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Evidence-Based Practices: Shaping Mental Health Services Toward Recovery

Illness Management and Recovery Workbook

Handout 5:
Using Medication Effectively

“Since everyone is different, finding the right medication is a personal thing. Now that I’ve found the right combination for myself, my life has improved tremendously. Have your doctor try something else if your symptoms are still severe enough that they are affecting your life.”

David Kime, artist, writer, floral designer

Introduction

This handout discusses medications for psychiatric disorders. Information is provided about the effects of medications, including their advantages and disadvantages. People are encouraged to make their own choices about taking medications. Strategies for getting the most out of medications are described.

Why is medication recommended as part of the treatment for mental illness?

Medications are some of the most powerful tools available for reducing symptoms and decreasing the risk of relapses. When people take medications regularly as part of their treatment, they are less affected by symptoms and they are less likely to have relapses.

In handout #3, you learned about the “stress-vulnerability model.” This model is based on evidence that both biological vulnerability and stress contribute to the symptoms of mental illness. Medications reduce biological vulnerability by helping to correct the chemical imbalance in the brain, which leads to symptoms.

When people take medications as part of their treatment, they usually:

• Experience symptoms less often or less intensely.
• Concentrate better and think more clearly.
• Fall asleep more easily and sleep more restfully.
• Accomplish more of their goals.

How do you make an informed decision about medication?

You need to make informed decisions about all treatment options, including medication. In making your decision about medications, it is important to learn as much as you can and to weigh the possible benefits and possible drawbacks of taking medication.

Your doctor is vital to your decision-making process. She or he is an expert about medication and has experience helping others find effective medications.

However, it is also important for you to be very active in making decisions about medication. After all, you are the expert about your own experience of mental illness and what makes you feel better or worse.

Therefore, the best method for making a decision involves a partnership between you and your doctor, using both of your expertises together. It helps to have some questions in mind when you are deciding about taking medication or switching medications. Asking your doctor some of the questions on the following chart may be helpful.

Questions You Can Ask Your Doctor

How will this medication benefit me? What will it help me with?

How long does it take the medication to work? How long before I feel some of the benefits?

What side effects might I get from the medicine? Are there any side effects from long-term use?

What can be done if I get side effects?

Will I need blood tests to make sure that I have the right level of the medication in my bloodstream?

What if the medication doesn’t work for me?

Other:

Question: What questions would you like to ask your doctor about medications?

What are your personal beliefs about medication?

People have different beliefs about medication, based on their culture, their family background, and their own experience.

Some people have strong positive beliefs about medications. Make a check mark next to any of following quotations which reflect your beliefs:

_____ “My uncle is diabetic and takes insulin. He leads a normal life. I have a mental illness and take medication for it. It’s the same thing to me.”

_____ “My medicine helps get rid of the symptoms I was having. It’s made a world of difference to my peace of mind.”

_____ “I tried everything I could on my own—exercise, relaxation techniques, counseling. I was still miserable and depressed until I tried some medicine.”

Other people have strong negative beliefs about medications. Make a check mark next to any of the following quotations, which reflect your beliefs:

_____ “In my culture, we don’t believe in Western medicines. I only want to use herbal remedies.”

_____ “I’m afraid of the long-term effects on my body of using medications.”

_____ “It’s a matter of will power. I shouldn’t need a drug to make me feel better.”

It helps to be aware of your own beliefs about medications, because they can interfere with your being objective. For example, if you have strong positive beliefs about medication, you might not ask enough questions about side effects. If you have strong negative beliefs, you might not find out enough about how the medicine could benefit you.

Question: What do you think about medications?

What are the benefits of medications for mental illness?

Medication has been found to be helpful in two important ways:

• reducing symptoms during and after an acute episode of the illness
• reducing the chances of having episodes in the future.

Reducing symptoms during an acute episode

When the symptoms of mental illness are the most severe and troublesome, it is usually described as being a relapse or an acute episode of the illness. The experience of having relapses varies widely from person to person. Some individuals have only one or a few acute episodes, while others have them more often.

During and after an acute episode, medications can help reduce the severity of the symptoms. Sometimes the medicine helps people quite rapidly, and they are able to relax, think more clearly, and feel less depressed in a few days. Other times it may take a few weeks before the symptoms are reduced significantly.

Reducing the likelihood of relapses

Taking medication on a regular basis helps people prevent relapses of severe symptoms. One person described his medication as a “protective layer between me and the symptoms.” Another person said medication “is my insurance policy for staying well.”

Taking medication is not a cure for mental illness, and there is no guarantee that you will not have an acute episode again. However, for most people, taking medication on a regular basis significantly reduces their risk of relapses and hospitalizations.

Question: Have you had an experience where stopping your medication has been re lated to worse symptoms or a relapse?

Which medications are used to improve psychiatric symptoms?

Different kinds of medications help different types of symptoms. There are several different types of psychiatric symptoms, and more than one medication may be required to treat them.

There are four major categories of medications, which are commonly used to treat major mental illnesses. The medications and their benefits are summarized on the following chart:

Medications and Their Benefits

Questions: Which medications have you taken?

Which symptoms did the medications help you with?

You can use the following checklist to record your answers.

Benefits From Medications I Have Used

What are the side effects of medication?

It is important to be informed about both the potential benefits and the potential side effects of the specific medication that you have been prescribed. Medications for mental illness, like drugs for treating other illnesses, can cause undesired side effects.

Medication affects people in different ways. Some people may have only a few side effects or no side effects at all from their medication. Others taking the same medication may have significant side effects. Your reaction to medication depends on many factors, including your age, weight, sex, metabolic rate, and other medicines you might be taking.
In most cases, the side effects are temporary, and improve over time as your body adjusts to the medication. Some types of side effects, which are much less common, can be long lasting and even permanent. The newer medications tend to have fewer and less severe side effects. The more serious side effects are associated with the older antipsychotic medications, such as haldol, stelazine and thorazine.

If you recognize that you are having side effects, it is important to contact your doctor as soon as possible. Your doctor needs to help you evaluate how serious the side effects are and what can be done about them. It is up to you to decide what side effects you can tolerate and what risks you are willing to accept.

When you have side effects, your doctor may advise you to try one of the following: reduce the dose of the medication, add another medication for the side effect, or switch to another medication. There are also some coping strategies for dealing with side effects that help reduce the discomfort or counteract the side effects.

Appendix #5 contains more specific information about side effects and strategies for coping
with them.

Question:

What side effects from medications have you experienced?

What did you do when you had side effects?

You can use the following checklist to record your answer.

Side Effects From Medications I have Used

From your point of view, what are the pros and cons of taking medication?

To make an informed decision about medications, it is important to weigh the potential benefits (the pros) and the potential drawbacks (the cons) of taking them. The following chart may be useful in summarizing the information:

The Pros and Cons of Taking Medications

If you decide to take medications, how can you get the best results?

Many people find that it can be difficult to remember to take medications regularly. “Behavioral tailoring” consists of the following strategies, which are designed to help you to fit taking medications into your regular routine. Since everyone has a different routine, it is important to tailor these strategies to meet your own needs.

• Simplify your medication schedule as much as possible.
  When you take several medications several times each day, it becomes difficult to keep track of all the doses. Talk to your doctor about making your medication schedule as simple as possible without losing any of the benefits. The fewer the medications you have to take and the fewer the number of times per day, the easier it is to keep track. Some medications are available in long-acting injectible forms that can be administered every two weeks.
  
  Example:
  “I used to have a very complicated medication schedule. Four different pills, some twice a day, some three times a day. It was very hard to keep track of. I worked with my doctor to get a medication schedule that was easier for me to manage. Gradually I’ve gone to taking two different pills, once a day. I hardly ever miss a dose now.”
  
• Take medications at the same time every day.
  Taking the medication at the same time (or times) every day makes it easier to remember. It also keeps the level of medication at a steady level in your bloodstream, which gives you maximum benefit throughout the day.
  
  “I take my pills every night before bed. This helps me to sleep better and to feel better the next day. If I skip a dose, or take it the next morning, I don’t feel as well.”
  
• Build taking medication into your daily routine.
  It is often easier to remember to take medication if it is done in conjunction with another daily activity. Examples of daily activities include brushing your teeth, showering, eating breakfast, and getting ready to go to work.
  
  Example:
  “Before I got into a routine, I kept forgetting to take my medicine. Now I make it part of having breakfast before I go to work. I have my cup of coffee, a bowl of cereal, a vitamin and my medication. It’s a habit that works for me. I don’t have to think about it.”
  
• Use cues to help yourself remember.
  Many people have developed their own cues to help remind them to take their medications regularly. Some examples of cues include: using a pill container that is organized into daily doses, using a calendar, making notes to yourself, keeping the pill bottle next to an item that is used daily, asking a relative or other supporter to help you remember.
  
  Examples:
  “I give myself a cue for remembering to take my medication by putting the bottle next to my toothbrush. Every night when I reach for the toothbrush, I am reminded to take my pills.”
  
  “I tape up a note next to the coffee pot, since I take my medication at breakfast.
  
  “My calendar is very important to me. I look at it often to check my schedule for the day. I put a check mark on the date right after I take my medication.”
  
• Keep the benefits in mind.
  Sometimes it helps to remind yourself of the reasons that you have decided to take medications. You could use the checklist “Benefits from Medications I have Used” which is located earlier in this handout.
  
  Example:
  “When I start to think that it’s a pain in the neck to keep taking medications, I remind myself why I decided to take them in the first place. I don’t want to get depressed again, and the medication helps me to do that.”

Questions:

If you take medication, what have you found helps you get the best results?

Would it be helpful to try some of the strategies listed above?

You can use the following checklist to record your answer.

Strategies for Getting the Best Results From Medication

Why is medication so complicated?

Everyone responds to medication in different ways. It can take time for you and your doctor to find the medication that helps you the most and has the fewest side effects.

Medications for mental illness usually take time to work. They are not like painkillers, for example, which have an effect within hours. It may take several weeks before you notice a difference in the way you feel. Talk to your doctor on a regular basis about how you are feeling, so that you can work together to find the best medicine for you. At the same time, continue to use as many recovery strategies as possible, such as self help programs, exercising, maintaining a healthy diet, and avoiding stressful environments. See handout #1 for more recovery strategies.

Examples of individual experiences with medication

Example 1
“I used to go on and off my medication because I didn’t think I needed it. I thought, ‘Why should I take medicine when I feel fine?’ But then I had to go to the hospital for relapses twice in one year. I hated that. Since I’ve been taking my medicine regularly for the past two years, I haven’t had a major relapse and I’ve been able to stay out of the hospital. I’ve even begun talking to my doctor about reducing
my dose.”

Example 2
“I’m still not sure about medication. I only had one episode of symptoms, and I’ve been feeling pretty much O.K. since then. I check in with my doctor once a week, though, and we’re keeping a close eye.”

Example 3
“My medicine helps to keep my mood stable. I don’t like the side effects, but the doctor and I are working on that. It’s just so much better for me not to have those wild mood swings. Now I can have a better relationship with my wife and keep my job. The tradeoff is worth it to me.”

Question: Do you have any questions about medications that you would like to ask your doctor?

Summary of main points about medication

• Medications are one of the most powerful tools available for reducing symptoms and preventing relapses.
• The best way to make a decision about medication is working in active partnership with your doctor.
• People may have strong beliefs about medications that can interfere with their making an informed decision.
• Taking psychiatric medications can help to reduce symptoms during and after an acute episode. When taken on a regular basis, they can reduce the risk of having relapses.
• There are four major categories of medications, which help improve different types of psychiatric symptoms
• Psychiatric medications can cause side effects.
• If you decide to take medications, you will get the best results by taking them at the same time every day.
• It is helpful to develop strategies for fitting medications into your daily routine.
• It can take time for you and your doctor to find the medication that is most effective for you.
• Talk to your doctor about any questions or concerns about medications or side effects.
  

Appendix 1: Antipsychotic medications

Antipsychotic medications are sometimes called “major tranquilizers” or “neuroleptics.” They are designed to reduce the symptoms of psychosis, including false perceptions (hallucinations), false beliefs (delusions), and confused thinking (thought disorders).

Antipsychotic medications not only help reduce psychotic symptoms during and after an acute episode, but also help prevent relapses and rehospitalizations. They are not addictive. Some of the newer medications also help reduce negative symptoms, including lack of energy, motivation, pleasure, and emotional expressiveness.

Two types of antipsychotic medications are available. The older generation antipsychotics include haldol, moban, mellaril, navane, prolixin, serentil, stelazine, thorazine and trilafon. The newer generation antipsychotics include clozaril, geodon, risperdal, seroquel, zeldox, and zyprexa. More medications are being developed all the time, so it is important to keep up-to-date with your doctor about what medications are available.

The following chart contains the brand names and chemical names of the antipsychotic medications currently available. Blank spaces are provided to write in the names of new medications as they become available.

Antipsychotic Medications

* newer generation antipsychotics

Side effects of antipsychotic medications

People have very different reactions to medications. Some people who take antipsychotic medications experience only a few side effects or none at all. Others experience several. It’s also important to keep in mind that each medication has its own side effects, so you need to talk to your doctor about the specific side effects that are associated with the medication that has been recommended to you.

The main advantage of the newer generation medications is that they cause very few of the extrapyramidal (muscle movement) side effects that the older generation medications caused, such as muscle stiffness, mild tremors, restlessness, and muscle spasms. They also cause significantly fewer problems related to sexual difficulties and irregular menstrual periods. However, both the older and newer antipsychotic medications can cause weight gain, and some of the newer ones do so even more.

Tardive dyskinesia is an undesirable neurological side effect. It causes abnormal muscle movements, primarily in the face, mouth, tongue and hands. Tardive dyskinesia is associated with long-term use of the older antipsychotic medications and ranges from mild to severe. It is important to let your doctor know if you notice any abnormal muscle movements, so that he or she can evaluate for tardive dyskinesia.

Some side effects of antipsychotic medications are rare, but can be very serious if they occur. “Agranulocytosis” is when people stop making the white blood cells needed to fight infections. It is a potentially dangerous side effect of clozaril. However, when regular blood tests are done to monitor white blood cell levels, clozaril can be a very safe medication.

Treatment of Side Effects

When you have side effects, contact your doctor immediately. After discussing the side effects and evaluating how serious they are, he or she may recommend one of the following: reduce the dose of the medication, add a side effect medication, or switch to another medication. The doctor may also suggest some things that you can do to help reduce the discomfort or counteract the side effects. See Appendix #5 for a list of some of these coping strategies.

Web sites for more information about medications

www.mentalhealth.com
www.mentalhealth.about.com

Appendix 2: Mood stabilizers

Mood stabilizing medications help treat problems with extremes of moods, including mania and depression. They help to reduce the acute symptoms and also help to prevent relapses and rehospitalizations. They are not addictive.

The following chart lists the most common medications in this category. Blank spaces are provided to fill in the names of any new mood stabilizing medications that become available.

Mood Stabilizing Medications

Side effects of mood stabilizers

Not everyone who takes mood stabilizers experiences side effects. However, it is important to be aware of possible side effects and to contact your doctor as soon as you notice them.

Lithium

Possible side effects of lithium include nausea, stomach cramps, thirst, fatigue, headache, and mild tremors. More serious side effects include: vomiting, diarrhea, extreme thirst, muscle twitching, slurred speech, confusion, dizziness, or stupor.
Although lithium is a natural chemical element, like oxygen or iron, it can be harmful if it is taken in too high a dose. To prevent this, the doctor must monitor the amount of lithium in the body by taking regular blood tests.

It is also important to have enough salt in your diet while taking lithium, because the sodium in salt helps to excrete lithium. This means you should avoid low-salt diets and prescription and over-the-counter diuretic medications such as Fluidex with Pamabrom, Aqua-Ban, Tri-Aqua, or Aqua-rid.

Tegretol and Depakote

Possible side effects of Tegretol and Depakote include: fatigue, muscle aching or weakness, dry mouth, constipation or diarrhea, loss of appetite, nausea, skin rash, headache, dizziness, decreased sexual interest, and temporary hair loss.

Some side effects are more serious, including: confusion, fever, jaundice, abnormal bruising or bleeding, swelling of lymph glands, vomiting, and vision problems (such as double vision). It is important to have regular blood tests to monitor the level of these medications, and to check for any changes in blood cells and liver function.Because these medications can cause sedation, you must be cautious when driving or operating heavy machinery. It is recommended to limit drinking to one alcoholic drink per week.

Treatment for side effects

When you have side effects, contact your doctor immediately. After discussing the side effects and evaluating how serious they are, he or she may recommend one of the following: reduce the dose of the medication, add a side effect medication, or switch to another medication. The doctor may also suggest some things that you can do to help reduce the discomfort or counteract the side effects. See Appendix #5 for a list of some of these coping strategies.

Web sites for more information about medications

www.mentalhealth.com
www.mentalhealth.about.com

Appendix 3: Antidepressants

Antidepressants treat the symptoms of depression, including low mood, low energy, appetite problems, sleep problems, and poor concentration. They help to reduce the acute symptoms and prevent relapses and hospitalizations. Antidepressants can also be effective for the treatment of anxiety disorders such as panic disorder, obsessive compulsive disorder and phobias. They are not addictive.

The newer generation antipsychotic medications, such as the family of drugs called serotonin selective reuptake inhibitors (SSRIs) tend to cause fewer side effects. SSRIs include Prozac, Paxil, Zoloft, Serzone, and Luvox. New medications continue to be developed.

The following chart lists the most common antidepressants. Blank spaces are provided to fill in the names of any new antidepressants that become available.

Antidepressant Medications

* newer generation antidepressants (SSRIs)

Side effects of antidepressants

Not everyone has side effects when they take antidepressants. But it is important to be aware of them in case you do. Tell your doctor about any of the following side effects: nausea, vomiting, excitement, agitation, headache, sexual problems, dry mouth, dizziness, sedation, weight gain, constipation, heart palpitations, cardiac abnormalities, insomnia, memory problems, overstimulation, hypertensive crisis.

Hypomania, mania and antidepressants

Sometimes a small percentage of people who take antidepressants develop symptoms of hypomania or mania over the course of a few weeks. The symptoms of hypomania include irritability, argumentativeness, agitation, decreased need for sleep, and excessive talking. The symptoms of mania include grandiosity, euphoria, hostility, extreme goal-directed behavior, and engagement in activities that are potentially harmful. If you experience these symptoms, notify your doctor immediately. He or she may lower your dosage of medication or stop it altogether.

Precautions when taking Marplan and Nardil

There are many foods and drugs that should be avoided when taking Marplan and Nardil, including foods that are high in tyramine, such as aged cheeses, aged meats such as salami and pepperoni, and yeast extracts (except when they are baked into breads, etc). You should also avoid drinking beer, Chianti wine, sherry wine and vermouth and taking certain medications such as Tegretol, Dopar, Sinemet, Demerol, Aldomet, Ritalin, decongestants and stimulants. It is important to obtain a complete list from your doctor of drugs and foods to avoid.

Although it is unusual, occasionally people develop carpal tunnel syndrome when they take Marplan or Nardil. This can be corrected by appropriate vitamin supplements.

Treatment of side effects

When you have side effects, contact your doctor immediately. After discussing the side effects and evaluating how serious they are, he or she may recommend one of the following: reduce the dose of the medication, add a side effect medication, or switch to another medication. The doctor may also suggest some things that you can do to help reduce the discomfort or counteract the side effects. See Appendix #5 for a list of some of these coping strategies.

For more information about medications

www.mentalhealth.com
www.mentalhealth.about.com

Appendix 4: Antianxiety and sedative medications

Antianxiety and sedative medications help reduce anxiety and feeling overly stimulated. Some of these medications also help people sleep.

Unlike other medications for mental illnesses, these medications take only one to two hours to take effect.

Also unlike other medications for mental illnesses, some antianxiety and sedative medications can be addictive and long-termuse should generally be avoided. If these medications are used, they should be carefully monitored.

The following chart lists the most common medications used for antianxiety and sedation. Blank spaces are provided to fill in the names of any new medications that become available. It is important to note that some of the medications can be used to help both anxiety and sleep problems, while others are used to help only one of these problems. Also, some of these medications are addictive, while others are not. It is important to talk to your doctor about the specific benefits and side effects of the medication you are taking.

Antianxiety and Sedative Medications

Side effects of antianxiety and sedative medications

Not everyone has side effects when they take antianxiety or sedative medications. It’s important to be aware of them if you do, however, and to talk to your doctor right away. The most common side effects are over-sedation, fatigue, and problems with memory or other cognitive abilities. Because of the sedating effect, you are advised to limit drinking no more than one alcoholic drink per week. You are also advised to be cautious when driving. As mentioned earlier, long-term use of some of these medications can lead to dependency.

Treatment of side effects

When you have side effects, contact your doctor immediately. After discussing the side effects and evaluating how serious they are, he or she may recommend one of the following: reduce the dose of the medication, add a side effect medication, or switch to another medication. The doctor may also suggest some things that you can do to help reduce the discomfort or counteract the side effects. See Appendix #5 for a list of some of these coping strategies.

Web sites for more information about medications

www.mentalhealth.com
www.mentalhealth.about.com

Appendix 5: Coping with side effects

The following charts list some of the common side effects of different categories of medications and some suggestions for coping with them or counteracting them. Blank spaces are provided for additional strategies that you find useful.

Coping with Side Effects of Psychiatric Medications

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