Psychotropic Medications
Special
Message
This
booklet is designed to help people understand how and why drugs
can be used as part of the treatment of mental health problems.
It is important for persons who use mental health services to be
well informed about medications for mental illnesses, but this booklet
is not a "do-it-yourself" manual. Self-medication
can be dangerous. Interpretation of both signs and symptoms of the
illness and side effects are jobs for the professional. The prescription
and management of medication, in all cases, must be done by a responsible
physician working closely with the patient and sometimes the patient's
family or other mental health professionals. This is the only way
to ensure that the most effective use of medication is achieved
with minimum risk of side effects or complications.
Oftentimes
an individual is taking more than one medication and at different
times of the day. It is essential to take the correct dosage of
each medication. An easy way to ensure this is to use a 7-day pill
box, available at the prescription counter in any pharmacy, and
to fill the box with the proper medications at the beginning of
each week.
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Introduction
Anyone
can develop a mental illness you, a family member, a friend, or
the fellow down the block. Some disorders are mild, while others
are serious and long-lasting. These conditions can be helped. One
way an important way is with psychotherapeutic medications. Compared
to other types of treatment, these medications are relative newcomers
in the fight against mental illness. It was only 41 years ago that
the first one, chlorpromazine, was introduced. But considering the
short time they've been around, psychotherapeutic medications have
made dramatic changes in the treatment of mental disorders. People
who, years ago, might have spent many years in mental hospitals
because of crippling mental illness may now only go in for brief
treatment, or might receive all their treatment at an outpatient
clinic.
Psychotherapeutic
medications also may make other kinds of treatment more effective.
Someone who is too depressed to talk, for instance, can't get much
benefit from psychotherapy or counseling; but often, the right medication
will improve symptoms so that the person can respond better.
Another
benefit from these medications is an increased understanding of
the causes of mental illness. Scientists have learned a great deal
more about the workings of the brain as a result of their investigations
into how psycho- therapeutic medications relieve disorders such
as psychosis, depression, anxiety, obsessive compulsive disorder,
and panic disorder.
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Just
as aspirin can reduce a fever without clearing up the infection
that causes it, psychotherapeutic medications act by controlling
symptoms. Like most drugs used in medicine, they correct or compensate
for some malfunction in the body. Psychotherapeutic medications
do not cure mental illness, but they do lessen its burden. In many
cases, these medications can help a person get on with life despite
some continuing mental pain and difficulty coping with problems.
For example, drugs like chlorpromazine can turn off the "voices"
heard by some people with schizophrenia and help them to perceive
reality more accurately. And antidepressants can lift the dark,
heavy moods of depression. The degree of response ranging from little
relief of symptoms to complete remission depends on a variety of
factors related to the individual and the particular disorder being
treated.
How
long someone must take a psychotherapeutic medication depends on
the disorder. Many depressed and anxious people may need medication
for a single period perhaps for several months and then never have
to take it again. For some conditions, such as schizophrenia or
manic-depressive illness, medication may have to be take indefinitely
or, perhaps, intermittently.
Like
any medication, psychotherapeutic medications do not produce the
same effect in everyone. Some people may respond better to one medication
than another. Some may need larger dosages than others do. Some
experience annoying side effects, while others do not. Age, sex,
body size, body chemistry, physical illnesses and their treatments,
diet, and habits such as smoking, are some of the factors that can
influence a medication's effect.
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To
increase the likelihood that a medication will work well, patients
and their families must actively participate with the doctor prescribing
it. They must tell the doctor about the patient's past medical history,
other medications being taken, anticipated life changes such as
planning to have a baby and, after some experience with a medication,
whether it is causing side effects. When a medication is prescribed,
the patient or family member should ask the following questions
recommended by the U.S. Food and Drug Administration (FDA) and professional
organizations:
- What
is the name of the medication, and what is it supposed to do?
- How
and when do I take it, and when do I stop taking it?
- What
foods, drinks, other medications, or activities should I avoid
while taking the prescribed medication?
- What
are the side effects, and what should I do if they occur?
- Is
there any written information available about the medication?
In
this booklet, medications are described by their generic (chemical)
names and in italics by their trade names (brand names used by drug
companies). They are divided into four large categories based on
the symptoms for which they are primarily used antipsychotic, antimanic,
antidepressant, and antianxiety medications. In addition, stimulants
used for attention- deficit/ hyperactivity disorder are listed.
An
index at the end of the booklet gives the trade name, and the generic
name, of the most commonly prescribed medications and notes the
section that contains information about each type.
Treatment
evaluation studies have established the efficacy of the medications
described here; however, much remains to be learned about these
medications. The National Institute of Mental Health, other Federal
agencies, and private research groups are sponsoring studies of
these medications. Scientists are hoping to improve their understanding
of how and why these medications work, how to control or eliminate
unwanted side effects, and how to make the medications more effective.
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A
person who is psychotic is out of touch with reality. He may "hear
voices" or have strange and untrue ideas (for example, thinking
that others can hear his thoughts, or are trying to harm him, or
that he is the President of the United States or some other famous
person).* He may get excited or angry for no apparent reason, or
spend a lot of time off by himself, or in bed, sleeping during the
day and staying awake at night. He may neglect his appearance, not
bathing or changing clothes, and may become difficult to communicate
with saying things that make no sense, or barely talking at all.
These
kinds of behaviors are symptoms of psychotic illness, the principal
form of which is schizophrenia. All of the symptoms may not be present
when someone is psychotic, but some of them always are. Antipsychotic
medications, as their name suggests, act against these symptoms.
These medications cannot "cure" the illness, but they
can take away many of the symptoms or make them milder. In some
cases, they can shorten the course of the illness as well.
There
are a number of antipsychotic (neuroleptic) medications available.
They all work; the main differences are in the potency that is,
the dosage (amount) prescribed to produce therapeutic effects and
the side effects. Some people might think that the higher the dose
of medication, the more serious the illness, but this is not always
true.
A
doctor will consider several factors when prescribing an antipsychotic
medication, besides how "ill" someone is. These include
the patient's age, body weight, and type of medication. Past history
is important, too. If a person took a particular medication before
and it worked, the doctor is likely to prescribe the same one again.
Some less potent drugs, like chlorpromazine (Thorazine),
are prescribed in higher numbers of milligrams than others of high
potency, like haloperidol (Haldol).
If
a person has to take a large amount of a "high-dose" antipsychotic
medication, such as chlorpromazine, to get the same effect as a
small amount of a "low-dose" medication, such as haloperidol,
why doesn't the doctor just prescribe "low-dose" medications?
The main reason is the difference in their side effects (actions
of the medication other than the one intended for the illness).
These medications vary in their side effects, and some people have
more trouble with certain side effects than others. A side effect
may sometimes be desirable. For instance, the sedative effect of
some antipsychotic medications is useful for patients who have trouble
sleeping or who become agitated during the day.
Unlike
some prescription drugs, which must be taken several times during
the day, antipsychotic medications can usually be taken just once
a day. Thus, patients can reduce daytime side effects by taking
the medications once, before bed. Some antipsychotic medications
are available in forms that can be injected once or twice a month,
thus assuring that the medicine is being taken reliably.
Most
side effects of antipsychotic medications are mild. Many common
ones disappear after the first few weeks of treatment. These include
drowsiness, rapid heartbeat, and dizziness when changing position.
Some
people gain weight while taking antipsychotic medications and may
have to change their diet to control their weight. Other side effects
that may be caused by some antipsychotic medications include decrease
in sexual ability or interest, problems with menstrual periods,
sunburn, or skin rashes. If a side effect is especially troublesome,
it should be discussed with the doctor who may prescribe a different
medication, change the dosage level or schedule, or prescribe an
additional medication to control the side effects.
Movement
difficulties may occur with the use of antipsychotic medications,
although most of them can be controlled with an anticholinergic
medication. These movement problems include muscle spasms of the
neck, eye, back, or other muscles; restlessness and pacing; a general
slowing-down of movement and speech; and a shuffling walk. Some
of these side effects may look like psychotic or neurologic (Parkinson's
disease) symptoms, but aren't. If they are severe, or persist with
continued treatment with an antipsychotic, it is important to notify
the doctor, who might either change the medication or prescribe
an additional one to control the side effects.
Just
as people vary in their responses to antipsychotic medications,
they also vary in their speed of improvement. Some symptoms diminish
in days, while others take weeks or months. For many patients, substantial
improvement is seen by the sixth week of treatment, although this
is not true in every case. If someone does not seem to be improving,
a different type of medication may be tried.
Even
if a person is feeling better or completely well, he should not
just stop taking the medication. Continuing to see the doctor while
tapering off medication is important. Some people may need to take
medication for an extended period of time, or even indefinitely.
These people usually have chronic (long-term, continuous) schizophrenic
disorders, or have a history of repeated schizophrenic episodes,
and are likely to become ill again. Also, in some cases a person
who has experienced one or two severe episodes may need medication
indefinitely. In these cases, medication may be continued in as
low a dosage as possible to maintain control of symptoms. This approach,
called maintenance treatment, prevents relapse in many people and
removes or reduces symptoms for others.
While
maintenance treatment is helpful for many people, a drawback for
some is the possibility of developing long-term side effects, particularly
a condition called tardive dyskinesia. This condition is characterized
by involuntary movements. These abnormal movements most often occur
around the mouth, but are sometimes seen in other muscle areas such
as the trunk, pelvis, or diaphragm. The disorder may range from
mild to severe. For some people, it cannot be reversed, while others
recover partially or completely. Tardive dyskinesia is seen most
often after long-term treatment with antipsychotic medications.
There is a higher incidence in women, with the risk rising with
age. There is no way to determine whether someone will develop this
condition, and if it develops, whether the patient will recover.
At present, there is no effective treatment for tardive dyskinesia.
The possible risks of long-term treatment with antipsychotic medications
must be weighed against the benefits in each individual case by
patient, family, and doctor.
Antipsychotic
medications can produce unwanted effects when taken in combination
with other medications. Therefore, the doctor should be told about
all medicine being taken, including over-the-counter preparations,
and the extent of the use of alcohol. Some antipsychotic medications
interfere with the action of antihypertensive medications (taken
for high blood pressure), anticonvulsants (taken for epilepsy),
and medications used for Parkinson's disease. Some antipsychotic
medications add to the effects of alcohol and other central nervous
system depressants, such as antihistamines, antidepressants, barbiturates,
some sleeping and pain medications, and narcotics.
Atypical
neuroleptics
In
1990, clozapine (Clozaril), an "atypical neuroleptic,"
was introduced in the United States. In clinical trials, this medication
was found to be more effective than traditional antipsychotic medications
in individuals with treatment-resistant schizophrenia, and the risk
of tardive dyskinesia is lower. However, because of the potential
side effect of a serious blood disorder, agranulocytosis, patients
who are on clozapine must have a blood test each week. The expense
involved in this monitoring, together with the cost of the medication,
has made maintenance on clozapine difficult for many persons with
schizophrenia. However, 5 years after its introduction in the United
States, approximately 58,000 persons were being treated with clozapine.
Since
clozapine's approval in the United States, other atypical neuroleptics
(also called atypical antipsychotics) have been introduced. Risperidone
(Risperdal) was released in 1994, olanzapine (Zyprexa) in 1996,
and quetiapine (Seroquel) in 1997. Several other atypical neuroleptics
are in development. While they have some side effects, these newer
medications are generally better tolerated than either clozapine
or the the traditional antipsychotics, and they do not cause agranulocytosis.
Like clozapine, they have shown little tendency to give rise to
tardive dyskinesia or other movement difficulties. Their main disadvantages
compared to the older medications are a greater tendency to produce
weight gain, and much higher cost.
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Bipolar
disorder (manic-depressive illness) is characterized by cycling
mood changes: severe highs (mania) and lows (depression). Cycles
may be predominantly manic or depressive with normal mood between
cycles. Mood swings may follow each other very closely, within hours
or days, or may be separated by months to years. These "highs"
and "lows" may vary in intensity and severity.
When
someone is in a manic "high," he may be overactive, overtalkative,
and have a great deal of energy. He will switch quickly from one
topic to another, as if he cannot get his thoughts out fast enough;
his attention span is often short, and he can easily be distracted.
Sometimes, the "high" person is irritable or angry and
has false or inflated ideas about his position or importance in
the world. He may be very elated, full of grand schemes which might
range from business deals to romantic sprees. Often, he shows poor
judgment in these ventures. Mania, untreated, may worsen to a psychotic
state.
Depression
will show in a "low" mood, lack of energy, changes in
eating and sleeping patterns, feelings of hopelessness, helplessness,
sadness, worthlessness, and guilt, and sometimes thoughts of suicide.
Lithium
The
medication used most often to combat a manic "high" is
lithium. It is unusual to find mania without a subsequent or preceding
period of depression. Lithium evens out mood swings in both directions,
so that it is used not just for acute manic attacks or flare-ups
of the illness, but also as an ongoing treatment of bipolar disorder.
Lithium
will diminish severe manic symptoms in about 5 to 14 days, but it
may be anywhere from days to several months until the condition
is fully controlled. Antipsychotic medications are sometimes used
in the first several days of treatment to control manic symptoms
until the lithium begins to take effect. Likewise, antidepressants
may be needed in addition to lithium during the depressive phase
of bipolar disorder.
Someone
may have one episode of bipolar disorder and never have another,
or be free of illness for several years. However, for those who
have more than one episode, continuing (maintenance) treatment on
lithium is usually given serious consideration.
Some
people respond well to maintenance treatment and have no further
episodes, while others may have moderate mood swings that lessen
as treatment continues. Some people may continue to have episodes
that are diminished in frequency and severity. Unfortunately, some
manic-depressive patients may not be helped at all. Response to
treatment with lithium varies, and it cannot be determined beforehand
who will or will not respond to treatment.
Regular
blood tests are an important part of treatment with lithium. A lithium
level must be checked periodically to measure the amount of the
drug in the body. If too little is taken, lithium will not be effective.
If too much is taken, a variety of side effects may occur. The range
between an effective dose and a toxic one is small. A lithium level
is routinely checked at the beginning of treatment to determine
the best lithium dosage for the patient. Once a person is stable
and on maintenance dosage, a lithium level should be checked every
few months. How much lithium a person needs to take may vary over
time, depending on how ill he is, his body chemistry, and his physical
condition.
Anything
that lowers the level of sodium (table salt is sodium chloride)
in the body may cause a lithium buildup and lead to toxicity. Reduced
salt intake, heavy sweating, fever, vomiting, or diarrhea may do
this. An unusual amount of exercise or a switch to a low-salt diet
are examples. It's important to be aware of conditions that lower
sodium and to share this information with the doctor. The lithium
dosage may have to be adjusted.
When
a person first takes lithium, he may experience side effects, such
as drowsiness, weakness, nausea, vomiting, fatigue, hand tremor,
or increased thirst and urination. These usually disappear or subside
quickly, although hand tremor may persist. Weight gain may also
occur. Dieting will help, but crash diets should be avoided because
they may affect the lithium level. Drinking low-calorie or no-calorie
beverages will help keep weight down. Kidney changes, accompanied
by increased thirst and urination, may develop during treatment.
These conditions that may occur are generally manageable and are
reduced by lowering the dosage. Because lithium may cause the thyroid
gland to become underactive (hypothyroidism) or sometimes enlarged
(goiter), thyroid function monitoring is a part of the therapy.
To restore normal thyroid function, thyroid hormone is given along
with lithium.
Because
of possible complications, lithium may either not be recommended
or may be given with caution when a person has existing thyroid,
kidney, or heart disorders, epilepsy, or brain damage. Women of
child-bearing age should be aware that lithium increases the risk
of congenital malformations in babies born to women taking lithium.
Special caution should be taken during the first 3 months of pregnancy.
Lithium,
when combined with certain other medications, can have unwanted
effects. Some diuretics substances that remove water from the body
increase the level of lithium and can cause toxicity. Other diuretics,
like coffee and tea, can lower the level of lithium. Signs of lithium
toxicity may include nausea, vomiting, drowsiness, mental dullness,
slurred speech, confusion, dizziness, muscle twitching, irregular
heart beat, and blurred vision. A serious lithium overdose can be
life-threatening. Someone who is taking lithium should tell
all the doctors including dentistshe sees about all other medications
he is taking.
With
regular monitoring, lithium is a safe and effective drug that enables
many people, who otherwise would suffer from incapacitating mood
swings, to lead normal lives.
Anticonvulsants
Not
all patients with symptoms of mania benefit from lithium. Some have
been found to respond to another type of medication, the anticonvulsant
medications that are usually used to treat epilepsy. Carbamazepine
(Tegretol) is the anticonvulsant that has been most widely
used. Manic-depressive patients who cycle rapidly that is, they
change from mania to depression and back again over the course of
hours or days, rather than months seem to respond particularly well
to carbamazepine.
Early
side effects of carbamazepine, although generally mild, include
drowsiness, dizziness, confusion, disturbed vision, perceptual distortions,
memory impairment, and nausea. They are usually transient and often
respond to temporary dosage reduction. Another common but generally
mild adverse effect is the lowering of the white blood cell count
which requires periodic blood tests to monitor against the rare
possibility of more serious, even life-threatening, bone marrow
depression. Also serious are the skin rashes that can occur in 15
to 20 percent of patients. These rashes are sometimes severe enough
to require discontinuation of the medication.
In
1995, the anticonvulsant divalproex sodium (Depakote) was
approved by the Food and Drug Administration for manic-depressive
illness. Clinical trials have shown it to have an effectiveness
in controlling manic symptoms equivalent to that of lithium; it
is effective in both rapid-cycling and non-rapid-cycling bipolar.
Though
divalproex can cause gastrointestinal side effects, the incidence
is low. Other adverse effects occasionally reported are headache,
double vision, dizziness, anxiety, or confusion. Because in some
cases divalproex has caused liver disfunction, liver function tests
should be performed prior to therapy and at frequent intervals thereafter,
particularly during the first six months of therapy.
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The
kind of depression that will most likely benefit from treatment
with medications is more than just "the blues." It's a
condition that's prolonged, lasting 2 weeks or more, and interferes
with a person's ability to carry on daily tasks and to enjoy activities
that previously brought pleasure.
The
depressed person will seem sad, or "down," or may show
a lack of interest in his surroundings. He may have trouble eating
and lose weight (although some people eat more and gain weight when
depressed). He may sleep too much or too little, have difficulty
going to sleep, sleep restlessly, or awaken very early in the morning.
He may speak of feeling guilty, worthless, or hopeless. He may complain
that his thinking is slowed down. He may lack energy, feeling "everything's
too much," or he might be agitated and jumpy. A person who
is depressed may cry. He may think and talk about killing himself
and may even make a suicide attempt. Some people who are depressed
have psychotic symptoms, such as delusions (false ideas) that are
related to their depression. For instance, a psychotically depressed
person might imagine that he is already dead, or "in hell,"
being punished.
Not
everyone who is depressed has all these symptoms, but everyone who
is depressed has at least some of them. A depression can range in
intensity from mild to severe.
Antidepressants
are used most widely for serious depressions, but they can also
be helpful for some milder depressions. Antidepressants, although
they are not "uppers" or stimulants, take away or reduce
the symptoms of depression and help the depressed person feel the
way he did before he became depressed.
Antidepressants
are also used for disorders characterized principally by anxiety.
They can block the symptoms of panic, including rapid heartbeat,
terror, dizziness, chest pains, nausea, and breathing problems.
They can also be used to treat some phobias.
The
physician chooses the particular antidepressant to prescribe based
on the individual patient's symptoms. When someone begins taking
an antidepressant, improvement generally will not begin to show
immediately. With most of these medications, it will take from 1
to 3 weeks before changes begin to occur. Some symptoms diminish
early in treatment; others, later. For instance, a person's energy
level or sleeping or eating patterns may improve before his depressed
mood lifts. If there is little or no change in symptoms after 5
to 6 weeks, a different medication may be tried. Some people will
respond better to one than another. Since there is no certain way
of determining beforehand which medication will be effective, the
doctor may have to prescribe first one, then another, until an effective
one is found. Treatment is continued for a minimum of several months
and may last up to a year or more.
While
some people have one episode of depression and then never have another,
or remain symptom-free for years, others have more frequent episodes
or very long-lasting depressions that may go on for years. Some
people find that their depressions become more frequent and severe
as they get older. For these people, continuing (maintenance) treatment
with antidepressants can be an effective way of reducing the frequency
and severity of depressions. Those that are commonly used have no
known long-term side effects and may be continued indefinitely.
The prescribed dosage of the medication may be lowered if side effects
become troublesome. Lithium can also be used for maintenance treatment
of repeated depressions whether or not there is evidence of a manic
or manic-like episode in the past.
Dosage
of antidepressants varies, depending on the type of drug, the person's
body chemistry, age, and, sometimes, body weight. Dosages are generally
started low and raised gradually over time until the desired effect
is reached without the appearance of troublesome side effects.
There
are a number of antidepressant medications available. They differ
in their side effects and, to some extent, in their level of effectiveness.
Tricyclic antidepressants (named for their chemical structure) are
more commonly used for treatment of major depressions than are monoamine
oxidase inhibitors (MAOIs); but MAOIs are often helpful in so-called
"atypical" depressions in which there are symptoms like
oversleeping, anxiety, panic attacks, and phobias.
The
last few years have seen the introduction of a number of new antidepressants.
Several of them are called "selective serotonin reuptake inhibitors"
(SSRIs). Those available at the present time in the United States
are fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine
(Paxil), and sertraline (Zoloft). (Luvox has
been approved for obsessive-compulsive disorder , and Paxil
has been approved for panic disorder.) Though structurally different
from each other, all the SSRIs' antidepressant effects are due to
their action on one specific neurotransmitter, serotonin. Two other
antidepressants that affect two neurotransmitters serotonin and
norepinephrine have also been approved by the FDA. They are venlafaxine
(Effexor) and nefazodone (Serzone). All of these newer
antidepressants seem to have less bothersome side effects than the
older tricyclic antidepressants.
The
tricyclic antidepressant clomipramine (Anafranil) affects
serotonin but is not as selective as the SSRIs. It was the first
medication specifically approved for use in the treatment of obsessive-
compulsive disorder (OCD). Prozac and Luvox have now
been approved for use with OCD.
Another
of the newer antidepressants, bupropion (Wellbutrin), is
chemically unrelated to the other antidepressants. It has more effect
on norepinephrine and dopamine than on serotonin. Wellbutrin
has not been associated with weight gain or sexual dysfunction.
It is contraindicated for individuals with, or at risk for, a seizure
disorder or who have been diagnosed with bulimia or anorexia nervosa.
Side
Effects of Antidepressant Medications
1.
Tricyclic Antidepressants
There
are a number of possible side effects with tricyclic antidepressants
that vary, depending on the medication. For example, amitriptyline
(Elavil) may make people feel drowsy, while protriptyline
(Vivactil) hardly does this at all and, in some people, may
have an opposite effect, producing feelings of anxiety and restlessness.
Because of this kind of variation in side effects, one antidepressant
might be highly desirable for one person and not recommended for
another. Tricyclics on occasion may complicate specific heart problems,
and for this reason the physician should be aware of all such difficulties.
Other side effects with tricyclics may include blurred vision, dry
mouth, constipation, weight gain, dizziness when changing position,
increased sweating, difficulty urinating, changes in sexual desire,
decrease in sexual ability, muscle twitches, fatigue, and weakness.
Not all these medications produce all side effects, and not everybody
gets them. Some will disappear quickly, while others may remain
for the length of treatment. Some side effects are similar to symptoms
of depression (for instance, fatigue and constipation). For this
reason, the patient or family should discuss all symptoms with the
doctor, who may change the medication or dosage.
Tricyclics
also may interact with thyroid hormone, antihypertensive medications,
oral contraceptives, some blood coagulants, some sleeping medications,
antipsychotic medications, diuretics, antihistamines, aspirin, bicarbonate
of soda, vitamin C, alcohol, and tobacco.
An
overdose of antidepressants is serious and potentially lethal. It
requires immediate medical attention. Symptoms of an overdose of
tricyclic antidepressant medication develop within an hour and may
start with rapid heartbeat, dilated pupils, flushed face, and agitation,
and progress to confusion, loss of consciousness, seizures, irregular
heart beats, cardiorespiratory collapse, and death.
2.
The Newer Antidepressants
The
most common side effects of these antidepressants are gastrointestinal
problems and headache. Others are insomnia, anxiety, and agitation.
Because of potentially serious interaction between these medications
and monoamine oxidase inhibitors, it is advisable to stop taking
one medication from 2 to 4 or 5 weeks before starting the other,
depending on the specific medications involved. In addition, some
SSRIs have been found to affect metabolism of certain other medications
in the liver, creating possible drug interactions.
3.
Monoamine Oxidase Inhibitors (MAOIs)
MAOIs
may cause some side effects similar to those of the other antidepressants.
Dizziness when changing position and rapid heartbeat are common.
MAOIs also react with certain foods and alcoholic beverages (such
as aged cheeses, foods containing monosodium glutamate (MSG), Chianti
and other red wines), and other medications (such as over-the-counter
cold and allergy preparations, local anesthetics, amphetamines,
insulin, some narcotics, and antiparkinsonian medications). These
reactions often do not appear for several hours. Signs may include
severe high blood pressure, headache, nausea, vomiting, rapid heartbeat,
possible confusion, psychotic symptoms, seizures, stroke, and coma.
For this reason, people taking MAOIs must stay away from
restricted foods, drinks, and medications. They should be sure that
they are furnished, by their doctor or pharmacist, a list of all
foods, beverages, and other medications that should be avoided.
Precautions
to be Observed When Taking Antidepressants
When
taking antidepressants, it is important to tell all doctors (and
dentists) being seen not just the one who is treating the depression
about all medications being used, including over-the-counter preparations
and alcohol. Antidepressants should be taken only in the amount
prescribed and should be kept in a secure place away from children.
When used with proper care, following doctors' instructions, antidepressants
are extremely useful medications that can reverse the misery of
a depression and help a person feel like himself again.
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Everyone
experiences anxiety at one time or another "butterflies in
the stomach" before giving a speech or sweaty palms during
a job interview are common symptoms. Other symptoms of anxiety include
irritability, uneasiness, jumpiness, feelings of apprehension, rapid
or irregular heartbeat, stomach ache, nausea, faintness, and breathing
problems.
Anxiety
is often manageable and mild. But sometimes it can present serious
problems. A high level or prolonged state of anxiety can be very
incapacitating, making the activities of daily life difficult or
impossible. Besides generalized anxiety, other anxiety disorders
are panic, phobia, obsessive-compulsive disorder (OCD), and posttraumatic
stress disorder.
Phobias,
which are persistent, irrational fears and are characterized by
avoidance of certain objects, places, and things, sometimes accompany
anxiety. A panic attack is a severe form of anxiety that may occur
suddenly and is marked with symptoms of nervousness, breathlessness,
pounding heart, and sweating. Sometimes the fear that one may die
is present.
Antianxiety
medications help to calm and relax the anxious person and remove
the troubling symptoms. There are a number of antianxiety medications
currently available. The preferred medications for most anxiety
disorders are the benzodiazepines. In addition to the benzodiazepines,
a non-benzodiazepine, buspirone (BuSpar), is used for generalized
anxiety disorders. Antidepressants are also effective for panic
attacks and some phobias and are often prescribed for these conditions.
They are also sometimes used for more generalized forms of anxiety,
especially when it is accompanied by depression. The medications
approved by the FDA for use in OCD are all antidepressants clomipramine,
fluoxetine, and fluvoxamine.
The
most commonly used benzodiazepines are alprazolam (Xanax)
and diazepam (Valium), followed by chlordiazepoxide (Librium,
Librax, Libritabs). Benzodiazepines are relatively fast-acting
medications; in contrast, buspirone must be taken daily for 2 or
3 weeks prior to exerting its antianxiety effect. Most benzodiazepines
will begin to take effect within hours, some in even less time.
Benzodiazepines differ in duration of action in different individuals;
they may be taken two or three times a day, or sometimes only once
a day. Dosage is generally started at a low level and gradually
raised until symptoms are diminished or removed. The dosage will
vary a great deal depending on the symptoms and the individual's
body chemistry.
Benzodiazepines
have few side effects. Drowsiness and loss of coordination are most
common; fatigue and mental slowing or confusion can also occur.
These effects make it dangerous to drive or operate some machinery
when taking benzodiazepines especially when the patient is just
beginning treatment. Other side effects are rare.
Benzodiazepines
combined with other medications can present a problem, notably when
taken together with commonly used substances such as alcohol. It
is wise to abstain from alcohol when taking benzodiazepines, as
the interaction between benzodiazepines and alcohol can lead to
serious and possibly life-threatening complications. Following the
doctor's instructions is important. The doctor should be informed
of all other medications the patient is taking, including over-the-counter
preparations. Benzodiazepines increase central nervous system depression
when combined with alcohol, anesthetics, antihistamines, sedatives,
muscle relaxants, and some prescription pain medications. Particular
benzodiazepines may influence the action of some anticonvulsant
and cardiac medications. Benzodiazepines have also been associated
with abnormalities in babies born to mothers who were taking these
medications during pregnancy.
With
benzodiazepines, there is a potential for the development of tolerance
and dependence as well as the possibility of abuse and withdrawal
reactions. For these reasons, the medications are generally prescribed
for brief periods of time days or weeks and sometimes intermittently,
for stressful situations or anxiety attacks. For the same reason,
ongoing or continuous treatment with benzodiazepines is not recommended
for most people. Some patients may, however, need long-term treatment.
Consult
with the doctor before discontinuing a benzodiazepine. A withdrawal
reaction may occur if the treatment is abruptly stopped. Symptoms
may include anxiety, shakiness, headache, dizziness, sleeplessness,
loss of appetite, and, in more severe cases, fever, seizures, and
psychosis. A withdrawal reaction may be mistaken for a return of
the anxiety, since many of the symptoms are similar. Thus, after
benzodiazepines are taken for an extended period, the dosage is
gradually tapered off before being completely stopped.
Although
benzodiazepines, buspirone, tricyclic antidepressants, or SSRIs
are the preferred medications for most anxiety disorders, occasionally,
for specific reasons, one of the following medications may be prescribed:
antipsychotic medications; antihistamines (such as Atarax, Vistaril,
and others); barbiturates such as phenobarbital; and beta-blockers
such as propranolol (Inderal, Inderide). Propanediols such
as meprobamate (Equanil) were commonly prescribed prior to
the introduction of the benzodiazepines, but today rarely are used.
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Special
Considerations
Children,
the elderly, and pregnant and nursing women have special concerns
and needs when taking psychotherapeutic medications. Some effects
of medications on the growing body, the aging body, and the childbearing
body are known, but much remains to be learned. Research in these
areas is ongoing.
While,
in general, what has been said in this booklet applies to these
groups, below are a few special points to bear in mind:
Children
Studies
consistently show that about 15 percent of the U.S. population below
age 18, or over 9 million children, suffer from a psychiatric disorder
that compromises their ability to function. It is easy to overlook
the seriousness of childhood mental disorders. In children, these
disorders may present symptoms that are different or less clear-cut
than the same disorders in adults. Younger children, especially,
may not talk about what's bothering them, but this is sometimes
a problem with older children as well. For this reason, having a
doctor, other mental health professional, or psychiatric team examine
the child is especially important.
There
is an array of treatments that can help these children. These include
medications and psychotherapy behavioral therapy, treatment of impaired
social skills, parental and family therapy, group therapy. The therapy
used for an individual child is based on the child's diagnosis and
individual needs.
When
the decision is reached that a child should take medication, active
monitoring by all caretakers (parents, teachers, others who have
charge of the child) is essential. Children should be watched and
questioned for side effects (many children, especially younger ones,
do not volunteer information). They should also be monitored to
see that they are actually taking the medication and taking the
proper dosage.
One
type of medication not covered elsewhere in this booklet is stimulants.
Three stimulants, methylphenidate (Ritalin) dextroamphetamine
(Dexedrine), and pemoline (Cylert) are more commonly
prescribed for children than adults. They are successfully used
in the treatment of attention- deficit/ hyperactivity disorder (ADHD).
ADHD is a disorder usually diagnosed in early childhood in which
the child exhibits such symptoms as short attention span, excessive
activity, and impulsivity. A child with ADHD should take a stimulant
medication only on the advice and under the careful supervision
of a physician.
The
use with children of the medications described in this booklet is
more limited than with adults. In the list of medications beginning
on page , commonly used psychotropic medications that have specific
indications and dose guidelines for children, as listed in the Physicians'
Desk Reference, are indicated by a double asterisk (**).
The
Elderly
Persons
over the age of 65 make up 12 percent of the population of the United
States, yet they receive 30 percent of prescriptions filled. The
elderly generally have more medical problems and often are taking
medications for more than one of these problems. In addition, they
tend to be more sensitive to medications. Even healthy older people
eliminate some medications from the body more slowly than younger
persons and therefore require a lower or less frequent dosage to
maintain an effective level of medication.
The
elderly may sometimes accidentally take too much of a medication
because they forget that they have taken a dose and take another
dose. The use of a 7-day pill box, as described on page of this
brochure, is especially helpful to an elderly person.
The
elderly and those close to them friends, relatives, caretakers need
to pay special attention and watch for adverse (negative) physical
and psychological responses to medication. Because they often take
more medications--not only those prescribed but also over-the-counter
preparations and home or folk remedies the possibility of negative
drug interactions is higher.
Pregnant,
Nursing, or Childbearing-Age Women
In
general, during pregnancy, all medications (including psychotherapeutic
medications) should be avoided where possible, and other methods
of treatment should be tried.
A
woman who is taking a psychotherapeutic medication and plans to
become pregnant should discuss her plans with her doctor; if she
discovers that she is pregnant, she should contact her doctor immediately.
During early pregnancy, there is a possible risk of birth defects
with some of these medications, and for this reason:
1)
Lithium is not recommended during the first 3 months of pregnancy.
2)
Benzodiazepines are not recommended during the first 3 months of
pregnancy.
The
decision to use a psychotherapeutic medication should be made only
after a careful discussion with the doctor concerning the risks
and benefits to the woman and her baby.
Small
amounts of medication pass into the breast milk; this is a consideration
for mothers who are planning to breast-feed.
A
woman who is taking birth-control pills should be sure that her
doctor is aware of this. The estrogen in these pills may alter the
breakdown of medications by the body, for example increasing side
effects of some antianxiety medications and/or reducing their efficacy
to relieve symptoms of anxiety.
For
more detailed information, talk to your doctor or mental health
professional, consult your local public library, or write to the
pharma- ceutical company that produces the medication or the U.S.
Food and Drug Administration, 5600 Fishers Lane, Rockville, MD 20857.
Reference
AHFS
Drug Information, 91. Gerald K. McEvoy, Editor. Bethesda, Maryland:
American Society of Hospital Pharmacists, Inc., 1991.
Bohn
J. And Jefferson J.W., Lithium and Manic Depression: A Guide.
Madison, Wisconsin: Lithium Information Center, rev. ed. 1990.
Goodwin
F.K. and Jamison K.R. Manic-Depressive Illness. New York:
Oxford University Press, 1990.
Jensen
P.S., Vitiello B., Leonard H., and Laughren T.P. Child and adolescent
psychopharmacology: expanding the research base. Psychopharmacology
Bulletin, Vol. 30, No. 1, 1994.
Johnston
H.F. Stimulants and Hyperactive Children: A Guide. Madison,
Wisconsin: Lithium Information Center, 1990.
Medenwald
J.R., Greist J.H., and Jefferson J.W. Carbamazepine and Manic
Depression: A Guide. Madison, Wisconsin: Lithium Information
Center, rev. ed., 1990.
Physicians'
Desk Reference, 48th edition. Montvale, New Jersey: Medical
Economics Data Production Company, 1994.
New
Developments in Pharmacologic Treatment of Schizophrenia. Rockville,
Maryland: National Institute of Mental Health, 1992.
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