What is Tardive dyskinesia?

Tardive dyskinesia (TD) is a neurologic disorder associated with the long-term use of certain medications (dopamine receptor-blocking agents) for some types of mental illnesses, such as major depressive disorder, bipolar disorder, and schizophrenia. TD causes involuntary movements of the body such as facial-tics, rapid eye blinking, sticking out of the tongue, lip pursing, and jaw clenching.

Some people experience involuntary twitching and jerking of their arms, legs, or torso. In this video, Lauren shares her personal experience with TD, and also sits down with Dr. Leslie Citrome, a psychiatrist and Clinical Professor of Psychiatry and Behavioural Sciences at New York Medical College, and who specializes in tardive dyskinesia.

Benzodiazepines Addiction and Abuse

Benzodiazepines are a class of drugs that are commonly prescribed as a short-term treatment for anxiety disorders, panic attacks, and insomnia.

Although safe and effective when taken as prescribed, benzodiazepine drugs like Xanax or Ativan can be misused for their effects.

Over time, benzodiazepine abuse can lead to severe physical dependendence, addiction, withdrawal symptoms, and other negative health consequences without treatment.

Benzodiazepines are what’s known as central nervous system depressants (CNS). When taken, they depress central nervous system activity, which can affect breathing and physical movement.

Benzodiazepines are known to enhance the effects of the brain chemical GABA. When taken, this can cause calmness, sedation, and reduce anxiety.

Benzodiazepines, also known as “benzos,” can be abused in several ways. What benzo abuse looks like can vary from person to person, and some signs may be less obvious than others.

What benzodiazepine abuse might look like:

  • taking higher doses than prescribed
  • taking doses more often
  • crushing and snorting benzodiazepines
  • injecting benzodiazepines
  • drinking alcohol to enhance drug effects
  • mixing benzos with other drugs to get high
  • taking someone else’s prescription

Chronic benzodiazepine abuse, characterized as a pattern of frequent benzodiazepine misuse, can be dangerous and may harm both physical and mental health.

Misusing benzodiazepines can be dangerous. Both acute and long-term dangers can occur by taking this type of drug in any way other than prescribed by a doctor.

Primary dangers of benzo abuse include:

  • severe dependency
  • drug addiction
  • drug overdose
  • increased risk of polysubstance abuse
  • worsened mental health conditions
  • potential brain damage

Benzodiazepines are rarely dangerous when taken as prescribed. But misusing benzodiazepines carries a risk of serious dangers, including drug overdose.

Benzodiazepine overdose can occur by taking excessively high doses of a benzodiazepine, or by combining the use of benzodiazepines with other drugs, such as opioids, alcohol, or heroin.

People who overdose on benzodiazepines may experience difficulty breathing, breathe very slowly, become unresponsive, or collapse. If this happens, call 911 right away.

Mixing benzodiazepines with other substances such as cocaine, heroin, methadone and alcohol can have serious effects on both short-term and long-term health, with the potential to affect vital organ function and increase the risk of drug overdose.

Common short-acting benzodiazepines include:

  • alprazolam (Xanax)
  • lorazepam (Ativan)
  • triazolam (Halcion)
  • midazolam (Versed)
  • temazepam (Restoril)
  • oxazepam (Serax)

Common long-acting benzodiazepines include:

  • Klonopin (clonazepam)
  • Valium (diazepam)
  • Librium (chlordiazepoxide)
  • flurazepam
  • clorazepate (Tranxene)

Paliperidone (Oral Route)

Brand names:

  • Invega
    • Extended-release tablet: 1.5 mg, 3 mg, 6 mg, 9 mg
  • Invega Sustenna
    • Extended-release injectable suspension: 39 mg, 78 mg, 117 mg, 156 mg, 234 mg

Generic name: paliperidone (pal ee PER i done)

Paliperidone is a medication that works in the brain to treat schizophrenia and schizoaffective disorder. It is also known as a second-generation antipsychotic (SGA) or atypical antipsychotic. Paliperidone rebalances dopamine and serotonin to improve thinking, mood, and behavior.

What Should I Discuss With My Healthcare Provider Before Taking Paliperidone?
  • Symptoms of your condition that bother you the most
  • If you have thoughts of suicide or harming yourself
  • Medications you have taken in the past for your condition, whether they were effective or caused any adverse effects
  • If you ever had muscle stiffness, shaking, tardive dyskinesia, neuroleptic malignant syndrome, or weight gain caused by a medication
  • If you experience side effects from your medications, discuss them with your provider. Some side effects may pass with time, but others may require changes in the medication.
  • Any psychiatric or medical problems you have, such as heart rhythm problems, long QT syndrome, heart attacks, diabetes, high cholesterol, or seizures
  • If you have a family history of diabetes or heart disease
  • All other medications you are currently taking (including over the counter products, herbal and nutritional supplements) and any medication allergies you have
  • Other non-medication treatment you are receiving, such as talk therapy or substance abuse treatment. Your provider can explain how these different treatments work with the medication.
  • If you are pregnant, plan to become pregnant, or are breast-feeding
  • If you smoke, drink alcohol, or use illegal drugs

Paliperidone tablets are usually taken 1 time per day with or without food.

Typically patients begin at a low dose of medicine and the dose is increased slowly over several weeks.

The dose of the tablets usually ranges from 3 mg to 12 mg. The dose of the Sustenna brand of long-acting paliperidone injection formulation usually ranges from 78 mg to 234 mg every month. The dose of the Trinza brand long-acting paliperidone injection formulation ranges from 273mg to 819mg every 3 months. Only your healthcare provider can determine the correct dose for you.

The tablets should be swallowed whole. They should not be chewed, crushed, or broken.

What Are Possible Side Effects Of Paliperidone?

Common side effects:

Tachycardia, drowsiness, extrapyramidal symptoms, restlessness, headache, increased prolactin, cholesterol abnormalities, increased glucose, vomiting, tremor.

Rare/serious side effects:

Paliperidone may increase the blood levels of a hormone called prolactin. Side effects of increased prolactin levels include females losing their period, production of breast milk and males losing their sex drive or possibly experiencing erectile problems. Long term (months or years) of elevated prolactin can lead to osteoporosis, or increased risk of bone fractures.

Some people may develop muscle related side effects while taking paliperidone. The technical terms for these are “extrapyramidal symptoms” (EPS) and “tardive dyskinesia” (TD). Symptoms of EPS include restlessness, tremor, and stiffness. TD symptoms include slow or jerky movements that one cannot control, often starting in the mouth with tongue rolling or chewing movements.

Temperature regulation: Impaired core body temperature regulation may occur; caution with strenuous exercise, heat exposure, and dehydration.

Second generation antipsychotics (SGAs) increase the risk of weight gain, high blood sugar, and high cholesterol. This is also known as metabolic syndrome. Your healthcare provider may ask you for a blood sample to check your cholesterol, blood sugar, and hemoglobin A1c (a measure of blood sugar over time) while you take this medication.

Antidepressants and Sexual Side Effects

Sexual side effects are common with antidepressants in both men and women, so your concern is understandable. Effects on sexual function can include:

• A change in your desire for sex

• Erectile problems

• Orgasm problems

• Problems with arousal, comfort and satisfaction

The severity of sexual side effects depends on the individual and the specific type and dose of antidepressant. For some people, sexual side effects are minor or may ease up as their bodies adjust to the medication. For others, sexual side effects continue to be a problem.

Antidepressants with the lowest rate of sexual side effects include:

• Bupropion (Wellbutrin XL, Wellbutrin SR)

• Mirtazapine (Remeron)

• Vilazodone (Viibryd)

• Vortioxetine (Trintellix)

Antidepressants most likely to cause sexual side effects include:

• Selective serotonin reuptake inhibitors (SSRIs), which include citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac), paroxetine (Paxil, Pexeva) and sertraline (Zoloft).

• Serotonin and norepinephrine reuptake inhibitors (SNRIs),which include venlafaxine (Effexor XR), desvenlafaxine (Pristiq) and duloxetine (Cymbalta).

• Tricyclic and tetracyclic antidepressants, such as amitriptyline, nortriptyline (Pamelor) and clomipramine (Anafranil).

• Monoamine oxidase inhibitors (MAOIs), such as isocarboxazid (Marplan), phenelzine (Nardil) and tranylcypromine (Parnate). However, selegiline (Emsam), an MAOI that you stick on your skin as a patch, has a low risk of sexual side effects.

If you’re taking an antidepressant that causes sexual side effects, your doctor may recommend one or more of these strategies:

• Waiting several weeks to see whether sexual side effects get better.

• Adjusting the dose of your antidepressant to reduce the risk of sexual side effects. But always talk with your doctor before changing your dose.

• Switching to another antidepressant that may be less likely to cause sexual side effects.

• Adding a second antidepressant or another type of medication to counter sexual side effects. For example, the addition of the antidepressant bupropion may ease sexual side effects caused by another antidepressant.

• Adding a medication to improve sexual function, such as sildenafil (Viagra), tadalafil (Cialis) or vardenafil (Levitra, Staxyn). These medications are approved by the Food and Drug Administration only to treat sexual problems in men. Limited research suggests that sildenafil may improve sexual problems caused by antidepressants in some women, but more information is needed on its effectiveness and safety in women.

Stopping medication because of sexual side effects is a common problem, and for most people this means depression returns. Work with your doctor to find an effective antidepressant or combination of medications that will reduce your sexual side effects and keep your depression under control.

If you’re pregnant or trying to become pregnant, tell your doctor, as this may affect the type of antidepressant that’s appropriate.

Be patient. Everyone reacts differently to antidepressants, so it may take some trial and error to identify what works best for you.

Sources: The Mayo Clinic, McLean Hospital, NAMI

What antidepressant is right for me?

Antidepressants are a popular treatment choice for depression. Although antidepressants may not cure depression, they can reduce symptoms. The first antidepressant you try may work fine. But if it doesn’t relieve your symptoms or it causes side effects that bother you, you may need to try another.

So don’t give up. A number of antidepressants are available, and chances are you’ll be able to find one that works well for you. And sometimes a combination of medications may be an option.

Finding the right antidepressant

There are a number of antidepressants available that work in slightly different ways and have different side effects. When prescribing an antidepressant that’s likely to work well for you, your doctor may consider:

• Your particular symptoms. Symptoms of depression can vary, and one antidepressant may relieve certain symptoms better than another. For example, if you have trouble sleeping, an antidepressant that’s slightly sedating may be a good option.

• Possible side effects. Side effects of antidepressants vary from one medication to another and from person to person. Bothersome side effects, such as dry mouth, weight gain or sexual side effects, can make it difficult to stick with treatment. Discuss possible major side effects with your doctor or pharmacist.

• Whether it worked for a close relative. How a medication worked for a first-degree relative, such as a parent or sibling, can indicate how well it might work for you. Also, if an antidepressant has been effective for your depression in the past, it may work well again.

• Interaction with other medications. Some antidepressants can cause dangerous reactions when taken with other medications.

• Pregnancy or breast-feeding. A decision to use antidepressants during pregnancy and breast-feeding is based on the balance between risks and benefits. Overall, the risk of birth defects and other problems for babies of mothers who take antidepressants during pregnancy is low. Still, certain antidepressants, such as paroxetine (Paxil, Pexeva), may be discouraged during pregnancy. Work with your doctor to find the best way to manage your depression when you’re expecting or planning on becoming pregnant.

• Other health conditions. Some antidepressants may cause problems if you have certain mental or physical health conditions. On the other hand, certain antidepressants may help treat other physical or mental health conditions along with depression. For example, venlafaxine (Effexor XR) may relieve symptoms of anxiety disorders and bupropion may help you stop smoking. Other examples include using duloxetine (Cymbalta) to help with pain symptoms or fibromyalgia, or using amitriptyline to prevent migraines.

• Cost and health insurance coverage. Some antidepressants can be expensive, so it’s important to ask if there’s a generic version available and discuss its effectiveness. Also find out whether your health insurance covers antidepressants and if there are any limitations on which ones are covered.

Types of antidepressants

Certain brain chemicals called neurotransmitters are associated with depression — particularly serotonin (ser-o-TOE-nin), norepinephrine (nor-ep-ih-NEF-rin) and dopamine (DOE-puh-meen). Most antidepressants relieve depression by affecting these neurotransmitters, sometimes called chemical messengers, which aid in communication between brain cells. Each type (class) of antidepressant affects these neurotransmitters in slightly different ways.

Many types of antidepressant medications are available to treat depression, including:

• Selective serotonin reuptake inhibitors (SSRIs). Doctors often start by prescribing an SSRI. These medications generally cause fewer bothersome side effects and are less likely to cause problems at higher therapeutic doses than other types of antidepressants are. SSRIs include fluoxetine (Prozac), paroxetine (Paxil, Pexeva), sertraline (Zoloft), citalopram (Celexa) and escitalopram (Lexapro).

• Serotonin and norepinephrine reuptake inhibitors (SNRIs).Examples of SNRI medications include duloxetine (Cymbalta), venlafaxine (Effexor XR), desvenlafaxine (Pristiq) and levomilnacipran (Fetzima).

• Atypical antidepressants. These medications don’t fit neatly into any of the other antidepressant categories. More commonly prescribed antidepressants in this category include trazodone, mirtazapine (Remeron), vortioxetine (Trintellix), vilazodone (Viibryd) and bupropion (Wellbutrin SR, Wellbutrin XL, others). Bupropion is one of the few antidepressants not frequently associated with sexual side effects.

Tricyclic antidepressants. Tricyclic antidepressants — such as imipramine (Tofranil), nortriptyline (Pamelor), amitriptyline, doxepin and desipramine (Norpramin) — tend to cause more side effects than newer antidepressants. So tricyclic antidepressants generally aren’t prescribed unless you’ve tried other antidepressants first without improvement.

Monoamine oxidase inhibitors (MAOIs). MAOIs — such as tranylcypromine (Parnate), phenelzine (Nardil) and isocarboxazid (Marplan) — may be prescribed, often when other medications haven’t worked, because they can have serious side effects. Using an MAOI requires a strict diet because of dangerous (or even deadly) interactions with foods — such as certain cheeses, pickles and wines — and some medications, including pain medications, decongestants and certain herbal supplements. Selegiline (Emsam), an MAOI that you stick on your skin as a patch, may cause fewer side effects than other MAOIs. These medications can’t be combined with SSRIs.

• Other medications. Your doctor may recommend combining two antidepressants, or other medications may be added to an antidepressant to enhance antidepressant effects.

Antidepressants and risk of suicide

Most antidepressants are generally safe, but the Food and Drug Administration (FDA) requires that all antidepressants carry black box warnings, the strictest warnings for prescriptions. In some cases, children, teenagers and young adults under 25 may have an increase in suicidal thoughts or behavior when taking antidepressants, especially in the first few weeks after starting or when the dose is changed.

Anyone taking an antidepressant should be watched closely for worsening depression or unusual behavior. If you or someone you know has suicidal thoughts when taking an antidepressant, immediately contact your doctor or get emergency help.

Keep in mind that antidepressants are more likely to reduce suicide risk in the long run by improving mood.

Making antidepressants work for you

To get the best results from an antidepressant:

• Be patient. Once you and your doctor have selected an antidepressant, you may start to see improvement in a few weeks, but it may take six or more weeks for it to be fully effective. With some antidepressants, you can take the full dosage immediately. With others, you may need to gradually increase your dose. Talk to your doctor or therapist about coping with depression symptoms as you wait for the antidepressant to take effect.

• Take your antidepressant consistently and at the correct dose. If your medication doesn’t seem to be working or is causing bothersome side effects, call your doctor before making any changes.

• See if the side effects improve. Many antidepressants cause side effects that improve with time. For example, initial side effects when starting an SSRI can include dry mouth, nausea, loose bowel movements, headache and insomnia, but these symptoms usually go away as your body adjusts to the antidepressant.

• Explore options if it doesn’t work well. If you have bothersome side effects or no significant improvement in your symptoms after several weeks, talk to your doctor about changing the dose, trying a different antidepressant (switching), or adding a second antidepressant or another medication (augmentation). A medication combination may work better for you than a single antidepressant.

• Try psychotherapy. In many cases, combining an antidepressant with talk therapy (psychotherapy) is more effective than taking an antidepressant alone. It can also help prevent your depression from returning once you’re feeling better.

• Don’t stop taking an antidepressant without talking to your doctor first. Some antidepressants can cause significant withdrawal-like symptoms unless you slowly taper off your dose. Quitting suddenly may cause a sudden worsening of depression.

• Avoid alcohol and recreational drugs. It may seem as if alcohol or drugs lessen depression symptoms, but in the long run they generally worsen symptoms and make depression harder to treat. Talk with your doctor or therapist if you need help with alcohol or drug problems.

Sources: The Mayo Clinic, NAMI, NIH, NIMH

Treatment Resistant Depression

If you’ve been treated for depression but your symptoms haven’t improved, you may have treatment-resistant depression. Taking an antidepressant or going to psychological counseling (psychotherapy) eases depression symptoms for most people. But with treatment-resistant depression, standard treatments aren’t enough. They may not help much at all, or your symptoms may improve, only to keep coming back.

If your primary care doctor prescribed antidepressants and your depression symptoms continue despite treatment, ask your doctor if he or she can recommend a medical doctor who specializes in diagnosing and treating mental health conditions (psychiatrist).

The psychiatrist reviews your medical history and may:

• Ask about life situations that might be contributing to your depression

• Consider your response to treatment, including medications, psychotherapy or other treatments you’ve tried

• Review all of the medications you’re taking, including nonprescription drugs and herbal supplements

• Discuss whether you’re taking your medications as prescribed and following other treatment steps

• Consider physical health conditions that can sometimes cause or worsen depression, such as thyroid disorders, chronic pain or heart problems

• Consider a diagnosis of another mental health condition,such as bipolar disorder, which can cause or worsen depression and may require different treatment; dysthymia, a mild but long-term (chronic) form of depression; or a personality disorder that contributes to the depression not getting better

Treatment-resistant depression symptoms can range from mild to severe and may require trying a number of approaches to identify what helps.

Medication strategies

If you’ve already tried an antidepressant and it didn’t work, don’t lose hope. You and your doctor simply may not have found the right dose, medication or combination of medications that works for you. Here are some medication options that your doctor may discuss with you:

Give your current medications more time. Antidepressants and other medications for depression typically take four to eight weeks to become fully effective and for side effects to ease up. For some people, it takes even longer.

Increase your dose, if indicated. Because people respond to medications differently, you may benefit from a higher dose of medication than is usually prescribed. Ask your doctor whether this is an option for you — don’t change your dose on your own as several factors are involved in determining the proper dose.

Switch antidepressants. For a number of people, the first antidepressant tried isn’t effective. You may need to try several before you find one that works for you.

• Add another type of antidepressant. Your doctor may prescribe two different classes of antidepressants at the same time. That way they’ll affect a wider range of brain chemicals linked to mood. These chemicals are neurotransmitters that include dopamine, serotonin and norepinephrine.

Add a medication generally used for another condition.Your doctor may prescribe a medication that’s generally used for another mental or physical health problem, along with an antidepressant. This approach, known as augmentation, may include antipsychotics, mood stabilizers, anti-anxiety medications, thyroid hormone or other drugs.

• Consider the cytochrome P450 (CYP450) genotyping test, if available. This test checks for specific genes that indicate how well your body can process (metabolize) a medication. Because of inherited (genetic) traits that cause variations in certain cytochrome P450 enzymes, medications may affect people differently. But a CYP450 test isn’t a sure way to tell which antidepressant will work — it only provides clues. And this test is not always covered by insurance.

Psychological counseling

Psychological counseling (psychotherapy) by a psychiatrist, psychologist or other mental health professional can be very effective. For many people, psychotherapy combined with medication works best. It can help identify underlying concerns that may be adding to your depression. For example, psychotherapy can help you:

• Find better ways to cope with life’s challenges

• Deal with past emotional trauma

• Manage relationships in a healthier way

• Learn how to reduce the effects of stress in your life

• Address substance use issues

If counseling doesn’t seem helpful, talk to your psychotherapist about trying a different approach. Or consider seeing someone else. As with medications, it may take several tries to find a treatment that works. Psychotherapy for depression may include:

• Cognitive behavioral therapy. This common type of counseling addresses thoughts, feelings and behaviors that affect your mood. It helps you identify and change distorted or negative thinking patterns and teaches you skills to respond to life’s challenges in a positive way.

• Acceptance and commitment therapy. A form of cognitive behavioral therapy, acceptance and commitment therapy helps you to engage in positive behaviors, even when you have negative thoughts and emotions. It’s designed for treatment-resistant conditions.

• Interpersonal psychotherapy. Interpersonal psychotherapy focuses on resolving relationship issues that may contribute to your depression.

• Family or marital therapy. This type of therapy involves family members or your spouse or partner in counseling. Working out stress in your relationships can help with depression.

• Psychodynamic treatment. The aim of this counseling approach is to help you resolve underlying problems linked to your depression by exploring your feelings and beliefs in-depth.

• Dialectical behavioral therapy. This type of therapy helps you build acceptance strategies and problem-solving skills. This is useful for chronic suicidal thoughts or self-injury behaviors, which sometimes accompany treatment-resistant depression.

• Group psychotherapy. This type of counseling involves a group of people who struggle with depression working together with a psychotherapist.

Procedures to treat depression

If medications and psychotherapy aren’t working, you may want to talk to a psychiatrist about additional treatment options:

Electroconvulsive therapy (ECT). While you are asleep, a carefully measured dose of electricity is passed through your brain, intentionally triggering a small, brief seizure. ECT seems to cause changes in brain chemistry that can relatively quickly reverse symptoms of major depression. Although there are potential side effects, such as temporary confusion or temporary memory loss, a series of ECT treatments may provide significant relief of severe depression.

• Repetitive transcranial magnetic stimulation (rTMS).Generally only used when ECT isn’t effective, rTMS uses magnetic fields to stimulate nerve cells in the brain to improve symptoms of depression. An electromagnetic coil is placed against your scalp near your forehead. The electromagnet used in rTMS creates electric currents that stimulate nerve cells in the region of your brain involved in mood control and depression.

• Vagus nerve stimulation (VNS). Generally, VNS is only tried after other brain stimulation therapies such as ECT and rTMS have not been successful in improving symptoms of depression. VNS stimulates the vagus nerve with electrical impulses. This treatment uses a device implanted in your chest that’s connected by a wire to a nerve in your neck (vagus nerve). Electrical signals from the implant travel along the vagus nerve to the mood centers of the brain, which may improve depression symptoms.

Be sure to find out whether your insurance covers any treatment that’s recommended.

Other steps you can take

To make the most of depression treatment:

Stick to your treatment plan. Don’t skip therapy sessions or appointments. It’ll take time to get better. Even if you feel well, don’t skip your medications. If you stop, depression symptoms may come back, and you could experience withdrawal-like symptoms. If side effects or drug costs are a problem, talk with your doctor and pharmacist to discuss options.

• Stop drinking or using recreational drugs. Many people with depression drink too much alcohol or use recreational drugs or marijuana. In the long run, alcohol and drugs worsen depression and make it harder to treat. If you can’t stop drinking alcohol or using drugs on your own, talk to your doctor or mental health professional. Depression treatment may be unsuccessful until you address your substance use.

• Manage stress. Relationship issues, financial problems, an unhappy work life and many other issues can all contribute to stress, which in turn worsens depression. Try stress-reduction techniques such as yoga, tai chi, meditation, mindfulness, progressive muscle relaxation or writing your thoughts in a journal.

• Sleep well. Poor sleep may worsen depression. Both the amount of time and how well you sleep can affect your mood, energy level, ability to concentrate and resilience to stress. If you have trouble sleeping, research ways to improve your sleep habits or ask your doctor or mental health professional for advice.

• Get regular exercise. Exercise has a direct effect on mood. Even physical activity such as gardening or walking can reduce stress, improve sleep and ease depression symptoms.

Don’t settle for a treatment that’s partially effective at relieving your depression or one that works but causes intolerable side effects. Work with your doctor or other mental health professional to find the best treatment possible, even though it may take time and effort to try new approaches.

Sources: The Mayo Clinic, McLean Hospital, NAMI, NIH, NIMH

Can Antidepressants Quit Working?

When depression symptoms improve after starting an antidepressant, many people need to continue taking medication long term to prevent symptoms from returning.

However, in some people, a particular antidepressant may simply stop working over time. Doctors don’t fully understand what causes the so-called “poop-out” effect or antidepressant tolerance — known as tachyphylaxis — or why it occurs in some people and not in others.

There also can be other reasons an antidepressant is no longer working for you, such as:

Worsening depression. It’s common for depression symptoms to return or worsen at some point, despite treatment. Called breakthrough depression, symptoms may be triggered by stress or appear with no apparent cause. The current dose of medication you’re taking may not be enough to prevent your symptoms when depression gets worse.

Another medical condition. Underlying health problems, such as hypothyroidism, can cause or worsen depression.

A new medication. Some medications for unrelated conditions can interfere with the way your body breaks down and uses antidepressants, decreasing their effectiveness.

Undiagnosed bipolar disorder. Bipolar disorder, formerly called manic-depressive disorder, causes periodic mood swings. While an antidepressant is sometimes used to treat bipolar disorder, a mood-stabilizing or antipsychotic medication is generally needed along with an antidepressant to keep emotional highs and lows in check.

Age. In some people, depression gets worse with age. As you get older, you may have changes in your brain and thinking (neurological changes) that affect your mood. In addition, the manner in which your body processes medications may be less efficient. You’re also likely to be taking more medications. All of these factors can play a role in depression.

In most cases, depression symptoms get better with adjustments to medication. Your doctor may recommend that you change the dose of your current antidepressant, change to another antidepressant or add another antidepressant or other type of medication to your current treatment. Psychological counseling (psychotherapy) also may help.

Because there are so many reasons depression treatment can stop working, you may need to see a medical doctor who specializes in diagnosing and treating mental illness (psychiatrist) to figure out the best course of action.

Antidepressants and Coping with Side Effects

Antidepressants can cause unpleasant side effects. Signs and symptoms such as nausea, weight gain or sleep problems can be common initially. For many people, these improve within weeks of starting an antidepressant. In some cases, however, antidepressants cause side effects that don’t go away.

Talk to your doctor or mental health professional about any side effects you’re having. For some antidepressants, monitoring blood levels may help determine the range of effectiveness and to what extent dosage can be adjusted to help reduce side effects. Rarely, antidepressants can cause serious side effects that need to be treated right away.

If side effects seem intolerable, you may be tempted to stop taking an antidepressant or to reduce your dose on your own. Don’t do it. Your symptoms may return, and stopping your antidepressant suddenly may cause withdrawal-like symptoms. Talk with your doctor to help identify the best options for your specific needs.

Nausea

Nausea typically begins early after starting an antidepressant. It may go away after your body adjusts to the medication.

Consider these strategies:

• Take your antidepressant with food, unless otherwise directed.

• Eat smaller, more-frequent meals.

• Suck on sugarless hard candy.

• Drink plenty of fluids, such as cool water. Try an antacid or bismuth subsalicylate (Pepto-Bismol).

• Talk to your doctor about a dosage change or a slow-release form of the medication.

Increased appetite, weight gain

You may gain weight because of fluid retention or lack of physical activity, or because you have a better appetite when your depression symptoms ease up. Some antidepressants are more likely to cause weight gain than others. If you’re concerned about weight gain, ask your doctor if this is a likely side effect of the antidepressant being prescribed and discuss ways to address this issue.

Consider these strategies:

• Cut back on sweets and sugary drinks.

• Select lower calorie nutritious foods, such as vegetables and fruits, and avoid saturated and trans fats.

• Keep a food diary — tracking what you eat can help you manage your weight.

• Seek advice from a registered dietitian.

• Get regular physical activity or exercise most days of the week.

• Talk to your doctor about switching medications, but get the pros and cons.

Fatigue, drowsiness

Fatigue and drowsiness are common, especially during early weeks of treatment with an antidepressant.

Consider these strategies:

• Take a brief nap during the day.

• Get some physical activity, such as walking.

• Avoid driving or operating dangerous machinery until the fatigue passes.

• Take your antidepressant at bedtime if your doctor approves.

• Talk to your doctor to see if adjusting your dose will help.

Insomnia

Some antidepressants may cause insomnia, making it difficult to get to sleep or stay asleep, so you may be tired during the day.

Consider these strategies:

• Take your antidepressant in the morning if your doctor approves.

• Avoid caffeinated food and drinks, particularly late in the day.

• Get regular physical activity or exercise — but complete it several hours before bedtime so it doesn’t interfere with your sleep.

• If insomnia is an ongoing problem, ask your doctor about taking a sedating medication at bedtime or ask whether taking a low dose of a sedating antidepressant such as trazodone or mirtazapine (Remeron) before bed might help.

Dry mouth

Dry mouth is a common side effect of many antidepressants.

Consider these strategies:

• Sip water regularly or suck on ice chips.

• Chew sugarless gum or suck on sugarless hard candy.

• Avoid tobacco, alcohol and caffeinated beverages because they can make your mouth drier.

• Breathe through your nose, not your mouth.

• Brush your teeth twice a day, floss daily and see your dentist regularly. Having a dry mouth can increase your risk of getting cavities.

• Talk to your doctor or dentist about over-the-counter or prescription medications for dry mouth.

• If dry mouth continues to be extremely bothersome despite the efforts above, ask your doctor the pros and cons of reducing the dosage of the antidepressant.

Constipation

Constipation is often associated with tricyclic antidepressants because they disrupt normal functioning of the digestive tract and other organ systems. Other antidepressants sometimes cause constipation as well.

Consider these strategies:

• Drink plenty of water.

• Eat high-fiber foods, such as fresh fruits and vegetables, brans, and whole grains.

• Get regular exercise.

• Take a fiber supplement (Citrucel, Metamucil, others).

• Ask your doctor for advice on stool softeners if other measures don’t work.

Dizziness

Dizziness is more common with tricyclic antidepressants and monoamine oxidase inhibitors (MAOIs) than with other antidepressants. These medications can cause low blood pressure, resulting in dizziness.

Consider these strategies:

• Rise slowly from sitting to standing positions.

• Use handrails, canes or other sturdy items for support.

• Avoid driving or operating machinery.

• Avoid caffeine, tobacco and alcohol.

• Drink plenty of fluids.

• Take your antidepressant at bedtime if your doctor approves.

Agitation, restlessness, anxiety

Agitation, restlessness or anxiety can result from the stimulating effect of certain antidepressants. Although having more energy can be a good thing, it may mean you can’t relax or sit still even if you want to.

Consider these strategies:

• Get regular exercise, such as jogging, biking or aerobics, or some type of physical activity, such as walking. Talk to your doctor first about what would be a good type of exercise or physical activity for you.

• Practice deep-breathing exercises, muscle relaxation or yoga.

• Consult your doctor about temporarily taking a relaxing or sedating medication or switching to an antidepressant that isn’t as stimulating.

Be alert for racing or impulsive thoughts along with high energy. If these develop, talk to your doctor right away because they may be signs of bipolar disorder or another serious disorder.

Sexual side effects

Many antidepressants cause sexual side effects. They can include reduced sex drive and difficulty reaching orgasm. Some antidepressants may cause trouble getting or keeping an erection (erectile dysfunction). Selective serotonin reuptake inhibitors (SSRIs) are more likely to cause sexual side effects than other antidepressants are.

Consider these strategies:

• Consider a medication that requires only a once-a-day dose, and schedule sexual activity before taking that dose.

• Talk to your doctor about switching to an antidepressant that may have fewer of these effects, such as bupropion (Wellbutrin, SR, Wellbutrin XL, others), or adjusting your medication to ease sexual side effects.

• Talk to your partner about your sexual side effects and how they change your needs. Adjusting your sexual routine may be helpful. For example, you may need a longer period of foreplay before having sexual intercourse.

• Talk with your doctor about options for medications, such as sildenafil (Viagra), that may temporarily ease sexual side effects or treat erectile dysfunction and any associated risks. Avoid over-the-counter herbal supplements that promise increased sexual desire and function — these are not regulated by the Food and Drug Administration (FDA) and some could be dangerous to your health.

Heart-related effects

Depending on your heart health and the type of antidepressant you take, you may need an electrocardiogram (ECG) before or periodically during treatment. The ECG is used to monitor what’s called the QT interval to make sure it’s not prolonged. A prolonged QT interval is a heart rhythm condition that can increase your risk of serious irregular heart rhythms (arrhythmias).

Certain antidepressants should not be used if you already have heart problems or if you’re taking an MAOI. Talk with your doctor about your heart health and any heart medications or other medications that you take.

Genetic variations

Some studies indicate that variations in genes may play a role in the effectiveness and risk of side effects of specific antidepressants. So your genes may, at least in part, determine whether a certain antidepressant will work well for you and whether you’re likely to have certain side effects.

Some locations already provide limited genetic testing to help determine antidepressant choice, but testing is not routine and it’s not always covered by insurance.

More studies are being done to determine what might be the best antidepressant choice based on genetic makeup. However, genetic testing is a part of — not a replacement for — a thorough psychiatric exam and clinical decisions.

Antidepressants and Pregnancy

Why is treatment for depression during pregnancy important?

If you have untreated depression, you might not seek optimal prenatal care or eat the healthy foods you and your baby need. Experiencing major depression during pregnancy is associated with an increased risk of premature birth, low birth weight, decreased fetal growth or other problems for the baby. Unstable depression during pregnancy also increases the risk of postpartum depression and difficulty bonding with your baby.

Are antidepressants an option during pregnancy?

Yes. A decision to use antidepressants during pregnancy, in addition to counseling, is based on the balance between risks and benefits. The biggest concern is typically the risk of birth defects from exposure to antidepressants. Overall, the risk of birth defects and other problems for babies of mothers who take antidepressants during pregnancy is very low. However, some antidepressants are associated with a higher risk of complications for your baby. Talking to your health care provider about your symptoms and medication options can help you make an informed decision.

If you use antidepressants during pregnancy, your health care provider will try to minimize your baby’s exposure to the medication. This can be done by prescribing a single medication (monotherapy) at the lowest effective dose, particularly during the first trimester.

Keep in mind that psychotherapy is also an effective treatment for mild to moderate depression.

Which’s antidepressants are considered OK during pregnancy?

Generally, these antidepressants are an option during pregnancy:

• Certain selective serotonin reuptake inhibitors (SSRIs). SSRI’s are generally considered an option during pregnancy, including citalopram (Celexa) and sertraline (Zoloft). Potential complications include maternal weight changes and premature birth. Most studies show that SSRI’s aren’t associated with birth defects. However, paroxetine (Paxil) might be associated with a small increased risk of a fetal heart defect and is generally discouraged during pregnancy.

• Serotonin and norepinephrine reuptake inhibitors (SNRIs). SNRI’s also are considered an option during pregnancy, including duloxetine (Cymbalta) and venlafaxine (Effexor XR).

• Bupropion (Wellbutrin). Although bupropion isn’t generally considered a first line treatment for depression during pregnancy, it might be an option for women who haven’t responded to other medications. Research suggests that taking bupropion during pregnancy might be associated with miscarriage or heart defects.

• Tricyclic antidepressants. This class of medications includes nortriptyline (Pamelor) and desipramine (Norpramin). Although tricyclic antidepressants aren’t generally considered a first line or second line treatment, they might be an option for women who haven’t responded to other medications. The tricyclic antidepressant clomipramine (Anafranil) might be associated with fetal birth defects, including heart defects.

Are there any other risks for the baby?

If you take antidepressants during the last trimester of pregnancy, your baby might experience temporary signs and symptoms of discontinuation — such as jitters, irritability, poor feeding and respiratory distress — for up to a month after birth. However, there’s no evidence that discontinuing or tapering dosages near the end of pregnancy reduces the risk of these symptoms for your newborn. In addition, it might increase your risk of a relapse postpartum.

The connection between antidepressant use during pregnancy and the risk of autism in offspring remains unclear. But most studies have shown that the risk is very small and other studies have shown no risk at all. Further research is needed.

A new study also suggests a link between use of antidepressants during pregnancy, specifically venlafaxine and amitriptyline, and an increased risk of gestational diabetes. More research is needed.

Should I switch medications?

The decision to continue or change your antidepressant medication will be based on the stability of your mood disorder. Talk to your health care provider. Concerns about potential risks must be weighed against the possibility that a drug substitution could fail and cause a depression relapse.

What’s the bottom line?

If you have depression and are pregnant or thinking about getting pregnant, consult your health care provider. Deciding how to treat depression during pregnancy isn’t easy. The risks and benefits of taking medication during pregnancy must be weighed carefully. Work with your health care provider to make an informed choice that gives you — and your baby — the best chance for long-term health.

Sources: The Mayo Clinic, NAMI, NIH, NIMH

Paroxetine (Oral Route)

US Brand Name

1. Brisdelle

2. Paxil

3. Paxil CR

4. Pexeva

Descriptions

Paroxetine is used to treat depression, obsessive-compulsive disorder (OCD), panic disorder, generalized anxiety disorder (GAD), social anxiety disorder (also known as social phobia), premenstrual dysphoric disorder (PMDD), and posttraumatic stress disorder (PTSD). Brisdelle™ is used only to treat moderate to severe hot flashes caused by menopause.

Paroxetine belongs to a group of medicines known as selective serotonin reuptake inhibitors (SSRIs). These medicines are thought to work by increasing the activity of the chemical called serotonin in the brain.

This medicine is available only with your doctor’s prescription.

This product is available in the following dosage forms:

• Tablet

• Capsule

• Suspension

• Tablet, Extended Release

Along with its needed effects, a medicine may cause some unwanted effects. Although not all of these side effects may occur, if they do occur they may need medical attention.

Check with your doctor immediately if any of the following side effects occur:

Less common

• Agitation

• chest congestion

• chest pain

• chills

• cold sweats

• confusion

• difficulty with breathing

• dizziness, faintness, or lightheadedness when getting up from a lying or sitting position

• fast, pounding, or irregular heartbeat or pulse

• muscle pain or weakness

• skin rash

Rare

• Absence of or decrease in body movements

• bigger, dilated, or enlarged pupils (black part of the eye)

• convulsions (seizures)

• difficulty with speaking

• dry mouth

• fever

• inability to move the eyes

• incomplete, sudden, or unusual body or facial movements

• increased sensitivity of the eyes to light

• poor coordination

• red or purple patches on the skin

• restlessness

• shivering

• sweating

• talking, feeling, and acting with excitement and activity you cannot control

• trembling or shaking, or twitching

Incidence not known

• Back, leg, or stomach pains

• blindness

• blistering, peeling, or loosening of the skin

• blue-yellow color blindness

• blurred vision

• constipation

• cough or hoarseness

• dark urine

• decreased frequency or amount of urine

• decreased vision

• difficulty with swallowing

• electric shock sensations

• eye pain

• fainting

• general body swelling

• headache

• high fever

• hives or itching skin

• inability to move the arms and legs

• inability to sit still

• increased thirst

• incremental or ratchet-like movement of the muscle

• joint pain

• light-colored stools

• lockjaw

• loss of appetite

• loss of bladder control

• lower back or side pain

• muscle spasm, especially of the neck and back

• muscle tension or tightness

• painful or difficult urination

• painful or prolonged erection of the penis

• pale skin

• puffiness or swelling of the eyelids or around the eyes, face, lips, or tongue

• raised red swellings on the skin, the buttocks, legs, or ankles

• red, irritated eyes

• sensitivity to the sun

• skin redness or soreness

• slow heart rate

• sores, ulcers, or white spots on the lips or in the mouth

• spasms of the throat

• stiff muscles

• stomach pain

• sudden numbness and weakness in the arms and legs

• swelling of the breasts

• swelling of the face, fingers, or lower legs

• swollen or painful glands

• tightness in the chest

• unexpected or excess milk flow from the breasts

• unusual bleeding or bruising

• unusual tiredness or weakness

• vomiting

• weight gain

• yellowing of the eyes or skin

Some side effects may occur that usually do not need medical attention. These side effects may go away during treatment as your body adjusts to the medicine. Also, your health care professional may be able to tell you about ways to prevent or reduce some of these side effects. Check with your health care professional if any of the following side effects continue or are bothersome or if you have any questions about them:

More common

• Acid or sour stomach

• belching

• decreased appetite

• decreased sexual ability or desire

• heartburn

• pain or tenderness around the eyes and cheekbones

• passing gas

• problems with urinating

• runny or stuffy nose

• sexual problems, especially ejaculatory disturbances

• sleepiness or unusual drowsiness

• stomach discomfort or upset

• trouble sleeping

Less common

• Abnormal dreams

• change in sense of taste

• congestion

• discouragement, feeling sad, or empty

• drugged feeling

• fast or irregular breathing

• feeling of unreality

• headache, severe and throbbing

• increased appetite

• itching of the vagina or genital area

• itching, pain, redness, or swelling of the eye or eyelid

• lack of emotion

• loss of interest or pleasure

• lump in the throat

• menstrual changes

• pain during sexual intercourse

• problems with memory

• sense of detachment from self or body

• sneezing

• thick, white vaginal discharge with no odor or with a mild odor

• tightness in the throat

• tingling, burning, or prickling sensations

• trouble concentrating

• voice changes

• watering of the eyes

• weight loss

• yawn