect on behaviour owing to their therapeutic action by the way of improving the illness and consequently the life of patients in the cases of depression, anxiety or schizophrenia.     

Overview of psychopharmacology in children and adolescents.

Provides a basic rationale for the involvement of school psychologists in many aspects of psychopharmacology with children, such as the identification of children who may benefit from medication and the systematic monitoring of the efficacy and side effects of various psychotropic drugs. A case is also made for the active participation of school psychologists in research programs involving various psychotropic agents, particularly those that affect learning and cognition. The classification of commonly used psychotropics and their indications are presented, as are issues associated with the medication of school children, including patient education, compliance, and multimodal or adjunctive therapies. Studies regarding attitudes and beliefs about medication held by parents, teachers, and children are reviewed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Contemporary trends in the development of psychopharmacotherapy

Modern period of psychopharmacology development is characterized by seven main features: changes in both clinical picture and course of psychic diseases; the use of psychotropic drug in general medicine; some new nosologic entities in ICD-10 which require of more accurate definition of the methods of therapy; progress in the study of biologic mechanisms of psychotropic drugs' action; appearance of numerous little-known preparations; discovery of some new aspects in action of well-known drugs; increase of the number of patients resistent to psychopharmacotherapy. Traditional and original classifications of psychotropic drugs are presented. Clinical analysis revealed that clear limits between separate groups of drugs are relative. Between the separate classes "transitional" drugs exist with distinct properties of both groups. Such drugs are thymoneuroleptics, thymotranquilizers, antidepressants with nootropic and neuroleptic properties, tranquilonootrops, etc. In accordance with the conception of "ideal" drug each class of psychotropic drugs was analyzed in terms of main advantages and defects. The advantages of some new drugs are considered.     

Tamoxifen activates cellular phospholipase C and D and elicits protein kinase C translocation

This epidemiological study focuses on cognitive change related to psychotropic drug use in a population-based sample of subjects aged 65 and over. Cognitive functioning was assessed in 1982 and 1988 by the Short Portable Mental Status by Pfeiffer, and cognitive decline was defined as an increase of more than 2 errors in 1988 relative to the 1982 assessment. Psychotropic drugs were classified into benzodiazepines and non-benzodiazepines. For both medications, four patterns of intake were considered: no use reported at both interviews, continuous use at both interviews, temporary use at the 1982 interview and new use at the 1988 interview. Depressive symptomatology was assessed by the Center for Epidemiologic Studies Depression Scale. The analysis was performed on 1200 subjects with no or minimal impairment at baseline for whom complete data were available. Univariate analyses showed cognitive decline associated with gender, level of education and new medical condition; it was also related to depressive symptomatology and psychotropic drug use. These two factors were the most strongly associated with decrease in performance in multivariate analyses. Cognitive decline differed according to class of psychotropic drugs and pattern of use: benzodiazepine temporary users exhibited a lower risk compared with never users (OR = 0.23, p = 0.056), non-benzodiazepine new users a higher risk (OR = 5.02, p < 0.001). Despite the simple measures of cognitive functioning and psychopathology, and the approximation in pattern of psychotropic drug use, these results emphasize the importance of considering psychotropic drugs in studies of cognitive decline in elderly subjects.     

Investigation of whether on-site general practice counsellors have an impact on psychotropic drug prescribing rates and costs

BACKGROUND: Counselling services are now widespread within general practice. Although the cost-effectiveness of such services has yet to be fully investigated, benefits could include a reduction in prescribing of psychotropic drugs and of other drugs. AIM: A study set out to determine whether practices with counsellors differed from those without in terms of their prescribing rates and costs of psychotropic drugs. METHOD: Prescribing analyses and cost (PACT) level two data reports for the quarter to November 1991 ending January 1992, as appropriate, were sought from 354 practices with counsellors and a matched sample of 216 practices without counsellors which had participated in a previous national survey of counselling in general practice. The drug groups examined were: hypnotics and anxiolytics; antidepressants; analgesics; all central nervous system drugs; and all drugs apart from central nervous system drugs. For each group of drugs, the numbers of prescribed items, total prescribing costs, and costs per item were expressed as a proportion of the practice's number of prescribing units (that is, the age-adjusted number of registered patients) and as a percentage of the average for similar practices in its family health services authority. Practice characteristics were compared between practices with an on-site counsellor and those without. Practices with and without counsellors were compared with respect to their prescribing indicators. RESULTS: PACT reports were obtained from 214 practices (response rate 38%)--126 with counsellors and 88 without. Practices with counsellors and practices without counsellors were well matched in terms of location, list size, proportion of elderly patients, training and fundholding status, and number of health promotion clinics. No significant differences were found between practices with and without counsellors in the prescribing indicators for any group of psychotropic drugs examined or for central nervous system drugs as a whole. CONCLUSION: There were no appreciable differences found in this study between practices with and without counsellors in terms of psychotropic drug prescribing rates or costs. The reasons for this are unclear; more indepth studies of individual counselling services are required.     

The tertiary effect of psychotropic drugs. Results of an anthropologic study conducted in southwestern France among elderly consumers

This article presents part of the results of a research conducted in the South-west of France on consumption by elderlies of psychotropic drugs. Two institutions have been chosen. The author was seeking to measure the consumption of psychotropic drugs before and after institutionalization, based on a medical questionnaire distributed to doctors working in these institutions. The author then examines the impact of this consumption on social relations, at home and within institutions, from an anthropologic perspective. Elderlies, members of their families, as well as doctors and other parties concerned by this consumption have been questioned during semi-directed interviews. Other than the general consumption of psychotropic drugs in the two institutions which the author attempts to understand the extent, only modifications in family relationships after the taking of drugs at home are exposed in this article.     

Psychotropic drug use in family practice

In an attempt to assess the precision of an illness-treatment "fit" between dispensing and actual need for psychotropic medications, the present study examined the dispensing patterns to consecutive attenders of private general practice. "Conservative" use of psychotropic drugs was indicated insofar as patients were seldom dispensed medication in the absence of emotional problems, and the presence of emotional problems frequently was not accompanied by the dispensing of medication. In addition, specific social and illness factors were located which could differentially predict either the presence of emotional problems, the use of psychotropic drugs, or both of these variables. The potential for constructing a more precise illness-treatment fit was considered.     

Sclerosing encapsulating peritonitis--a review

OBJECTIVE: To determine the pattern of use of psychotropic drugs in Sydney nursing homes. DESIGN: Survey of data from medical records of residents and interviews with residents and staff. SETTING: Central Sydney Health Area, June to December 1993. PARTICIPANTS: All residents of 46 of the 47 nursing homes in the western sector of the health area. MAIN OUTCOME MEASURES: Psychotropic drugs used regularly or as required. Degree of cognitive impairment and depression rated on interview with residents, using Mini-Mental State Examination and Geriatric Depression Scale. Behavioural disturbances reported by staff. RESULTS: Most residents (58.9%) were taking one or more psychotropic drugs regularly and another 7% were prescribed these drugs as required. Neuroleptics were taken regularly by 27.4% and as required by a further 1.4% (at least one dose in the previous four weeks), but doses were equivalent to more than 100 mg/day of chlorpromazine for only 8.8%. Neuroleptics were more likely to be given to residents with greater cognitive impairment and more disturbed behaviour. Other psychotropic drugs in regular use were: benzodiazepines (32.3%); hypnotics (26.6%); antidepressants (15.6%); and anxiolytics (8.6%). At least half of antidepressant doses were subtherapeutic. Of 874 residents who responded to a depression questionnaire, 30% scored as significantly depressed; one-third of these were taking antidepressants. CONCLUSIONS: The percentage of residents in Central Sydney nursing homes who were taking neuroleptics, hypnotics or anxiolytics is among the highest reported from geriatric institutions around the world. Prescribing practices in Australian nursing homes need to be reviewed.     

Rates of flu-like infection in patients with affective illness

Studies of immunologic profiles of depressed patients are suggestive of chronic viral infection and several investigators have found specific viral protein in some depressed patients. Moreover, several psychotropic drugs have anti-viral activity and can inhibit viral replication. In this preliminary report, we retrospectively examined the rate of reported flu-like episodes before and during psychotropic drug treatment in 236 affectively ill patients: 177 receiving lithium prophylaxis and 59 receiving chronic antidepressant medication. We observed a small but significant reduction in the mean rate of reported flu-like illness during lithium therapy (P < 0.001), with a greater reduction in men vs. women (P < 0.05). We also found a modest reduction in reported flu-like illness during chronic treatment with antidepressants (P = 0.08). Although these observations are preliminary in nature, they complement earlier reports that some psychotropic drugs may have anti-viral activity.     

Pharmacologic management of psychiatric illness during pregnancy: dilemmas and guidelines

OBJECTIVE: Given concerns about use of psychotropic medication during pregnancy, the authors reviewed the literature regarding the effects of prenatal exposure to psychotropic medications on fetal outcome. METHOD: A MEDLINE search of all articles written in English from 1966 to 1995 was performed to review information on the effects of psychotropic drug use during pregnancy on fetal outcome. Where sufficient data were available and when methodologically appropriate, meta-analyses were performed to assess risk of fetal exposure by psychotropic medication class. RESULTS: Three primary effects are associated with medication use during pregnancy: 1) teratogenicity, 2) perinatal syndromes (neonatal toxicity), and 3) postnatal behavioral sequelae. For many drug classes there are substantial data regarding risk for teratogenicity. Tricyclic antidepressants do not seem to confer increased risk for organ dysgenesis. The available data indicate that first-trimester exposure to low-potency phenothiazines, lithium, certain anticonvulsants, and benzodiazepines may increase the relative risk for congenital anomalies. However, the absolute risk of congenital malformations following prenatal exposure to most psychotropics is low. CONCLUSION: Exposure to certain psychotropic drugs in utero may increase the risk for some specific congenital anomalies, but the rate of occurrence of these anomalies even with the increased risk remains low. Use of psychotropic medications during pregnancy is appropriate in many clinical situations and should include thoughtful weighing of risk of prenatal exposure versus risk of relapse following drug discontinuation. The authors present disorder-based guidelines for psychotropic drug use during pregnancy and for psychiatrically ill women who wish to conceive.     

Breast cancer and benign breast disease patients evaluated in relation to oxidative stress

The 'WHO Analgesic Ladder' is a well validated approach for the selection of appropriate analgesic therapy for cancer pain as well as pain in AIDS. The mainstay of analgesic intervention for cancer and AIDS pain of moderate to severe intensity continues to be the appropriate use of opioid analgesics. There is, however, a growing appreciation for the role of adjuvant analgesics, such as antidepressants and other psychotropic medications, at each step of the WHO Analgesic Ladder, particularly in the treatment of neuropathic pain. Knowledge of the indications and usefulness of psychotropic analgesic drugs in cancer and AIDS pain populations will be most important to clinicians practicing in psycho-oncology/AIDS settings, particularly since these drugs are useful not only in the treatment of psychiatric complications of cancer and AIDS, but also as adjuvant analgesic agents in the management of pain. This paper reviews the literature on the use of antidepressants, psychostimulants, neuroleptics, anticonvulsants and other psychotropic analgesics in the management of cancer and AIDS pain. Mechanisms of analgesia, drug selection, and recommendations for clinical usage are discussed. The appropriate and timely use of psychotropic adjuvant analgesic drugs represents an opportunity for active psychiatric contribution to the multidisciplinary management of cancer and AIDS pain.     

Ethical and pragmatic issues in the use of psychotropic agents in young children

OBJECTIVE: To provide an overview of the knowledge base concerning the prescribing of psychotropic agents in young children with mental disorder and related mental health problems. METHOD: Relevant information is reviewed concerning the knowledge base available to inform pediatric psychopharmacology prescribing practices. RESULTS: Very few psychoactive medications have been adequately tested for safety and efficacy in young children, despite relatively high rates of prescribing. CONCLUSION: Behavioral and psychotherapeutic strategies are often the wisest first therapeutic intervention for this age group. Psychotropic medications may be required, but should be used cautiously in young children, while additional studies are being conducted.     

Insights into the mechanism of heterodimerization from the 1H-NMR solution structure of the c-Myc-Max heterodimeric leucine zipper

Drawing on data from a morbidity survey of sampled households in 25 small villages in Espirito Santo, Brazil, this article is concerned with reports of "nerves" (nervos) or nerve problems (problema de nervos). Reported cases of nervos (30 percent of all reports of illness) included a variety of symptoms: insomnia, body pains, dizziness, trembling, weakness, and emotional states ranging from feelings of sadness to anger. In one-third of the accounts, "overwork" was mentioned as the main cause, due both to its direct physical effect and to stress related to economic hardship and responsibility. In 88 percent of the cases, the afflicted person regularly used at least one psychotropic drug to relieve symptoms. Daily use of drugs occurred in 68 percent of the cases, and in 47 percent of cases people were reported as "dependent" on the drugs. The extensive use of psychotropic drugs suggests medicalization of nervos, creating a sick role for patients and keeping at an individual level the problems resulting in nervos.     

Longitudinal prescribing patterns of psychotropic drugs in nursing home residents.

Changes in the use of psychotropic drugs in a large nursing home were examined both in terms of usage for the total facility and in longitudinal changes within individuals. Data for the nursing home showed a gradual increase in use of antidepressants; a decrease in use of antianxiety medications and of sedative-hypnotics. Changes in the number of residents prescribed antipsychotics were not marked. Data within residents showed a great variability in number of psychotropic drugs used, in number of changes in dosage, and in specific patterns of medication change. The first drug change after admission (excluding day of admission) was more likely to involve initiation rather than discontinuation of psychotropic drugs. The medications studied were used over 4–7 months on the average, covering 20–30% of the resident's nursing home stay. The findings suggest that there is continued monitoring of psychotropic medications in the nursing home. (PsycINFO Database Record (c) 2010 APA, all rights reserved)