by Rajnish Mago
by Joseph F. Goldberg, Carrie L. Ernst, Stephen M. Stahl
Reviewed by Rajnish Mago, MD:
It is no secret that the book Managing the Side Effects of Psychotropic Medications by Goldberg and Ernst is a fantastic resource for anyone who prescribes psychotropic medications.
– Charles Nemeroff, MD, PhD (Chairman of the Department of Psychiatry at the University of Miami) wrote:
“A very welcome addition to the busy practitioner’s armamentarium. It provides in a single source important and often hard to find guidance on managing side effects of commonly (and uncommonly) prescribed psychiatric medications. It will be a very, very useful resource for psychiatrists…”
From the First Edition:
– Jerrold Rosenbaum, MD (Chairman of the Department of Psychiatry at Harvard Medical School) wrote that he upgraded his own knowledge substantially by reading this book.
– Michael Gitlin, MD (Professor of Psychiatry at UCLA) wrote that this book will remain on his desk, not on his bookshelf.
– Stephen Stahl, MD (Professor of Psychiatry at UC San Diego) called it “a valuable and unique work of practical scholarship”.
Related Pages
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In 2015, I was searching for a source on Amazon. I came across the first edition of Dr. Mago’s book on side effects. Since then I am a member here. I never heard of the website before reading this book. It was a gate open for a new knowledge. I still own my first edition book and review it every while. Thank you, Raj
Thanks, Dr. Elaghoury, for being a loyal Member for so many years! We have published a LOT more on side effects on our website since that first edition. Also, several of the articles have been updated over time. So, I recommend against using the first edition now. Please note that our website, simpleandpractical.com always has the most up-to-date version of any of our articles.
I’ve been using the first eduction of this book for years. It is my go to resource when patients or myself suspect a medication side effect that needs addressed. I appreciate the clear explaination of the possible medications that may be the offenders and the mechanism by which they occur. Knowing the physiology—which is explained in enough detail—allows the clinician to chose treatment options make sense to employ. Owning this book makes me feel empowered to be a better provider and psychopharmacologist to my patients. Thank you kindly for continuing to update and improve this most necessary textbook in the practice of psychiatry.
I have many patients, especially female patients, complaining of dry eye associated with SSRIs. I always recommend Omega 3 supplements. Love this option because the benefits of Omega 3 supplements on generalized inflammation and mood are a plus with or without the benefit of managing uncomfortable dry eyes.
-Love a copy of the book
Thanks, Christina! Great comment. This is a topic that we have not yet covered on SPMH but will do so. Could you please also comment on the following? Which preparation of omega 3 do you use, how much, roughly what percentage of your patients show improvement in dry eye, and where did you personally learn about this potential treatment?
Would appreciate the book.
Risperidone causes nasal stuffiness in some individuals- as if they have a cold- unclear of mechanism behind the side effect.
Thanks, Srihari! You are right that risperidone causes nasal congestion. The mechanism is alpha-1 blockade that causes dilation of the blood vessels in the nose. Other alpha-1 blockers like prazosin also cause nasal congestion.
I would love to get a copy of this book. I had sent this comment on 10/16/18 in response to Dr. Mago’s comments.
I first employed the strategy of combining a low dose of aripiprazole with risperidone in 2016 in a young male patient and it successfully reduced the prolactin levels. However, dealing with the patient’s insurance company has been somewhat nightmarish .
Thanks, Naushad! Did you have to convince the insurance company to let you prescribe TWO second-generation antipsychotics? What did you say to them that worked?
– Raj
I would love a copy of the book! I have had success using terazosin to help manage ssri-induced hyperhidrosis when other strategies (such as reducing the dose or trials of an alternative agent) have failed
I have another tip. Patients on atypical antipsychotics can possibly prevent and in some cases decrease expected weight gain with the addition of Metformin. I use 1000 mg BID . In addition some of those weight inducing antipsychotics cause hyperprolactinemia and related side effects. I have used Metformin to decrease Prolactin with success.
John D. Justice MD
Agree! Will write on this soon. See Zheng et al. Adjunctive metformin for antipsychotic-related hyperprolactinemia: A meta-analysis of randomized controlled trials. J Psychopharmacol. 2017 May;31(5):625-631. PubMed PMID: 28372526. Thanks for drawing our readers’ attention to this potential solution.
I had one patient complain of menstrual irregularities after starting Zoloft. The problem went away when we discontinued it and never happened again with Prozac. Not sure why but as i said it happened to only one person but i am curious if other people have the same experience.
Secondly, I Nuedexta caused another patient to experience erectile dysfunction although it did help some with mood lability. The only other medication was Cymbalta 30 mg.
Clinicians too often dismiss side effects as “the cost of doing business”, without appreciating that side effects are a major reason behind non-adherence, impact quality of life immensely, and that often much can actually be done to manage them. I would love to read this book to expand my ability to help my patients!
If a patient has the MTHFR polymorphism that indicates they would greatly benefit from L-Methylfolate and they are on methotrexate for rheumatoid arthritis, is there a risk of impacting the role of methotrexate by adding L-Methylfolate and therefore exacerbating the arthritis.
Mo Dattu, MD
From Dr. John Justice:
I have two tips:
1. The use of low dose lithium to increase the WBC count
In patients on clozapine ( for clozapine induced neutropenia or leukopenia)
2. The addition of low dose aripiprazole for hyperprolactinemia induced by high potency antipsychotics in cases which the High potency antipsychotic is otherwise efficacious.
I first employed the strategy of combining a low dose of aripiprazole with risperidone in 2016 in a young male patient and it successfully reduced the prolactin levels. However, dealing with the patient’s insurance company has been somewhat nightmarish .
For those with akathisia or RLS, check a ferritin and replete as low iron can exacerbate these conditions. Ginger 250-500mg for nausea/migraines. Would love a copy.
I would also love a copy of the book!
I work almost exclusively with pregnant and postpartum women. There are many resources for psychotherapy specialists in my area, but I am the only reproductive psychiatrist in my region that has any comfort level prescribing psychotropic medication to pregnant and lactating women. I think, in discussing prescribing in this population with other mental health and non-mental health care providers, the hallmark of this generalized discomfort is the overestimation of risks and the underestimation of benefits. Pregnant women are a vulnerable population, but not only to side effects of medications, but even more so to the mental health changes that accompany both normal and high risk pregnancies. A mentally (and physically) well state in a pregnant woman, maintained by psychotropic medications and other mental health treatments, is the goal and biggest benefit that can very generously outweigh risks, whether known or unknown, of any given psychotropic or combination of psychotropics. With well educated providers who don’t automatically take women off their psychotropics the second they get pregnant, the less stigma will be associated with prescribing in this population, and the more comfort not only psychiatrists but also OB/GYNs, GPs, and even pediatricians will exhibit.
I will get off my soapbox now. 🙂
I’d love a copy of the book. MAOIs have unnecessarily strict prescribing guidelines. For more information, visit Dr. Ken Gillman’s authoritative website: http://www.psychotropical.com
I have the earlier edition and would love the newest!
I have been wondering whether restless leg syndrome can be evoked by stimulants. I have a 61 year old patient recently taken off her stimulants when hospitalized for an unrelated medical condition. She quickly developed restless legs and in light of the concerns about “augmentation” with dopaminergic agonists used to treat the condition, I wondered about stimulants (eg concerta and adderall) creating a condition in which RLS would result if the stimulants are ever withdrawn.
Another comment: have been thinking about the “bipolar divide” in our field. Recently comparing Rajnish’s skepticism of bipolar scales with the James Phelps website. It occurs to me there is a testable emiprical issue that would help this debate a great deal. The question is: do people who are “a little bipolar” according to bipolar scales (that look for soft signs of bipolarity) respond better to our treatments for bipolar depression (ie lamictal, latuda, etc) than to standard antidepressants? It seems to me that the whole debate hinges on a good research answer to this question.
Thanks for the opportunity to win the book! My tip: For
decreased appetite with stimulants, be creative with meals and meal times. Eat dinner at 3pm before an afternoon dose. Move dinner time later. Eat a hearty breakfast and take a light snack for lunch… And so on. For kids, use a meal shake (e.g. carnation instant breakfast) as the drink with a meal (not instead of the meal).
I have recently used buspirone to manage the sexual side effect from SSRI and several people felt it even helped with the flattening affect side effect from SSRI. Not sure if this is a placebo effect or if the additional anti-anxiety effect of buspirone makes people feel less dulled.
I would love a copy of the book.
I have recently had several bipolar spectrum adolescents who have had some initial mood benefit from Lamotrigine but have not tolerated doses above 25 mg due to nausea and dizziness. I have used the pediatric dose of 5 mg q1-2 weeks to titrations at a rate tolerable to them and seen full remission of depression.
Would love to be blessed with a copy. I spend time working on nutrition to cope with weight gain. I weave it into self care. Recipes and samples
I’d love a copy! SSRIs can cause diaphoresis and “hot flashes”, which complicates treatment for PMDD in women entering perimenopause, as it can be difficult to tell whether women are experiencing peimenopause or wider effects.
Dear Sir
According to Leucht et al. network meta-analysis of RCTs of the effectiveness of antipsychotics (2013), as well as observational studies, olanzapine is one of the most effective antipsychotic fors total, positive, negative and general symptoms of schizophrenia. After all, olanzapine can induce serious metabolic syndrome especially in younger patients. Recently we have added aripiprazole (10 mg) which is D2 receptor partial agonist without HT2C antagonism to olanzapine treatment, in a patient with metabolic syndrome. Adjunctive aripiprazole, after 8 weeks of treatment improved symptoms of metabolic syndrome, as well as negative and positive symptoms of psychosis without causing notable akathisia.
Best regards.
Thanks, Senad! Has this case been published yet? Can you please email me your case report at mago@simpleandpractical.com.
I’d love a copy of this book! A tip to share a split the dose of guanfacine ER , for example 1mg BID seems better tolerated than 2mg ER once daily for kids when sedation does not improve ~ 7 days . Worth the extra work to push for via prior auth when indicated.
I have two (which the book likely covers) 1)Mirtazapine can reduce akathisia. 2) In sitauations of drug induced hyperprolactinemia where the offending antipsychotic can’t be changed or lowered, addition of Aripiprazole can lower the prolactin level.
Thank you for sharing that! Very helpful.
Thank you Dr. Mago, I trust your judgement
I happen to be acquainted with Dr. Goldberg and know him to be an extremely insightful and eminently well informed psycho-pharmacologist and compassionate psychiatrist. I am in awe that no less a person than Dr. Jerrold Rosenbaum said what he said and Dr. M. Gitlin and the maven of clinical Psycho-pharmacology, Dr. S. Stahl made their laudatory comments. I would love to peruse and absorb the facts in this book by referring it as many times as I can. Jerrold Rosenbaum, MD (Chairman of the Department of Psychiatry at Harvard Medical School) wrote that he upgraded his own knowledge substantially by reading this book.
– Michael Gitlin, MD (Professor of Psychiatry at UCLA) wrote that this book will remain on his desk, not on his bookshelf.
– Stephen Stahl, MD (Professor of Psychiatry at UC San Diego) called it “a valuable and unique work of practical scholarship”.
I noticed that everyone has different side effects with medication. I am treating a young man who will take his medication for a few days to a month. Then stops and has severe aggressive behavior to everyone to the point he gets law enforcement called. He just says the voice tells him he doesn’t need the medicine and the cycle starts over.
I would love a copy. Buspirone can cause severe blurry vision and has for several of my patients
Thanks! Yes, buspirone caused blurred vision in 2% of patients in clinical trials. See https://simpleandpractical.com/wp-content/uploads/2016/11/Potential-SEs-of-buspirone-Buspar.pdf
I would love a copy! One clinical tip is that buspirone can cause blurry vision that can cause difficulties driving at night
Would look forward to utilizing this book! Seems one of a kind!
I would love a copy of this book. I often have to discontinue a medication that has efficacy, due to the side effects, and I’d love to hear innovative and expert ways to manage side effects. Some of the most troubling are weight gain, dry mouth and the “flattening effect” that some patients with ADHD experience, despite the medication helping them with much needed focus. I look forward to reading this book. Thank you for the opportunity!
Thanks. For ways to manage side effects, please see the “Menu” at the top of every page on this website. Under Menu, go to “Side Effects.”
often side effects seem less tolerable when a person doesn’t feel like the provider believes they are negatively impacting the person’s quality of life.
That’s a great point! Thanks.
I would love to have a copy
Ajita: You may be be able to win a free copy! All you have to do is to post a comment with some tip or comment or observation regarding some side effect of a psychotropic medication.
I’ve borrowed the earlier edition, this is a great book! Highly recommend it!
Hi Dr.Goldberg,
Thank you for your contribution of the book to learners of psychopharmacology. I started practicing psychiatry over a year ago and I have heard your APA annual meetings. They have been very informative and provides practical aspects relevant to clinical practice. I was wondering if you could write us an email through S&P mental health on management of psychotic disorders in patients with comorbid RLS. I have had difficulty with starting dopamine agonists for RLS on one hand and other hand managing psychotic symptoms by initiating antipsychotics. Also, your please share your approach to treatment of Tardive Dyskinesia with regards to new pharmaceutical agents.
Look forward to hearing from you.
Would love to receive a copy of this book. One of the side effects of clozapine that I learned of was myoclonic jerks; had a patient on 150mg/day who continued to complain that his knees would buckle under him and he would fall down. A search of the literature showed that indeed he was having myoclonic jerks, and there were case reports of patients having the very same problem.
Agree! Knee buckling, also known as “negative myoclonus” has been reported with clozapine. Thanks for pointing this out for our readers.
The first edition has been a tremendous resource in my practice. It has served as a tool to help me navigate the common and perhaps less common or less commonly reported side effects of this treatment modality. I was able to help a client manage hyperhidrosis associated with his otherwise efficacious treatment. The first edition has been a popular resource for the students I precept, and I can’t wait to read about the pearls from the 2nd edition.
Superb. Would love to receive a copy of this book.