SIDE EFFECTS OF OCD TREATMENT USING MEDICATION
Sperhaps the main reason why SRIs are among the most widely prescribed drugs in the world is that they have relatively few side effects. A recent study involving more than six thousand patients showed that far fewer patients (13.9 percent) stopped SRIs because of side effects than stopped standard antidepressants. In my own clinical practice I have treated hundreds of patients with SRIs. The dose has usually needed to be adjusted, the type of SRI has often needed to be changed, and on occasion medication has needed to be stopped all together. But I have never had a patient who experienced either a nonreversible or a medically harmful side effect.Unfortunately, misinformation abounds regarding the side effects of these drugs. Probably the most common unfounded belief about SRIs is that they cause addiction. The truth is that not a single study has shown them to be habit-forming. Furthermore, the personality of the OCDer, guilt-prone and overly responsible, tends to prevent addiction to anything. I have never treated, nor even heard of, a patient who became addicted to an SRI prescribed for OCD.Another common but unfounded fear is that the SRIs can cause suicidal, or even homicidal, behaviors. This specter was raised by a 1990 article in the American Journal of Psychiatry which reported that 6 out of 172 hospitalized patients on Prozac had become preoccupied with suicidal thoughts. Subsequent studies on many thousands of patients, however, proved that suicidal and homicidal thoughts are no more common with Prozac than with other antidepressants. The number of people who have been prescribed Prozac to date—over 40 million—dictates that almost everything will have happened to someone while on the drug, simply by chance. Yet the mistaken idea that Prozac causes Jekyll-and-Hyde personality changes surfaced once again when defense lawyers tried to argue that David Wisbecker, who in 1989 killed eight of his coworkers in a plant in Kentucky with an assault rifle, did it because he was on Prozac. The issue, hopefully, was put to rest permanently in 1995, when the courts completely discredited the “Prozac defense” in the Wisbecker case. The Federal Drug Administration, whose mission it is to oversee the safety of medications prescribed in the United States, and which is often criticized for being too restrictive, subsequently rejected a petition that the Prozac label include even a warning about suicidal or violent behavior. The FDA has repeatedly reaffirmed the safety of Prozac and the other SRIs.Some widely available books do a good job of realistically appraising the risks of side effects of SRIs and other psychiatric medications. I found three good ones in my local bookstore: Complete Drug Reference ; Essential Guide to Psychiatric Drugs by Jack Gorman (St. Martin’s Press, 1995); and Prozac: Questions and Answers by Ronald Fieve, M.D. (Avon Books, 1994), the eminent psychiatrist at Columbia University who did much of the pioneering work on bipolar disorder. Unfortunately, the “product inserts” that accompany medications and the Physicians Desk Reference, a compilation of product inserts, do a poor job of appraising side effects. They are designed largely to prevent malpractice suits against pharmaceutical companies and simply list every side effect that has ever been reported.The truly significant side effects of the SRIs—all affecting only a minority of patients—are nausea, nervousness, sexual problems, irritability, and nightmares.
Gastrointestinal Symptomsnausea, and sometimes vomiting of diarrhea, are among the most common side effects of SRIs: 20-30 percent of people experience them in the first one to two weeks of treatment. These side effects usually respond to either dose reduction or taking medications with food; often, however, they are the reason patients stop treatment with a given agent. These side effects are most troublesome with sertraline (Zoloft) and fluvoxamine (Luvox).
Nervousness, Headaches, and Insomniathese side effects, affecting 15-20 percent of people taking the SRIs, are all related to an activating effect of these medications that some patients describe as being like the “caffeine jitters.” Such reactions are strongest with fluoxetine (Prozac) and are, indeed, the most common reason why people stop that medication. These side effects usually last only a few months, and then the body adjusts to them. After that, they are sometimes replaced by their opposites, apathy and sleeping too much. All respond immediately to lowering the dose of medication. All can also be effectively treated by the addition of an antianxiety medication such as clonazepam (Klonopin) or lorazepam (Ativan).Interference with Sexual Functioningthis side effect—most often either an inability to attain orgasm or a loss of interest in sex—was underreported at first, but it is now clear that it occurs in fully 30—40 percent of people taking SRIs. This side effect, too, usually responds to dose reduction. A number of my patients on short-acting SRIs, such as paroxetine (Paxil), sertraline (Zoloft), and fluvoxamine (Luvox), have reported that skipping medication for two days allows a return of full sexual function without a loss of antiobsessional effect. Two recent studies have supported this observation. Adding medications of various types to an SRI can also reverse sexual side effects, and yohimbine (Yocon), buspirone (Buspar), buproprion (Wellbutrin), trazodone (Desyrel), and cyproheptadine (Periactin) have all been tried in this regard. In my practice, however, these counteractive drugs have proved disappointing. Only Yocon and Desyrel have worked at all, and those in only a few patients.
Irritability and Nightmaressince the data are strong that the neurotransmitter serotonin plays a role in regulating anger (for instance, violent criminals have low levels of serotonin metabolites in the spinal fluid), it is not surprising that SRIs have an effect on irritability. Fortunately, this is usually a positive effect. Typical is the story of an eighteen-year-old woman who had been kicked off sports teams, run away from home, and been punished by her parents since age six for her short fuse and overly aggressive behaviors. After three months on an SRI she told me, “I’m much calmer now. I think before I act. For the first time ever, I sat down and talked to my sister for a full hour.” A study at Harvard in 1991 looking at outbursts of anger among people on SRIs found that outbursts went down in 71 percent of patients and up in 6 percent.The increased irritability that does occur in a small number of people can, it must be admitted, be a problem. I have had several patients, all with prior histories of hostile behaviors, who had to stop SRIs because of marked increases in anger. One patient, for instance, who had served time for assault and battery, had to stop his SRI because, as he put it, “It made me feel like when I was on steroids: say hello and I snap out.” I should add, however, that I have never had a patient who acted harmfully because of the effects of these medications.A larger problem with the SRIs is the occurrence of nightmares, often of physical harm. Rather than the 0-5 percent reported in clinical trials, perhaps 10—15 percent of my patients are bothered by vivid, troublesome dreams. These patients respond to decreasing the dose of medication, or changing to a different SRI.Other Side Effectstremor and sleeping excessively can occasionally become problems after many months of treatment with an SRI. Patients so affected usually respond to a lowered dosage. Allergic reactions, primarily rash, occur in about 3 percent of people taking SRIs. Because tetatogenic effects (adverse consequences of drugs on the developing fetus) have not been well studied, SRIs should be stopped, if possible, during pregnancy. Large numbers of pregnant women have taken SRIs, however, and so far there have been very few problems reported.Dry mouth, constipation, drowsiness, and memory loss occur as a group and are referred to as anticholinergic effects. They are by far the most frequently seen with clomipramine (Anafranil) and occur to a lesser extent with paroxetine (Paxil). Anticholinergic side effects always respond to dose reduction. Chewing sugarless gum or sucking on lemon drops (which stimulates salivation) can also be helpful for dry mouth. Other potential problems specific to clomipramine (Anafranil) are heart conduction abnormalities (patients who are over forty should have an electrocardiogram before starting Anafranil) and a lowering of the seizure threshold.
Medication Interactionsthe sris — in this case clomipramine (Anafranil) much less than the others—have a strong effect on the liver’s metabolism of certain medications. As a result, the SRIs have the potential to dangerously increase the blood levels of many drugs, including antidepressants, anticonvulsants, blood sugar medications, heart medications, pain medications, and allergy medications. Although I have never had a patient who ran into a major problem in this regard, these drug interactions are potentially serious. For the older person on a number of medications, these drug interactions represent the major drawback to the use of an SRI.
Alcoholcan a patient drink while on medications? Psychiatrists tend to take the conservative position that it is better not to consume any alcohol while on any psychiatric medication. It should be pointed out, however, that many patients drink socially while on SRI medications without a problem. There is, in fact, no direct, harmful interaction between alcohol and the SRI drugs. The case is somewhat different with benzodiazepine medications, such as lorazepam (Ativan), clonazepam (Klonopin), and alprazolam (Xanax). Here there is an interaction, and alcohol should be avoided.*28/338/2*
Comments are closed.