www.chrisbojrabmd.com
Medication Information For Patients:
Selecting the optimum medication or combination of medications is part science and part “art”. As someone committed to practicing science-based medicine, I make every effort to maximize my reliance on the science and minimize my reliance on the “art”. My rationale for this approach is based on my understanding of the fact that we are all subject to our own biases and other factors that can influence our perception of reality.
The classic conflict in this regard is an over-reliance on data from double-blind, placebo controlled trials versus an over-reliance on our own personal experience as physicians in prescribing certain medications. The criticism of over-reliance on clinical trial data is that they are not “real-world” settings as patients participating in clinical trials are carefully selected to minimize other confounding factors such as the presence of other mental health or other general health conditions, the influence of the concurrent use of other medications, the use of alcohol or drugs, and a variety of other individual differences affecting medication response. The criticism of over-reliance on our own experience is that physicians, like everyone else, are subject to our own biases based on past experiences with medications, the impressions of our colleagues’ experiences with the medication, and a variety of other factors.
I have selected your medication regimen based on my understanding of the data from the clinical trials submitted to the FDA, my expert understanding of your symptoms and possible diagnosis, the mechanisms of action of the medications (our best understanding of how these medications work in your body), and my extensive experience in the use of these medications (tempered by my natural skepticism and understanding of my own potential biases).
The reason(s) I have recommended your medication regimen may include one or more of the following considerations
- Your diagnosis
- The type of symptoms that you have reported
- Other aspects of your general health
- The likelihood that you as in individual may be more or less vulnerable to certain side effects
- Your previous experience with other medications
- Data from genetic testing that I sometimes recommend as a means of improving my understanding of specific genetic information that may provide some guidance in better understanding the ways in which your body may process or be more or less likely to respond to certain classes of medications.
Side Effects:
All medications can cause side effects. Not all patients are at the same level of risk for side effects. If you look at the package insert for any medication, you will find that nearly every side effect has been reported for nearly every medication by some patient at some point in time. Keep in mind that studies have shown that patients are 7-10 time more likely to take the time to report a negative potential side effect than they are the benefit of a medication. Whenever you read something on a blog post or in a wiki or chat, you are not seeing a balanced overview of the typical response that patients have when taking a medication. With all due humility, I am your best source of information for the potential risks and benefits that you may experience with your medications. If you have questions or concerns about something you are experiencing with your medication, we should discuss this during our office appointments or you are welcome to contact me through the office and we will do our best to address your questions and concerns.
It’s All Relative:
Please keep in mind, that there is considerable variability in the way in which different individuals respond to and tolerate different medications. The following is presented as general guidelines for side effects that may be experienced by patients taking different classes of medications. This list is not exhaustive, rather, it reflects some of the more common side effects as well as some very rare but more important side effects. Most patients do not experience these side effects, and the majority of patients who do experience side effects find that they begin to improve or resolve within the first couple of weeks of taking a medications. Also keep in mind that the medication information forms available through your pharmacy are overly inclusive by design. One of the best ways to look at this information in detail is to review what is referred to as the “package insert” of any medication. This document shows the percentage of patients experiencing side effects who took the actual medication as well as the percentage of patients who reported the same side effect when they took a “placebo” (an inactive sugar pill that looked identical to the real medication). It is also helpful to look at the “discontinuation rates” reported in the package insert – this describes the percentage of patients who stopped the medication because of a suspected side effect compared to the percentage of patients who stopped taking the placebo because of the same suspected side effect. There are some side effects that may be relatively common, but they may be relatively mild or short-lived, such that patients did not choose to stop the medication because the side effect was so mild or that the amount of benefit derived from taking the medication outweighed the side effects.
General Information On Side Effect By Category Of Medications:
Antidepressants:
- Sedation
- Nausea
- Loose bowel movements
- Headache
- Feeling an initial period of activation or anxiety (even though most of these meds are helpful for anxiety in the long run)
- Increased appetite/weight gain
- Decreased appetite/weight loss
- Easier bruising or prolonged bleeding
- Decreased sex drive
- Prolonged time to reach orgasm
- Impaired erections
- Dizziness, flushing, nausea, if you stop certain of these medications abruptly
- Feeling emotionally flattened out (not an intended effect of the medication, but experienced by a small percentage of patients with certain types of antidepressants)
Antianxiety Medications – Benzodiazepines such as Xanax, Klonopin, Ativan, Valium, etc. and many (but not all) Sleep Medications:
- Potential for addiction
- Tolerance (building up immunity to the anti-anxiety benefit of the medication over time)
- Sedation
- Impairment in driving, balance, motor skills
- Impairments in balance (older patients at greater risk)
- Impairments in concentration and memory
- Respiratory suppression
- Increased risk of insomnia, anxiety, and sometimes seizures if you are taking a larger dose of these medications and if you stop them suddenly
- These risks may be substantially higher if you are using narcotic pain medications or other sedating substances such as alcohol or other sedating medications!
Antipsychotic/Mood Stabilizing Medications (used in psychosis, bipolar disorder, and sometimes as adjunctive medications for OCD, depression, or severe anxiety)
- Increased appetite
- Weight gain
- Increased cholesterol
- Increased triglycerides
- Increased blood sugar
- Increased prolactin (a hormone that can rarely cause menstrual cycle irregularities, engorgement of breast tissue and rarely breast milk production)
Stimulant Medications – used to treat attention deficit disorder
- Potential for addiction
- Tolerance (building up immunity to the anti-anxiety benefit of the medication over time)
- Decreased appetite
- Weight loss
- Anxiety
- Irritability
- Tics or movement disorders
Risk of “Suicidality” associated with the use of antidepressant medications in patients under the age of 24.
Very rarely, some patients have reported experiencing suicidal thoughts after taking antidepressant medications. This risk was reported in a review of about 24 studies that was conducted in the United Kingdom when researchers reviewed the cases of about 3,000 patients 18 years old and younger. Some criticisms of this data is that it was from a “meta-analysis” which is not a double blind, placebo controlled trial, but instead a review of a group of 24 studies. In some of these studies, some patients with milder depression were treated with counseling along, and in some studies patients with more severe depression, patients were treated with medications as well. The study reported “suicidality” as patients reporting thoughts of suicide or other patients reporting fleeing thoughts of anxiety/anger/or impulsive thoughts of not wanting to be alive. This was reported in 2% more patients who were taking antidepressant medications compared to patients who were receiving counseling only. In this review of 24 studies covering approximately 3,000 patients, there were zero actual suicides.
Having depression is a risk factor for suicide. Suicide is the third leading cause of death in patients under the age of 18 (following accidents and cancer). In the United States, there had been a steady 10-year decline in the risk of suicide, until 2004. In 2004, the FDA required that all antidepressants add a ‘’boxed warning” on the potential risk of suicide associated with the use of antidepressants in patients under the age of 18. Probably because of that warning, the number of antidepressants prescribed to patients under the age of 18 DECREASED by roughly 20%. In that same one-year period, the number of actual completed suicides by patients under the age of 18 INCREASED by almost 20%. Again, the review of studies indicated a 2% increase in thoughts of suicide, and when the use of antidepressants decreased by 20%, the number of actual suicides increased by 20%. This is not to suggest that there is no risk of suicide associated with antidepressant use in younger people (the warning was later revised to include patients under the age of 24, not just 18). Rather, I share this information to provide a more balanced view of the potential risks and benefits of the use of antidepressant medication in younger patients suffering from clinical depression. Obviously, anyone experiencing worsening or changing symptoms (especially suicidal thoughts or feelings) should immediately report this to their healthcare provider.
Chris Bojrab, MD