Medications side effects

Many studies have examined the efficacy of a variety of psychosocial treatments for alcohol, cocaine, and opioid use disorders, alone and in conjunction with pharmacotherapy. However, only a handful of studies have explored how these two treatment approaches may interact. More research is needed to further explore the ways in which psychosocial interventions may be used in conjunction with pharmacotherapy to optimize outcomes for both treatments. Providing encouragement for abstinence, greater treatment retention, medication adherence, and coping with medication side effects are some potential applications of psychosocial therapies. 

TABLE 39-3. ADHD Medication Side-Effect Profiles, Management, and Monitoring... 

What are the expected differences in side-effect profiles between ethnic groups, in particular with selective serotonic re-uptake inhibitors and atypical antipsychotics Can the morbidity of medication side effects be reduced, hence increasing treatment compliance and effectiveness ... 

Pain intensity, pain relief, and medication side effects must be assessed on a regular basis. The timing and regularity of assessment depend on the type of pain and the medications administered. Postoperative pain and acute exacerbations of cancer pain may require hourly assessment, whereas chronic nonmalignant pain may need only daily (or less frequent) monitoring. 

Detoxification, as mentioned in Chapter 2, may involve the use of certain medications to prevent severe discomfort or even possible medical side effects related to withdrawal symptoms. These medicines can range from tranquilizers (often benzodiazepines) and antidepressants to anticonvulsives and antihypertensives, and the medical protocol for detox will depend on the drug or drugs being abused, the client s vital signs and other symptoms, and the known risk for certain withdrawal symptoms associated with the drugs being used. The duration... 

Finally be aware of the fact that diseases in the upper part of the gastrointestinal tract are common in the elderly and can cause severe complications and even be fatal. Drugs that are often used in the elderly due to chronic diseases with inflammation and pain are often the cause of gastritis, peptic ulcers and hiatus hernia. The risks of medication side effects as a reason for the problem must be taken into account when treating elderly for peptic ulcers and stomach pain. 

The risks of medication side effects must be taken into account when treating elderly for peptic ulcers and stomach pain... 

Some medication side effects also occur only after prolonged administration and, as such, are products of the adaptive response to the continued administration of the medication. For example, taking a so-called conventional or typical antipsychotic for a long period of time can cause involuntary movements called tardive dyskinesias. These dyskinesias are believed to occur after chronic administration of the antipsychotic has caused changes in the density and/or sensitivity of dopamine receptors in brain regions that coordinate movement. 

Although traumatic brain injury (TBI) is not, in and of itself, a psychiatric illness, it nonetheless warrants attention in our discussion of psychiatric medicines for two important reasons. First, it is not unusual for TBI to produce psychiatric symptoms severe enough to require pharmacological treatment. Second, treatment with psychiatric medicines after TBI often raises clinical concerns that are unique to these patients. More specifically, an injured brain is often especially vulnerable to medication side effects. Thus, the medical axiom first, do no harm is particularly important when treating TBI patients and must be considered when deciding whether to use psychiatric medicines, and if so, what medicines to use, and at what doses. 

In this case, a more careful psychiatric and physical examination can be of help. Although there are admitted similarities to depression and the negative symptoms of schizophrenia, Parkinson s disease is also associated with a resting tremor, called cogwheel rigidity, and at times drooling. These other symptoms are not typically due to psychiatric illness. If these symptoms are present, one should investigate the possibility of a medication side effect or the presence of Parkinson s disease. 

Diarrhea is the frequent passage of watery, unformed stools. Its many causes include IBS, infectious disorders, thyrotoxicosis, malabsorption, medication side effect, and laxative abuse. Attempts to treat diarrhea should first focus on the patient s list of medications followed by a search for an underlying systemic disorder. Opioids and 5-HT3 receptor antagonists, such as alosetron, slow motility and can therefore decrease or eliminate diarrhea. 

More troubling still, several of the teenagers were so distraught by their illnesses and the way they were treated at school that they had to drop out for a while and sometimes change schools. Two students even described hospitalization as a respite from school. One explained I wanted a break from school. I was like, Please put me in the hospital. For others, medication side effects made school unbearable ... 

Apathy and frontal lobe-like syndromes. A reversible, dose-related frontal lobe-like syndrome characterized by apathy, indifference, loss of initiative, and/or disinhibition has been reported in adults on SSRI therapy (Hoehn-Saric et al.l990, 1991). Recently, five cases of amotivational syndrome in youths, 10 to 17 years of age, were reported (Garland Baerg, 2001). Symptoms had a delayed onset, were dose related, and were reversible. The authors caution that such presentation may go underrecognized or may be mistakenly attributed to residual depression or to avoidance rather than to a medication side effect. 

This chapter describes the structure and neurochemical function of TCAs, metabolism and significant interactions with other medications, side effects, and specific recommendations for monitoring of side effects in children and adolescents. Because of the recent concern regarding the sudden deaths of children stabilized on TCAs, particular attention will be paid to the potential cardiovascular effects of these medications. The chapter will focus on the five TCA medications that have been most widely used in children amitriptyline (AMI), nortriptyline (NT), imipramine (IMI), desipratnine (DMI), and clomipramine (CMI). 

Behavior. Activity level, restlessness, distractibility, behavioral inhibition, expressions of anxiety, engagement with the parents and with the interviewer, and evidence of medication side effects should be observed. Increased activity level could be a symptom of anxiety, ADHD, or mania. Particular rating scales may be useful, as discussed in Chapter 32 of this text. 

Language and speech. Speech spontaneity, articulation, vocabulary, and prosody should be noted. Pedantic speech may be a symptom of Asperger s disorder or of a nonverbal learning disorder. Diminished speech may be the result of depression or autism. Excessive speech may be the result of anxiety, ADHD, or hypo-mania. Unusual speech may be an early sign of neu-rodevelopmental vulnerability to psychosis. Slurred speech may be evidence of a neurologic abnormality or a medication side effect. 

Alertness. Alertness involves attention, the ability to shift sets, and concentration, and cognitive abilities. Somnolence could be a symptom of a disorder such as depression or a medication side effect. 

Practically, unless there is any contraindication (e.g., medication side effects), the treatment that was efficacious in inducting remission of the acute episode should be used for maintenance therapy. Patients who are maintained only on medication should be offered psychotherapy to help them cope with the psychosocial scars induced by the depression. Further, many depressed youths live in environments charged with stressful situations and their parents usually have psychiatric disorders. In these instances multimodal treatments are particularly needed. 

Medical illness or medication side effects may directly affect cognition virtually all classes of medication have been implicated. In adult patients, glucocorticoids can impair memory at relatively low doses (Keenan et ah, 1995 Newcomer et ah, 1999), as there are postulated effects on hippocampal neurons. Newcomer et ah, (1999) have reviewed the literature on illnesses in adults in which memory inversely correlates with cortisol levels, such as in Cushing s disease, Alzheimer s dementia, schizophrenia, and depression. There is no similar literature on the pediatric population. The risk of memory impairment puts chronic steroid treatment, such as that seen in certain pediatric rheumatologic disorders and severe asthmatics, for example, into a different perspective, however. Documentation of memory both before and during chronic steroid treatment might help determine detrimental effects in the pediatric population. 

The commonly used classes of antidepressants are discussed in the following sections, and information about doses and half-lives is summarized in Table 2-1. The antidepressant classes are based on similarity of receptor effects and side effects. All are effective against depression when administered in therapeutic doses. The choice of antidepressant medication is based on the patient s psychiatric symptoms, his or her history of treatment response, family members history of response, medication side-effect profiles, and comorbid disorders (Tables 2-2 and 2-3). In general, SSRIs and the other newer antidepressants are better tolerated and safer than TCAs and MAOIs, although many patients benefit from treatment with these older drugs. In the following sections, clinically relevant information is presented for the antidepressant medication classes individually, and the pharmacological treatment of depression is also discussed. The use of antidepressants to treat anxiety disorders is addressed in Chapter 3. 

It is a clinical challenge to distinguish symptoms of the illness from medication side effects. Many symptoms that patients attribute to antidepressant treatment—such as constipation, poor memory or concentration, nausea or vomiting, diarrhea, difficulty... 

Boshes RA, Davis JM. Medical side effects of psychoactive drugs. In Berger PA, Brodie HK, eds. American handbook of psychiatry. Vol. 8. New York Basic Books, 1986. 

Although there are many disorders of attention, ranging from lack of appropriate sleep or motivation in a normal person, to medication side effects to any number of psychiatric and cognitive disorders, here we will only discuss attention deficit disorder, the disorder of attention for which there is the greatest use of stimulant medications as therapeutic agents. 

Magharious W, Goff DC, Amico E. Relationship of gender and menstrual status to symptoms and medication side effects in patients with schizophrenia. Psychiatry Res 1998 77(3) 159-66. 

Strous RD, Alvir JM, Robinson D, Gal G, Sheitman B, Chakos M, Lieberman JA. Premorbid functioning in schizophrenia relation to baseline symptoms, treatment response, and medication side effects. Schizophr Bull 2004 30 265-78. 

Albert K. is a 54-year-old engineer, receiving treatment for a major depression. This rigid, obsessional man came for his appointment a week after being started on tricyclic antidepressants. During the past week he had written a computer program to track medication side effects on a daily basis, and he brought a data sheet with him to the session. 

Basal ganglia Controls aspects of motor behavior Neuronal pathways connecting limbic system and prefrontal lobes Parkinson s disease, antipsychotic medication side effects (extrapyramidal symptoms (EPS)) Obsessive-compulsive disorder... 

Sometimes schizophrenics feel better not taking antipsychotic medications because they are able to entertain more grandiose notions about themselves and thereby lift their mood. Even more commonly, premature discontinuation occurs because patients are plagued by very unpleasant medication side effects. Like other people, they understandably don t like to suffer, and they respond by discontinuing. Appropriate education of patients regarding side effects and medical intervention (many side effects can be controlled with other medications) can improve the quality of life and greatly enhance compliance. It may be helpful to present medications as a tool for the person to use to help them control their illness, as a diabetic uses insulin. 

Part three deals with the different classes of psychopharmaceuticals, including dosage and choice of medication, side effects, and mechanism of action (where and in so far as it has been established). Also covered are precautions for monitoring medication effects and serum levels, and guidelines for educating patients and their families about the effects and side effects of these drugs. 

In this appendix we discuss a potentially problematic area the identification of, and response to, psychotropic-induced side effects. The most obvious danger of failing to accurately differentiate medication side effects from a disease process is the possibility that one might increase the dose of the very medication responsible for the the side effects. Similarly, unwarranted diagnoses may be assigned or unnecessary medications added. 

At times, making this distinction is nearly impossible. Not only is the clinician required to separate strikingly similar medication side effects and psychiatric symptomatology, but the patient may be only marginally able to give a useful subjective description. 

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