Psychological Side Effects
All drugs have side effects. That’s a trade-off most people have come to accept. But if you are being treated for heartburn, you would hardly expect to start feeling like you are losing your mind.
Hallucinations, anxiety, depression, suicidal thoughts, insomnia, nightmares, paranoia, memory loss and delirium are not necessarily signs of mental illness. Rather, they can be unanticipated adverse reactions brought on by many common medicines.
This is a controversial issue, one which many doctors are reluctant to discuss with their patients. When a drug is working well, it can relieve symptoms, prevent complications, and prolong life. Little attention may be given to its potential side effects.
But some drugs may cause psychological and emotional changes. If these are not recognized as drug side effects, they might be treated with other medications. It can turn into a vicious cycle.
This is especially true in the elderly, who are more susceptible to side effects and are usually less likely to complain about them. All too often an older person will accept a symptom as just another sign of the aging process, when in fact the problem could be caused by a prescription drug, an over-the-counter medication or a combination of both.
For example, Xanax (alprazolam), one of the most commonly prescribed drugs in America, is used to treat anxiety. It belongs to a class of drugs called benzodiazepines. In rare cases, such drugs may cause depression, manic symptoms, memory impairment or difficulty concentrating. Sudden withdrawal may provoke signs of physical dependence and even seizures.
Halcion (triazolam) is a chemical cousin of Xanax. Because Halcion has a very short duration of action, physicians assumed it would be safer than other sleeping pills. As a result of this attitude, Halcion became the most popular “hypnotic” on the market. Unfortunately, the Food and Drug Administration (FDA) has no scientific way of tracking adverse drug reactions, so no one really knows how dangerous the drug really is. But in recent years a scandal has swirled around Halcion. There have been rumors of fraud and cover-up.
Reports have surfaced that Halcion may impair memory the day after people take this sleeping pill (anterograde amnesia). Although an individual may appear normal to friends and relatives, he may be unable to remember things he did or observed.
Some people taking Halcion have experienced “rebound” anxiety after taking this medication. This may occasionally proceed to restlessness, panic attacks and perhaps even aggression.
Seldane (terfenadine), the antihistamine that has become popular because it rarely causes sedation, has occasionally been reported to provoke central nervous system (CNS) reactions. Although physicians rarely mention side effects, some people have apparently experienced symptoms such as anxiety, insomnia, cold sweats, headache, agitation, euphoria, or giddiness within a few hours of taking the medicine.
Anyone who notices psychological or emotional changes while taking any drug should notify a physician immediately. Family members must also be vigilant for personality changes that may be brought on by medicine. Drug-induced mental problems are far too often overlooked or ignored.
Antipsychotic drugs, such as Thorazine (chlorpromazine), Mellaril (thioridazine) and Haldol (haloperidol), are given to treat serious mental illness. Ironically, some of the symptoms induced by this type of drug – memory impairment, delirium, confusion or agitation – may be hard to distinguish from symptoms of the underlying condition.
A relentless restlessness that forces people to move or pace endlessly is a frustrating side effect of such medicines. Even more insidious is tardive dyskinesia (TD), a potentially irreversible kind of brain damage that produces uncontrollable muscle movements. Lip-smacking, grimaces, and neck-twisting motions are not uncommon.
A newer medicine called Clozaril (clozapine) is much less likely to cause these devastating complications. It may also help some people who have not responded to the usual antipsychotic drugs. Unfortunately, Clozaril can cause a life-threatening blood disorder and requires frequent monitoring, which makes the cost of this medicine extremely high.
Medications like Elavil or Endep (amitriptyline), Norpramin (desipramine), Aventyl or Pamelor (nortriptyline), Tofranil or Janimine (imipramine) and Sinequan (doxepin) save lives. When people feel helpless and hopeless, antidepressants can help get them out of the dark pit of despair and may help prevent suicidal action.
But antidepressants may also produce psychological side effects. Some people experience manic symptoms, hyperactivity, insomnia and restlessness. Others become drowsy, lethargic and have difficulty concentrating. Hallucinations and paranoia are rare but possible complications. Sudden discontinuation of a drug like Elavil may bring on irritability and insomnia. If such drugs need to be stopped, the dose should be phased down gradually.
A controversy over a drug hailed as a breakthrough for depression has been in the news. Eli Lilly & Co. which manufactures Prozac (fluoxetine), has been hit with lawsuits filed by people claiming that Prozac caused violent behavior and suicidal thoughts. The company maintains that Prozac is no more likely than other antidepressants to produce suicidal preoccupation. Health professionals find it hard to believe an antidepressant could make someone suicidal. Perhaps not, but because the FDA has no way of scientifically monitoring the situation we have no way of actually answering this question. Reported Prozac side effects include anxiety, headache, nervousness and insomnia.
Some psychological symptoms don’t start until a person stops taking the drug. Benzodiazepines such as Valium (diazepam), Librium (chlordiazepoxide), Ativan (lorazepam), Halcion (triazolam), Serax (oxazepam), Xanax (alprazolam) or others may produce side effects either during use or upon withdrawal. Stopping suddenly may cause disorientation, fear, insomnia, anxiety and agitation. Seizures have occurred in people with no history of epilepsy.
Getting off Benzos
How do you get off benzos without suffering from withdrawal symptoms?
The first thing – and we cannot stress this enough – is that cutting back on benzodiazepines requires medical supervision. This is under no circumstances a self-help project!
Unfortunately, doctors don’t always agree on the best way to phase off anti-anxiety agents. Some have a hard time accepting that a prescription intended to help alleviate stress or insomnia could cause dependence. Regardless of that, most experts now agree that when such medications are taken for long periods, gradual weaning is appropriate.
But how should that be done? Drug companies have provided ambiguous instructions to physicians. The maker of Xanax offers the following: “To discontinue treatment in patients taking XANAX, the dosage should be reduced slowly in keeping with good medical practice.” Big deal! Thanks for nothing. The trouble is, no one seems to know what “good Medical practice” is. The company goes on to say, “In all patients, dosage should be reduced gradually when discontinuing therapy or when decreasing the daily dosage. Although there are no systematically collected data to support a specific discontinuation schedule, it is suggested that the daily dosage be decreased by no more than 0.5 mg every three days. Some patients may require an even slower dosage reduction.”
With guidelines like that it’s no wonder some patients have experienced symptoms such as anxiety, restlessness, extreme sensitivity to sound, light and touch, panic, depersonalization, jitteriness, agitation, impaired concentration, faulty memory, depression, headache, fatigue, muscle cramps, muscle twitch, sweating, diarrhea, blurred vision, appetite decrease, weight loss and insomnia.
Over the last decade it has become clear that each person reacts differently; some have far less difficulty getting off benzos than others. We have heard from people who stopped their medicine fairly quickly (over a few weeks) with no unpleasant reactions. Others, however, described a “living hell” that took many months to resolve. A few poor souls experienced withdrawal symptoms for more than a year.
Dr. Otis L. Baughman, III, at Self Memorial Hospital in Greenwood, South Carolina, has developed a slow-tapering program that seems very sensible to us. First he switches people from short-acting drugs, like Xanax, to longer-acting drugs, such as Klonopin (clonazepam). Depending upon the patient and the circumstances he may start someone on 2 mg of Klonopin, twice daily. Over the first two weeks he may gradually reduce that dose from 2 mg to 1 mg twice a day. Over the next month he gradually reduces the dose to 1.5 mg a day (0.5 mg in the morning and 1 mg at night). Depending upon the progress of the patient, he may reduce the dose of Klonopin over the subsequent month to 1 mg per day (0.5 mg twice daily). The next month will see a small reduction to 0.75 mg per day (0.25 mg in the morning and 0.5 mg at night). Over the next month he tries to reduce the dosage by 0.25 mg slowly. Finally, he tries to get the patient to 0.25 mg every other day for two weeks and then every third day for two weeks until the drug can be ultimately eliminated.
This is a very slow process, and Dr. Baughman’s approach may not be appropriate for everyone. Your doctor may want to check Dr. Baughman’s recommendations for benzodiazepine withdrawal in detail. (The article is “Anxiolytic Perspectives for Primary Care Physicians,” published in Family Practice Recertification, vol. 11, 1989, pages 117-125.) Then she will be able to design your tapering-off program.
Why Am I Feeling So Blue?
OK, so you aren’t hallucinating, you’re not confused, you don’t have any anxiety. But, even though no major tragic event has occurred recently in your life, you are down in the dumps, you feel hopeless and you are not sleeping well. You might very well be suffering from depression, so you should go see your doctor right away armed with the name and dosage frequency of every single drug you are currently taking and those you have recently stopped taking.
With this information, your doctor might be able to tell whether you are suffering from drug-induced depression, the symptoms of which can sneak up on you little by little.
Research shows that almost one out of four people taking beta-blockers [heart and blood pressure medicine such as Inderal (propranolol), Lopressor (metoprolol), Blocadren (timolol) or Corgard (nadolol)] were also receiving antidepressant medication. The implication is that depression is a relatively common side effect of such drugs.
Because many physicians do not mention depression and because symptoms can come on slowly, people may not realize that their psychological state is linked to medicine. If they mention depression, the doctor may then add an antidepressant. We have always felt that trying to counteract one drug’s side effects with another drug is a little like watching a dog trying to chase its tail. A more holistic approach might involve a complete reevaluation of the original treatment so that drug-induced depression can be eliminated entirely.
Hormones can also affect mood. Both estrogen and progesterone can bring on depression in susceptible individuals. Millions of women take one or both of these, as they are found in birth control pills and commonly prescribed as Premarin and Provera for menopausal symptoms. Estrogen brands include: Estrace, Estraderm, Estratab, Menrium, Ogen, Tace and others.
Even eye drops can cause some people problems. Beta blockers such as Betoptic and Timoptic can be absorbed into the body to cause depression. The moral: if you suspect your medicine is making you feel blue, contact your doctor immediately.
OTCs-Not Wimpy Drugs
It’s easy to walk into a pharmacy, supermarket, or convenience store and buy something to take care of your sniffles or cough. All you have to worry about is driving or operating heavy machinery right? If you don’t need a prescription, then it’s not really a drug, right? Wrong on both counts.
Although psychological reactions to over-the-counter drugs are rare, these medications do have the potential to cause side effects, just like anything your doctor prescribes. It is especially important to remember that the combination of prescription drugs and over-the-counter medication could be responsible for drug-induced mental symptoms.
Your doctor should be made aware of any other drugs you are taking, even something as seemingly innocuous as a cough remedy like Nyquil (pseudoephedrine, doxylamine, dextromethorphan, acetaminophen, alcohol) or an asthma medicine such as Primatene P (theophylline, ephedrine, Phenobarbital). Only then will he be able to determine whether a drug interaction is at the root of the illness.
Overuse of oral decongestants or cough remedies can cause unwanted psychological effects. Dextromethorpan is a common ingredient in many cough preparations such as Cheracol D Cough Liquid, Formula 44D, Naldecon Senior DX Liquid, and Robitussin-DM. When taken according to instructions there is rarely a problem. But an overdose of this cough suppressant can cause dizziness, confusion, slurred speech, excitation, hallucinations, and a number of other side effects. Teenagers have been abusing dextromethorpan-containing cough medicines, sometimes with tragic results.
Children and Medication
Children are not just little adults, either mentally or physically. They do not always react to medications the same way adults do. Physicians writing in the British Medical Journal have reported cases of children who suffered terrifying visual hallucinations – most of which involved insects or spiders – after having taken a cold medicine containing both an antihistamine and a decongestant.
Visual hallucinations are rare in children, but one wonders how many times irritability, dizziness, and nightmares are blamed on the illness rather than the treatment. After all, if Mom takes an over-the-counter remedy and has no problem with it, why can’t Junior?
Antihistamines, common in the majority of allergy and cold remedies, can cause drowsiness in adults. But for children, antihistamines can act as a stimulant. A child who wakes up with a cough may be given a multi-symptom medication that could have him wired for hours.
Protecting Mental Health
What do you do if you suspect a medicine you are taking is producing psychological symptoms? First, DON’T STOP taking that medication. It gets a little tricky after that, however. The physician, – your gastroenterologist, for example – may be fully aware of the physical side effects that are common for the drug in question. But he may be less knowledgeable about how that drug affects the central nervous system. Or he may not be aware of other drugs you are taking, including over-the-counter medications.
Quite possibly, you will need to find a doctor or even a psychiatrist who understands neuropharmacology, in order to get you back on the road to good health – mentally and physically.
If Grandpa’s personality starts changing and he seems depressed and forgetful, it may not be old age and senility. The dose of his heart medicine may be too great and that could be producing a toxic psychological reaction. A simple blood test might reveal the source of the problem.
Clearly not all psychiatric symptoms are brought on by medicine. Sometimes depression, anxiety or hallucinations happen because of severe stress or biochemical changes within the brain. But all psychological symptoms deserve careful evaluation by a health professional capable of determining if a medication is contributing to the problem.
If you have any questions or comments, feel free to write: The People’s Pharmacy, P.O. Box 52027, Durham, NC 27717-2027. You may also wish to order one of our many publications or audio cassette tapes.