There are a few basic things to note when taking any psychiatric medication. These rules pretty much apply to all of the meds covered in this site. I deal with the whole issues of side effects, brand vs. generic drugs and how to read PI sheets separately, as they are big freakin’ deals in of themselves.First you need decide if it’s bad enough to require any form of medication, and for that you should be seeing a talk therapist and you should belong to a support group. A psychiatrist is basically going to figure out the right meds for you and that’s going to be about it. Sometimes they’ll do therapy, but often not. For more information on, and reasons why you should be seeing a talk therapist and belong to a support group, take a look at my page on support groups. Both will help you determine if you really do need some type of medication. And if you do, the services of both therapist and support group are vital to complete what the drugs do. Meds alone are not going to fix your problems!
First you should stop drinking grapefruit juice and eating grapefruit. Really. Grapefruits contain an enzyme that messes with the enzymes that metabolize a majority of these medications, thus altering a med’s effectiveness. That’s why those wacky grapefruit diets work for some people. Not all meds are affected by grapefruit, just some 60% of them. Some drugs, mostly old-school tranquilizers like Halcion and Versed, are actually enhanced by grapefruit enzymes. Some meds like Neurontin (gabapentin), Keppra (levetiracetam) and lithium are not extensively metabolized and are mainly processed your kidneys or different liver enzymes entirely, so the grapefruit rule doesn’t apply at all. But if you’re taking a cocktail of medications it becomes confusing as to what do which liver enzymes metabolize. So just play it safe and give up the grapefruit juice, grapefruit sodas and grapefruits. And that’s just not when you take your meds, that’s all day, every day. This information is documented in your PI sheets, buried in there somewhere, if you can’t mix grapefruit and a particular medication. However, not all drug companies seem to be up on the grapefruit thing, even if their meds are metabolized by CYP450 3A4, the most popular liver enzyme and the one isozyme of the cytochrome P450 family that seems most affected by grapefruit juice.
If you really need to know what is and isn’t affected by grapefruit juice, you can look it up here on a site dedicated to grapefruit-drug interactions, or just check my favorite drug-drug interaction site.
You should also wash down all meds with water and drink plenty of water to assist in the metabolism process. Milk and milk equivalents are OK for meds that are to be taken with foods. In almost all cases it is not the drug you take that does the job, but the metabolized bits processed by your liver that work the magic. This time the heavily kidney-processed drugs like lithium, Topamax (topiramate) and Neurontin (gabapentin) are especially dependent upon extra water to work their best and to avoid a lot of the nastier side effects of lithium and Topamax (topiramate).
Some meds you need to take with food and some meds you need to take on an empty stomach, that’s a given. But some meds, especially some of the anticonvulsants and the MAOIs, are really sensitive to particular foods, so what you eat one day can make your meds work better and what you eat another day can make them work worse than baseline. Read those patient information sheets carefully and dig into the drug companies’ web sites if you notice day-to-day variations in the efficacy of your medications. Never mind about the warning I had about citrus juice and extended-release meds I had before. I was full of crap. Stomach acid is way more acidic than straight lemon juice. Basic biology people. That’s why you should check out several different pages, and not get all of your information from a high school drop-out like me. At least I did write the evidence was spotty on that one.
The day-to-day thing is even more complicated for girls taking anticonvulsants, which is covered in the anticonvulsant section. Yes, ladies, your powerful girly hormones can affect your meds. Conversely many of the meds can affect your hormones. Guys have these girly hormones too, which accounts for some of the freakier side effects of the TCAs. But the interaction of estrogen and anticonvulsants is fairly well known, at least amongst psychopharmacologists. So a woman’s monthly cycle can affect the efficacy of certain medications from day to day. In some cases birth control pills will smooth out that ride, in other cases birth control pills will make it worse or will be worthless. Go ahead and scream like Rosanne Barr in PMS hell, it is frustrating and confusing. If you’re bipolar and/or epileptic, we’ll get through this somehow. If you’re female and neither bipolar nor epileptic, the hormone thing probably won’t have as much of an impact on your meds.
While we’re on the subject of girly hormones, did you know that the dosages for psychiatric medications are standardized for non-smoking Caucasian males of average weight aged between 20 and 65 with no liver or kidney problems? Geez, I don’t know why that group of people is singled out for special treatment, it’s not like they run the country or anything. So if you’re not standard, i.e. you fall outside a single one of the aforementioned criterion, you may need to have your dosage adjusted. Say you’re female. Or you’re not white. Or you smoke. I discuss this in more detail in the section on how to read the PI sheets, as that is where you will learn if you will need to adjust your dosage for not being part of the Power Elite.
How much of a difference does it make? A teenage Japanese boy who smokes gets six times as much of the active metabolites of Zyprexa (olanzapine) than a non-smoking Caucasian woman above A Certain Age (i.e. 65 or older).
A lot of the meds are going to mess with your tummy and give you a variety of digestive problems like nausea, diarrhea and the like. You may have to just tough it out and not take any over the counter remedies because those could interfere with the metabolism of the drugs. Read the patient information sheet or ask your pharmacist to look up if it’s safe to mix Pepto-Bismol or antacids or Alka Seltzer or any over the counter meds. With a lot of these drugs it can make a big difference!
This is what you need to call your doctor about right away:
Really blurry or double vision; a little blurred vision is common with a lot of meds, including SSRIs and atypical antipsychotics. If you wear contact lenses, make sure the proper lenses are in the correct eyes.
Fainting or losing consciousness.
Weird bruising that can’t be accounted for; a lot of weird bruising means you need to get to the ER immediately with all of your prescription bottles in hand.
Hair loss; not thinning, that just sucks, but hair falling out in clumps.
A sudden manic reaction, no matter how much fun you’re having at the time.
A rash accompanied by a fever; if it’s a big, itchy rash and/or a high fever, it’s off to the emergency room, especially if you’re taking an anticonvulsant.
If you’re experiencing any of those symptoms and your doctor is not available, it’s emergency room time. If you’re taking an anticonvulsant, especially Lamictal (lamotrigine) and you experience a rash but no fever, don’t be surprised. They’re rash meds. I’ll cover that in more detail in the section about anticonvulsants in general and Lamictal (lamotrigine) in particular.
There is a difference between the brand and generic forms of medications. I cover that on a page dedicated just to that subject. It is not in your head that you notice a difference. It’s real and it’s documented.
Practically every medication has cornstarch in it, which is no big deal for most people. But if you’re allergic to corn like Mouse and I are, that’s yet one more thing to mess with you. If you need to and can afford it, investigate having your meds custom-made by a compounder. However, there have been some problems with compounders of late, some resulting in the deaths of their clients. Ouch.
Check the PI sheet for the initial dosage of the med. Or if in your doctor’s office, ask to look it up in the PDR or whatever equivalent is handy. Are you starting out at the lowest dosage? If not, why not? When you’re switching from one med to another within the same class, say between atypical antipsychotics or benzodiazepines or SSRIs, then it makes perfect sense to start a new drug at a higher dosage, because your brain is already acclimated to the chemical signals it’s receiving. I have the equivalents of what each med is for its counterparts within a class for the SSRIs, benzos and atypicals. Your liver might object to the new med at first, but your liver is far more likely to come around about these things than your brain is. But if you’re starting something you’ve never had before, e.g. you’ve never had an anticonvulsant or an antipsychotic, then you really should be starting at the lowest dosage and working your way up. Maybe even starting at below the initial dosage. Hey, that’s why God invented pill splitters (see below). If the really low dosage doesn’t work, you can always go up, but if you start out too high, it’s kinda hard to untake a med. Starting out low helps make dealing with side effects easier. I’ll cover the specifics for such things on the pages for individual meds and on the pages dealing with meds for specific disorders. The exception to this rule is if you’re in a crisis. But if you’re in a crisis I doubt if you’re reading this site. If you’re a family member reading this site for someone who is in a crisis, believe me, 5mg a day of Zyprexa (olanzapine) is tough to start at, but the alternative is much, much worse. Zyprexa sucks donkey dong but it saves lives while doing so.
Then there’s exercise. You’ve always read and heard the bit about getting regular exercise to stave off depression, keep your moods stable and so forth. Well it does make a big difference when you’re taking meds, because the exercise gets your blood circulating better which both helps the metabolism process and gets more oxygen and metabolites to your brain. I’ve found the most bang for my buck from a combination of Yoga and Qi Gong. Once I started doing them regularly my agoraphobia and depression became less problematic. They really did make my meds work better, or something. I’m not the only one to note the increased efficacy of medications after a program of regular exercise was begun. Jogging, weight lifting, martial arts, it doesn’t really matter. A lot of different people on a lot of different types of meds for a lot of different disorders doing a lot of different types of exercises have reported the same thing: once they began to do something regularly that improved circulation and increased the amount oxygen to their brains, their various symptoms improved. I know a lot of you will be exercising to lose weight, especially since many of these meds will often cause you to gain weight. Mouse worked out like a maniac (har-har) and she still gained over 50 pounds thanks to the TCAs. The sad truth is that you may still gain weight despite your additional exercise. This can be doubly depressing, because you have the self-esteem issues of weight and the issue of being a failure. Then you stop exercising, the meds are then working less well, and you get even more depressed. Talk about your vicious cycle! So keep exercising even if you gain weight. Again, all the more reason for something like Yoga or Qi Gong, where there aren’t as many promises of weight loss. Yeah, some Yoga schools and tapes and DVDs make weight loss claims. Don’t buy into them! Rather, think of any weight loss as gravy.
Metabolism of drugs is a big deal, and often a med won’t work properly for someone because they can’t metabolize it properly. Roche has just developed a test to check if someone is going to metabolize some drugs properly or not, but we have no idea when or if that will reach the market or what effect it will have on the drugs we cover in this site.
The Mayo Clinic has developed a test to see how the critical enzyme group Cytochrome P450 should be working for you. It’s a genetic test, not a test of the actual isozymes themselves, so it would just extrapolate if your genes put your liver together in a way that would metabolize meds quickly, slowly, efficiently or inefficiently. It won’t pick up any subsequent damage you may have done to your liver. Hey, this is a lot better than nothing. If you and your doctor suspect metabolism issues in general, contact the Mayo Clinic about their test. The CYP450 group metabolizes just about everything you would take.
In the PI sheet for Strattera Eli Lilly mentions a similar test for enzyme CYP2D6 (a.k.a. P450 IID6 and P450 2D6, ain’t nothing like standards, folks), the enzyme that metabolizes Strattera (atomoxetine), Prozac (fluoxetine), Paxil (paroxetine) and the TCAs. If you and your doctor suspect metabolism issues with just these meds, or anything else that relies upon the 2D6 isozyme (as it is also known) and your doctor doesn’t know about the test, maybe somebody at Eli Lilly can tell you where and how to get it done. I don’t know if that test is genetic like the Mayo test or if it’s a test of the current state of how your enzyme is working.
The PI sheet will often tell you what enzymes metabolize which drugs, and sometimes even mention the differences for poor metabolizers and fast metabolizers, but other than the aforementioned tests, I don’t know of any way you can ask your doctors to find out if any other specific enzymes are up to speed. I have no clue how the drug companies themselves were able to lump people who participated in the clinical trials into different metabolism groups, other than timing the plasma concentrations of the drugs and just inferring it all through bio-statistics. Of course now the latest research indicates that the genetics around the receptors in your brain may be a bigger factor than the genetics around the enzymes in your liver. Just when we think we get this shit sort of figured out, those damn scientists have to come around and tell us that everything we know is wrong.
What enzymes are used by which drugs is a big deal, because if too many drugs use the same enzyme then you won’t be able to metabolize one, or more, or any of the drugs you’re taking! So many drugs are metabolized by the isomers of enzyme CYP450 that there is a book that is just interactions of drugs for that single enzyme. Your doctor should look that all up in the PDR (see below) before prescribing any combination of medications, but it’s ultimately up to you to double check on any drug-drug interactions. In addition to what’s in the PI sheets, this site: https://www.aidsmeds.com/cmm/DrugsNewContent.asp has all the skinny on which drugs interact with each other and with foods. Just enter all your meds and they’ll tell you mild, moderate and severe interactions.
Other liver enzymes are pretty popular as well. If two or more meds don’t play well together in your liver, you wind up not getting the desired effects from one or more of the meds.
Those of us in the bipolar spectrum need to be aware of the paradoxical reaction to meds. Frequently drugs have the opposite effects on us. This is a somewhat known effect in the medical world, and is common in children, the elderly and the bipolar. Opiates can make us manic, antipsychotics can make us hear voices and keep us awake instead of sedating us, benzodiazepines make us anxious and keep us up all night, and antidepressants can make us suicidally depressed if they just don’t invoke the special hell of a mixed state. Sometimes it’s not intended effects that are paradoxical, but side effects, like people losing weight when taking Depakote (divalproex sodium) or Zyprexa (olanzapine). The calming effects of stimulants on people with ADD/ADHD is not an example of the paradoxical reaction, although it may seem that way, which just further confuses the distinction between and diagnoses of ADD and bipolar. You never know the drugs to which you’re going to have a paradoxical reaction. You don’t know if the reaction will be permanent, temporary or just short-term. Let’s take mine. Opiates always make me manic, that’s a given. Sometimes it will be a dysphoric mania, which really sucks, but I get manic from any opiate before nodding off. Risperdal (risperidone) used to keep me up at nights, but now it puts me to sleep. And benzos, my reaction to benzos is weird. When I first take a benzo, any benzo (and I react to all of them the same regardless, not just in this way) it makes me anxious and nervous for about half an hour, then I get all calm and relaxed. It doesn’t matter if I’m anxious to start with. If I’m taking lorazepam to fix a disrupted sleep cycle (about the only reason I take it these days), I can expect to get nervous at first. So I have a paradoxical reaction to benzodiazepines that lasts half an hour, then they act to spec afterwards. In conversations with my mother I’ve found that I’ve had similar paradoxical reactions to anesthetics. I hope I never need surgery again. It certainly explains some of my psychological make up to this day, having surgery as a little kid and not being fully under.
If you take more than one medication, or you take one or more medications several times a day, you need to invest in a pill organizer. The one shown in the link is the one I have, although mine is blue. There may be better models, but I was at Walgreen’s and it was there. It works well for me. If you’re taking anticonvulsants or antipsychotics you may be experiencing memory problems, and having your meds in one of these is a good way to know if you took your meds when you were supposed to. One problem of staying med compliant is just forgetting to take the damn things, and a pill organizer is a big help in dealing with that issue.
Please, people, I can’t stress the importance of staying med compliant. While some medications, like the atypical antipsychotics are very forgiving if you skip a dose or two, others, like Paxil (paroxetine), will basically never speak to you again if you miss a dose. You can’t just decide on your own to mess around with what you take, when you take it or how you take it. And I personally think the biggest problem with psychiatric meds and teenagers, especially the SSRIs, is that the kids are inconsistent in how they take the pills. Which just leads them to feeling worse, which gets blamed on the meds and you can see where this is going. I plan on writing a more detailed article about kids and antidepressants in the future.
If you’re paying full retail for your meds, or if you’re taking SSRIs, you’ll want to invest in a pill splitter. The splitter part of the example given isn’t very good, but the product itself is just too much fun. Some Walgreen’s stores sell superior splitters, and Kaiser distributes a very high-quality splitter. Anyway, why you need a splitter is simple – many drugs cost the same, or nearly the same regardless of the dosage. Now you can’t split capsules and you must never, ever tamper with a drug that is extended release, controlled release, sustained release or anything like that. But for a lot of pills you can split them in half and save a lot of money. I used to buy my Risperdal (risperidone) from Canada and get it in twice the dosage I normally take and split the pill in half, so I wound up paying, get this, one twelfth, that’s right, 8 & 1/3 cents on the dollar what it would cost to buy 0.25mg tablets here in the US. I explain in the section on SSRIs as to why you’ll want a splitter.
Never, ever throw away the PI sheet that comes with a med you take. Why? That’s your proof of purchase. A doctor is always going to ask you what meds you’ve taken before. Well, how the hell are you going to have any proof that you’ve taken a particular med? Save the PI sheet and one empty prescription bottle, even if it’s just a sample box or bottle. It doesn’t matter if it’s the fake PI sheet from an HMO, you need something. Always demand one when taking a new medication, and be the biggest asshole in the world if you need to be in order to get one. Printing one out from this site won’t do it. That’s not proof of purchase. This helps you, too, and I’ll cover this more in the section on talking with your doctor and organizing your medical history. Just believe me, some doctors don’t always believe us nutcases when it comes to our medical histories.
Finally, there’s the pregnancy thing. Most of the medications are not for use during pregnancy; many are not for use during nursing. Specific information is in the PI sheet, which is linked to each med. Practically all of the meds are pregnancy category C (they messed up fetal rats, effect on humans unknown) or worse. Very few of the meds don’t get passed through to breast milk. If I happen to notice that a med is safe for either pregnancy or breast feeding, I will note it. You must do some serious cost-benefit analysis regarding either risking something weird happening or stopping your meds and getting pregnant, especially when you consider that sometimes when you stop taking a med and then start again after the changes in your body following pregnancy it just doesn’t work the same. Then there’s the issue of a lot of these issues being genetic. Please, factor in adoption in your considerations. Lots of babies and kids need homes as it is.