Drugs are not the only treatment for mood disorders. Psychotherapy remains an important component in the management of these disorders, and electroconvulsive therapy (ECT) has a long history of efficacy and safety when drugs are ineffective, poorly tolerated or cannot be used. Some drugs are recommended here for indications that have not been approved by the FDA.

Many drugs can cause psychiatric symptoms, but a causal connection is often difficult to establish. Psychiatric symptoms that emerge during drug treatment could also be due to the underlying illness, previously unrecognized psychopathology, or psychosocial factors. The withdrawal of some drugs can cause symptoms such as anxiety, psychosis, delirium, agitation or depression.

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Peptic ulcers caused by treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) are mainly gastric ulcers. The greater the number of office visits and the longer the counseling time, the higher the smoking cessation rates have been.

A combination of the corticosteroid budesonide and the long-acting beta₂-agonist formoterol (Symbicort - AstraZeneca) has become available in a metered dose inhaler for long-term maintenance treatment of asthma in patients ≥ 12 years old. A combination product that contains fluticasone propionate and salmeterol (Advair) is already available for this indication in the US. Neither one of these combinations is approved for acute treatment of asthma symptoms. A dry powder inhaler formulation of Symbicort has been available in Europe and Canada for several years.

Rasagiline (Azilect - Teva), a monoamine oxidase-type B (MAO-B) inhibitor, was recently approved by the FDA for once-daily oral treatment of Parkinson's disease (PD). It can be taken alone for treatment of early disease or with levodopa/carbidopa (Sinemet, and others) for advanced disease. Selegiline (Eldepryl, and others), the first MAO-B inhibitor marketed in the US, has been available since 1988; a new lower-dose disintegrating tablet (Zelapar) was recently approved.

Drugs are not the only treatment for psychiatric illness. Psychotherapy remains an important component in the management of these disorders, and cognitive behavioral therapy (CBT) is used for many of them as well. Electroconvulsive therapy (ECT) has a long history of efficacy and safety when drugs are ineffective or cannot be used.

Duloxetine hydrochloride (Cymbalta - Lilly), a selective serotonin and norepinephrine reuptake inhibitor (SNRI) available for treatment of depression, has also been approved by the FDA for treatment of neuropathic pain associated with diabetic peripheral neuropathy (DPN). Duloxetine is one of two drugs approved specifically for management of neuropathic pain due to diabetes; the other, pregabalin (Lyrica - Pfizer), will be marketed soon and will be reviewed in the next issue of The Medical Letter.

Five different selective serotonin reuptake inhibitors (SSRIs) are promoted for treatment of depression and a sixth (fluvoxamine) for use in obsessive compulsive disorder. Which one should we prescribe for our patients?

In the February 2003 update of the Adverse Drug Interactions Program and in the Handbook of Adverse Drug Interactions 2003, the potentially lethal interaction between selective serotonin reuptake inhibitors (SSRIs) and monoamine oxidase inhibitors (MAOIs) was inadvertently omitted for citalopram (Celexa) and escitalopram (Lexapro). This interaction could occur with any SSRI.

The number of drugs marketed for psychiatric indications has increased sharply in recent years. The recommendations in this article are based on the results of controlled trials and on the experience and opinions of Medical Letter consultants. Interactions with other drugs can be found in The Medical Letter Handbook of Adverse Drug Interactions, 2003.

Atomoxetine (Strattera - Lilly) is the first non-stimulant drug to be approved by the FDA for treatment of attention deficit hyperactivity disorder (ADHD). Unlike other drugs approved for use in ADHD, it is not a controlled substance and is approved for use in adults as well as children. Older non-stimulant drugs that have been used to treat ADHD, although not FDA-approved, include the alpha₂-agonist clonidine (Catapres, and others) and the tricyclic antidepressant desipramine (Norpramin, and others) (Medical Letter 1996; 38:109).

Sibutramine hydrochlorid monohydreate (Meridia - Knoll), which is structurally related to amphetamine, has been approved by the FDA for treatment of obesity. It is classified by the Drug Enforcement Agency (DEA) as a schedule IV controlled substance.

Zolmitriptan (Zomig - Zeneca), a selective serotonin (5-HT1)-receptor agonist, is now available in the USA for oral treatment of migraine headache. Zomitriptan structurally resembles sumatriptan (Imitrex - Medical Letter 34:91, 1992). Drugs currently used for acute treatment of migraine include injectable, oral and nasal spray formulations of sumaptriptan, injectable dihydroergotamine, dihydroergotamine nasal spray, ergotamine tartrate alone or with caffeine, and various analgesics. Anoterh 5-HT1-receptor agonist, naratriptan (Amerge - Gaxo Wellcome), has been approved by the FDA but has not been marketed yet.

Superseded by Drugs of Choice Handbook
Insomnia is a commom complaint, particularly among the elderly. Many drugs are approved by the US Food and Drug Administration (FDA) for treatment of insomnia, including five benzodiazepines and zolpidem (Ambien), a non-benzodiazepine that binds to benzodiazepine receptors in the brain. Some drugs marketed for other indications, such as antihistamines, antidepressants and antipsychotics, are also used as hypnotics. For many patients, nonpharmacological treatment of insomnia may be more effective than drugs, especially in the long term (CM Morin et al, Am J Psychiatry, 151:1172, 1994).

Tramadol hydrochloride (Ultram - Ortho-McNeil), a centrally-acting analgesic marketed in Germany since 1977, was recently approved by the US Food and Drug Administration for oral treatment of moderate to moderately severe pain. Despite some opioid activity, tramadol has not been scheduled as a controlled substance.

Nefazodone (Serzone - Bristol-Myers Squibb) was recently approved by the US Food and Drug Administration for treatment of depression. A phenylpiperazine, nefazodone is chemically related to trazodone (Desyrel, and others).

Aspirin is now widely used for antithrombotic prophylaxis in patients who have had angina pectoris or a myocardial infarction and has also been tried in healthy people to prevent myocardial infarction. Recent studies have focused on increasingly lower doses of the drug. The use of aspirin in patients who have had transient ischemic attacks or strokes will not be discussed here.

The US Food and Drug Administration has approved the marketing of 5% doxepin hydrochloride cream (Zonalon - GenDerm) for treatment of pruritus due to eczematous dermatoses. Oral doxepin is used as a tricyclic antidepressant (Sinequan, and others).

Acrivastine/Pseudoephedrine (Semprex-D) for Seasonal Allergic Rhinitis (Burroughs-Wellcome), a combination of acrivastine with pseudoephedrine hydrochloride, has been approved by the US Food and Drug Administration for treatment of seasonal allergic rhinitis. Acrivastine is a new H 1 -receptor antagonist with a chemical structure similar to that of triprolidine (Actidil, and others) (RN Brogden and D McTavish, Drugs, 41:927, 1991). Pseudoephedrine is an α -adrenergic agonist. The combination is available only by prescription.

Since the introduction of fluoxetine (Prozac - Medical Letter, 30:45, 1988), bupropion (Wellbutrin - Medical Letter, 31:97, 1989), sertraline (Zoloft - Medical Letter, 34:47, 1992) and paroxetine (Paxil - this issue), the choice of an antidepressant has become more difficult. Should these widely prescribed new drugs replace tricyclic antidepressants such as amitriptyline (Elavil, and others), imipramine (Tofranil, and others), or nortriptyline (Aventyl, and others) for treatment of most patients with depression?

Altretamine (Hexalen - US Bioscience; Hexastat - Rh ne-Poulenc in Canada), formerly known only by its chemical name, hexamethylmelamine, was recently approved by the US Food and Drug Administration as a single agent for palliative oral treatment of persistent or recurrent ovarian cancer.

Alprazolam (Xanax - Upjohn), a triazolobenzodiazepine previously available in the USA for treatment of anxiety (Medical Letter 24:41, 1982), was recently approved by the US Food and Drug Administration (FDA) for treatment of panic disorder, with or without agoraphobia. According to one report, alprazolam was the fifth most widely prescribed drug in the USA last year (American Medical News, March 4, 1991, page 4).

Patients with Parkinson's disease have a deficiency of the neurotransmitter dopamine, a catecholamine. Dpamine itself cannot be used to treat the disease because it does not cross the blood-brain barrier, but its metabolic precursor, levodopa, does cross into the brain and is converted to dopamine by a decarboxylase present both in the brain and in the intestinal tract (JM Cedarbaum, Clin Pharmacokinet, 13:141, 1987).

Fluoxetine (Prozac - Dista), a phenylpropylamide, is the first serotonin-reuptake blocker introduced in the USA for treatment of . It is being promoted as causing fewer adverse effects than other antidepressants. Claims of greater safety and patient tolerability have often been made for new non-tricyclic antidepressants in recent years, but unpredicted adverse effects have emerged with widespread use, including priapism with trazodone (Desyrel - Medical Letter, 26:35, 1984) and fatal hemolytic anemia with nomifensine (Merital - Medical Letter, 27:73, 1985).