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Psych Progress

Challenges and Dilemmas of Side Effects and Their Management

Ann Robinson Endowed Chair in Psychiatry, Professor and Chairman, Department of Psychiatry and Behavioral Sciences, Eastern Virginia Medical School; Attending Psychiatrist, Sentara Norfolk General Hospital, Norfolk, Va.

First published in Psychiatry Weekly, Volume 8, Issue 9, April 22, 2013

Survival analyses in large, naturalistic studies of patients on maintenance pharmacotherapy for recurrent affective illness and chronic schizophrenia consistently show that poor adherence to prescribed medications is a major contributor to relapse and exacerbation. Yet, for a variety of complex reasons that include psychodynamic and somatic issues and their interactions, poor medication adherence remains a challenging problem that is frustrating for clinicians, family members, and for patients themselves.

The need for chronic medication can be a subtle and consistent reminder to many patients that their “neurochemical balance” is easily disrupted, leading to mood instability or frank psychosis. Unfortunately, if these patients are not followed carefully and regularly by clinicians whom they implicitly trust and respect, early indications of exacerbation and relapse may be missed or dismissed by patients when pointed out by an impartial, but mistrusted, outside observer with whom the patient does not have a relationship. Also, as mood becomes dysphoric, judgment and insight may become impaired with a commensurate decrease in willingness to accept medical recommendations and advice.

The problems are confounded by the very real and medically adverse side effects associated with many of our medications. Akathisia, an inner sense of motor restlessness, and tonic contractions of major skeletal muscle groups are unpleasant and painful. Similarly, just a little more than a decade ago, clinicians struggled with the risks of socially disfiguring, sometimes irreversible dyskinetic movements of the oral-buccal-lingual area with first-generation antipsychotic medications, and it has only been about two decades since clinicians did not have to rely solely on cardiotoxic tricyclic antidepressants for the treatment of major depressive disorder.

Even with newer medications the problems of side effects still plague us. In fact, major concerns with newer side effects have emerged. Today’s clinicians must be fully familiar with metabolic syndrome, including weight gain, hyperglycemia, insulin-resistance, and lipid abnormalities. On the upside, this may translate into once underserved patients receiving regular physical examinations from their psychiatrists, including weights and body mass index, blood pressure, and glucose and lipid levels. Some psychiatrists are counseling their patients about diet and exercise.

New and sometimes unexpected concerns emerge and are expressed by patients, especially in this Internet information age. Most recently, clastogenicity has emerged as a concern, the possibility that psychotropics can lead to breakage of DNA and “genotoxicity,” which might influence fertility and the ability to have healthy offspring.

The issues of side effects and their management are complex and not to be trivialized, especially in our patients, many of whom are exquisitely sensitive to discomfort. Psychiatric clinicians have an obligation to monitor side effects, and must be prepared to check metabolic and other laboratory parameters regularly.

Disclosure: Dr. Deutsch reports no affiliations with, or financial interests in, any organization that may pose a conflict of interest.

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