This booklet is designed to help mental health patients and their
families understand how and why medications can be used as part
of the treatment of mental health problems.
It is important for you to be well informed about medications you
may need. You should know what medications you take and the dosage,
and learn everything you can about them. Many medications now come
with patient package inserts, describing the medication, how it
should be taken, and side effects to look for. When you go to a
new doctor, always take with you a list of all of the prescribed
medications (including dosage), over-the-counter medications, and
vitamin, mineral, and herbal supplements you take. The list should
include herbal teas and supplements such as St. John's wort, echinacea,
ginkgo, ephedra, and ginseng. Almost any substance that can change
behavior can cause harm if used in the wrong amount or frequency
of dosing, or in a bad combination. Drugs differ in the speed, duration
of action, and in their margin for error.
If you are taking more than one medication, and at different times
of the day, it is essential that you take the correct dosage of
each medication. An easy way to make sure you do this is to use
a 7-day pillbox, available in any pharmacy, and to fill the box
with the proper medication at the beginning of each week. Many pharmacies
also have pillboxes with sections for medications that must be taken
more than once a day.
This booklet is intended to inform you, but it is not a "do-it-yourself"
manual. Leave it to the doctor, working closely with you, to diagnose
mental illness, interpret signs and symptoms of the illness, prescribe
and manage medication, and explain any side effects. This will help
you ensure that you use medication most effectively and with minimum
risk of side effects or complications.
Anyone can develop a mental illness—you, a family
member, a friend, or a neighbor. Some disorders are mild; others
are serious and long-lasting. These conditions can be diagnosed
and treated. Most people can live better lives after treatment.
And psychotherapeutic medications are an increasingly important
element in the successful treatment of mental illness.
Medications for mental illnesses were first introduced in the early
1950s with the antipsychotic chlorpromazine. Other medications have
followed. These medications have changed the lives of people with
these disorders for the better.
Psychotherapeutic medications also may make other kinds of treatment
more effective. Someone who is too depressed to talk, for instance,
may have difficulty communicating during psychotherapy or counseling,
but the right medication may improve symptoms so the person can
respond. For many patients, a combination of psychotherapy and medication
can be an effective method of treatment.
Another benefit of these medications is an increased understanding
of the causes of mental illness. Scientists have learned much more
about the workings of the brain as a result of their investigations
into how psychotherapeutic medications relieve the symptoms of disorders
such as psychosis, depression, anxiety, obsessive-compulsive disorder,
and panic disorder.
Just as aspirin can reduce a fever without curing the infection
that causes it, psychotherapeutic medications act by controlling
symptoms. Psychotherapeutic medications do not cure mental illness,
but in many cases, they can help a person function 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 psychosis and help them to see reality
more clearly. And antidepressants can lift the dark, heavy moods
of depression. The degree of response—ranging from a little
relief of symptoms to complete relief—depends on a variety
of factors related to the individual and the disorder being treated.
How long someone must take a psychotherapeutic medication depends
on the individual and the disorder. Many depressed and anxious people
may need medication for a single period—perhaps for several
months—and then never need it again. People with conditions
such as schizophrenia or bipolar disorder (also known as manic-depressive
illness), or those whose depression or anxiety is chronic or recurrent,
may have to take medication indefinitely.
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 have side effects, and 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.
You and your family can help your doctor find the right medications
for you. The doctor needs to know your medical history, other medications
being taken, and life plans such as hoping to have a baby. After
taking the medication for a short time, you should tell the doctor
about favorable results as well as side effects. The Food and Drug
Administration (FDA) and professional organizations recommend that
the patient or a family member ask the following questions when
a medication is prescribed:
• 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, or other medications should I avoid
while taking the prescribed medication?
• Should it be taken with food or on an empty stomach?
• Is it safe to drink alcohol while on this medication?
• What are the side effects, and what should I do if they
occur?
• Is a Patient Package Insert for the medication available?
This booklet describes medications by their generic (chemical) names
and in italics by their trade names (brand names used by pharmaceutical
companies). They are divided into four large categories—antipsychotic,
antimanic, antidepressant, and antianxiety medications. Medications
that specifically affect children, the elderly, and women during
the reproductive years are discussed in a separate section of the
booklet.
Lists at the end of the booklet give the generic name and the trade
name of the most commonly prescribed medications and note the section
of the booklet that contains information about each type. A separate
chart shows the trade and generic names of medications commonly
prescribed for children and adolescents.
Treatment evaluation studies have established the effectiveness
of the medications described here, but much remains to be learned
about them. 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.
A person who is psychotic is out of touch with reality. People with
psychosis may hear "voices" or have strange and illogical
ideas (for example, thinking that others can hear their thoughts,
or are trying to harm them, or that they are the President of the
United States or some other famous person). They may get excited
or angry for no apparent reason, or spend a lot of time by themselves,
or in bed, sleeping during the day and staying awake at night. The
person may neglect appearance, not bathing or changing clothes,
and may be hard to talk to—barely talking or saying things
that make no sense. They often are initially unaware that their
condition is an illness.
These kinds of behaviors are symptoms of a psychotic illness such
as schizophrenia. Antipsychotic medications 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 an episode of the illness
as well.
There are a number of antipsychotic (neuroleptic) medications available.
These medications affect neurotransmitters that allow communication
between nerve cells. One such neurotransmitter, dopamine, is thought
to be relevant to schizophrenia symptoms. All these medications
have been shown to be effective for schizophrenia. 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 prescribed,
the more serious the illness; but this is not always true.
The first antipsychotic medications were introduced in the 1950s.
Antipsychotic medications have helped many patients with psychosis
lead a more normal and fulfilling life by alleviating such symptoms
as hallucinations, both visual and auditory, and paranoid thoughts.
However, the early antipsychotic medications often have unpleasant
side effects, such as muscle stiffness, tremor, and abnormal movements,
leading researchers to continue their search for better drugs.
The 1990s saw the development of several new drugs for schizophrenia,
called "atypical antipsychotics." Because they have fewer
side effects than the older drugs, today they are often used as
a first-line treatment. The first atypical antipsychotic, clozapine
(Clozaril), was introduced in the United States in 1990. In clinical
trials, this medication was found to be more effective than conventional
or "typical" antipsychotic medications in individuals
with treatment-resistant schizophrenia (schizophrenia that has not
responded to other drugs), and the risk of tardive dyskinesia (a
movement disorder) was lower. However, because of the potential
side effect of a serious blood disorder—agranulocytosis (loss
of the white blood cells that fight infection)—patients who
are on clozapine must have a blood test every 1 or 2 weeks. The
inconvenience and cost of blood tests and the medication itself
have made maintenance on clozapine difficult for many people. Clozapine,
however, continues to be the drug of choice for treatment-resistant
schizophrenia patients.
Several other atypical antipsychotics have been developed since
clozapine was introduced. The first was risperidone (Risperdal),
followed by olanzapine (Zyprexa), quetiapine (Seroquel), and ziprasidone
(Geodon). Each has a unique side effect profile, but in general,
these medications are better tolerated than the earlier drugs.
All these medications have their place in the treatment of schizophrenia,
and doctors will choose among them. They will consider the person's
symptoms, age, weight, and personal and family medication history.
Dosages and side effects. Some drugs are very potent and the doctor
may prescribe a low dose. Other drugs are not as potent and a higher
dose may be prescribed.
Unlike some prescription drugs, which must be taken several times
during the day, some antipsychotic medications can be taken just
once a day. In order to reduce daytime side effects such as sleepiness,
some medications can be taken at bedtime. Some antipsychotic medications
are available in "depot" forms that can be injected once
or twice a month.
Most side effects of antipsychotic medications are mild. Many common
ones lessen or disappear after the first few weeks of treatment.
These include drowsiness, rapid heartbeat, and dizziness when changing
position.
Some people gain weight while taking medications and need to pay
extra attention to diet and exercise to control their weight. Other
side effects may include a decrease in sexual ability or interest,
problems with menstrual periods, sunburn, or skin rashes. If a side
effect occurs, the doctor should be told. He or she may prescribe
a different medication, change the dosage or schedule, or prescribe
an additional medication to control the side effects.
Just as people vary in their responses to antipsychotic medications,
they also vary in how quickly they improve. Some symptoms may diminish
in days; others take weeks or months. Many people see substantial
improvement by the sixth week of treatment. If there is no improvement,
the doctor may try a different type of medication. The doctor cannot
tell beforehand which medication will work for a person. Sometimes
a person must try several medications before finding one that works.
If a person is feeling better or even completely well, the medication
should not be stopped without talking to the doctor. It may be necessary
to stay on the medication to continue feeling well. If, after consultation
with the doctor, the decision is made to discontinue the medication,
it is important to continue to see the doctor while tapering off
medication. Many people with bipolar disorder, for instance, require
antipsychotic medication only for a limited time during a manic
episode until mood-stabilizing medication takes effect. On the other
hand, some people may need to take antipsychotic medication for
an extended period of time. 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.
Multiple medications. Antipsychotic medications can produce unwanted
effects when taken with other medications. Therefore, the doctor
should be told about all medicines being taken, including over-the-counter
medications and vitamin, mineral, and herbal supplements, and the
extent of alcohol use. Some antipsychotic medications interfere
with antihypertensive medications (taken for high blood pressure),
anticonvulsants (taken for epilepsy), and medications used for Parkinson's
disease. Other antipsychotics add to the effect of alcohol and other
central nervous system depressants such as antihistamines, antidepressants,
barbiturates, some sleeping and pain medications, and narcotics.
Other effects. Long-term treatment of schizophrenia with one of
the older, or "conventional," antipsychotics may cause
a person to develop tardive dyskinesia (TD). Tardive dyskinesia
is a condition characterized by involuntary movements, most often
around the mouth. It may range from mild to severe. In some people,
it cannot be reversed, while others recover partially or completely.
Tardive dyskinesia is sometimes seen in people with schizophrenia
who have never been treated with an antipsychotic medication; this
is called "spontaneous dyskinesia."1 However, it is most
often seen after long-term treatment with older antipsychotic medications.
The risk has been reduced with the newer "atypical" medications.
There is a higher incidence in women, and the risk rises with age.
The possible risks of long-term treatment with an antipsychotic
medication must be weighed against the benefits in each case. The
risk for TD is 5 percent per year with older medications; it is
less with the newer medications.
Bipolar disorder is characterized by cycling mood changes: severe
highs (mania) and lows (depression). Episodes may be predominantly
manic or depressive, with normal mood between episodes. Mood swings
may follow each other very closely, within days (rapid cycling),
or may be separated by months to years. The "highs" and
"lows" may vary in intensity and severity and can co-exist
in "mixed" episodes.
When people are in a manic "high," they may be overactive,
overly talkative, have a great deal of energy, and have much less
need for sleep than normal. They may switch quickly from one topic
to another, as if they cannot get their thoughts out fast enough.
Their attention span is often short, and they can be easily distracted.
Sometimes people who are "high" are irritable or angry
and have false or inflated ideas about their position or importance
in the world. They may be very elated, and full of grand schemes
that might range from business deals to romantic sprees. Often,
they show poor judgment in these ventures. Mania, untreated, may
worsen to a psychotic state.
In a depressive cycle the person may have a "low" mood
with difficulty concentrating; lack of energy, with slowed thinking
and movements; changes in eating and sleeping patterns (usually
increases of both in bipolar depression); feelings of hopelessness,
helplessness, sadness, worthlessness, guilt; and, sometimes, thoughts
of suicide.
Lithium. The medication used most often to treat bipolar disorder
is lithium. Lithium evens out mood swings in both directions—from
mania to depression, and depression to mania—so it is used
not just for manic attacks or flare-ups of the illness but also
as an ongoing maintenance treatment for bipolar disorder.
Although lithium will reduce severe manic symptoms in about 5 to
14 days, it may be weeks to several months before 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. Antidepressants may also
be added to lithium during the depressive phase of bipolar disorder.
If given in the absence of lithium or another mood stabilizer, antidepressants
may provoke a switch into mania in people with bipolar disorder.
A person may have one episode of bipolar disorder and never have
another, or be free of illness for several years. But for those
who have more than one manic episode, doctors usually give serious
consideration to maintenance (continuing) treatment with lithium.
Some people respond well to maintenance treatment and have no further
episodes. Others may have moderate mood swings that lessen as treatment
continues, or have less frequent or less severe episodes. Unfortunately,
some people with bipolar disorder may not be helped at all by lithium.
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.
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. Blood lithium levels
are checked at the beginning of treatment to determine the best
lithium dosage. Once a person is stable and on a maintenance dosage,
the lithium level should be checked every few months. How much lithium
people need to take may vary over time, depending on how ill they
are, their body chemistry, and their physical condition.
Side effects of lithium. When people first take lithium, they may
experience side effects such as drowsiness, weakness, nausea, fatigue,
hand tremor, or increased thirst and urination. Some may disappear
or decrease quickly, although hand tremor may persist. Weight gain
may also occur. Dieting will help, but crash diets should be avoided
because they may raise or lower the lithium level. Drinking low-calorie
or no-calorie beverages, especially water, will help keep weight
down. Kidney changes—increased urination and, in children,
enuresis (bed wetting)—may develop during treatment. These
changes 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 may be given along with lithium.
Because of possible complications, doctors either may not recommend
lithium or may prescribe it with caution when a person has thyroid,
kidney, or heart disorders, epilepsy, or brain damage. Women of
childbearing age should be aware that lithium increases the risk
of congenital malformations in babies. Special caution should be
taken during the first 3 months of pregnancy.
Anything that lowers the level of sodium in the body—reduced
intake of table salt, a switch to a low-salt diet, heavy sweating
from an unusual amount of exercise or a very hot climate, fever,
vomiting, or diarrhea—may cause a lithium buildup and lead
to toxicity. It is important to be aware of conditions that lower
sodium or cause dehydration and to tell the doctor if any of these
conditions are present so the dose can be changed.
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, blurred vision, confusion,
dizziness, muscle twitching, irregular heartbeat, and, ultimately,
seizures. A lithium overdose can be life-threatening. People who
are taking lithium should tell every doctor who is treating them,
including dentists, about all medications they are 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. Some people with symptoms of mania who do not benefit
from or would prefer to avoid lithium have been found to respond
to anticonvulsant medications commonly prescribed to treat seizures.
The anticonvulsant valproic acid (Depakote, divalproex sodium) is
the main alternative therapy for bipolar disorder. It is as effective
in non-rapid-cycling bipolar disorder as lithium and appears to
be superior to lithium in rapid-cycling bipolar disorder.2 Although
valproic acid 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 valproic acid has caused liver dysfunction, liver function
tests should be performed before therapy and at frequent intervals
thereafter, particularly during the first 6 months of therapy.
Studies conducted in Finland in patients with epilepsy have shown
that valproic acid may increase testosterone levels in teenage girls
and produce polycystic ovary syndrome (POS) in women who began taking
the medication before age 20.3,4 POS can cause obesity, hirsutism
(body hair), and amenorrhea. Therefore, young female patients should
be monitored carefully by a doctor.
Other anticonvulsants used for bipolar disorder include carbamazepine
(Tegretol), lamotrigine (Lamictal), gabapentin (Neurontin), and
topiramate (Topamax). The evidence for anticonvulsant effectiveness
is stronger for acute mania than for long-term maintenance of bipolar
disorder. Some studies suggest particular efficacy of lamotrigine
in bipolar depression. At present, the lack of formal FDA approval
of anticonvulsants other than valproic acid for bipolar disorder
may limit insurance coverage for these medications.
Most people who have bipolar disorder take more than one medication.
Along with the mood stabilizer—lithium and/or an anticonvulsant—they
may take a medication for accompanying agitation, anxiety, insomnia,
or depression. It is important to continue taking the mood stabilizer
when taking an antidepressant because research has shown that treatment
with an antidepressant alone increases the risk that the patient
will switch to mania or hypomania, or develop rapid cycling.5 Sometimes,
when a bipolar patient is not responsive to other medications, an
atypical antipsychotic medication is prescribed. Finding the best
possible medication, or combination of medications, is of utmost
importance to the patient and requires close monitoring by a doctor
and strict adherence to the recommended treatment regimen.
Major depression, the kind of depression that will most likely benefit
from treatment with medications, is more than just "the blues."
It is a condition that lasts 2 weeks or more, and interferes with
a person's ability to carry on daily tasks and enjoy activities
that previously brought pleasure. Depression is associated with
abnormal functioning of the brain. An interaction between genetic
tendency and life history appears to determine a person's chance
of becoming depressed. Episodes of depression may be triggered by
stress, difficult life events, side effects of medications, or medication/substance
withdrawal, or even viral infections that can affect the brain.
Depressed people will seem sad, or "down," or may be unable
to enjoy their normal activities. They may have no appetite and
lose weight (although some people eat more and gain weight when
depressed). They may sleep too much or too little, have difficulty
going to sleep, sleep restlessly, or awaken very early in the morning.
They may speak of feeling guilty, worthless, or hopeless; they may
lack energy or be jumpy and agitated. They may think about killing
themselves and may even make a suicide attempt. Some depressed people
have delusions (false, fixed ideas) about poverty, sickness, or
sinfulness that are related to their depression. Often feelings
of depression are worse at a particular time of day, for instance,
every morning or every evening.
Not everyone who is depressed has all these symptoms, but everyone
who is depressed has at least some of them, co-existing, on most
days. Depression can range in intensity from mild to severe. Depression
can co-occur with other medical disorders such as cancer, heart
disease, stroke, Parkinson's disease, Alzheimer's disease, and diabetes.
In such cases, the depression is often overlooked and is not treated.
If the depression is recognized and treated, a person's quality
of life can be greatly improved.
Antidepressants are used most often for serious depressions, but
they can also be helpful for some milder depressions. Antidepressants
are not "uppers" or stimulants, but rather take away or
reduce the symptoms of depression and help depressed people feel
the way they did before they became depressed.
The doctor chooses an antidepressant based on the individual's symptoms.
Some people notice improvement in the first couple of weeks; but
usually the medication must be taken regularly for at least 6 weeks
and, in some cases, as many as 8 weeks before the full therapeutic
effect occurs. If there is little or no change in symptoms after
6 or 8 weeks, the doctor may prescribe a different medication or
add a second medication such as lithium, to augment the action of
the original antidepressant. Because there is no way of knowing
beforehand which medication will be effective, the doctor may have
to prescribe first one and then another. To give a medication time
to be effective and to prevent a relapse of the depression once
the patient is responding to an antidepressant, the medication should
be continued for 6 to 12 months, or in some cases longer, carefully
following the doctor's instructions. When a patient and the doctor
feel that medication can be discontinued, withdrawal should be discussed
as to how best to taper off the medication gradually. Never discontinue
medication without talking to the doctor about it. For those who
have had several bouts of depression, long-term treatment with medication
is the most effective means of preventing more episodes.
Dosage of antidepressants varies, depending on the type of drug
and the person's body chemistry, age, and, sometimes, body weight.
Traditionally, antidepressant dosages are started low and raised
gradually over time until the desired effect is reached without
the appearance of troublesome side effects. Newer antidepressants
may be started at or near therapeutic doses.
Early antidepressants. From the 1960s through the 1980s, tricyclic
antidepressants (named for their chemical structure) were the first
line of treatment for major depression. Most of these medications
affected two chemical neurotransmitters, norepinephrine and serotonin.
Though the tricyclics are as effective in treating depression as
the newer antidepressants, their side effects are usually more unpleasant;
thus, today tricyclics such as imipramine, amitriptyline, nortriptyline,
and desipramine are used as a second- or third-line treatment. Other
antidepressants introduced during this period were monoamine oxidase
inhibitors (MAOIs). MAOIs are effective for some people with major
depression who do not respond to other antidepressants. They are
also effective for the treatment of panic disorder and bipolar depression.
MAOIs approved for the treatment of depression are phenelzine (Nardil),
tranylcypromine (Parnate), and isocarboxazid (Marplan). Because
substances in certain foods, beverages, and medications can cause
dangerous interactions when combined with MAOIs, people on these
agents must adhere to dietary restrictions. This has deterred many
clinicians and patients from using these effective medications,
which are in fact quite safe when used as directed.
The past decade has seen the introduction of many new antidepressants
that work as well as the older ones but have fewer side effects.
Some of these medications primarily affect one neurotransmitter,
serotonin, and are called selective serotonin reuptake inhibitors
(SSRIs). These include fluoxetine (Prozac), sertraline (Zoloft),
fluvoxamine (Luvox), paroxetine (Paxil), and citalopram (Celexa).
The late 1990s ushered in new medications that, like the tricyclics,
affect both norepinephrine and serotonin but have fewer side effects.
These new medications include venlafaxine (Effexor) and nefazadone
(Serzone).
Cases of life-threatening hepatic failure have been reported in
patients treated with nefazodone (Serzone). Patients should call
the doctor if the following symptoms of liver dysfunction occur—yellowing
of the skin or white of eyes, unusually dark urine, loss of appetite
that lasts for several days, nausea, or abdominal pain.
Other newer medications chemically unrelated to the other antidepressants
are the sedating mirtazepine (Remeron) and the more activating bupropion
(Wellbutrin). Wellbutrin has not been associated with weight gain
or sexual dysfunction but is not used for people with, or at risk
for, a seizure disorder.
Each antidepressant differs in its side effects and in its effectiveness
in treating an individual person, but the majority of people with
depression can be treated effectively by one of these antidepressants.
Side effects of antidepressant medications. Antidepressants may
cause mild, and often temporary, side effects (sometimes referred
to as adverse effects) in some people. Typically, these are not
serious. However, any reactions or side effects that are unusual,
annoying, or that interfere with functioning should be reported
to the doctor immediately. The most common side effects of tricyclic
antidepressants, and ways to deal with them, are as follows:
• Dry mouth—it is helpful to drink
sips of water; chew sugarless gum; brush teeth daily.
• Constipation—bran cereals, prunes, fruit, and vegetables
should be in the diet.
• Bladder problems—emptying the bladder completely
may be difficult, and the urine stream may not be as strong as
usual. Older men with enlarged prostate conditions may be at particular
risk for this problem. The doctor should be notified if there
is any pain.
• Sexual problems—sexual functioning may be impaired;
if this is worrisome, it should be discussed with the doctor.
• Blurred vision—this is usually temporary and will
not necessitate new glasses. Glaucoma patients should report any
change in vision to the doctor.
• Dizziness—rising from the bed or chair slowly is
helpful.
• Drowsiness as a daytime problem—this usually passes
soon. A person who feels drowsy or sedated should not drive or
operate heavy equipment. The more sedating antidepressants are
generally taken at bedtime to help sleep and to minimize daytime
drowsiness.
• Increased heart rate—pulse rate is often elevated.
Older patients should have an electrocardiogram (EKG) before beginning
tricyclic treatment.
The newer antidepressants, including SSRIs, have different types
of side effects, as follows:
• Sexual problems—fairly common, but reversible, in
both men and women. The doctor should be consulted if the problem
is persistent or worrisome.
• Headache—this will usually go away after a short
time.
• Nausea—may occur after a dose, but it will disappear
quickly.
• Nervousness and insomnia (trouble falling asleep or waking
often during the night)—these may occur during the first
few weeks; dosage reductions or time will usually resolve them.
• Agitation (feeling jittery)—if this happens for
the first time after the drug is taken and is more than temporary,
the doctor should be notified.
• Any of these side effects may be amplified when an SSRI
is combined with other medications that affect serotonin. In the
most extreme cases, such a combination of medications (e.g., an
SSRI and an MAOI) may result in a potentially serious or even
fatal "serotonin syndrome," characterized by fever,
confusion, muscle rigidity, and cardiac, liver, or kidney problems.
The small number of people for whom MAOIs are
the best treatment need to avoid taking decongestants and consuming
certain foods that contain high levels of tyramine, such as many
cheeses, wines, and pickles. The interaction of tyramine with MAOIs
can bring on a sharp increase in blood pressure that can lead to
a stroke. The doctor should furnish a complete list of prohibited
foods that the individual should carry at all times. Other forms
of antidepressants require no food restrictions. MAOIs also should
not be combined with other antidepressants, especially SSRIs, due
to the risk of serotonin syndrome.
Medications of any kind—prescribed, over-the-counter, or herbal
supplements—should never be mixed without consulting the doctor;
nor should medications ever be borrowed from another person. Other
health professionals who may prescribe a drug—such as a dentist
or other medical specialist—should be told that the person
is taking a specific antidepressant and the dosage. Some drugs,
although safe when taken alone, can cause severe and dangerous side
effects if taken with other drugs. Alcohol (wine, beer, and hard
liquor) or street drugs, may reduce the effectiveness of antidepressants
and their use should be minimized or, preferably, avoided by anyone
taking antidepressants. Some people who have not had a problem with
alcohol use may be permitted by their doctor to use a modest amount
of alcohol while taking one of the newer antidepressants. The potency
of alcohol may be increased by medications since both are metabolized
by the liver; one drink may feel like two.
Although not common, some people have experienced withdrawal symptoms
when stopping an antidepressant too abruptly. Therefore, when discontinuing
an antidepressant, gradual withdrawal is generally advisable.
Questions about any antidepressant prescribed, or problems that
may be related to the medication, should be discussed with the doctor
and/or the pharmacist.
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 include irritability,
uneasiness, jumpiness, feelings of apprehension, rapid or irregular
heartbeat, stomachache, 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
make the activities of daily life difficult or impossible. People
may have generalized anxiety disorder (GAD) or more specific anxiety
disorders such as panic, phobias, obsessive-compulsive disorder
(OCD), or post-traumatic stress disorder (PTSD).
Both antidepressants and antianxiety medications are used to treat
anxiety disorders. The broad-spectrum activity of most antidepressants
provides effectiveness in anxiety disorders as well as depression.
The first medication specifically approved for use in the treatment
of OCD was the tricyclic antidepressant clomipramine (Anafranil).
The SSRIs, fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine
(Paxil), and sertraline (Zoloft) have now been approved for use
with OCD. Paroxetine has also been approved for social anxiety disorder
(social phobia), GAD, and panic disorder; and sertraline is approved
for panic disorder and PTSD. Venlafaxine (Effexor) has been approved
for GAD.
Antianxiety medications include the benzodiazepines, which can relieve
symptoms within a short time. They have relatively 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 for people taking benzodiazepines to drive or operate
some machinery. Other side effects are rare.
Benzodiazepines vary in duration of action in different people;
they may be taken two or three times a day, sometimes only once
a day, or just on an "as-needed" basis. 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.
It is wise to abstain from alcohol when taking benzodiazepines,
because the interaction between benzodiazepines and alcohol can
lead to serious and possibly life-threatening complications. It
is also important to tell the doctor about other medications being
taken.
People taking benzodiazepines for weeks or months may develop tolerance
for and dependence on these drugs. Abuse and withdrawal reactions
are also possible. For these reasons, the medications are generally
prescribed for brief periods of time—days or weeks—and
sometimes just for stressful situations or anxiety attacks. However,
some patients may need long-term treatment.
It is essential to talk with the doctor before discontinuing a benzodiazepine.
A withdrawal reaction may occur if the treatment is stopped abruptly.
Symptoms may include anxiety, shakiness, headache, dizziness, sleeplessness,
loss of appetite, or in extreme cases, seizures. A withdrawal reaction
may be mistaken for a return of the anxiety because many of the
symptoms are similar. After a person has taken benzodiazepines for
an extended period, the dosage is gradually reduced before it is
stopped completely. Commonly used benzodiazepines include clonazepam
(Klonopin), alprazolam (Xanax), diazepam (Valium), and lorazepam
(Ativan).
The only medication specifically for anxiety disorders other than
the benzodiazepines is buspirone (BuSpar). Unlike the benzodiazepines,
buspirone must be taken consistently for at least 2 weeks to achieve
an antianxiety effect and therefore cannot be used on an "as-needed"
basis.
Beta blockers, medications often used to treat heart conditions
and high blood pressure, are sometimes used to control "performance
anxiety" when the individual must face a specific stressful
situation—a speech, a presentation in class, or an important
meeting. Propranolol (Inderal, Inderide) is a commonly used beta
blocker.
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.
In general, the information throughout this booklet applies to these
groups, but the following are a few special points to keep in mind.
Children
The 1999 MECA Study (Methodology for Epidemiology of Mental Disorders
in Children and Adolescents) estimated that almost 21 percent of
U.S. children ages 9 to 17 had a diagnosable mental or addictive
disorder that caused at least some impairment. When diagnostic criteria
were limited to significant functional impairment, the estimate
dropped to 11 percent, for a total of 4 million children who suffer
from a psychiatric disorder that limits their ability to function.6
It is easy to overlook the seriousness of childhood mental disorders.
In children, these disorders may present symptoms that are different
from or less clear-cut than the same disorders in adults. Younger
children, especially, and sometimes older children as well, may
not talk about what is bothering them. For this reason, it is important
to have a doctor, another mental health professional, or a psychiatric
team examine the child.
Many treatments are available to help these children. The treatments
include both medications and psychotherapy—behavioral therapy,
treatment of impaired social skills, parental and family therapy,
and group therapy. The therapy used 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, and others
who have charge of the child) is essential. Children should be watched
and questioned for side effects because 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 on the correct schedule.
Childhood-onset depression and anxiety are increasingly recognized
and treated. However, the best-known and most-treated childhood-onset
mental disorder is attention deficit hyperactivity disorder (ADHD).
Children with ADHD exhibit symptoms such as short attention span,
excessive motor activity, and impulsivity which interfere with their
ability to function especially at school. The medications most commonly
prescribed for ADHD are called stimulants. These include methylphenidate
(Ritalin, Metadate, Concerta), amphetamine (Adderall), dextroamphetamine
(Dexedrine, Dextrostat), and pemoline (Cylert). Because of its potential
for serious side effects on the liver, pemoline is not ordinarily
used as a first-line therapy for ADHD. Some antidepressants such
as bupropion (Wellbutrin) are often used as alternative medications
for ADHD for children who do not respond to or tolerate stimulants.
Based on clinical experience and medication knowledge, a physician
may prescribe to young children a medication that has been approved
by the FDA for use in adults or older children. This use of the
medication is called "off-label." Most medications prescribed
for childhood mental disorders, including many of the newer medications
that are proving helpful, are prescribed off-label because only
a few of them have been systematically studied for safety and efficacy
in children. Medications that have not undergone such testing are
dispensed with the statement that "safety and efficacy have
not been established in pediatric patients." The FDA has been
urging that products be appropriately studied in children and has
offered incentives to drug manufacturers to carry out such testing.
The National Institutes of Health and the FDA are examining the
issue of medication research in children and are developing new
research approaches.
The use of the other medications described in this booklet is more
limited with children than with adults. Therefore, a special list
of medications for children, with the ages approved for their use,
appears immediately after the general list of medications. Also
listed are NIMH publications with more information on the treatment
of both children and adults with mental disorders.
Persons over the age of 65 make up almost 13 percent of the population
of the United States, but they receive 30 percent of prescriptions
filled. The elderly generally have more medical problems, and many
of them are taking medications for more than one of these conditions.
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 are also more likely to take too much of a medication
accidentally because they forget that they have taken a dose and
take another one. The use of a 7-day pill-box, as described earlier
in this brochure, can be especially helpful for 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, folk, or herbal remedies—the possibility
of adverse drug interactions is high.
Because there is a risk of birth defects with some psychotropic
medications during early pregnancy, a woman who is taking such medication
and wishes to become pregnant should discuss her plans with her
doctor. In general, it is desirable to minimize or avoid the use
of medication during early pregnancy. If a woman on medication discovers
that she is pregnant, she should contact her doctor immediately.
She and the doctor can decide how best to handle her therapy during
and following the pregnancy. Some precautions that should be taken
are:7
• If possible, lithium should be discontinued
during the first trimester (first 3 months of pregnancy) because
of an increased risk of birth defects.
• If the patient has been taking an anticonvulsant such
as carbamazepine (Tegretol) or valproic acid (Depakote)—both
of which have a somewhat higher risk than lithium—an alternate
treatment should be used if at all possible. The risks of two
other anticonvulsants, lamotrigine (Lamictal) and gabapentin (Neurontin)
are unknown. An alternative medication for any of the anticonvulsants
might be a conventional antipsychotic or an antidepressant, usually
an SSRI. If essential to the patient's health, an anticonvulsant
should be given at the lowest dose possible. It is especially
important when taking an anticonvulsant to take a recommended
dosage of folic acid during the first trimester.
• Benzodiazepines are not recommended during the first trimester.
The decision to use a psychotropic medication
should be made only after a careful discussion between the woman,
her partner, and her doctor about the risks and benefits to her
and the baby. If, after discussion, they agree it best to continue
medication, the lowest effective dosage should be used, or the medication
can be changed. For a woman with an anxiety disorder, a change from
a benzodiazepine to an antidepressant might be considered. Cognitive-behavioral
therapy may be beneficial in helping an anxious or depressed person
to lower medication requirements. For women with severe mood disorders,
a course of electroconvulsive therapy (ECT) is sometimes recommended
during pregnancy as a means of minimizing exposure to riskier treatments.
After the baby is born, there are other considerations. Women with
bipolar disorder are at particularly high risk for a postpartum
episode. If they have stopped medication during pregnancy, they
may want to resume their medication just prior to delivery or shortly
thereafter. They will also need to be especially careful to maintain
their normal sleep-wake cycle. Women who have histories of depression
should be checked for recurrent depression or postpartum depression
during the months after the birth of a child.
Women who are planning to breastfeed should be aware that small
amounts of medication pass into the breast milk. In some cases,
steps can be taken to reduce the exposure of the nursing infant
to the mother's medication, for instance, by timing doses to post-feeding
sleep periods. The potential benefits and risks of breastfeeding
by a woman taking psychotropic medication should be discussed and
carefully weighed by the patient and her physician.
A woman who is taking birth control pills should be sure that her
doctor knows this. The estrogen in these pills may affect the breakdown
of medications by the body—for example, increasing side effects
of some antianxiety medications or reducing their ability to relieve
symptoms of anxiety. Also, some medications, including carbamazepine
and some antibiotics, and an herbal supplement, St. John's wort,
can cause an oral contraceptive to be ineffective.
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