Taking medication is one of the most decisive things you can do to ﬁght back against the effects of mental illness
Many mental illnesses are associated with changes in the natural chemistry of the brain. Certain medications help the brain to restore its usual chemical balance – reducing symptoms so that the person feels better. These include antidepressants (for Depression), antipsychotic medications (for psychotic illnesses such as Schizophrenia) and mood stabilizers (for Bipolar disorder).
It is usually helpful to combine medication with psychological ‘talking’ therapies, ongoing support in the community, and ﬁnding ways for you to help yourself.
How medication is taken
Medications are usually taken as tablets, sometimes by injection, in a syrup or wafer. The size of dose is not necessarily an indication of how severe symptoms are.
Some people have depot injections. This means that the medication releases slowly from a muscle over a period of time, usually between a week and a month. Some people prefer injections because they are not good at remembering to take tablets, or just because it makes life simpler.
What if there are side-effects?
We all react differently to medications, and body mass and rate of metabolism can affect the amounts needed to be helpful. Age, gender, whether we smoke, and other factors may also mean that we react differently to the same dosage. If you have any concerns about the unwanted side-effects of medication, make sure you discuss them with your doctor.
Doctors have a responsibility to prescribe the most effective medication at the lowest effective dose, so that any unwanted side-effects are kept to a minimum. They can only do this, though, if told as clearly as possible how well you feel the current medication is working. This is an important contribution that you and family and other carers can make to the effectiveness of the treatment.
How long does it take for medication to work?
It can be some weeks before the medication starts to take effect and reduce symptoms.
Once the best medication and dosage have been established, a maintenance dose will be determined from then onward, to help avoid a return of symptoms. This may be needed for some months or longer, depending on need.
In some circumstances, you can be legally required to take medication
If a doctor considers that it is absolutely essential for you to take medication – for your own safety or that of others, for example – then you can be legally required to take it. This may mean a support team supervising the medication to help you remember to take it. It may mean asking you to take it as an injection.
When someone has been diagnosed with major Depression, they will probably be treated with antidepressant medication.
The symptoms of Depression are associated with changes in a particular brain chemical called serotonin. Antidepressant medications assist the brain to restore its usual chemical balance. This helps reduce or get rid of some of the symptoms.
Sixty to seventy percent of people with major Depression respond to initial appropriate antidepressant treatment. Antidepressants may also be helpful (in combination with psychological treatments) in the treatment of anxiety disorders.
What are different types of antidepressant?
There is a range of antidepressants available and it is generally thought that they have similar effectiveness. However antidepressant drugs differ in their likely side-effects and their safety in overdose. These are key considerations for a doctor when deciding which one to prescribe.
In some cases, where the Depression is particularly severe, the newer antidepressants may not be as effective as the older tricyclic and MAOI antidepressants, such as amitriptyline (Endep, Tryptanol) and imipramine (Tofranil), for example.
Side-effects such as dry mouth, blurred vision, constipation, urinary retention, sedation, and weight gain have been associated with the tricyclic antidepressants. Once again, it is important to discuss any side-effects immediately with the doctor.
As there are differences in the way people respond to each antidepressant, the doctor may have to change the medication to ﬁnd the one that works best for you. It may take between one and four weeks from beginning to take the antidepressant before it starts to have an effect.
What about the newer antidepressants?
Newer antidepressants have fewer side-effects and are safer in overdose than the older antidepressants.
These newer antidepressants are sometimes referred to by the class they fall into: SSRI, SNRI, RIMA, NaSSA and NARI.
- fluoxetine (Prozac, Lovan, Auscap20, Fluohexal, Fluoxebell, Zactin),
- paroxetine (Aropax, Oxetine, Paxtine)
- sertraline (Zoloft, Xydep, Concorz, Eleva)
- citalopram (Cipramil, Celepram, Ciazil, Talam, Talohexal)
- ﬂuvoxamine (Luvox, Faverin, Mavox, Voxam), venlafaxine (Efexor), mirtazapine (Avanza, Mirtazon, Remeron, Axit-30)-reboxetine (Endronax)
- moclobemide (Aurorix, Arima, Clobemix, Maosig, Mohexal).
Some people may experience side-effects with the newer antidepressants, especially when starting – for example: nausea, reduced sexual function, agitation, diarrhoea, headache, insomnia and in some cases restlessness and agitation. Not everyone will experience these side-effects but if you do, then discuss this with your doctor.
Antipsychotic medication works to minimise the symptoms of Psychosis – such as thought disturbance, delusions and hallucinations – and to minimise the risk of having another episode.
The ﬁrst antipsychotic medicine, chlorpromazine, was developed in the 1950s. Others have since been developed, and they have become an important part of treatment for psychotic illnesses.
Before the development of antipsychotic drugs (also known as neuroleptics), there was no effective treatment for psychotic symptoms. This meant that people had to stay for many years (and perhaps indeﬁnitely) in psychiatric hospitals.
Now most people who experience a psychotic illness can live in the community and beneﬁt from other forms of treatment and support offered by a range of mental health professionals, as well as family and other carers.
How does antipsychotic medication help?
Psychotic symptoms are associated with changes in a particular brain chemical called dopamine. Antipsychotic medications assist the brain to restore its usual chemical balance. This helps reduce or get rid of some of the symptoms. It can take some weeks before the medication starts to work.
Antipsychotic medications cannot ‘cure’ mental illnesses for good, but they are effective in eliminating, or at least reducing, psychotic symptoms such as hallucinations, delusions and thought disorder.
Until recently, they have been far less useful in the treatment of so-called ‘negative’ symptoms such as social withdrawal and loss of motivation and emotional expression. Continuing to take a ‘maintenance dose’ of these medications also helps minimise the risk of further episodes.
What are the types of antipsychotic medications?
There are two types of antipsychotic medication: typical (older) and atypical (newer). While both are effective, the atypical ones are considered superior because they generally have fewer side-effects than older medications and may be more effective in treating ‘negative’ symptoms such as lack of motivation. While no single antipsychotic medication is totally effective for everyone, they are improving.
Atypical antipsychotic medications currently available on prescription in Australia include:
- Amilsulpride (Solian) – Tablet or solution. Approved for use by people with Schizophrenia
- Aripriprazole (Abilify) – Tablet. Approved for use by people with Schizophrenia
- Clozapine (Clozaril, Clopine) – Tablet. Approved for use by people with Schizophrenia and who have not been helped by other medications. People taking clozapine have regular blood tests to check for early signs of a very rare but serious blood disorder. These tests ensure serious problems do not develop
- Olanzapine (Zyprexa) – Tablet, quick-dissolving wafer. Approved for use by people with schizophrenia or bipolar disorder. An injectable form (Zyprexa Intramuscular) is also approved for use in people with agitation in Schizophrenia or Bipolar disorder
- Quetiapine (Seroquel) – Tablet. Approved for use in people with Schizophrenia, and for acute mania associated with Bipolar disorder
- Risperidone (Risperdal) – Tablet, quick-dissolving wafer, or solution. Approved for use in people with Schizophrenia and related psychoses, and for acute mania associated with Bipolar disorder. A long-acting injectable form (Risperdal Consta) is also approved for use in people with Schizophrenia and related psychoses.
What happens if someone stops taking medication?
Medical research shows that if someone suddenly stops taking antipsychotic medication against their doctor’s advice, it can lead to a return of psychotic symptoms.
If you are not comfortable about the medication you are taking, it is important to discuss this with the treating doctor so that action can be taken without the risk of symptoms returning.
What are the possible side-effects of antipsychotic medication?
It is important to remember that the same medication can affect people quite differently. In other words, not everyone who takes a particular medication will experience the same unwanted side-effects.
The most common side-effects of antipsychotic medication include drowsiness, weight gain, loss of periods in women, and a fall in blood pressure on standing, which can cause dizziness.
Some people may experience what are called ‘extrapyramidal side-effects’ (EPS). The word ‘extrapyramidal’ simply refers to the muscles which control body posture and muscle tension. Extrapyramidal reactions affect these muscles and cause involuntary movements and abnormal body postures.
These reactions do not occur in all people taking antipsychotics, and they are less likely to occur with atypical antipsychotics than with the older, typical ones.
Examples of extrapyramidal side-effects are:
- Parkinsonism – a stiffening and weakening of muscles, particularly in the face, a shufﬂing walk, and trembling hand movements. This is more likely to occur on high doses or when a medication is ﬁrst prescribed
- Akathisia – a severe sense of physical or mental restlessness
- Dystonia – a reaction which causes muscles to go into spasms.
While these unwanted effects show that the medication is starting to take effect, they are understandably worrying. The most important thing to remember about taking medication is to discuss any side-effects immediately with the treating doctor, who can help to minimise these by lowering the dose, changing the medication, prescribing an antiparkinsonian medication, or sometimes simply changing the time of day it is taken.
Clozapine (Clozaril, Clopine)
Clozapine (Clozaril, Clopine) has a rare but potentially fatal side-effect on white blood cells in a small proportion of people. This medication is very helpful for many people, so to make sure this problem does not occur, everyone prescribed clozapine has a regular blood test to ensure that they can be taken off the medication before any harm occurs.
What is tardive dyskinesia?
Tardive dyskinesia refers to certain involuntary movements, which appear in some people who take an antipsychotic medication for a long time. The movements usually involve the mouth and tongue but other parts of the body may also develop movements over which the person has no control.
It is not known how common tardive dyskinesia is among people who have been taking an antipsychotic for a long time, but it is thought that only a minority of people develop the symptoms.
Tardive dyskinesia does not respond to anti-parkinsonian or other treatments, and the best way of dealing with it is prevention, by using the lowest antipsychotic dose possible.
The risk of developing tardive dyskinesia may be reduced in people using the new generation of antipsychotic medications.
Mood-stabilising medication – lithium carbonate
A drug called lithium carbonate (Lithicarb, Quilonum) is helpful for many people who have Bipolar disorder.
People with Bipolar disorder (sometimes called manic depression) experience extremes of mood, ranging from ‘highs’ of irrational over-excitement to ‘lows’ of depression and despair. Lithium carbonate can help reduce the frequency of the recurrence of major depression and can also reduce the symptoms of manic or ‘high’ episodes.
Possible side-effects of lithium carbonate
A variety of blood and urine tests are taken before beginning lithium, as it can occasionally accumulate in the body and cause unwanted (and potentially harmful) effects. To prevent this, a blood test is repeated regularly during treatment to monitor the lithium concentration and to conﬁrm that the dose is at the right level.
The signs of lithium toxicity are nausea, vomiting and diarrhoea, probably preceded by increasing tiredness, difficulties in concentrating, unsteadiness and increased thirst. If it appears that someone has a toxic reaction, the treating doctor should be consulted immediately. In most cases of toxicity, the lithium will be eliminated from the body within about two days after stopping the treatment.
People taking lithium long term should have thyroid, kidney and central nervous system monitoring. Other possible side-effects of lithium (when taken at recommended levels) are a ﬁne tremor, muscular weakness and cognitive difficulties such as memory problems.
Other mood-stabilizing medications
Sometimes the doctor may decide it is better to prescribe other antimanic drugs instead of lithium, such as carbamazepine (Tegretol, Teril) or sodium valproate (Epilim, Valpro). Blood tests are still required to check that the dose is effective and to monitor for unwanted (and potentially harmful) effects.
Some antipsychotic medications such as olanzapine (Zyprexa), quetiapine (Seroquel) and risperidone (Risperdal) are approved for the treatment of Bipolar disorder.
Helpful tips about taking medication
Here are some helpful tips and things you should be aware of when taking medication.
Dealing with drowsiness
If you ﬁnd that your medication makes you drowsy, there are things that can be done to help. With tablets, for example, the largest dose of the day can be taken just before bedtime, so the major part of the sedative effect occurs while you are already asleep.
If you receive an injection, the drowsiness will be strongest immediately after receiving it. If possible, the injection should be arranged for a time when the initial drowsiness is least likely to cause inconvenience to you. If these techniques don’t work, ask the doctor about a less sedating medication or the possibility of lowering the dose.
Research shows that people with a mental illness often get more physical illnesses too. This is probably because those affected are far more likely to smoke and less likely to exercise. Smoking can also counteract the helpful effects of medication.
For a number of reasons, then, it is especially important to look after your physical health – by eating healthily, reducing or quitting smoking, and taking regular exercise such as walking or swimming.
For further information, please see Guide to Healthy Living.
Drinking alcohol is strongly discouraged for people who have Depression. Alcohol itself is a depressant. This means that it slows down the normal activity of the body. The body slows down even more when alcohol is taken with the sedating antidepressant or antipsychotic medications. For example, if someone who is taking an antipsychotic drug drinks alcohol, they might feel much more drowsy than either alcohol or the drug alone would make them feel.
In an ideal world people would avoid alcohol whilst on medication, but this is not always realistic. Talk to the treating doctor about how much alcohol can be safely consumed and what the likely effects might be.
Cannabis and other drugs
Cannabis and other recreational drugs can bring on a drug-induced Psychosis (where symptoms are experienced for a relatively short period). They can also induce a psychotic episode in someone who has a vulnerability to an illness such as Schizophrenia, and increase the frequency and severity of episodes.
Use of cannabis is associated, too, with increased depression and suicidal thinking, especially for women.
Use of such drugs is strongly discouraged for anyone affected by, or vulnerable to, a depressive or psychotic illness.
It is important that anyone who is planning to have a baby or is already pregnant discusses with her doctor the likely effect of medication on the foetus. As some medications can have a harmful effect on the foetus at any stage in development, it is important that this is discussed as early as possible, ideally when the pregnancy is being planned.
If possible, all medications should be avoided in the ﬁrst twelve weeks of pregnancy when the risks of abnormality are higher. This will not always be possible and in these circumstances, the treating doctor’s advice is especially important.
Neither antipsychotic medications nor antidepressants appear to affect the development of the foetus although some new-born babies have shown symptoms of withdrawal.
The use of mood-stabilising medications when a woman conceives and in the ﬁrst twelve weeks of pregnancy has been associated with problems in the development of the foetus.
Withdrawal from the medication or prescription of an alternative may be necessary. As high concentrations of lithium pass through breast milk, it is recommended that mothers taking this drug should be cautious and seek advice about any risks of breastfeeding the baby.
The antipsychotic medication chlorpromazine (Largactil) commonly causes people to be extra sensitive to sunlight. People taking this drug should avoid strong sunlight (for example, at the beach or snow), wear suitable clothing including a hat, and wear high factor sunscreen if exposure to the sun is unavoidable. If this is a problem, ask the doctor about changing the medication.
Being ‘sunsmart’ is advisable for people taking any antipsychotic medication, just as it is for everyone.
A number of medications carry a warning that since they are likely to make people less alert, driving a motor vehicle or operating machinery may be unsafe. This possibility varies from person to person, and may also vary over time. For example, if you take medication by depot injection, it might be best to avoid driving or operating machinery immediately after having the injection.
Think about whether your medication does make it unsafe for you to drive or do other things, and discuss this with your doctor if it is a concern. Some antidepressants can also affect physical coordination, particularly in the ﬁrst few days of treatment.
Getting the best from medication
While it isn’t always easy to keep taking medication, this is one of the most important things you can do to reduce the symptoms of mental illness and feel better. Here are some ways to make it easier:
- find out and be involved as much as possible in the treatment process. Ask the doctor to explain clearly what the goals of treatment are, what it is going to be like, and the advantages and disadvantages of different types of treatment. If you would like printed information about the medication, ask your doctor or pharmacist. You can also contact Medicines Line on 1300 888 763 or at www.medimate.org.au
- taking medications at different times of the day can be complicated. If this is so, talk to the doctor about reducing the number of times the medication has to be taken, or about taking it at night so the side-effects interfere less with daily life. Dosage dispensers (available from pharmacies) or calendar reminders can also be useful to ensure medication is taken at the right time
- family or friends can help support the process of taking medication. It is important, therefore, that they understand the medication, how it helps, and any potential side-effects
- let the doctor know any problems that the medication is causing as they may be able to make changes to the prescription or dosage
- store medication in an appropriate place away from heat and damp which can damage them. That is why you shouldn’t store your medication in the bathroom, near a sink or in your car. Medication should not be left within reach of children. It’s important, too, to only take medication that is specifically prescribed for you and only in the prescribed dose.