Major Tranquilizers—even atypical ones–
are not Mood Stabilizers!
Lately I have noticed a disturbing trend: more and more patients are referring to an atypical major tranquilizer—Abilify, Seroquel, Geodon, Zyprexa, Risperdol—as a “mood stabilizer.”
What is the difference? and Why is this disturbing?
There are crucial differences between these two classes of drugs:
- They have importantly different ways of affecting the brain
- They have different side effects
- They have different long-term effects
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First, bear in mind that the human body, and the brain in particular, is made up of marvelously intricate systems in dynamic equilibrium. These systems– muscles, hormones, fluids, and neural transmitters–create crucial balances, balances that continually interact, adjusting to one and other. Bear in mind also that when a system in equilibrium is pushed in one direction it responds by pushing back in an opposite direction, like a spring. The balance then shifts in that system and all the other systems that interact with it. So, even when a drug “selectively” targets a single neurotransmitter—serotonin, for example—it affects numerous other neural transmitters that are in equilibrium with that neural transmitter, sometimes unpredictably.
Mood Stabilizers: Mood stabilizers work by limiting the activity of key neurons but only when the neuron becomes overactive. They do not affect the activity of a cell when it is functioning at a normal pace.
Mood stabilizers accomplish this by limiting the neuron’s energy (electrical potential) or by limiting a neuron’s ability to accumulate substances (metabolites) that generate energy. Either way they do not affect normal equilibriums in the brain.
Major Tranquilizers: By contrast, atypical major tranquilizers affect the concentration of two or more neural transmitters, causing numerous shifts in the brain’s equilibriums. These shifts can result in immediate or long term side effects.
Mood stabilizers also have side effects but we are beginning to learn that several mood stabilizers—and perhaps others—have a long term effect of increasing regeneration of brain cells. They are neuro-protective.
The confusion between these two kinds of drug is not accidental.
Atypical major tranquilizers are being promoted for use in bipolar disorder.
- One motive for this promotion is a desire to have a single medication that will work on the various symptoms seen in bipolar disorder: manic arousal, depression, agitation, and anxiety. So much simpler for physicians and patients!
- Another motive promoting this trend is an old idea that the use of multiple medications—polypharmacy—is dangerous. It violates longstanding medical principles of parsimony. This older idea also dates from a time when less was understood about how drugs are metabolized and how they interact.
However, up to date understanding of bipolar disorder recognizes that different symptoms respond better to different drugs. Some forms of anxiety (for example, panic attacks) are best treated with a minor tranquilizer. Manic arousal requires the use of a major tranquilizer, but usually for a limited period of time. Symptoms of ADD will often respond to a stimulant, but often their use is safe only in combination with a mood stabilizer. Depression may require and antidepressant but also often for a limited period of time. As in cooking, several spices work better than a single one, but they need to be combined subtly and in sparing amounts.
There are circumstances in which an atypical (or typical) major tranquilizer is a crucial tool, but it needs to be recognized for what it is.
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