Over the last thirty plus years, many new psychiatric medications have been developed. In addition, research has found that there are many medications developed for non-psychiatric conditions that are therapeutic in the psychiatric realm. That is all very good news.
If you do internet research about your condition, or about medications, you will quickly become confused. Here are some examples:
You have depression. Your psychiatrist is recommending a particular medication. Your internet search reveals that this medication is used in the treatment of depression. You then search on the name of the medication and it says, “FDA approved for use in schizophrenia.” You think to yourself, “Do I have schizophrenia?”
You have ADD (attention deficit disorder). Your psychiatrist is recommending that you try a medication called guanfacine, one of the medications listed on the internet that treats ADD. During your internet search for guanfacine, you find it’s a medication to treat high blood pressure. But you don’t have high blood pressure?
You’re having difficulty sleeping. Your psychiatrist recommends a medication to help you with sleep. When researching insomnia you see this medication listed. But when you research the medication, it is classified as an antidepressant. But you’re not depressed.
Let’s break this down. There are several different methods used in classifying medications. The most common methods are:
- Group by the illness it treats (e.g., antihypertensives, antidepressants, antibiotics)
- Group by chemical structure (e.g., sulfa drugs)
- Group by its mechanism of action (e.g., hydrogen pump inhibitors, serotonin reuptake inhibitors)
- Group by medical subspecialty (e.g., neurologic drugs, cardiovascular drugs)
Confusion arises because medications can cross categories and be used to treat multiple diseases, be used in several specialties, and can have more than one mechanism of action. Thus knowing your condition is not sufficient to know what treatment would be best for you.
To add one more layer of complexity, medications require approval from the FDA (Federal Drug Administration) in order to be prescribed. The first time it is approved, it must be approved for a specific indication or disease. However we find that any given medication can be beneficial to treat a disease for which the FDA did not give specific approval. As one example, you have been hearing recently quite a bit in the news about the use of hydroxychloroquine for COVID. It is not FDA approved for COVID, but nevertheless it is used to treat it.
Treating a patient with a medication that does not have a specific FDA approval for that condition is called, “Off Label Use.” It is not prohibited at all. In nearly all studies, at least 20% of all medications prescribed are used “off label.” In psychiatry, the percentage is much higher. The reason that the FDA does not add additional indications to a drug is purely economical. If the drug company that manufactures the drug does not want to have the huge expense of conducting extensive clinical trials to prove the drug is effective for another condition, it will not do it. The drug company knows that it can forego the time and expense because doctors will prescribe it anyway “off label.”
Therefore, if a physician recommends a medication and you see that it is not FDA approved for your condition, it is not unusual. Of course you should ask your physician about it. You will likely hear that in both clinical trials as well as the doctor’s own experience, the medication is certainly indicated and likely to be helpful to you, otherwise it would not be recommended.
Here are a few common situations encountered when confusion can arise about medications and their classifications.
Antipsychotics – Antipsychotics are medications traditionally used to treat psychosis, like schizophrenia, or affective psychosis, like mania. Today they are widely used and are highly effective in treating other conditions such as: depression, anxiety, obsessive compulsive disorder, insomnia, bipolar disorder. A better way to classify these medications would be by their chemical structure. Because they treat a variety of conditions, the term “antipsychotic” is misleading.
Antidepressants – The most common antidepressants used today are the SSRIs (serotonin reuptake inhibitors) and the SNRIs (serotonin-norepinephrine reuptake inhibitors). However they are used extensively for other conditions such as anxiety, panic, obsessive compulsive disorder, eating disorders and pain disorders. In addition, they are weak mood stabilizers and therefore are occasionally used for individuals with mild bipolar disorder. Hence, not infrequently patients with one of these other conditions will ask why they are being given an “antidepressant” when their problem is not depression.
Mood Stabilizers – Several decades ago it was discovered that medications for epilepsy/seizures are highly effective in stabilizing moods particularly in patients with bipolar disorder. Some are also widely used for migraines and pain disorders. You can already imagine the most common confusion in patients being prescribed these medications: “But I don’t have epilepsy!”
These are but a few examples of the confusion that arises when trying to understand the medications recommended to you. Obviously the goal is that you receive the treatment that is most helpful to you. Understanding your treatment is of equal importance. The internet is a wondrous invention but it can never replace the relationship you have with your physician.