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One of the biggest obstacles people have to starting any medication, especially a psychiatric/neurological medication, has to do with side effects - called adverse reactions and adverse events by researchers and people in the pharmaceutical industry. Side effects are usually the first, if not only thing a plurality of people look up when searching for information about a med.

1.  Keep it Simple

One of the core philosophies of Crazy Meds is a very simple calculus you’re faced with when it comes to side effects (and many other things in life):

Which sucks less?

Take all the symptoms of your condition(s) and all of the side effects you’re most afraid of, annoyed with, sick of, etc. Write them down, type them up, imagine them in your hands. Extrapolate into the future, keeping in mind that your condition(s) will keep getting worse if left untreated, while almost all of the side effects will go away, or diminish, or you’ll acclimate to them, or you’ll find a way to mitigate them. Then ask yourself, “Which situation sucks less?”

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2.  No Matter Where You Go, There You Are

Regardless which med you take you’ll probably get one or more of these side effects. Usually they will be gone, or at least will diminish to the point where you barely notice it most of the time, within a week or two. A month at the most.

• Headache
• Drowsiness/fatigue - even when taking stimulants in some circumstances.
• Insomnia, instead of or alternating with the drowsiness.
• Nausea
• Assorted other minor GI complaints (constipation, diarrhea, etc.)
• Generally feeling spacey / out of it
• Which can all add up to the ever-helpful “flu-like symptoms.”
• All crazy meds can, and probably will affect your dreams as well. There is no way of telling if that will be good or bad, let alone permanent or temporary.

Individual medications will also have their own short-term side effects. E.g. The pins & needles feeling (paresthesia) you get with Topamax.

2.1  What’s in a Name?

A group of specific side effects are referred to as “anticholinergic.” In the world of crazy meds anticholinergics are drugs that block (are antagonists of) the muscarinic¹ receptors. They’re anti-cholinergic because eventually the neurotransmitter acetylcholine is involved. The same is true for the nicotinic receptors. The ABCDS of anticholinergic side effects are:

• Anorexia (weight loss)
• Blurry vision
• Confusion
• Constipation
• Dry Mouth
• Sedation
• Stasis of urine (fancy doctorese for urinary retention, or: sitting/standing there and nothing happens for what seems like half an hour)

So how come you never lose weight with meds with anticholinergic side effects? Because almost all of them are also potent antihistamines. The blurry vision and weight loss usually go away. It’s a coin toss as to whether or not the confusion, sedation, and urinary retention go away or at least diminish in intensity, or hang around indefinitely. The best you can hope for with the constipation and dry mouth are they get better.
tricyclic/tetracyclic antidepressants (TCAs) and antipsychotics (APs) are the worst offenders.

2.2  Then Why do I Still Need to Buy Benadryl for my Allergies?

Because most of the meds that are potent antihistamines (e.g. Zyprexa, one of the most potent antihistamines on the planet) affect only, or at least mostly, the histamine receptors in your brain. While Benadryl (diphenhydramine) works throughout your entire body, including your brain.
Side effects of antihistamines include:

• Dizziness
• Dry mouth
• Headache
• Increased appetite and
• Increased weight
• Daytime (or whenever you need to be awake) sedation

Keep in mind that being potent antihistamines is why you take some meds, like Seroquel and Remeron (mirtazapine). Antihistamines are great meds to deal with insomnia and anxiety.

3.  Talk to your Doctor About…

In case you didn’t read it on the page about discontinuing medications, here are side effects you need to immediately call your doctor about:

• Severe allergic reactions.
  • Especially fast-spreading, itchy rashes accompanied with a fever.
• Making your symptoms worse.
• Fainting (syncope) or otherwise losing consciousness.
• Your hair falling out in clumps, and not just thinning.
• Seizures if you’re not epileptic or your epilepsy was under control. Otherwise you and your doctor can figure out if the med in question had anything to do with it.
• Irregular heartbeats and similar problems (cardiac dysrhythmia/arrhythmia).
• Manic reaction (you get way too happy and/or want to smash everything in sight), especially if you’re not bipolar.
• Inexplicable bruises all over the place, especially lots of little bruises in clusters that look sort of like a big rash.
• The whites of your eyes turning yellow and/or your skin looking waxy and yellowish. Along with all the bruising this is a symptom of jaundice.
• Blood dyscrasias, which is fancy doctor talk for way too many or too few white or red blood cells, or some other weird problem with your blood. How the hell would you know about this? Lots of meds, crazy and otherwise, call for regular blood tests to look for this sort of thing. Your doctor should order regular blood tests if you’re taking Tegretol/Carbatrol/Equetro (carbamazepine) or Clozaril (clozapine), or if you have a history of such problems. If they didn’t and another health care provider found you have a blood problem due to your meds, you may want to find another doctor for your crazy meds.

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4.  Guilt by Association

Persistent side effects that many, but not all, crazy meds have in common. These are the ones people complain about the most, so it just seems like every med will cause them. These are also the side effects of drugs that work, and are the ones where people are trying to decide if the adverse reaction sucks more than the condition the med is treating. The side effect that gets the most complaints of all drugs, crazy or otherwise, and is the number one reason people stop taking them is: making the symptoms worse.
So here they are, along with probable causes and the drugs where they are most likely to be actual problems, in the order (as best as I can tell²) which they are bitched about the most and loudest:

4.1  Weight gain

There are three known³ reasons as to why some meds make you fat.

1. H1 Antihistamines. This is most common way a drug can fatten you up like a veal calf. Most APs, especially Zyprexa are strong-to-potent antihistamines and, as I wrote above, antihistamines make you hungry and encourage you to keep the weight on. Being a potent antihistamine is also why you take these meds as they help you sleep and help fight anxiety. TCAs, especially Remeron, are also strong-to-potent antihistamines and notorious for weight gain.
2. Serotonin 5HT_2C Antagonists. Drugs that interfere with serotonin at this specific receptor at going to make you gain weight. As with antihistamines these meds will make you hungry and keep the weight on. This is the primary reason why second-generation APs, especially Zyprexa and Seroquel, will cause you to pack on the pounds. Additionally they will mess with your insulin resistance, which is why your risk for diabetes increases if you take Geodon or Abilify and don’t gain any weight. And just like antihistamines you take these meds because they are 5HT_2C antagonists, as that helps regulate dopamine. Other 5HT_2C antagonists include Remeron and Prozac.
3. Decreasing corticotropin-releasing factor (CRF). Unlike the above two, this one is somewhat obscure, in the world of psychopharmacology at any rate. Like the other two it is possibly why the meds - Lithium, Depakote, SSRIs, SNRIs, and assorted APs and other antidepressants (ADs) work.

4.2  Loss of libido and other sexual dysfunction

• The drugs most associated with sexual side effects are SSRIs and SNRIs
  • The most notorious of which is Paxil (paroxetine), with Lexapro and Prozac (fluoxetine) tied for second.
• The mechanism as to why this happens is that you’re getting too much serotonin at your 5HT_2A receptors, which then has a negative effect on norepinephrine and dopamine.
• While APs can also cause sexual dysfunction, due to their blocking dopamine, they are more selective about where that is done.
• Second-generation APs like Risperdal (risperidone), some of the older first-generations APs like Haldol (haloperidol), and even some ADs like Remeron and trazodone block serotonin at the 5HT_2A receptors, so sexual side effects are less of a problem than they would otherwise be.

As anticonvulsants/antiepileptic drugs (AEDs) can affect your hormones there’s a general risk for sexual side effects, but they still can’t touch SSRIs & SNRIs.

4.3  Lethargy and daytime sleepiness, with or without insomnia

• If it can make you fat, it will also make you sleepy.⁴
• Additionally, anything working on dopamine directly by blocking dopamine at your D₂ receptors (i.e. every antipsychotic on the planet) will also make you sleepy.
• And anything that blocks serotonin at the 5HT_2A receptors will make you want to sleep, which includes half the APs on the planet, along with Remeron, trazodone, and nefazodone.
• AEDs are as bad as APs when it comes to making you you sleepy.
• Hell, except for stimulants and Wellbutrin, practically every crazy med can persistently make you sleepy. Unless you’re bipolar and/or have severe ADHD, in which case stimulants and Wellbutrin can persistently make you sleepy.

4.4  Hair loss

Hair thinning/loss is tied to hormones. Lithium is the worst offender, as it messes with your thyroid, with Depakote a close second, and Lamictal a distant third. Again - hair thinning is an annoying side you can live with. Hair falling out in clumps is a warning sign of a serious problem.

4.5  Movement disorders: tremor, shakes, akathisia, extrapyramidal symptoms (EPS), and tardive dyskinesia (TD)

• Movement disorders, like extrapyramidal symptoms (EPS) and tardive dyskinesia (TD), as well as some hormonal problems associated with prolactin such as increased breast size (AKA porno boobs) and lactation when there shouldn’t be any (e.g. you’re a guy), are almost always caused by APs and are the result of interference with dopamine at your D₂ receptors.
• While the rule of thumb is the older APs are more likely to cause a movement disorder than the newer ones, that’s not always the case. Risperdal and Invega are far more likely to cause EPS or TD than Thorazine (chlorpromazine).
• You don’t even have to be taking an AP, as SSRIs that TCAs can indirectly lower the amount of dopamine you get there. Oops.

4.6  Memory loss, brain fog, and other cognitive problems

• While every crazy med can cause these problems temporarily for a few weeks, AEDs are the absolute worst when it comes to these problems.
• Topamax (topiramate) AKA Dopamax, Stupamax, is the best known for making you the stupidest, but Zonegran (zonisamide) is just as bad.
• Gabitril (tiagabine), Tegretol (carbamazapine) and Trileptal (oxcarbazepine) almost always cause severe cognitive problems to start with, but they usually go away, or at least get better.
• It’s a coin-toss with Neurontin (gabapentin), AKA Morontin.
• Your guess is as good as mine as to why this happens.

4.7  Nausea, bad gas, acid reflux, constipation, diarrhea, and other GI problems

As mentioned above, nausea and other GI problems can happen with any med, crazy or not, and usually go away within a couple of weeks. When they don’t, it’s more than just annoying.

• Depakote (divalproex sodium) and other valproates are the worst of the most commonly prescribed crazy meds
  • but are infrequently-prescribed medications that are worse (e.g. Felbatol (felbamate))
  • and some meds are worse with specific GI issues (e.g. the constipation you get from TCAs)⁵.
• There are as many causes as there are GI problems, but when it comes to persistent tummy troubles and crazy meds there’s a simple explanation - you have brain juice (serotonin, norepinephrine, dopamine, etc.) receptors in your guts.⁶
  • So Abilify’s currently unique way of working is also why it causes acid reflux, AKA the “Abilify burp,” and some drugs used to treat severe gastric issues, like metoclopramide, are practically APs.

4.8  Acne and other skin problems

As with hair loss, drug-induced acne is generally due to hormones, so lithium is the crazy med most likely to give you a problem with AEDs coming in second. As for dermatological problems in general nothing comes close to Lamictal.

Now that we know about the side effects can potentially stop you from taking just about any med that would otherwise help you feel a hell of a lot better, what, if anything, can you do about them?

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¹ Yes, they are named after the Amanita muscaria mushroom.

² See the bibliography page for sources in addition to anecdotal evidence (i.e. what I read on teh Interwebs). The data from the papers cited and the anecdotal evidence I get, even from non-drug-forum sources, are overwhelmingly from women. Men barely outnumber women complaining about sex problems (anyone surprised?) and movement disorders, but more women complain about hair thinning and hair loss than men do.

³ At least that I know of.

⁴ Just like food, only for completely different reasons.

⁵ Anyone who doesn't think constipation can be a serious problem hasn't wound up in the hospital with a tear in their rectum from an Olympic movement. Go ahead and laugh, even I thought it was funny a couple weeks after it happened to me.

⁶ You also have CYP450 genes in your brain, which really opens up a can of pharmacodynamic worms.

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Page created by: Jerod Poore. Date created: 30 May 2011 Last edited by:

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