Ask the pharmacist...

My son has psychosis and epilepsy and has been prescribed sulpiride. He takes 7.5 ml twice a day. Unfortunately, his psychosis has returned with a vengeance. When we go to see his psychiatrist, will he be able to give my son any more help with his medication, or is he just going to have to live with this terrible state of mind?

 

There is a good chance an effective and safe antipsychotic can be found. The main difficulty is that some antipsychotics lower the seizure threshold and so can worsen epilepsy. However, most antipsychotics can be safely used in epilepsy, and so there should be a range of options available. The most effective antipsychotic, clozapine, has the greatest effect on seizure threshold but even this drug has been successfully used in people with epilepsy.

 

My son has schizoaffective disorder. He has been ill for 8 years. He has tried to use all the newer atypical antipsychotics, some more than once  – either the side effects were unliveable with, or they did not control the psychosis effectively. In March 2008 he went onto Zaponex (clozapine). Three weeks ago he had to stop taking it – he weighs nearly 25 stone (he put on over 10 stone since being on Zaponex), he was asleep for 16 hours a day, and he had such severe muscle cramps and pain that it was difficult for him to even climb the stairs to his own flat. What is the situation with asenapine? Is there any chance that he would be prescribed that? His current antidepressant is duloxetine, but it isn't working properly and he is very depressed.

Clozapine is the most effective antipsychotic. It is unlikely that asenapine will prove to be as effective as clozapine.  Asenapine will be available in Europe next year.

 

Sometimes clozapine can be prescribed at the same time as aripiprazole (another antipsychotic) and this seems to cause a weight reduction and sometimes a reduction in sleepiness. I have not come across clozapine causing muscle cramps.

 

Alternatives to duloxetine include mirtazapine (which is a sedative) or escitalopram (which isn't).  Adding mirtazapine to duloxetine might also help.

 

I am a female of 27. I would like to ask you about the withdrawal symptoms of Remeron, 15mg, which I have been taking for 10 months. I stopped it abruptly and substituted it with Trazodone, 50mg, which I had taken before the Remeron for a whole year as required by my psychiatrist. Once I stopped taking Remeron, I suffered from great fatigue for 4 days and then I became better. Now after stopping for 10 days and after regaining my health, I started to have the same symptoms as before, but in a lower degree including fatigue, nausea, constipation, diarrhoea, headache and depression.

1. Is it normal to have the symptoms again?

2. How long will these symptoms last?

3. Are they withdrawal symptoms of Remeron or side-effects of Trazodone?

1. No. Most withdrawal symptoms occur shortly after stopping a drug and then lessen over time. Mirtazapine (Remeron) is cleared from the body over 2-3 days so one might expect withdrawal symptoms to emerge after a day or two.

 

2. It is rare for withdrawal symptoms from any drug to last more than one or two weeks.

 

3. They could be neither. Trazodone causes sedation, nausea and dizziness although not normally at 50mg a day (an extremely low dose). Withdrawal from mirtazapine may include insomnia, nausea, mood changes and anxiety.

 

Recently, having my son diagnosed with schizophrenia, I have been doing online research and have found many blogs to raise questions and problems that I can't find answers to. Some people on blogs are saying that eating properly and/or natural therapies can work well on mental illnesses. Can proper diets or specific foods help, like eating lots of fish and fruit/vegetables, reducing caffeine and trans fat or lard in our diets? Someone also said that even though nicotine is a stimulant, stopping smoking will increase the effectiveness of medications, is this true?

 

Having a healthy diet is helpful in many ways but there is little solid evidence that diet influences symptoms of mental illness. Fish oils, given in fairly high doses, may help depression and psychosis. They may also slow the emergence of symptoms in people with early signs of schizophrenia. Commercial preparations of fish oils (Maxepa, Omacor) can be prescribed.

 

Smoking cigarettes accelerates the activity of the liver in metabolising some medicines.  When someone stops smoking, metabolism is reduced and drug levels rise. This may make some medicines more effective.

 

My daughter was told she had schizophrenia about 8 years ago. She is quite stable and sees a psychiatrist about once every 9 months. She has no other support from mental health services. She thinks she is better and ready to come off her drugs and has been talking to me about doing this. I don't know whether it's a good idea or not and have no one to ask. Should I try to talk her out of this or is it now okay for her to come off the drugs as she has been stable for so long?

 

Clinical trials suggest that stopping antipsychotic medication greatly increases the risk of relapse. The risk of relapse is to some extent dependent on the number of previous psychotic episodes or relapses experienced. Those with multiple prior episodes have a very high risk of relapse, for example.

 

As a rough rule, stopping antipsychotic medication will result in relapse for about three quarters of people over the following two years. Over the same period, less than a quarter of those staying on antipsychotics will relapse. Stopping treatment should be done gradually and under the supervision of the psychiatrist.

 

My daughter has put on so much weight since she was medicated following her first episode a year ago when she was sectioned. I realise this is a side effect but can she do anything to lose weight. Is there any point trying? Do all antipsychotics make you gain weight or is there one that she could try that doesn’t have this side effect?

 

Aripiprazole (Abilify) rarely causes weight gain and nor does ziprasidone (not available in the UK). However, switching drugs always presents a risk of relapse. Adding aripiprazole to other antipsychotics sometimes causes weight loss but other side effects may occur.

 

Antipsychotics cause weight gain by increasing appetite and food intake. To counter this increased calorie intake, exercise can help. Any movement is useful in expending calories, even walking. There is no secret to weight loss – eat less, move more. Simple to understand, but difficult to do.

 

My GP told me I have had an aural hallucination, when I told him that after a period of cumulative stress I heard shouting that woke me up. I was prescribed risperidone. I have taken myself off this as I was beginning to put on weight and wanted to try and get pregnant. I have not had any aural hallucinations again but a new GP thinks I should go back on the antipsychotic as a preventative measure. But this seems to have been a one-off case – have you heard of cases where it escalates or returns if heavy stress is encountered? I have a diagnosis of reactive depression but nothing else.

 

Perhaps one in ten people hear voices at some point in their lives. Most do not seek or need treatment.

 

Depression sometimes causes people to hear voices but this only usually happens during the period of depression. Once the depression resolves, so do the voices.

 

Any long-term (more than 6 weeks) prescribing of antipsychotics such as risperidone should probably only be done by a psychiatrist.

 

I have recently started taking quetiapine x l 400mg tablet at night for psychotic depression but about an hour after I have taken it I get a pounding headache, get really dizzy and feel as though my blood is boiling. Is this a common side effect?

 

Quetiapine causes something called ‘postural hypotension’. This means that the blood pressure may be lower than normal on sitting or standing. This lowered blood pressure often leads to dizziness and sometimes headache.  Most people develop a tolerance to this side effect after a few weeks. For those that do not, the best idea is often to take the nightly dose just before going to sleep. Other options include splitting the dose (morning and night) or reducing the dose (to, say, 300mg). Options should be discussed with your prescriber.

 

Does alcohol have an effect on antipsychotic medication. Does it make it less effective if you drink a lot of beer?

 

In general, alcohol should not be taken (except in strict moderation) by people taking antipsychotics. The main reason for this is that the sedative effects of alcohol can combine with the sedative effects of antipsychotics. This may lead to severe drowsiness and to accidents.

 

If alcohol is taken within recommended limits, it is unlikely that the effectiveness of antipsychotics will be reduced. When taken in excess (more than 3-4 units a day or 6 units at one time), alcohol probably reduces the effectiveness of antipsychotics, leading to a greater risk of relapse.

 

I have been taking venlafaxine 37.5mg for 3 years now, and if I forget to take just one I don't sleep. Last weekend I forgot to take it and then on the evening had a few drinks, went to bed slept well and in the morning got up to let the dogs out. When I was in the kitchen, I heard a distinct voice saying: “got a bad head have we?”, and no-one else was down stairs. I told my doctor and she just smiled and gave me my monthly prescription. Does that mean there's nothing to worry about? Or could the drug be causing me to hear voices?

 

Missing a dose of venlafaxine or other similar drugs can cause symptoms such as dizziness, insomnia and anxiety. Only very, very rarely are symptoms such as delusions or hallucinations experienced. In any case, such symptoms are only usually seen with older MAOI-type antidepressants.

 

Hearing voices is something experienced by up to 1 in 10 people at some time in their lives. It is usually nothing to worry about.

 

What research has been carried out about the anaesthetic drug lignocaine and its possible role in causing the symptoms of bipolar disorder and psychosis? Could it be that having an epidural that contains lignocaine could cause puerperal psychosis?

 

The product literature for lignocaine (lidocaine) does not list psychosis as an adverse effect. There are, however, a few cases reported in the medical literature of short-lived psychosis occuring during or after intravenous lignocaine. I am not aware of any reported cases in people receiving epidural lignocaine.

 

I am writing this on behalf of my husband who is in hospital. He is 72-years-old. He went in hospital before Xmas to have a pill changed and they have taken him off all medication. They have put him on a small dose of medication, but he is not well at all and has started to head butt people. I warned them about this, he was supposed to be watched 24/7, but still managed to head butt another person. His medication was: amitriptylene 175mg, lorazepam, 6mg, merrille, 100mg, zopiclone, 15mg, lithium, 800mg.

Is it right to take him off all these drugs at the same time?

All medicines that are taken long-term should generally be reduced slowly before stopping. Stopping lithium suddenly may cause rebound hypomania or depression and an increase in the rate of cycling (mood swings). Stopping lorazepam suddenly will cause anxiety and possibly panic, amongst other symptoms. Stopping amitriptyline suddenly is likely to cause insomnia, anxiety and diarrhoea. Stopping zopiclone suddenly is likely to cause insomnia and possibly anxiety.

 

I am currently in receipt of 750mg Depakote 2 X daily. I am showing ‘elevated levels’ (a figure of 4.8 was mentioned) on liver function tests. My faeces are pale, I have an itchy anus, as well as feeling a need to rest in the day. I am concerned that indefinite treatment with Depakote will cause irreversible damage to my liver.

I am on section 3, 117 indefinite leave, so I cannot choose to alter my medical regime even though I fear it is harming me physically. How can I get an objective second opinion on the risk to my liver?

 

Valproate (Depakote) only very rarely causes serious liver damage in adults. There are many tests for liver function and it is not clear to which your result pertains. It is quite ‘normal’ to have apparently abnormal liver test results when taking drugs that are metabolised by the liver. High levels in one or two tests do not usually indicate any important toxic effect on the liver. You should request repeat liver function tests and an explanation of their meaning, but be reassured that liver damage is very unlikely.