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Factsheet: Medication Information Page 2

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.

ANTIANXIETY MEDICATIONS

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.

MEDICATIONS FOR SPECIAL GROUPS

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.

THE ELDERLY

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.

WOMEN DURING THE CHILDBEARING YEARS

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.

For More Information:

For help finding treatment, support groups, medication information, help paying for your medications, your local Mental Health America affiliate, and other mental health-related services in your community, please click here to access our Frequently Asked Questions and Answers. If you or someone you know is in crisis now, seek help immediately. Call 1-800-273-TALK (8255) to reach a 24 hour crisis center or dial 911 for immediate assistance.

Page last updated: 11/14/2006