Medication Questions

Hi. Many have probably read some posts by me. I am a community pharmacist who has worked closely (as a pharmacy consultant) with a mental health clinic in a moderately large city in Canada. My specialties are the proposed mechanisms of the medications, as well as the proposed mechanisms of symptomatology and etiology of depression (and schizophrenia). I also specialize in compliance control (I prefer the term concordance) and am an outspoken critic of the stigma of mental illness.

I volunteer my time to teach third year pharmacy students "The Community Pharmacist's Role in Mental Health" section of their Professional Practice course (Pharm 403). I also give presentations to various community groups, consumer groups, and families of consumers on new medications, or general interests relating to pharmacy (herbal medication's place in mental health has been a big draw over the last few years). I believe that those who have a medical disorder should be educated in that disorder, so that they are empowered to become involved in and responsible for their own treatment. I believe that a doctor-patient relationship is a two-way street, and treatment should be arrived at through consensus, with input from all parts of the treatment team (incl. the patient's pharmacist, therapist, social worker, nutritionist, family, and anyone else deemed applicable by the patient.

I also accompany the head psychiatrist for the northern part of my province twice a year to update general practioners, pharmacists, and mental health specialists on the latest medications, and to address any pharmacy concerns that they may have.

I would also like to offer to try to answer any pharmacy-related questions that anyone who reads and/or posts on this, Dr.Grohol's website, if anyone so wishes.

CAVEATS

1) I will only answer questions about medications and pharmacy situations. I cannot prescribe or suggest medications, as I am not licenced to do so. I may give a list of options to take back to your doctor. I need to stay within the boundaries of my knowledge base.

2) My word is not gospel. It is based on my knowledge of the material, which is updated frequently, through the following of several psychiatry, pharmacology, and pharmacy journals. As science advances, my answers may change.

3) Always get a second opinion on anything that I say; preferably from your doctor. He/She will have a much better understanding of you than I could ever hope to.

4) If anyone notices any mistake that I may make, please bring it to my attention. I am capable of screwing up, just like the next guy.

5) I also suffer occasionally from a relapse of my chronic depression; so there may be times that I will take a day or two to fully answer your questions. This does not happen very often, though.

6) This service is free. I do it to help others learn about their disorder and it's treatment. I too learn something new every time I answer a question. This makes me better at my job (no, I won't pay you for my learning, either ;^)

Thank you for your time, and I look forward to answering any question that you may have.

Sincerely - Cam

Let me just add that I appreciate CamW coming on this board and sharing his expertise and opinions with us. He is most welcomed here and I have the utmost confidence in his opinions. But his caveats are important to keep in mind, and I'm very glad he posted them...

John

Yes, Cam, we can all thank you for sharing your knowledge. It really is great of you to offer some insight. Let me add that as an Rx Tech myself, it takes a very special person to go on to become a Pharmacist--and I am NOT that special person! LOL I am happy just being a tech. But I do enjoy working in nursing or having more direct patient care much better. Even all the gross stuff. :-)

Good idea to put those little reminders for people at the end of your post!! Sometime people forget that a pharmacist can not prescribe, or diagnose, and his (or her) word is not even close to that of God. Pharmacists carry tremendous responsibility and many people just don't understand that even they have limits, too. Thanks again, Cam, and DocJohn, too, for inviting him.

I am taking Zoloft now for between 3 and 4 weeks. I see improvement on some symptoms but I am wondering when the increased energy comes. Does that take longer to achieve in most cases? Do you know what dose gives the increased energy? I am at 25 mg. per day so far. Thanks in advance, Cam. CQ

CQ - The dose at which people respond to SSRIs like Zoloft™ (sertraline) varies widely. The vast majority of people
with depression respond to either 50mg or 100mg per day. I find that anxiety disorders respond to lower doses, while
those with panic disorder and OCD respond to higher doses.

Lack of energy is just one depressive symptom. You have to look at the group. The symptoms tend to respond to
treatment in varying degrees, and at different times in treatment. For instance, "in general", sleep and appetite are the first
to return (1 to 3 weeks); then energy and initiative begin to return (2 to 5 weeks); then the resolution of most of the other
depressive symptoms (4 to 16 weeks).

In your case, energy and initiative should have begun to resolve, although you may not get a complete restoration of
energy until a majority of the depression is resolved. This may involve more than just the medication working; you may
need some counseling to help with the issues that caused the depression, in the first place.

If I were you, I'd wait one more week and if there isn't much more improvement, you may want to ask you doc about a
dosage increase. I am all in favor of increasing antidepressant dosages slowly. This way you avoid many of the start-up
side effects (eg. headache, nausea, diarrhea, insmonia, etc.) that cause so many people to discontinue these drugs early. I
feel that this slower route to alleviation of depressive symptoms produces a longer lasting, more thorough base with which
to work on what caused the depression, in the first place.

I hope that this is of some help. - Cam

Thanks. I haven't had the energy I once had but maybe I never will. I went through a long illness that may be part of the cause for lack of it, too. Long story but it involves the liver and damage and the results of treatment, good results and bad ones. Some liver disease is also thought to be connected with depression and I believe that, too. I've had severe symptoms, too, and several disorders so I may need a higher dose if I can tolerate it. As for counseling I've had plenty in the past and learned a lot. I do need a counselor or even a good friend for support and to try to get to making decisions to change some things, though. I've had a difficult time finding a compatible one. I think my problems have more of a physiological basis now and the last psychiatrist I had agreed with that knowing my total medical history, that is. My chemistry is very messed up in other words and from a whole lot of trauma and some medicines I believe, too. I'm not complaining because the medicines saved my life. The problem with me is because of my liver I cannot tolerate higher doses often but we will see and I'm not sure if the doctor wanted me to go up to 50 or not. I really don't see a lot of resolve on many depressive symptoms yet, no kidding. But then I have had to take risperdal and similar combined with an antidepressant for some of my depressive and other symptoms. May need to do that again. I have horrible thoughts all morning long and find it hard to get out of bed. I have to call the doctor and find out if he wanted me to increase as I can't remember. I will try the increase of Z route first because I'd rather take one drug than 2 or 3 or 4 and so on! The less the better, for me. I'm already taking other things for other problems, too. Thanks again, good ideas. CQ

My 15 year old son takes 150mg zoloft a day and 25mg trazadone at night. He has tested positive for benzodiazopines. I have heard of this being a possibility due to the medication. What is your take on this and do you have any info to share on this?

Hi Cam, I have a question about side effects of Lexapro. I take 10mg at bedtime. I've been on it for about 6 months. I have a lot of myoclonic jerks (think that's what they're called) which seems to have started since I began the med. A lot means 3 - 4 in an evening or night. I'll start to drop off to sleep, jerk awake, and repeat the cycle again. Lately it seems like I almost fall into a dream, because I hear a voice that seems to be talking right in my face, which makes me startle and wake. Have you ever seen anything to relate this to Lexapro?
Thanks, Quay

That is a good question for me too because I am constantly getting those kind of jerking motions when dropping off to sleep.....like you, 3-4 or more each night. The only thing I am on is seroquel (200mg/night) & fentynal (for my migraines 200ug/hr). It has only started this year after getting out of the medical hospital for treatment of malnutrition/anorexia which started when I went through a trauma at the end/beginning of this year with the death of my Mother. It is the strangest sensation.....& I hate it......just think I am finally able to sleep & wham....jerked into being awake. My pdoc said it was just a normal thing & nothing to worry about, so no worries, just curious.

Debbie

Hi,

I have been a mess now for 7 months...went through an abusive relationship (with a lot of legal stuff involved), had to leave grad school, dealing with my family moving to a location i do not like (3 years ago)...

I stopped functioning totally on Jan 19 after going to court.

Probably PTSD/depression...with some agoraphobia (I constantly feel like something horrible is going to happen)

My question:

I have allergies to everything.

I am on Klonopin .5 3 times a day...I can't eat a lot or sleep well (I am contatnly nauseuous and throwing up for no medical reason) ...have reacted to serzone, zoloft, paxil very badly in the past.

I have no idea what to do with medication. I am afraid it is going to make me worse considering i already can't maintain my body weight (lost 6 pounds in a month and i am 4' 11''.

Suggestions?

Hi. I have been experiencing those myoclonic jerks off and on for about 1 year. I've noticed that since my Doctor added Wellbutrin to my Cymbalta(A.M.)...followed by 2 mg. of Klonopin at bedtime.....they have increased in frequency and strength. They are very distubing. Hard to get a good night's sleep with all of this movement.

I'd like to know what are the possible triggers that precipitate the myoclonic jerking phenomena.

~Dottie