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An Introduction to Medications and Side Effects, by Abbey Strauss, M.D.
Over
the years many people suffered from emotional problems that defied treatment. In the last fifty years a series of pharmacologic
discoveries have shown that many emotional problems have a biochemical basis and that with the use of proper medications many
of these conditions can be controlled. This has produced a revolution in the treatment and understanding of large groups of
mental illnesses. Psychotherapeutic medications require that patients take them at adequate doses for sufficient periods of
time, otherwise their effectiveness may never be realized. Also, some of these medications may have an addictive potential.
However, the incidence of any addictive problems is quite rare when the medications are being properly used.
All medications
have side effects, but looking at the list of side effects of these medications should not dissuade someone from using these
medicines in their proper doses. The potential benefits of these medications far outweigh the possible side effects. Doctors
usually proceed with an adequate trial of a particular medication in each patient to determine if it in fact produces relief
from the undesired symptoms. Remember that side effects are not seen in most people who take these medications, and many of
the side effects that occur early in the treatment often lessen or disappear as time passes. Also, when the medications work,
people report that they gladly put up with minor side effects as the price they must pay for other therapeutic effects. The
lists of side effects below does not mention the percentage of people getting every side effect and many times the incidence
of a side effect can be the report of just a very few people. Also, some of the side effects are dose related or the result
of a mixture of drugs, and sometimes the appearance of some side effect indicates that an adequate amount of the medication
is being used. Some side effects require that the drug be stopped, other side effects do not. Great care and clinical experience
are needed in order to determine exactly what is causing a side effect. Any questions about side effects must be discussed
with the prescribing physician.
ANTIDEPRESSANTS MEDICATIONS
Anti-depressants can be roughly categorized into five
groups, depending upon their chemical structure and the way they work 1) tricyclics and tetracyclics (TCA's); 2) monoamine
oxidase inhibitors (MAOI's); 3) serotonin-specific reuptake inhibitors (SSRI's); 4) miscellaneous.
(1) Tricyclics
and Tetracyclics
These, along with the MAOI's, are considered the classic antidepressant drugs; they are also effective
in a wide range of other disorders, including panic disorder, generalized anxiety disorder, post-traumatic stress disorder,
obsessive-compulsive disorder, eating disorders, and pain disorder. Enuresis and ADHD are the most common established indications
for the tricyclics in children.
Side Effects
These drugs share a number of common side effects the possibility
of inducing manic episodes (especially in bipolar I patients), anticholinergic effects (dry mouth, constipation, blurred vision,
and urinary retention), sedation, orthostatic hypotension, fatigue, poor concentration, and dizziness. Some patients may also
experience such symptoms as tachycardia and other cardiac arrythmias, psychomotor stimulation, allergic reactions, weight
gain, and a variety of other less common symptoms, such as insomnia, tremors, weakness, sweating, vomiting, nervousness, peripheral
neuritis, atoxia, endocrinal effects, and changes in blood sugar concentration. In some cases decreased libido and sexual
performance become a problem. In rare cases a patient may experience hallucinations, seizures, convulsions, or other esoteric
symptoms such as black tongue, leucophenia, jaundice, esinophilia, purpura, or agranulocytosis. As a general rule, the side
effects associated with this class of drugs are not severe, and will usually decrease with prolonged use. Dosages will vary
according to age, body weight, health condition, and tolerance.
Some of the generic names follow (trade names in parenthesis)
amitriptyline (Elavil, Endep, Enden, Tryptizol)
amitriptyline + (perphenazine, Etrafon, Triavil)
amoxapine (Asendin)
clomipramine (Anafranil)
desipramine (Norpramine, Pertofrane)
dothiepin (Prothiaden)
doxepin (Adapin, Sinequan)
imipramine (Tofranil, Janimine)
lofepramine (Gamanil--not used in US)
maprotiline (Ludiomil)
nortriptyline
(Pamelor, Ventyl, Aventyl)
protriptyline hydro-chloride (Vivactil)
trimipramine (Surmontil)
(2) Monoamine
Oxidase Inhibitors (MAOI's)
These drugs are generally accepted as being equal in efficacy to other antidepressant drugs
but are currently used less frequently because of the dietary precautions that must be followed (total avoidance of tyramine-containing
foods) and the interactions with numerous other medications. They are often used as an alternative for patients who do not
respond to the tricyclics and tetracyclics, or in atypical depressions. In addition to depression, MAOI's are use d to treat
bipolar disorder, panic disorder with agoraphobia, posttraumatic stress disorder, eating disorders, social phobia, and pain
disorder.
Side Effects
Among the more common adverse side effects are orthostatic hypotension, weight gain, edema,
sexual dysfunction, insomnia, sweating, dizziness, blurred vision, weakness, drowsiness, and constipation. Occasionally a
patient will experience m uscle pains, difficulty in urinating, myoclonus, or parathesia. Particular care must be taken not
to ingest food containing appreciable amounts of tyramine (alcohol, especially beer and wines, broad beans, aged cheese, nuts,
beef or chicken liver, orange pulp, canned figs, chocolate, yeast and yeast vitamin supplements, caffeine-containing products
like coffee and colas, meat extracts, summer sausages, packaged soups, and pickled or smoked fish, poultry, or other meats),
as they are likely to have a hype rtensive reaction that can be life-threatening. In addition, certain medicines must also
be avoided, such as anesthetics (spinal or local) containing epinephrine, antiasthmatic medications, antihypertensives, antihistimines,
diet pills, narcotics (such as Demerol), certain allergy medicines, APC or empirin compounds, L-Dopa or L-tryptophan, cold
and hayfever preparations, sinus medicines, sympathomimetics, SSRI's, and the tricyclic and tetracyclic drugs.
Some of
the generic names follow (trade names in parenthesis)
brofaromine (Consonar--not sold in US)
chlorgyline (*)
isocarboxazid
(Marplan)
moclobemide (Aurorix, Manerix --not sold in US)
pargyline (Eutonyl)
phenelzine (Nardil)
selegeline
(Eldepryl)
tranylcypromine (Parnate)
(3) Serotonin-specific Reuptake Inhibitors (SSRI's)
These drugs, along
with the tricyclic and tetracyclic drugs and the MAOI's, are considered the major antidepressant drugs; they are also effective
in a wide range of disorders, including bipolar I disorder, dysthymic disorder, eating disorders, panic disorder, obsessive-compulsive
disorder, and borderline personality disorder. Because they generally have fewer adverse side effects than other classes of
antidepressants they are more widely prescribed; one SSRI, fluoxetine (Prozac), the least cardiotoxic of all antidepressants,
has become the most widely prescribed antidepressant and is one of the top ten most prescribed drugs in the US.
Side
Effects
The most common adverse side effects involve the central nervous system and the gastrointestinal system; they
include headache, nervousness, insomnia, drowsiness, anxiety, agitation, nausea, diarrhea, anorexia, and dyspepsia. More rarely
p atients may experience sexual dysfunction or allergic reactions (rashes). These drugs are generally considered to well-tolerated,
and some adverse symptoms may lessen or disappear with continued use.
Some of the generic names follow (trade names in
parenthesis)
citalopram (not sold in US)
fluoxetine (Prozac)
fluvoxamine (Luvox)
paroxetine (Paxil)
sertraline
(Zoloft)
serzone (?)
(4) Miscellaneous
These are the drugs that, because of their chemical properties or the
way in which they work, do not fit in any of the other categories. The sympathomimetics are recognized as being effective
in the treatment of depressive disorders in special populations, such as the medically ill. Other medications work independently
as antidepressants, while others work as adjuvant (facilitator or enhancer) or to potentiate other antidepressant drugs; adjuvants
are so indicated on the chart.
Side Effects
Side effects vary depending upon the chemical composition of the compound.
Bupropion, for example has very few serious side effects; they include headache, insomnia, upper respiratory complaints, nausea,
restlessness, agitation, and irrit ability, but not the anticholinergic effects and orthostatic hypotension seen in many of
the others. The only significant adverse effect from L-tryptophan is nausea, or, in very rare cases, hepatotoxicity. The most
common adverse effects of lithium treatment are gastric distress, weight gain, tremor, fatigue, and mild cognitive impairment.
Nefazodone seems to be fairly benign, not displaying the sedation, orthostatic hypotension, and priapism that is seen in some
others. Side effects of pindolol are usually mild, the most common being male impotence, as with all beta-blockers. The sympathomimetics
are usually associated with anxiety, irritability, insomnia, and dysphoria. When taking thyroid hormones, patients sometimes
experience weight loss, palpitations, nervousness, diarrhea, abdominal cramps, sweating, tachycardia, increased blood pressure,
tremors, headache, and insomnia; osteoporosis may also occur with long-term treatment. Trazadone sometimes produces sedation,
orthostatic hypotension, dizziness, headache, dry mouth, and nausea. Occasionally gastric irritation occurs. Nausea, somnolence,
dry mouth, dizziness, nervousness, constipation, asthenia, anxiety, anorexia, blurred vision, and sexual dysfunction were
associated with venlafaxine.
Some of the generic names follow (trade names in parenthesis)
bupropion (Wellbutrin)
dextroamphetamine (Dexedrine)
liothyronine (Cytomel)
L-tryptophan (not used in US)
lithium (adjuvant) (Eskalith,
Lithane, Cibalith-S, Lithobid, Lithonate, Lithotabs)
methylphenidate (Ritalin)
nefazodone (not used in US)
pemoline
(Cylert)
pindolol (Visken)
thyroxine (adjuvant) (Levoxine, Levothroid, Synthroid)
trazadone (Desyrel)
venlafaxine
(Effexor)
ANTIANXIETY MEDICATIONS (ANXIOLYTICS)
Formerly called the "minor tranquilizers", the medicines in this
group are primarily used in the treatment of anxiety; they are also used for some other disorders, such as depression, panic
disorder, social phobia, bipolar I disorder, akathisia, and substance withdrawal. Because they have a higher therapeutic index
and less abuse potential, the benzodiazepines (which comprise the largest number in this group) have largely replaced the
barbituates in treatment for these disorders, and are also widely used a s sedatives and hypnotics as well as anesthetics,
anticonvulsants, and muscle relaxants. Antihistimines are occasionally used to treat anxiety disorders, as are the beta-blockers.
Side Effects
The most common adverse side effect of the benzodiazepines is drowsiness. Used over a long period
of time, patients can build up a tolerance to them, and may suffer withdrawal symptoms when they discontinue use. Other less
common side effects are dizziness, ataxia, and, rarely, mild cognitive deficits and allergic reactions. Serious adverse effects
may be experienced when other sedative substances, like alcohol, are taken concurrently with the benzodiazepines. Buspirone
may cause headache, nausea, dizziness, and, rarely, insomnia. Occasionally a minor feeling of restlessness is associated with
this drug. Clonidine may produce dry eyes and mouth, fatigue, sedation, dizziness, nausea, hypotension, and constipation.
Some patients also experience sexual dysfunction. In rare cases, patients can experience insomnia, depression, nightmares,
and hallucinations. Fluid retention can also become a problem if not treated with diuretics. The beta-blockers sometimes will
result in hypotension, bradycardia, nausea, vomiting, diarrhea, and consitpation. Serious adverse reactions, such as agitation,
confusion, and hallucinations, are rarely seen. It should be noted that some physicians find the anxiolitics to be very addictive;
caution should be observed.
Some of the generic names follow (trade names in parenthesis)
Alprazolam (Xanax)
Atenolol
(Tenormin)
buspirone (BuSpar)
chlordiazepoxide (Librium, Libritabs, Lipoxide)
clonazepam (Klonopin)
clonodine
(Catapres)
clorazepate (Tranxene)
diazepam (Valium, Valrelease, Zetran)
estazolam (ProSom)
ethyl alcohol (Alcohol,
Ethanol)
flunitrazepam (Rohypnol, Hipnosedon--not used in US)
flurazepam (Dalmane)
halazepam (Paxipam)
hydroxyzine
hydro-chloride (Atarax)
hydroxyzine pamoate (Vistaril)
lorazepam (Ativan, Alzapam)
meprobamate Miltown (no longer
used)
benactyzine (Deprol)
metoprolol (Lopressor)
naldolol (Corgard)
oxazepam (Serax)
prazepam (Centrax)
propranolol (Inderal)
quazepam (Doral)
temazepam (Restoril)
triazolam (Halcion)
zolpidem (Ambien)
ANTIPSYCHOTIC
MEDICATIONS
This group, formerly known as the "major tranquilizers", or neuroleptics, is comprised mainly of a set of
drugs known as dopamine-blockers, along with a few others that work in different ways to achieve the same ends. These drugs
target the idiopathic psychoses that have no known cause, such as schizophrenia, schizophreniform disorder, schizoaffective
disorder, delusional disorder, brief psychotic disorder, manic episodes, and major depressive disorder with psychotic features,
as well as being commonly used in the treatment of patients who are severely agitated and violent. They have a wide application
for a variey of disorders, including movement disorders, anxiety disorders, and psychoses that have organic causes.
Side
Effects Potent drugs usually have potent side effects, and the antipsychotic drugs are no exception. Of the nonneurological
adverse side effects associated with this class of drugs, cardiac effects may be the most dangerous; they have been hypothesized
to be a causal factor in sudden death to patients taking the drug, although this connection may be premature. Orthostatic
hypotension, agranulocytosis, anticholinergic effects (described previously), nausea, vomiting, adverse endocrine effects,
sexual dysfunction, weight gain, allergic dermatitis, photosensitivity, irreversible pigmentation of the eyes, jaundice, muscle
spasms, restlessness, tremors, vertigo, drowsiness, slurred speech, and bizarre dreams are some of the reported side effects.
The neurological adverse effects associated with this group of drugs are potentially more serious; in fact, a whole separate
group of medication-induced movement disorders has been included in the DSM-IV since their appearance. Among these effects
that are neuroleptic-induced are parkinsonism, acute dystonia, acute akathisia, and occasionally, irreversible tardive dyskinesia.
Neuroleptic malignant syndrome, which is life-threatening, has been reportedly connected with antipsychotic drug treatment,
and epil eptogenic effects have also been observed in some cases. Sedation can also be a problem.
Some of the generic
names follow (trade names in parenthesis)
Dopamine-blockers
acetophenazine (Tindal)
butaperazine (Repoise--not
used in US)
carphenazine (Proketazine--not used in US)
chlorpromazine (Thorazine, Largactil--not used in US)
chlorprothixene
(Taractan)
droperidol (Inapsine, Droleptan--not used in US)
flupenthixol (Depixol--not used in US)
fluphenazine
(Prolixin, Permitil, Modecate--not used in US)
haloperidol (Haldol)
loxapine (Loxitane)
mesoridazine (Serentil)
molindone (Moban, Lidone)
perphenazine (Trilafon)
pimozide (Orap)
piperacetazine (Quide--not used in US)
prochlorperazine
(Compazine, Stemetil--not used in US)
promazine (Sparine)
remoxipride (Roxiam--not used in US)
risperidone (Risperdal)
thioridazine (Mellaril)
thiothixene (Navane)
trifluoperazine (Stelazine)
triflupromazine (Vesprin)
zuchopenthixol
(Clopixol--not used in US)
Other antipsychotic drugs
carbamazepine (Tegretol)
chlormethiazile (Hemineverin--not
used in US)
clozapine (Clozaril)
fluspirilene (Redeptin--not used in US)
lithium (adjuvant) (Eskalith)
raclopride
(Dogmatil--not used in US)
respirine (Serpasil)
sulpiride (Dolmatil--not used in US)
valproate (Depakene)
ANTIMANIC
MEDICATIONS
Many of the drugs that have already been discussed have been found to be efficacious in effecting mood regulation
or stabilization, such as the benzodiazepines, carbamazepine, clozapine, the dopamine receptor antagonists, lithium, L-tryptophan,
and valproate. Also included in this category are the calcium channel inhibitors or blockers, which are listed below. In addition,
the lithium trade names associated with mood stabilization are listed below.
Side Effects
The most common adverse
side effects associated with the calcium channel inhibitors are hypotension, bradycardia, and AV heart block. Other symptoms
include constipation, nausea, dry mouth, gastric distress, diarrhea, dizziness, headache, fatigue, and, occasionally, hyperactivity,
akathisia, and parkinsonism.
Some of the generic names follow (trade names in parenthesis)
diltiazem (Cardizem)
nifedipine
(Adalat, Procardia)
nimodipine (Nimotop)
verapamil (Calan, Isoptin)
lithium carbonate (Cibalith-S, Camcolt, Priadel,
Liskonum, Phasal--these are not used in US)
SEDATIVES AND HYPNOTIC MEDICATIONS
This class includes the barbituates,
which are among the first drugs to be used in clinical psychiatric treatment, being introduced in the US in 1903. One of the
oldest sedative-hypnotic drugs still in use, chloral hydrate, has been used since 1869. Because of their high abuse potential
and lower therapeutic index, the barbituates are now less commonly prescribed than the newer anxiolytic compounds, such as
the benzodiazepines and buspirone, which are considered much safer. Four others of the class, carbamates, piperidinediones,
cyclic ethers, and tertiary carbinols, are still available for use, but are used so rarely because of their high abuse potential
and toxic effects, that they are not listed below.
Side Effects
A high abuse potential is associated with these
drugs, the barbituates in particular. Drowsiness, confusion, constipation, blurred vision, edema, vertigo, paradoxical dysphoria,
hyperactivity, cognitive disorganization, lethargy, fatigue, headache, syncope, ataxia, and in rare cases, Stevens-Johnson
syndrome, megaloblastic anemia, and osteopenia. Many of the adverse side effects are similar to those of the benzodiazepines.
Some of the generic names follow (trade names in parenthesis)
amobarbital (Amytal)
aprobarbital (Alurate)
butabarbital
(Butisol)
chloral hydrate (Noctec)
ethchlorvynol (Placidyl)
L-tryptophan (not in use in US)
mephobarbital
(Mebaral)
methohexital (Brevital)
nitrazepam (Mogadon)
pentobarbital (Nembutal)
phenobarbital (Luminal, Barbita,
Solfoton)
secobarbital (Seconal)
zolpidem (Ambien)
MEDICATION USED TO OFFSET THE SIDE EFFECTS OF OTHER MEDICATIONS
This rather inclusive group encompasses the anti-parkinsonsism, anticonvulsant, anticholinergic, side-effect medicines
which target the neuroleptic-induced movement disorders, such as parkinsonism, malignant syndrome, acute dystonia, acute akathisia,
tardive dyskinesia, postural tremor and various other movement disorders that are extrapyramidal side effects (EPS). Included
are the beta-adrenergic receptor antagonists (beta-blockers), the anticholinergics and amantadine, certain antihistamines,
bromocriptine, some of the benzodiazepines (see above), dantrolene, and L-dopa.
Side Effects
Oddly enough, medicines
that target side-effects can themselves have side-effects, such as hypotension and bradycardia, nausea, vomiting, diarrhea,
and constipation with the beta-adrenergic receptor antagonists; anticholinergic effects (se e above), abuse potential, dizziness,
insominia, irritability, depression, anxiety, ataxia, nausea, livedo reticularis (mostly the lower extremities), and, rarely,
seizures, with the anticholinergics and amantadine; antihistamines are associated with seda tion, dizziness, and hypotension,
and, occasionally, paradoxical excitement and agitation, poor motor coordination, epigastric distress, nausea, vomiting, diarrhea,
constipation, dry mouth, urinary retention, blurred vision, and some abuse potential; brom ocriptine can result in nausea,
headache, dizziness, vomiting, abdominal cramps, constipation, and, rarely, syncope or orthostatic hyptension, cardiac arrhythmias,
and, very rarely (mostly in long-term and elderly patients), hallucinations, delusions, con fusion, and other behavioral changes;
dantrolene may cause muscle weakness, drowsiness, dizziness, light-headedness, nausea, diarrhea, malaise, and fatigue, as
well as speech disturbances, headache, visual disturbances, alteration of taste, depression, co nfusion, hallucinations, nervousness,
insomnia, and, with long-term use, hepatitis, seizures, and pleural effusion with pericarditis; L-dopa is associated with
abuse potential, nausea, vomiting, orthostatic hypotension, cardiac arrhythmias, and, with long -term use, abnormal involuntary
movements and psychiatric disturbances, including psychosis, depression, and mania.
Some of the generic names follow (trade
names in parenthesis)
Beta-Adrenergic Drugs (Beta-blockers)
atenolol (Tenormin)
chlorthalidone (Tenoretic)
metoprolol (Lopressor)
nadolol (Corgard)
propranolol (Inderal)
Anticholinergics and Amantadine
amantadine
(Symmetrel, Symadine)
benztropine mesylate (Cogentin)
biperidin (Akineton)
ethopropazine (Parsidol)
orphenadrine
citrate (Norflex, Dispal, Biophan--not used in US,Norgesic, Norflex--not used in US--Disipal--not used in US)
procyclidine
(Kemadrin)
trihexyphenidyl (Artane, Tremin, Trihexane, Trihexy-5)
Antihistamines
cyproheptadine (Periactin)
diphenhydramine (AllerMax, Banophen, Belix, Benadryl, Dephen Cough, Dormarex-2, Genahist, Hydramine, Nidryl, Nordryl,
Nytol, Phendry, Sleep-Eze-3, Sominex 2, Twilite) Bromocriptine
bromocriptine (Parlodel)
Dantrolene
dantrolene
(Dantrium)
L-Dopa
L-dopa (levodopa) (Dopar, Larodopa)
Miscellaneous
bethanechol (Urecholine)
phenytoin
carbemazepine (Tegretol)
MEDICATIONS USED FOR ATTENTION DEFICIT DISORDER (HYPERACTIVITY)
This category is
devoted almost exclusively to the amelioration of attention-deficit/hyperactivity disorder (ADHD) effects. It includes the
sympathomimetics, clonidine, and some of the tricyclic antidepressants.
Side Effects
The symptoms associated with
amphetamines, antidepressants, and clonidine have been discussed above; the sympathomimetics have been noted to cause anxiety,
irritability, insomnia, dysphoria, decreased appetite, and, less commonly, movement disorders such as tics, Tourette's disorderlike
symptoms, and dyskinesia. High dosages can cause dry mouth, pupillary dilation, bruxism, formication, and emotional lability,
as well as a delusional disorder similar to paranoid schizophrenia.
Some of the generic names follow (trade names in parenthesis)
amphetamine (Benzedrine)
clonidine hydro-chloride (Catapres)
desipramine hydro-chloride (Norpramin, Pertofrane)
dextroamphetamine (Dexedrine)
imipramine hydro-chloride (Tofranil, Janimine)
methylphenidate (Ritalin)
pemoline
(Cylert)
Psychotherapeutic Drugs 2
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