Table of Contents

Contents

List of Illustrations and Tables

Preface

Acknowledgments

SECTION ONE

1. Diagnosis and Treatment: Basic Principles

Descriptive Psychiatry and DSM-IV

Pharmacotherapy and Its Implications for Other Therapies

Evaluating Treatments: The Meaning of the Word Effective

Goals of Pharmacotherapy

Some General Issues in Psychopharmacological Treatment

FDA Approval and PDR Doses

Polypharmacy

Practice Guidelines

Who Should Have a Medication Consultation?

SECTION TWO

2. Biological Basis of Psychopharmacology

Neurotransmission: How Cells Communicate

How Medications Work

Neurotransmitters That Help Regulate Mood and Behavior

Neuroimaging Techniques in Psychiatric Disorders

Biological Hypotheses of the Major Psychiatric Disorders

Mood Disorders

Schizophrenia

Anxiety Disorders

SECTION THREE

3. Mood Disorders

Diagnosis

Major Depression

Subtypes of Major Depressive Disorder

Melancholic Depression

Major Depression with Psychotic Features

Atypical Depression

Seasonal Depression

Postpartum Depression

Bipolar Disorder

Natural History, Epidemiology, and Genetics

Presentations of Mild Mood Disorders

Dysthymia

Cyclothymia

Recurrent Brief Depressions and Minor Depressions

Medical Differential Diagnosis and Evaluation

Medications Causing Depression

Laboratory Evaluation

Psychiatric Differential Diagnosis

Depression

Mourning

Demoralization

Adjustment Disorder with Depressed Mood

Premenstrual Syndrome

Dementia Syndromes

Mania

Psychopharmacological Treatment

Pharmacotherapy of Major Depression (Unipolar Depression)

First-Line Agents

Second-Line Agents

Monoamine Oxidase (MAO) Inhibitors

Electroconvulsive Treatment

Other Options

Mood Stabilizers

Stimulants

Light Therapy

Antianxiety Agents

Strategies Used in Treatment-Resistant Depressions

Continuation Treatment of Unipolar Depression

Maintenance Treatment of Unipolar Disorder

Pharmacotherapy of Bipolar Disorder

Treatment of Acute Manic Episodes

Continuation Treatment of Manic or Hypomanic Episodes

Bipolar Depression -- Acute and Continuation Treatment

Maintenance Treatment of Bipolar Disorder

4. Anxiety Disorders and Insomnia

Diagnosis

Natural History, Epidemiology, and Genetics

Medical Differential Diagnosis

Medical and Laboratory Evaluation

Psychiatric Differential Diagnosis

Psychopharmacological Treatment

Acute Treatment of Panic Disorder

Continuation and Maintenance Treatment for Panic Disorder

Social Phobia

Obsessive Compulsive Disorder

Post-traumatic Stress Disorder

Generalized Anxiety Disorder

Continuation and Maintenance

Treatment of Generalized Anxiety

Insomnia

Diagnosis

Treatment

5. Schizophrenia and Related Disorders

Diagnosis

Subtypes of Schizophrenia

Natural History, Epidemiology, and Genetics

Disorders Related to Schizophrenia

Schizophreniform Disorder

Schizoaffective Disorder

Delusional Disorder

Schizotypal Personality Disorder

Medical Differential Diagnosis

Laboratory Evaluation

Psychiatric Differential Diagnosis

Psychopharmacological Treatment

Psychopharmacological Treatment of Acute Schizophrenia

Alternative Treatments of Acute Schizophrenia

Acute Treatment of Schizoaffective Disorder

Continuation Treatment of Acute Schizophrenia

Maintenance Treatment of Schizophrenia

Maintenance Treatment of Schizoaffective Disorder

Treatment of Depression in Schizophrenia

6. Disorders of Impulse Control: Eating Disorders, Drug and Alcohol Abuse, and Adult Attention Deficit/Hyperactivity Disorder (ADHD)

Eating Disorders

Anorexia Nervosa

Bulimia Nervosa

Adult Attention Deficit/Hyperactivity Disorder

Psychopharmacological Treatment

Alcohol and Drug Abuse

Alcohol Abuse

Cocaine Abuse

Opiate Abuse (Heroin and Narcotic Analgesics)

Other Drugs

7. Personality Disorders

Diagnosis

Subtypes

Cluster A: Odd or Eccentric Personality Disorders

Cluster B: Emotional or Chaotic Personality Disorders

Cluster C: Anxious or Fearful Personality Disorders

Natural History, Epidemiology, and Genetics

Psychopharmacological Treatment of Personality Disorders

Conceptual Models of Pharmacotherapy: What Are We Treating?

Psychopharmacological Treatment of Specific Personality Disorders

Cluster A: Odd or Eccentric Personality Types Cluster

B: Emotional or Chaotic Personality Types Cluster

C: Anxious or Fearful Types

Depressive Spectrum Personality Disorders

Management Issues

8. Treatment of Special Populations: Children/Adolescents, the Elderly, and Women

Child and Adolescent Disorders

Mood Disorders

Diagnosis

Pharmacotherapy

Childhood Schizophrenia

Diagnosis

Pharmacotherapy

Pervasive Developmental Disorders: Autistic Disorder, Asperger's Syndrome, and Related Entities

Diagnosis

Pharmacotherapy

Anxiety Disorders

Diagnosis

Pharmacotherapy

Attention Deficit/Hyperactivity Disorder

Diagnosis

Pharmacotherapy

Sleep Disorders

Diagnosis

Pharmacotherapy

Behavioral Conditions

Enuresis

Conduct Disorder

Aggressive, Destructive Behavior in Mentally Retarded Children

Tourette's Disorder

Diagnosis

Pharmacotherapy

Geriatric Disorders

Pharmacotherapy for Common Disorders

Mood Disorders

Psychotic Disorders

Anxiety Disorders and Insomnia

Medications Used in Treating Dementias

Female-Specific Issues and Disorders

Premenstrual Syndrome

Medications During Pregnancy

Antidepressants

Antianxiety Drugs

Mood Stabilizers

Antipsychotics

Electroconvulsive Treatment

Postpartum Period and Breastfeeding

Menopause

SECTION FOUR

9. Antidepressants

History

Classification

Cyclic Antidepressants

Clinical Uses

Biologic Effects

Choosing a Cyclic Antidepressant

Antidepressant Classes: Prescribing Techniques and Side Effects

General Principles

Selective Serotonin Reuptake Inhibitors (SSRIs)

Novel Antidepressants

Tricyclic Antidepressants (and Related Compounds)

Monoamine Oxidase (MAO) Inhibitors

Clinical Uses

Biologic Effects

Choice of Agents and Techniques for Prescribing

Food and Drug Interactions

Other Side Effects

10. Lithium and Other Mood Stabilizers

History

Lithium

Clinical Uses

Biologic Effects

Techniques for Prescribing

Side Effects

Lithium's Effects on Thyroid and Kidneys

Lithium Toxicity

Lithium Discontinuation

Anticonvulsant Mood Stabilizers

Carbamazepine

Clinical Uses

Biologic Effects

Techniques for Prescribing

Side Effects

Valproate

Clinical Uses

Biologic Effects

Techniques for Prescribing

Side Effects

11. Antianxiety Medications and Hypnotics

History

Benzodiazepines

Clinical Uses

Biologic Effects

Choosing a Benzodiazepine

Techniques for Prescribing

Benzodiazepine Withdrawal

Other Side Effects

Zolpidem Buspirone

Nonbarbiturate Sedatives and Hypnotics

Barbiturates

L-Tryptophan and Melatonin

Antihistamines

Clonidine

Beta-blockers

In the Future

12. Antipsychotics

History

Clinical Uses

Biologic Effects

Choosing an Antipsychotic

Atypical Antipsychotics

Techniques for Prescribing

Side Effects

Acute Side Effects

Dystonic Reactions

Akinesia

Akathisia

Neuroleptic

Malignant Syndrome

Non-Neurological Side Effects

Tardive Dyskinesia

Antiparkinsonian Medications

13. Electroconvulsive Therapy (ECT); Stimulants

ECT

Clinical Uses

Mechanisms of Action

Techniques of Administration

Side Effects

Stimulants

Clinical Uses

Mechanisms of Action

Techniques of Administration

Side Effects

SECTION FIVE

14. The Split Treatment Model: Interactions Between Psychotherapy and Pharmacotherapy

Early Models, Early Problems

Psychotherapy/Pharmacotherapy Interactions: Theoretical Issues

Therapeutic Split Model

Advantages of the Split Model

Disadvantages of the Split Model

Psychodynamics of Psychopharmacology

Patient Education

Medication Compliance: Intra- and Interpersonal Factors

Technical Aspects of Split Treatment

Choosing a Psychopharmacologist

Finding a Psychopharmacologist in Your Community or Group

The Consultation Process

The Initial Consultation

Working in an Ongoing Split Treatment

Appendix: Psychiatric Medications

References

Index

About the Author

Michael J. Gitlin, M.D. is an authority on psychopharmacology who has published numerous articles. He is Clinical Professor of Psychiatry and Director of the Affective Disorders Program and of the General Outpatient Clinic at the UCLA Neuropsychiatric Hospital.

Reviews

Stanley R. Grahame, Ph.D. Clinical Director, Fifth Avenue Center for Counseling and Psychotherapy Director of Training, Greenwich Institute for Psychoanalytic Studies A concise, comprehensive review of the field of psychopharmacology which succeeds in communicating a mass of relevant data in an easily understandable text without talking down to the nonmedical psychotherapist. It is a triumph in communication of what every therapist should know about...patients who are receiving medication, who should be receiving medication, and who should not be receiving medication. The best book of its kind to date.

Lester Grinspoon, M.D. Associate Professor of Psychiatry, Harvard Medical School Editor, Harvard Medical School Mental Health Letter Since the introduction of chlorpromazine in 1953, a biological revolution has confronted psychotherapists with a vast array of medications which can enhance their effectiveness in treating a large variety of mental disorders. The practice of psychotherapy now requires an understanding of these drugs, including their indications, mechanisms of action, side effects, and especially the complex relationship between drug treatment and psychotherapy. For that purpose Gitlin's well-written, thorough, and comprehensive book is the best I have seen -- a text that will be useful not only to therapists without medical training but also to the psychopharmacologically sophisticated.

Judith Marks Mishne, D.S.W. Professor, New York University School of Social Work This most readable, jargon-free text is clear, astute, and bridges the split between those physicians who prescribe medication and those therapists who do not....Dr. Gitlin's dual knowledge base and his respect for both methods of intervention are clear, as he demonstrates comfort with the split treatment model and collegial regard for the nonmedical clinician. This text is a must as a clinical guide for the nonphysician therapist.

Robert O. Pasnau, M.D. Professor of Psychiatry, University of California, Los Angeles Chief of Staff, Neuropsychiatric Institute Hospital Assistant Dean, School of Medicine It is extremely useful for those psychiatrists, like me, who as psychotherapists are becoming increasingly convinced that combined pharmacology and psychotherapy is the treatment of choice of the majority of our patients. Most of my patients want to know why and how medications work, and they are becoming increasingly knowledgeable about side effects and dependency.