The Top 5 Side Effects of Psychotropics and How to Manage Them
Psychotropic medications may cause a range of side effects, but clinicians can tap a variety of strategies to help patients manage them, Psych Congress Steering Committee members explained at the Psych Congress preconference.
Here is a look at the side effects they identified as the top 5, and recommendations for how to treat them:
Antidepressants, mood stabilizers and atypical antipsychotics are the most common contributors to weight gain, said Saundra Jain, MA, PsyD, LPC, Adjunct Clinical Affiliate at the University of Texas at Austin School of Nursing and executive director of the Mental Aerobics Project.
She said a mix of pharmacologic and nonpharmacologic interventions is needed to manage weight gain, which can be from 4 to 37 pounds over the course of treatment. Early intervention is the key to preventing significant drug-related weight gain, she said.
Nonpharmacologic strategies include mindfulness, exercise, individual and group counseling, psychoeducation, surgery, and programs such as Weight Watchers and Overeaters Anonymous.
There are 5 medications approved by the FDA for long-term use for weight loss, Dr. Saundra Jain said: lorcaserin, orlistat, liraglutide, the combination of phentermine & topiramate, and naltrexone combined with bupropion.
Anhedonia and Emotional Flattening
Anhedonia is a side effect that is often overlooked and underrecognized, said Rakesh Jain, MD, MPH, Clinical Professor Department of Psychiatry, Texas Tech Health Sciences Center, School of Medicine, Midland, Texas. It has been missed in clinical trials because most of them have been 9 weeks or less, he said.
“It’s really problematic, it’s really common, and it’s really easy to miss,” he said, noting that people who are taking a selective serotonin reuptake inhibitor (SSRI) or serotonin–norepinephrine reuptake inhibitor have about a 50% chance of experiencing emotional flattening.
Anhedonia can be a harbinger of a future depressive episode, make depression treatments less effective, and impact relationships, Dr. Rakesh Jain said.
“Flattened human emotion is not good existence, either for the person or for the family around them,” he said.
He encouraged clinicians to be more proactive in talking with patients about anhedonia, use clinical scales to try to detect and measure it and, if necessary, consider reducing medication dosages or switching to a different class of antidepressants. Medications with different mechanisms of action help improve anhedonia, he said.
Psychotropic medications as well as other agents can result in various sleep disturbances, from insomnia to problematic levels of sedation and mixtures of the 2, said Charles L. Raison, MD, co-chair of Psych Congress and professor, School of Medicine and Public Health, University of Wisconsin, Madison.
“If sedation becomes a real problem or disrupted sleep becomes a real problem, it’s well worth examining all of the medicines that our psychiatric patients are on and asking ourselves are they all really necessary, are we giving people things that are synergistic in ways that we don’t want them to be synergistic in,” Dr. Raison said.
Different antidepressants may impact sleep differently, and their effects can vary by patients, he said.
As sleep problems are often chronic, Dr. Raison recommended turning to nonpharmacologic strategies such as sleep hygiene education, stimulus control, sleep restriction, cognitive behavioral therapy, and relaxation. There are many steps patients can take to treat insomnia before turning to medication, he said.
A number of medications are FDA approved to treat insomnia, and they all involve tweaking GABA function, Dr. Raison said. A new and novel medication is suvorexant, an orexin antagonist that he said does not cause the feelings of sleepiness people experience on other sleep drugs during wakefulness.
Many other medications are used off-label for sleep disturbances, but are less understood and have less research behind them on their effects on sleep, according to Dr. Raison.
Another newer treatment Dr. Raison cited is the Cerêve Sleep System, a prescription device involving a cooling pad placed on the forehead that was recently cleared by the FDA. “The data are pretty interesting. It really looks like this could be something useful,” he said.
Many psychotropic drugs, including antidepressants and antipsychotics, cause different types of sexual dysfunction, said Jon W. Draud, MD, MS, Clinical Professor of Psychiatry, University of Tennessee College of Medicine in Memphis.
First-generation medications tend to cause worse sexual side effects than some newer agents, he said. The problems may not begin until a few months into treatment, so clinicians may want to consider the risk of side effects before choosing a drug for a patient, he said.
Dr. Draud said sexual side effects are a major reason for noncompliance with drug therapy, and encouraged clinicians to proactively ask patients about their sexual history and sex life.
“If you’re not even asking about basic sexual dysfunction, I would encourage you to do so, because really this is a big deal for patients,” Dr. Draud said. “If we don’t ask about it, we are really remiss, especially if we are giving them medications that are well known to cause sexual side effects.”
Lowering medication dosages or switching medications, either within or across different classes, can help reduce the side effects, he said.
Clinicians need to be alert for hyperprolactinemia, as few patients will proactively report it, said Vladimir Maletic, MD, MS, Clinical Professor of Psychiatry and Behavioral Science at the University of South Carolina School of Medicine, in Greenville.
“It is hidden. It is sneaky. It is chronic, and it is disruptive,” he said.
Prolactin is regulated by a number of medications and physiological mechanisms, he said. Many first-generation antipsychotics cause huge increases in prolactin, and minor increases are seen with SSRIs and monoamine oxidase inhibitors (MAOIs), he said.
Hyperprolactinemia has some “very insidious manifestations,” Dr. Maletic said, including loss of bone mass, sexual dysfunction, irregular menstrual cycles, infertility, and increased risk of cardiovascular disorders and breast cancer. It can also have neuropsychiatric effects—including anger, anxiety, irritability, and hostility—which patients being treated with psychotropics may already have.
To treat hyperprolactinemia, clinicians can decrease the dose of an existing antipsychotic or switch to one that has low impact on prolactin, such as aripiprazole or quetiapine. An adjunctive dopamine receptor agonist can be used, and oral contraceptives can be used in women to make up for estrogen deficiency.
“Management of the Top 5 Psychotropic Side Effects.” Presented at the 29th Annual U.S. Psychiatric & Mental Health Congress preconference; October 20, 2016; San Antonio, TX.