Issues in Usage Benzodiazepines

Benzodiazepines (see Table 4.17) will be reviewed only briefly here, as their use is only adjunctive to the core agents in manic-depressive disorder. As outlined above, some studies have documented efficacy for clonazepam and lorazepam in the treatment of acute mania, although they are not likely to be of equal efficacy to lithium, neuroleptics, or anticonvulsants. They are

ills on the part of the l the part of the

in Usage: Antidepressants of the basic 1 be found in the reviews by Frazer (1994), and Stahl (2000). To review briefly, several types have been established a: (Table 4.16). Tricyclic ;

; first i i the 1950s (Kuhn, 1958). Their i is thought to involve increasing the amount of i receptors (reviewed in Hemnger & Charney, 1987), clearly do not completely explain their .

(Crane, 1957; to exert their effects by .They achieve this effect by down) of norepinephrine and serotonin by e oxidase. They are effective

the past several years relatively sc (SSRIs), which, as the name implies, increase the amount of s in the synapse by blocking its reuptake into for

(e.g., Sussman, 1994). Their side effect profile differs from that of the tricyclic antidepressants, and they are often well tolerated by persons with < (Rudorfer, Manji, & Potter, 1994). Importantly, toxicity in is relatively less than tricyclic antidepressants.

¬°thoughTheir structures are novel, recall that the old tricyclic ; ( ^ nts inhibit reuptake of both these compounds as well. Three additional agents that are not classified in the above groups i and the closely

: are multicyclic (four-ring),

TABLE 4.19 Side Effects of


: Side Effects





Lethargy Blurred v


Tremor Ataxia

Lethargy Ataxia

Blurred vision






TABLE 4.21



Allergic reactions/rash

Low blood juigiit sensitivity


Light sensitivity


(in epilepsy) ania (paradoxical)

Thioridazine (x)

' or with only some of the drugs of this <

TABLE 4.22 Dietary;


Broad beans

Any pickled, fish decrease serotonin effects at selected groups of postsynaptic serotonin receptors. Trazodone is highly sedative, which can be useful in treating depressive episodes in which insomnia predominates; however, this property often precludes increasing the dose sufficiently high to reach antidepressant levels. This "unwanted" side effect, on the other hand, has led to its

Nefazodone is less sedating but typically must be given twice a day.

Bupropion is chemically quite different from other antidepressants and

Bupropion is chemically quite different from other antidepressants and

, there is undoubtedly a role for dopamine in mood disorders as well (see chapter 3). Furthermore, it is likely that bupropion has additional nondopaminergic effects that are relevant to its antidepressant properties. Bupropion also has been proposed to induce mania less frequently than other and to have mood-stabilizing effects in manic-depressive (e.g., Haykal & Akiskal, 1990; Sachs, Lafer, Truman, Noeth, & 1994; Shopsin, 1983), but other data indicate that bupropion has the same ability to induce mania or rapid cycling as other antidepressants (Fogelson et al., 1992).

Major side effects of antidepressants are summarized in Table 4.23. In addition, comprehensive reviews of antidepressant side effects can be found in the general references noted earlier in the chapter or in several more specific reviews (e.g., Depression Guideline Panel, 1993; Ferguson, 2001; Montgomery, 1998; Rudorfer et al, 1994; Settle, 1998). ^

depressive disorder, electroconvulsive therapy has clearly been established'as an effective agent both for acute mania and for depression. As for other treatments, data specifically on manic-depressive disorder lag behind that for unipolar depression. Two reports describe beneficial effects of high-intensity visible spectrum light of the type used to treat seasonal affective disorder in persons with depressive episodes during manic-depressive disorder, Deltito and colleagues (Deltito, Moline, Potlak, Martin, & Maremmami, 1991) found reported a small case series of persons with manic-depressive disorder who had a good response to light treatment for depressive episodes < the summer. Though preliminary, each of these reports : exploration of potential effects of light treatment in manic-depressive disorder, apart from seasonal factors, is *

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