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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 four 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)
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