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are usually transient and manageable with ibuprofen or
bismuth subsalicylate. Over the long run, side effects
such as weight gain and/or sexual dysfunction may or
may not become issues. Many patients do not gain
weight for the first six months, if they gain it at all. At
that time, the anxiety may be much better managed and
responsive to psychotherapeutic intervention. Similarly,
many patients will report some kind of sexual dysfunc-
tion, but many will not. Patients tell me the most about
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decreased libido, increased time to achieve orgasm, or
inability to achieve orgasm. Depression also causes de-
creased libido, so many patients simply want to feel bet-
ter and see if their sexual desire improves as a function
of the depression s lifting and wait to assess the poten-
tial side effects at that time. Some men already suffer
from premature ejaculation, which makes the delayed
time to orgasm a welcome side effect. Inability to or-
gasm as a function of the medication breaks the deal for
most patients. Thankfully, there are alternatives that
cause less sexual dysfunction but still treat depression.
A unique side effect that can go missed while taking an
SRI is the induction of mania or hypomania. Charac-
teristically, patients who have this side effect have a
history of major depression and/or manic or hypoman-
ic behavior from prior periods in their lives. The SRI
simply elicits the elevated aspect of mood. However,
there are patients who start to experience hypomanic
signs just from the SRI, often at low doses and within
the first week or two. Hypomanic behaviors include
not needing to sleep as much, increasing euphoria
and/or irritability, and feeling like one s mind is moving
more quickly than at baseline (mania is a more severe,
longer lasting form of hypomania). A hypomanic per-
son might also feel increasingly creative, sensual, sexu-
al, or bubbly. Most patients with hypomania love it and
wonder what the problem would ever be, but those
people either do not know or have denied the danger of
becoming frankly manic. Mania can endanger one s en-
tire career, marriage, and life via the grandiosity, reck-
lessness, and lack of judgment with which it so often
presents. Statistically, most patients receive an SRI
from a well-intentioned but busy primary care doctor
who prescribes it but cannot see the patient again for
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several weeks. In that time, the induction of hypomanic
behavior can take place and can easily be missed by
someone not trained to detect the subtleties of these
early shifts.
82. What do I need to know about
benzodiazepines?
The benzodiazepines often work like a double-edged
sword highly effective in the right situation but
also with hazards of their own. They work rapidly,
efficaciously, and with a minimum of side effects if
dosed properly. They can take a mind which feels
like a hurricane in progress and settle it quickly to
feel like a reasonably clear day. Benzodiazepines tend
to work less well with time and may require greater
dosages to achieve the same effect. Without starting
a second medication which can be used more longi-
tudinally and with a greater safety margin. Stopping
benzodiazepines can be difficult and can risk creat-
ing rebound anxiety. As long as you know about the
risks of dependency (it can be hard to get off of them
without a careful, willful, downward taper of medica-
tion), withdrawal (it can be uncomfortable, if not life
threatening, to discontinue them cold turkey), and
long-term side effects of regular high-dose usage
(like memory impairment), then the benefits can be
maximized via judicious therapeutic use. I tend to
prefer the longer-acting benzodiazepines, such as
clonazepam, as they avoid the more sudden shifts in
blood level and the accompanying rebound symp-
toms of anxiety that can occur. Starting a benzodi-
azepine immediately for relief at the same time as
starting an SRI for longer term irrigation can allow a
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doctor to begin to wean a patient off of the benzodi-
ozepine in several weeks after the SRI has taken
root. This strategy works well and without undue
complications most of the time.
83. Are antipsychotics ever used to
treat anxiety?
The atypical antipsychotics have a unique place in the
Antipsychotic
treatment of anxiety disorders. Most of us would begin a psychiatric medica-
tion that is used to
with either or both of the above medicines (e.g., a ben-
treat psychosis (such
zodiazepine and an SRI). However, some patients can-
as hearing voices or
paranoia), as well as
not take benzodiazepines because of a history of
severe anxiety.
substance abuse or would prefer not to because of that [ Pobierz całość w formacie PDF ]