THE CRUX – Medication Quick Review

Personal Psychiatry [Redstone Mil Database Image]

How Do I Choose a Medication – The Crux

Medications are treatment assistants; they are not treatments. They are shield generators, helpful because humans are biologically wired toward the depressive emotions. This is an evolutionarily weighted preference priority. Poor cognition and behaviour patterns can unbalance this further, to an unforgiving degree. This is when medications can be useful.

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But only ever as a tool; never a stand alone treatment. Though dose, symptoms and life events matter – none of these eclipse the reality that cognition and behaviour must be altered to take advantage of medication effects. Hard work on self is always required. This work is ongoing, but some core precepts are invaluable and likely universal. Medications give you a space to work within not otherwise available to you. They provide a “shield” to:

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> Allow  favourable emotions to fire more readily.
> Break the trained & natural inclinations towards depressive affect.
> Allow interaction to restore vocational, social and personal functioning.
> Allow an opportunity to enact psychotheraputic strategies. Medications are not:
> Anything BUT an assistant to create a space to perform self-work.
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As for choosing medications, you best work with your medical staff continuously. Medications effect everyone a little bit differently. Also, most doctors are very busy, important people. Too busy to check every new profile of a medication thoroughly through the literature; especially for a single patient. I, on the other hand, am not busy. Even so; massive Lancet reviews and meta-trials sneak in unpublished, un-peer reviewed drug company studies to their analyses; despite at times displaying prominently that they have “no disclosures”. This is not infrequent.
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They also lie outright or “forget” on occasion. You can not ever easily prove this. None of this makes those studies bad or cherry picked, necessarily; I’m just giving you information that reading the abstract alone would not provide. In addition, there are many other statistical and comparison troubles that the best among us get headaches watching out for. And that is when people don’t fake their data, when everything is on the up and up – this still occurs. These companies settle out of court for US$70’000’000 or US$120’000’000 – & they do it a lot. There is a fertile ground for foul play. This, too, is worth bearing in mind.
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And no-one reads retractions.
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 Retracted studies, however, DO get sighted. Keep this in mind when doing research. Expect to have to taper off, & to dose down with a similar longer half life medication from the same class to reduce withdrawal side effects.
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caution!
They will not tell you there are withdrawal side effects (sometimes called “discontinuation syndrome”) or that “brain zaps” occur (sometimes called “dizziness”). Loss of sex drive. Sometimes neuroleptic level weight gain (*they all cause some). And be prepared for a rough first few months in most cases: there is far more serotonin in your gut than your brain. To suffice it to say, review tables 1 and 2 at the end of this article for final questions before you decide.
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AntiD’s from “new” classes only to begin on as a J Chronicle top 5 are:
For AntiD’s:-
1. Sertraline
2. Mirtazapine (Extreme weight gain & sedation at doses below 45mg*[Table 1 & 2])
3. Escitalopram
4. Citalopram* (Healing brain post stroke [2013]; cardiac warning >40mg [2013])
5. Venlafaxine* (Efficacious, but addictive)
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In the sedatives, try doxylamine or different brands of diazepam or oxazepam for sleep aides or calmatives; & yes, brand makes a difference here. Also, sedation and anxiolytic properties are nowhere near the same thing. Doctors can not seem to grasp this. h1 antags like mirtazapine and doxylamine do not anxiolise. And if you do not sleep quickly, they can induce panic via some of the activated sub systems: again, complex and beyond the scope. But if your doctor tries to pass off sedation as an anxiolytic – that is drug company cool-aide. Or not, good luck! But it is.
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You do not need alprazolam at any dose for frequent use. Not even for panic. Great drug, even novel antiD effects not seen in most sedatives; but short half life is just generally not a good idea. Z drugs fall here. Short acting (but as such sharper, painful withdraw), non drowsy wake, a lot of med school use, & even some miracle properties beyond the scope of this piece – but also you may paint your neighbor, while naked, in your sleep while also murdering your children, and not remember when you wake. Just worth a mention. All drugs have side effects. The key is are the worst side effects risks greater or less than your worst symptoms.
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Trouble falling asleep it tough to treat – harder than staying asleep. And all may increase risk of the dementures, but that data is new. In the powerful sedatives and stabilizers – do not take them unless you are sure. The side effect profiles are terrible, thus your symptoms need to be worse. Beyond that, the newer atyps are a diverse group. I defer broadly to Cipriani et al from their work in the Lancet [2011], aside from the reservations outlined in the previous section.
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For maniacs, out of 68 random controlled trials and ~16’000 participants the neurolepts were found to be “significantly more effective than…stablisers”. This is for the acute phase. Recommendations are for Olanzipine, Rispiridone, and Haliperidol. Quentiapine fell behind Lithium, though, for 4th place. I’d put both further down – but they’re all pretty bad. Unless they help you:-
For Maniacs:-
1. Olanzipine
2. Rispiridone
3. Haliperidol
4. Lithium
5. Quentiapine
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For Schizo-subtypes, and BiPD with psychosis, I think it is worthwhile mentioning that some specialists, such as Dr Mark Vonnegut, posit that “…nearly all patients who reconstructed a life, got a job and their relationships balanced…” were on lithium (2012).
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Otherwise, for the schizophrenias I defer to Leucht et al in their Lancet meta correction [2013], with the provisos contained in the previous section. There was difference found in both efficacy and side effect profiles, however the side effects alone showed the grandest discrepancies. These data were drawn from ~43’000 patients across 212 trials. There is some recommendation for a more personalized approach to specific symptoms and better divisions than just something akin to “typical” and “atypical”; rather suggesting 7 domains based on effect specificity. This is welcome, and would doubtlessly better assist physicians.
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However, patients, or their relatives, best review these data by effect and side effects for themselves. The efficacy results were as follows:-
For Schizos:-
1. Clozapine
2. Amisulpride
3, Olanzipine
4. Risperidone
5. Paliperidone
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But at the end of the day, you must rebuild yourself into a new more functional model. Medications do still ultimately come down to trial & error. Our brains are unique. One ring of carbon atoms can be a lot, between friends. Change your habits by force of will. Acknowledge you will never feel like doing so; and then do so now. Your first idea is your best idea. Action over inaction in all cases where inaction doesn’t weigh more heavily in your favour (ie keep you alive or out of prison).
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Psychiatric medications are only to assist, not to treat you. If you are afraid of hard work, your medication will not work for you. But if you recruit it; it will work WITH you.
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As a final note, some items to consider. Ear mark these for further research.
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First, remember doctors are far from all knowing. Research is far from complete (ever),  and almost always greatly flawed (even when not corrupt).
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And all medications have withdrawal/trade offs/side effects.
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Despite drug company pushes (and despite their fines in the billions to stop): there is no cause for children to be given antipsychotics. Though too long a topic to complete here.
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And the brain does not “shrink” pathologically if “early psychotic breaks” are not treated (though it does, it is far easier to show, from taking certain medications long term).
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There is also every reason to believe that antipsychotic withdrawal is causal in psychosis – even in those not “predisposed”. Ceasing any medication abruptly, arguably, could be expected to precipitate its opposite.
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Small samples; short follow up; wrong statistics; and company selected submissions, without raw data, or pre-registered trials: this can not count as science. Irrespective of artists’ renditions of coloured pictures of brains, or the like.
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Treat medications as assistants only. Accept no diagnosis as final. And seek advocates to assist in questioning all medical care – do this, and you will be just fine. But do be active in your own healthcare.
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And that is it. So, as far as getting your medical advice from, what is essentially, a blog goes: I think you’ve done quite well for yourself. Well done.
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You are one step closer to happiness.
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JJR.
Cognition, Humour & Medical Error Researcher for the Chronicle LS
JJR. (2013). What Psychiatric Medication I Should Take?-Top 5, J Chron. Lett. & Sci (1), The Jaded Medicine Collection, Sept, Ed 7.
* Image from .Mil database, Redstone. Other Images are marked with reference on table.
*All drugs have rebound. Do not take short half life drugs.
*Change to longer half life similar family drugs to dose down to relieve withdrawal and rebound.
*& before you begin, if possible, rule out all organic/axis III causes before long term medications. Thyroid, thiamine, MR of head – to name but a few items that too often go unchecked. And intend all interventions to be temporary.
[+++] Research Blog Marker
 …
Refer
Cochrane A/Ds (etal Review Papers):
Cochrane AntiPsychs (etal Review Papers)(Typ/ATypNlpts):
UCLA Psychiatry GR (2016) [Clozapine Pitch]- http://tinyurl.com/zrhpsbd
Cochrane: Atypical Antipsychotics (2011a2016) – http://tinyurl.com/j7b3ws7
Cochrane: “Improvement Outcome May Not Be Clinically Meaningful” (2010) – http://tinyurl.com/zcfjche
Cochrane: [Risperidone Pitch] – http://tinyurl.com/hssrgz5
Cochrane: Dosing Neurolepts by SFX [Rdone Base]- http://tinyurl.com/juljwg2
UCLA GR Psychiatry GR (2016) Cognitive Remediation in Schizophrenia & It’s Value – http://tinyurl.com/hdldx56
Cochrane: Long-Acting Drugs [Neurolepts Atyp] (2016): “Evidence Low-Mod at Best” – http://tinyurl.com/hpwtgb9
Biological Psychiatry (2013) Recommendations for lab monitoring of atypical antipsychotics – http://tinyurl.com/hb78o62
JClinPsychiatry (2015): Monitoring of Serum Concentrations of Antipsychotic Drugs – http://tinyurl.com/hfzv64g
Lancet (Review)
JAMA (Review)
Withdrawal and Side Effects
CCHR: Children on AntiPsychotics Au and Related Deaths (2015) – http://tinyurl.com/n7ky85o
PLOSMed: Antipsychotic Maintenance Treatment: Time to Rethink? (2015) http://tinyurl.com/hfhcnf8
IntJ Basic & ClinPharm: Antipsychotic discontinuation syndrome following risperidone withdrawal – http://tinyurl.com/jum4qlh
UnivClgLondon: Does antipsychotic withdrawal provoke psychosis? Review – DOI: 10.1111/j.1600-0447.2006.00787.x/ http://tinyurl.com/9h3tsf8
Table 1

Table 2

antidepressants 90s sfx chart
Table 3
https://i1.wp.com/www.mdedge.com/sites/default/files/images/RTEmagicC_CP012090051_t1_01.jpg.jpg
Table 4
https://i0.wp.com/www.mdedge.com/sites/default/files/images/RTEmagicC_CP012090051_t2.jpg.jpg

About J.Chron.Ltt.&Sci. [JRR]

~CogSc (Humour); NeuroPsych; Philosophy (Death/Identity); Methods (Research); Intelligence/Investigation (Forensic); Medical Error~
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