Table of Contents (hide)
- 1. Whatcha Gonna Do About It?
- 1.1 Does this Pill Make Me Look Fat?
- 1.2 I Can’t Get it up with a Forklift
- 1.3 Just Five More Minutes, Then I’ll get out of Bed
- 1.4 I Just Want to Tear my Hair Out
- 1.5 Shakin’ All Over
- 1.6 I Forgot What I was going to Write
- 1.7 I am So Sick of Taking these Meds!
- 1.8 Life is Like High School
- 1.9 The Itchy and Scratchy Show
- 2. Only You Can Prevent Treatment-Resistance. Unless You were Born to be Refractory.
Now that we know what side effects most crazy meds have, what, if anything, can we do about the persistent ones everyone complains about?
§1. Whatcha Gonna Do About It?
How to reduce side effects is a factor of the med(s) in question, the condition being treated, and a whole bunch of stuff in the person’s life. When it comes to dealing with some of the annoying, but not deal-breaking side effects common to all of them, you basically have to be patient and wait a couple of weeks. Also ask yourself, and your doctor, if you’re taking too high a dosage. If the dosage was increased (titrated) to a target dosage regardless of how the drug made you feel at any dosage before (e.g. you felt fine at 20mg a day but your doctor told you to keep increasing the dosage until you were at 50mg a day) and you’re experiencing side effects, talk to your doctor about lowering the dosage. Along the same lines drug-drug and drug-food interactions are responsible for numerous side effects because they slow down the elimination metabolism (how fast you clear) a drug, so you’re getting the functional equivalent of a higher dosage. There’s one more, somewhat ironic interaction. Drugs metabolized by the CYP3A4 enzymes, such as Tegretol (carbamazapine) and Viibryd may have their metabolism slowed if you’re significantly overweight.
As for the side effects that stick around and cause people to stop taking meds that are otherwise working for them, here’s what I’ve found that works anywhere from sometimes to often, for some to many people.1
§1.1 Does this Pill Make Me Look Fat?
Weight gain is the number one complaint for meds that actually work. How do you deal with it?
- All the usual stuff still applies, like eating less and exercising more,2 but you’ll probably need more than that.
- Metformin is probably your best bet.
- Unless you have epilepsy or migraines, Topamax (topiramate) usually causes more problems, but every now and then can make whatever you’re taking work better for psychiatric conditions.
- Axid (nizatidine) is used for ulcers and GERD and works the histamine H2 receptors, and drug-induced weight gain stems from the H1 receptors. It failed all over the place.
§1.2 I Can’t Get it up with a Forklift
Close behind weight gain in complaints are the various sexual side effects (SSE).
- For SSRI & SNRI-induced SSE the usual methods are:
- Adding BuSpar (buspirone). This has the added bonus of helping with any anxiety symptoms you may have.
- Adding Wellbutrin (bupropion). This can augment your antidepressant (AD), but isn’t always a good idea.
- Adding a dopamine agonist like Mirapex (pramipexole) or Requip (ropinirole). This often works better than Wellbutrin. Sometimes a little too much better.
- Adding Remeron (mirtazapine). No, really. As long as whoever loves you sees you for your true self and doesn’t care that you weigh twice as much as you used to.
- Using Viagra, Cialis, or some other erectile dysfunction medication. As odd as it might sound, even women use these.
- Switching to another med. Paxil (paroxetine) and Lexapro (escitalopram) are the worst offenders in the SSRI-induced SSE sweepstakes, Zoloft (sertraline) has the fewest problems. Switching to something completely different is another option, like Wellbutrin or Remeron, but a very different medication might not work for you as well, if at all.
- The drug holiday is often suggested, but I don’t recommend it. Not only could you be subject to SSRI/SNRI discontinuation syndrome, but your AD may not work as well each time you do this.
- As SSE caused antiepileptic drugs/anticonvulsants (AEDs) are typically hormonal in nature, there’s not much you can do that won’t mess you up in some other way. So far there is all of one recommended solution: switch to Lamictal.
- Like AEDs, SSE caused by antipsychotics (APs) can be hormonal, but the reason for this is much simpler: it’s the way dopamine is messed with. And as that is ultimately, albeit indirectly, the same reason why SSRIs and SNRIs cause sexual dysfunction, a lot of the treatments will similar. There’s also a lot of overlap with the treatment for AP-induced movement disorders:
- Reducing the dosage and hoping your med still works well enough.
- Trying a different med, which is usually switching from a first-generation AP to a second- or third-generation AP.
- Or switching from whatever you take to Abilify.
- Just remember: frequently changing meds can make you treatment-resistant.
- Adding a dopamine agonist like bromocriptine.
- Using Viagra, Cialis, or some other erectile dysfunction medication.
- Lithium-induced SSE is also hormonal, but the hormones in question are mediated by your thyroid. At least you can get a test and do something about it without messing up your therapy.
- Keep in mind: wanting to have sex five times a day when you’re over 40 (and weren’t living in a monastery or convent most of your life) was probably a symptom of hypersexuality, so a reduced sex drive could be an indication that the meds are working.
§1.3 Just Five More Minutes, Then I’ll get out of Bed
Lethargy and excessive sleepiness can be fairly difficult to counter, as most pharmacological treatments will exacerbate the conditions you’re treating with the medications for which somnolence is an adverse reaction. In English: taking pills to treat these side effects usually screw you up more.
- One solution is so simple that most people, including doctors, don’t even consider it: take the damn meds before going to bed instead of in the morning.
- Along the same lines, take them a couple hours before going to bed.
- If you take meds twice a day, and they have a half-life greater than 16 hours, try taking them all at once before going to bed. Or a couple hours before going to bed.
- As always, there’s the option of switching meds.
- Caffeine. Is it your friend? How the hell should I know? I can tell you if it could be a problem:
- If you take Luvox (fluvoxamine). You have to be extremely careful with anything caffeinated if you take Luvox.
- If you take Topamax. Topamax + caffeine can sometimes cause panic attacks. “Sometimes” meaning it sometimes happens to some people who take Topamax.
- As this reaction is intermittent, lasts anywhere from one day to as long as you’re taking Topamax, and is an interaction between Topamax and another drug that have no common pharmacokinetic attributes, you’re not going to find it in the PI sheet, and I can’t blame Ortho-McNeil Caroliner Rainbow Neurologics (or whatever they’re calling themselves this month) for leaving it out.
- If you’re taking anything for anxiety or insomnia, why are you drinking coffee in the first place?
- OK, now we come to pills. And despite all the shit I give Cephalon for managing to get the FDA to sign off on a new disease (shift work sleep disorder) just so they could get Provigil approved for it, Provigil and Nuvigil are really effective in dealing with medication-induced lethargy and excessive sleepiness. They also have drug-drug interactions up the wazoo, so you win some and and you lose some.
§1.4 I Just Want to Tear my Hair Out
Treating hair loss is somewhat nebulous.
- Various shampoo formulations and dietary supplements have worked wonders for some and were a complete waste of money for others.
- All I can really tell you is use extreme caution with any supplement containing selenium. Selenium is a necessary trace element, and not getting enough of it can lead to hair loss.
- One of the first symptoms of selenium toxicity: hair loss.
§1.5 Shakin’ All Over
Drug-induced movement disorders are usually caused by APs and handled in ways similar to AP-induced SSE:
- Reducing the dosage and hoping your med still works well enough.
- Trying a different med and hoping that works well enough.
- Taking a dopamine agonist like bromocriptine and hoping that doesn’t interfere with any AP you might be taking.
- Taking a potent anticholinergic such as Cogentin (benztropine mesylate). This option tends to suck the most, but is the least likely to mess with any AP you’re taking.
- Anticholinergics like Cogentin do nothing as far as prolactin-related problems (SSE, enlarged breasts, surprise lactation) are concerned.
- Some newer APs like Zyprexa and clozapine are potent anticholinergics in their own right, which may be the reason why risk of movement disorders when you take them is virtually non-existent.
- If you do take an anticholinergic or crazy med with potent anticholinergic properties, especially Zyprexa, smoking will negate its effects. Which is ironic when you consider that smoking helps to prevent Parkinson’s.
§1.6 I Forgot What I was going to Write
The stupids. It’s what I hate the most. I don’t care about the kidney stones, the athlete’s foot on my fingers (and chest, and thighs, and back, and feet, and shoulders, and it just keeps spreading), the extreme photosensitivity or anything else. I’ve tried so many things. I’ve researched my ass off. The only things that work:
- Adjusting your dosage
- Switching meds
- Sometimes taking additional meds help, but they come with their own problems. The most helpful are:
- Stimulants (so much fun if you’re bipolar and/or epileptic and/or have an anxiety disorder)
- Antipsychotics. No, really. As odd as that may sound, APs can help with the brain fog, memory problems, etc. caused by other meds.
- Of course, if the stupids are being caused by an AP, an additional AP isn’t going to help. Unless it’s Abilify or another third generation AP. And mixing stimulants and APs can be counterproductive.
§1.7 I am So Sick of Taking these Meds!
What’s the point of taking a drug if you’re just going to puke it up, right?
- Something as simple as taking your meds with food can be all you need to do to deal with nausea, acid reflux and a host of other problems. While there are some meds that work better when taken on an empty stomach, the difference usually isn’t significant.
- To the point where the only med I can think of that significantly works better when taken while fasting (the technical term for “before eating”) is Lovaza (omega-3-acid ethyl esters), and that’s only when used off-label to treat depression.
- Which it rarely is, because it’s way cheaper to buy decent omega-3 fish oil and take that on an empty stomach.
- Most non-prescription/over-the-counter (OTC) remedies will work for practically every GI problem.
- Just check the full PI sheet of your prescription medication for any drug-drug interaction with the active ingredient of the OTC remedy as well as the product name of whatever remedy you’re about to take. You never know what sort of bizarre interaction will crop up.
- Yogurt and other probiotics can be helpful with chronic GI issues.
- Not with everything and not all the time.
- And you can’t combine them with MAOIs that have food restrictions.
- We’re in somewhat better than placebo territory, but still can’t call it one way or the other.
- Getting them in food (yogurt, kim chee, etc.) is usually better than taking them in pill form.
- They are not going to be enough with Viibryd, although you’ll probably want to eat more yogurt, etc. to replenish what you’d be losing as you crap your guts out every day.
- For chronic constipation, stool softeners are your new best friends.
§1.8 Life is Like High School
Sanity before vanity is one thing, but looking like the before picture in a Proactiv ad is another. Acne is treated, more or less, as if you were back in high school.
- Just be careful with any prescription medication.
- In addition to the usual drug-drug interactions, as there can be unexpected ones that won’t necessarily show up in any of the drug-drug interaction checkers.
- Because crazy meds can affect hormones, and once you’ve got different meds messing with your hormones in different ways, well, as IBM used to say, “unexpected results may occur.”
- And antibiotics can trigger mania. It’s common enough to have its own term: antibiomania. While the bipolar are the most at risk for this one, you don’t necessarily need to be bipolar for antibiotics to make you batshit crazy.
- So you should probably make taking meds to deal with acne your last option, because you could wind up seriously crazier.
§1.9 The Itchy and Scratchy Show
As for other dermatological issues, it gets tricky. You’d think something like dry skin could be handled by whatever lotion is on sale at Walgreen’s. The problem is crazy meds, especially AEDs, make you more susceptible to lots of other problems, such as contact dermatitis and eczema. Before you started taking a particular medication these things may have never bothered you:
- Household cleaners
- Fabric softener and dryer sheets
- Clothing - either the fabrics or something the clothes came in contact with
- Facial creams
but now they do. Or specific brands/types of them do, and do so because the medication has now made you sensitive to one or more of the top causes of rashes, hives, contact dermatitis, etc.:
- Fragrances. Used in cosmetics, insecticides, antiseptics, soaps, perfumes, and dental products.
- Formaldehyde. Used as a preservative in fiberboard (that new office smell), paints, medications, household cleaners, cosmetic products, and fabric finishes.
- Quaternium 15. A preservative in self-tanners, shampoo, nail polish, sunscreen.
- Neomycin sulfate. An antibiotic in first aid creams and ointments.
- Several metals, especially cobalt chloride, nickel, and gold. While mostly used in the obvious places, cobalt chloride is also used in hair dyes and antiperspirants.
- Poison ivy, poison oak, poison sumac, and other natural things that are outdoors and always trying to kill us.
Eliminating common skin irritants from your life may prevent you from needlessly discontinuing a medication due to something like contact dermatitis, which is often mistaken for much more serious problems: Stevens-Johnson Syndrome (AKA the Lamictal Rash) or toxic epidermal necrolysis (TEN).
Rashes that are common to AEDs, especially Lamictal (lamotrigine) are best dealt with before they happen. This means avoiding common skin irritants, using products with as few ingredients as possible, and protecting yourself from sunlight using as little sunscreen as possible (hats, long-sleeve shirts, realizing that the outside is trying to kill us all).
For even more information about household products, skin allergies and irritants see:
- Allergies Triggered by Cosmetics
- Are You Allergic to Your Beauty Products?
- Household Irritants: Skin-Friendly Cleaning Tips for Your Family
§2. Only You Can Prevent Treatment-Resistance. Unless You were Born to be Refractory.
If you keep switching medications because you didn’t want to deal with minor and/or temporary side effects you may wind up treatment-resistant. So even if you go back to a med that used to work for you, it may not work as well, if at all. As usual, don’t just take my word for it…
When initial treatment is not effective or tolerable after 6 to 8 weeks of therapy, the American Psychiatric Association (APA) treatment guidelines recommend dose titration, augmentation, or switching. In the case of a therapy switch, the body of evidence suggests that selection of an agent with a different mechanism of action than the initial agent may be the most effective treatment. Furthermore, when patients maintain continuous therapy for the recommended treatment duration, outcomes are improved compared with patients who discontinue therapy early. As a result, the most effective treatment strategies promote improved patient compliance as well as the use of agents associated with a reduced incidence of premature discontinuation and therapy change early in the treatment program.--Treatment-resistant depression: managed care considerations
There you have it. Patients are idiots for not sticking with their meds if the meds aren’t making symptoms way worse, or the side effects aren’t dangerous (e.g. irregular heartbeats, allergic reactions) or aren’t otherwise utterly intolerable (it’s been six weeks and you’re still sleeping 12 hours a night and are groggy the other 12); and doctors are idiots for continuing to prescribe one SSRI after another after two different SSRIs (e.g. Celexa and any of the others except for Lexapro)3 didn’t come close to working.
Granted riding the med-go-round for stupid reasons isn’t the only reason for treatment-resistance.
Clinical factors associated with treatment resistance in major depressive disorder: results from a European multicenter study.
Found that frequently changing meds for a good reason (intolerable side effects) was as much at fault as bad reasons (personality disorders, side-effect phobia), as well as comorbid conditions, misdiagnoses and losing the genetic lottery.
When you read between the lines of the discrete aspects in this study the psychological reasons outnumber the psychiatric.
New approaches to managing difficult-to-treat depressions.
This study takes a far more simplistic view: too many drug changes due to people not staying on meds long enough to give them a change to work. Along with substance abuse (something most others don’t take into account and is probably important) and, perhaps, hypothyroidism. Buh? That’s it, a wonky thyroid? At least everyone else acknowledges a genetic factor for some portion of the population, albeit a small one. I think there are more genetic factors than just hypothyroidism.
A view from Riggs: treatment resistance and patient authority - III. What is psychodynamic psychopharmacology? An approach to pharmacologic treatment resistance.
Too many meds, not enough therapy. The basic idea is there is no quick fix. Familiar, no? The study is playing to the audience, being published in a journal dedicated to psychoanalysis, and therapy won’t solve everything, but not enough people with depression are getting the therapy they need to stay on a freaking med long enough to give it a chance.
The effect tends to hang around for some time.
Impact of prior treatment exposure on response to antidepressant treatment in late life.
Many years after their last depressive episode one third of treatment-resistant old people failed to, or took a longer time to respond to Paxil. One fourth of those who had an inadequate response with prior treatment failed to, or took a longer time to respond, while 14% of people who were never previously treated failed to, or took a longer time to respond.
2 And we can all see how well that worked.
3 And if your doctor wants you to try Celexa after Lexapro didn't work (or vice versa), then you probably need to find another doctor.
Dealing with Common Side Effects of All Crazy Meds by Jerod Poore is copyright © 2011
Page created by: Jerod Poore. Date created: 30 May 2011 Last edited by: Jerod Poore on: April 26, 2013, at 11:16 AM
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1 While there are plenty of books to help you with hypochondria, for some reason there’s not much in the way of websites. Then again, staying off of the Internet is a large part of curing/managing the disorder.
2 Have I mentioned how open source operating systems for commercial applications is one of the dumbest ideas in the history of dumb ideas?
[begin rant] I rent a dedicated server for Crazy Meds. It’s sitting on a rack somewhere in Southern California along with a bunch of other servers that other people have rented. The hardware is identical, but no two machines have exactly the same operating systems. I don’t even need to see what is on any of the others to know this. If somebody got their server at the exact same time, with the exact same features as I did, I’m confident that there would be noticeable differences in some aspects of the operating systems. So what does this mean? For one thing it means that no two computers in the same office of a single company have the same operating system, and the techs can spend hours figuring out what the fuck the problem could be based on that alone. It also means that application software like IP board that runs the forum here has to have so many fucking user-configurable bells and whistles that even when I read the manual I can’t find every setting, or every location that every flag needs to be set in order for a feature to run the way I want it to run. And in the real world it means you can get an MBA not only with an emphasis on resource planning, but with an emphasis on using SAP - a piece of software so complex there are now college programs on how to use it. You might think, “But don’t people learn how to use Photoshop or Adobe Illustrator in college?” Sure, in order to create stuff. And in a way you’re creating stuff with SAP. But do you get a Bachelor of Fine Arts degree with an emphasis on Photoshop?
Back in the Big Iron Age the operating systems were proprietary, and every computer that took up an entire room with a raised floor and HVAC system, and had less storage and processing power than an iPhone, had the same operating system as every other one, give or take a release level. But when a company bought application software like SAP, they also got the source code, which was usually documented and written in a way to make it easy to modify the hell out of it. Why? Because accounting principles may be the same the world over, and tax laws the same across each country and state, but no two companies have the same format for their reports, invoices, purchase orders and so forth. Standards existed and were universally ignored. If something went wrong it went wrong the same way for everyone, and was easy to track down. People didn’t need to take a college course to learn how to use a piece of software.
I’m not against the open source concept entirely. Back then all the programmers read the same magazines, so we all had the same homebrew utilities. We even had the forerunner to QR Code to scan the longer source code. Software vendors and computer manufacturers sponsored conventions so we could, among other things, swap recipes for such add-ons and utilities. While those things would make our lives easier, they had nothing to do with critical functions of the operating system. Unless badly implemented they would rarely cause key application software to crash and burn. Whereas today, with open source everything, who the hell knows what could be responsible some part of a system failing. [/end rant]
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