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General
Educating patients about side effects
Knowledge is power: Effective strategies for educating patients about potential adverse effects
Potential side effects of psychotropic medications (with handouts for each medication)
“Sensitive to medications“
How to assess persons who are “sensitive to medications.”
How to manage a person who is “sensitive to medications”
Boxed warnings
What are boxed warnings (so-called “black box warnings”)
What to do about boxed warnings
Other general articles about side effects
How common are side effects of antidepressants?
Side effects: what’s the big deal?
Dose reduction to manage adverse effects
Some medications have a low “therapeutic index”. What’ exactly is that?
How to identify potentially significant side effects hidden behind “misleading means”
Can medication X cause side effect Y?
Side Effects: Test Your Knowledge
Cardiovascular risk screening form
Acne (acneiform eruptions)
What is acne vulgaris?
Why should mental health clinicians care about acne?
Lithium and acne: Evaluation and management
Acneiform eruption associated with lamotrigine
Can isotretinoin (Accutane®, Roaccutane®) cause depression or suicidality?
What do published studies on isotretinoin and depression/ suicidality show?
Akathisia
Akathisia: Introduction
Akathisia: Clinical features
Which second-generation antipsychotics have a lower or higher risk of causing akathisia?
Is lumateperone less likely to cause extrapyramidal symptoms (including parkinsonism or akathisia)?
Akathisia: Identification and evaluation
Barnes Akathisia Rating Scale
Akathisia: Treatment
Akathisia: First-line treatments
Mirtazapine may cause akathisia at higher doses
Gabapentin for the treatment of akathisia?
Anticholinergics for the treatment of akathisia?
Amantadine for the treatment of akathisia?
Vitamin B6 for the treatment of akathisia?
Agranulocytosis—see “Neutropenia/ Agranulocytosis”
Anticholinergic toxicity
Clinical case: New onset of acute anxiety and physical symptoms
How does toxicity from anticholinergic medications present clinically?
In older adults, avoid medications with anticholinergic activity
Are doxepin’s anticholinergic effects dose-dependent?
Use a rating scale for anticholinergic burden from medications
Bleeding
How do antidepressants increase the risk of bleeding?
Antidepressants and bleeding: When and what to ask
Are antidepressants that don’t inhibit serotonin uptake less likely to increase the risk of bleeding?
Who is at a higher risk of bleeding with antidepressants?
Antidepressants and degree of inhibition of serotonin reuptake
Which antidepressants in patients with a history of, or at higher risk for, bleeding
Are some SSRIs associated with a lesser or greater risk of bleeding?
What is “easy” bruising and what could be causing it?
Key facts that we should know about von Willebrand disease
A patient with antidepressant-associated bruising and von Willebrand disease
How to manage patients with increased bruising on a serotonin reuptake inhibitor
Antidepressants and risk of stroke
Psychotropic medications and surgery or anesthesia
5-HTTLPR and adverse effects of antidepressants
Blurred vision
Psychotropic medications and blurred vision
Some questions to ask in evaluating a patient with blurred vision
Bruxism
Bruxism (teeth-grinding): Consequences and causes
Don’t miss bruxism in patients with ADHD—it can cause significant problems
Awake bruxism is common and harmful, but typically undiagnosed and untreated
How to screen for possible bruxism
Management of antidepressant-induced bruxism
Cancer risk
Some antidepressants may increase the risk of breast cancer recurrence
Which antipsychotics to avoid or prefer in women with breast cancer
Does folate/ L-methylfolate supplementation DECREASE or INCREASE the risk of breast cancer?
Semaglutide injection (Wegovy™): Serious side effects, warnings, and contraindications
Cognitive impairment
Constipation
Management of clozapine-induced constipation
Non-medication interventions that we should recommend for constipation
How to choose and use a fiber supplement
Why and how to recommend increased intake of soluble fiber
Over-the-counter treatments for constipation: A simple and practical guide
Check for these “alarm” symptoms/ signs in patients with constipation
Don’t recommend docusate (Colace®) for constipation
Diarrhea
Discontinuation syndromes (withdrawal)
Discontinuation syndromes (withdrawal)—Anticholinergics
Cholinergic rebound syndrome
Discontinuation syndromes (withdrawal)—Antidepressants
Antidepressant discontinuation (withdrawal): Introduction
Antidepressant discontinuation (withdrawal): Risk factors
Antidepressant discontinuation (withdrawal): Clinical features
Antidepressant discontinuation (withdrawal): Management
Anticholinergic medication for antidepressant discontinuation syndrome?
Antidepressant discontinuation (withdrawal): Duloxetine
How can duloxetine can be tapered very slowly?
Antidepressant discontinuation and “brain zaps”
Discontinuation syndromes (withdrawal)—Dopamine agonists
Dopamine agonist withdrawal syndrome (DAWS)
Dry mouth (Xerostomia)
Watch out for dry mouth
How to manage dry mouth
Why and how to deal with dry mouth (patient handout)
Dry mouth (xerostomia) management: pilocarpine “mouthwash”
Recommend xylitol-containing products to prevent dental cavities (caries)
XyliMelts® Dry Mouth delivers xylitol for several hours—even while sleeping
Dyslipidemia
Dyslipidemia is a huge contributor to disease and death—but often undiagnosed and untreated
How to monitor for dyslipidemia in patients treated with an antipsychotic
Elevated LDL cholesterol or triglycerides must be brought down without much delay
The lipid panel (profile): Why, when, and how to order it
Check for these causes if triglycerides are high
For moderate hypertriglyceridemia, implement these lifestyle interventions
Dystonia
Why prescribers of antipsychotic medications should know about acute dystonia
What increases or decreases the risk of medication-induced acute dystonia?
Recommendations for reducing the risk of antipsychotic-induced acute dystonia
Recommendations for treating antipsychotic-induced acute dystonia
Edema
Excessive sweating (Hyperhidrosis)
Antidepressant-induced excessive sweating (ADIES)
Antidepressant-induced excessive sweating (ADIES) or hyperhidrosis: Clinical features
Antidepressant-induced excessive sweating (ADIES) or hyperhidrosis: Management
Which topical antiperspirant when something strong is needed?
Little-known but important instructions for correctly using a topical antiperspirant
Which topical antiperspirants can be used on the face, neck, and body?
Topical anticholinergics for localized hyperhidrosis
Potential side effects of glycopyrrolate
What to do about excessive sweating in this patient with OCD
Glaucoma
Psychotropic medication induced glaucoma
Are psychiatric medications safe AFTER laser iridotomy for narrow-angle glaucoma?
Hair loss (Alopecia)
How to evaluate suspected medication-induced hair loss
Valproate and hair loss (alopecia)
All about lithium-induced hair loss
Can patchy hair loss be due to an antidepressant?
Does any antidepressant have a lower or higher risk of causing hair loss?
Which brands of selenium should we recommend?
How much selenium to recommend for valproate-induced hair loss
When to consider recommending biotin supplementation
Biotin can interfere with many laboratory tests—and lead to serious misdiagnosis
How exactly to use topical minoxidil foam
Headache
Hepatic damage—see “Liver damage”
Hyperammonemia (elevated serum ammonia level)
False positive elevation of plasma ammonia
Valproate (Depakote®) and elevated serum ammonia level (hyperammonemia)
Think twice before adding topiramate to valproate
L-carnitine (levocarnitine; Carnitor®): Basic information
Hyperlipidemia—see “Dyslipidemia”
Hyperparathyroidism
Lithium induced hyperparathyroidism
How to screen for lithium-induced hyperparathyroidism
Lithium-induced hyperparathyroidism: Management
How to calculate corrected serum calcium
Sensipar® (cinacalcet) Prescribing Information
Hyperprolactinemia
How to measure and interpret serum prolactin
Potential harms from hyperprolactinemia
When do we say that amenorrhea or oligomenorrhea are present?
Which antipsychotics have a low risk of increasing serum prolactin levels?
Does lurasidone (Latuda®) really have a low risk of increasing serum prolactin?
Does olanzapine (Zyprexa®) really have a low risk of increasing serum prolactin?
Does ziprasidone (Geodon®) really have a low risk of increasing serum prolactin?
Antidepressant-induced hyperprolactinemia
Can buspirone cause increased prolactin or galactorrhea?
Management of antipsychotic-induced hyperprolactinemia
A case of risperidone-induced hyperprolactinemia
*Prophylactic* bromocriptine with risperidone?
Hypersalivation (Sialorrhea)
Clozapine-induced hypersalivation (sialorrhea)
Clozapine-induced hypersalivation (sialorrhea): Treatment
Hypertension (Increased blood pressure)
Key facts about increased blood pressure on venlafaxine
Do psychostimulant medications cause clinically-significant increases in blood pressure?
How exactly should blood pressure be monitored in persons on stimulants
How to manage stimulant-induced hypertension
How to correctly measure blood pressure
Should we use automated blood pressure instruments?
Hyponatremia/ Syndrome of Inappropriate ADH Secretion
Hyponatremia due to psychotropic medications
How common is new-onset hyponatremia during antidepressant treatment?
Can bupropion cause hyponatremia?
Does mirtazapine really have a lower risk of causing hyponatremia?
How to diagnose SIADH
What next after antidepressant-induced hyponatremia?
How exactly to do fluid restriction
Does medication-induced hyponatremia change lithium blood levels?
Hypothyroidism
An introduction to lithium-induced hypothyroidism
How common is lithium-induced hypothyroidism?
What are the risk factors for lithium-induced hypothyroidism?
How should lithium-induced hypothyroidism be evaluated?
Antithyroid antibodies: An overview
How should lithium-induced hypothyroidism be managed?
Infertility
Insomnia
Kidney stones
Liver damage
Liver damage—Evaluation
How to order and interpret Hepatic (Liver) Function Tests
A resource for looking up hepatotoxicity with a medication, herb, or supplement
False-positive elevation of plasma ammonia
Liver damage—Antidepressants
Antidepressants can injure the liver, some more than others
How to use antidepressants in persons with liver disease
Liver damage—Second-generation antipsychotics
Loss of appetite (Anorexia)
Mania or hypomania
Side effects—Mania or hypomania
Which medications can cause manic symptoms?
How to differentiate substance/medication-induced bipolar disorder from bipolar I or II disorder
Complementary/ herbal products can sometimes cause mania
Also see below: Antidepressant-induced mania or hypomania
Side effects—Antidepressant-induced mania or hypomania
What is antidepressant-induced mania or hypomania?
What are the risk factors for antidepressant-induced mania or hypomania?
Does bupropion really have a lower risk of switching in bipolar disorder?
Pharmacogenetics and the risk of antidepressant-induced switching to mania or hypomania
Review of studies: 5-HTTLPR polymorphisms and the risk of antidepressant-induced mania/ hypomania
How should antidepressant-induced mania or hypomania be managed?
Also see above: “Side effects—Mania or hypomania”
Metabolic acidosis
Metabolic acidosis
How to monitor for possible metabolic acidosis
What is the anion gap and how can we easily calculate it from the lab results?
Topiramate and metabolic acidosis
How to manage metabolic acidosis due to topiramate
Myocarditis
Nausea
Medication-induced nausea: Introduction
Medication-induced nausea: Level 1 (basic) strategies for prevention and management
Ginger for medication-induced nausea?
What are the potential side effects of ginger root?
Medication-induced nausea: Level 2 (intermediate) strategies for prevention and management
How can vortioxetine-induced nausea be treated?
Ondansetron (Zofran®), QT prolongation, and psychotropic medications
Neutropenia/ Agranulocytosis
A primer on the absolute neutrophil count (ANC)
Why we sometimes specifically order a “Complete Blood Count with Differential”
Benign ethnic neutropenia (BEN)
Is it true that mirtazapine (Remeron®) can cause agranulocytosis?
Clozapine REMS program
How to use lithium to treat neutropenia
Oral sores
Orthostatic hypotension
Dizziness/ Orthostatic hypotension
How to correctly measure and interpret orthostatic blood pressure and pulse
Management of orthostatic hypotension: Basic (level 1) strategies
Management of orthostatic hypotension: Intermediate (level 2) strategies
Management of orthostatic hypotension: Advanced (level 3) strategies
Warning–the patient may faint after the very first dose
Should we use automated blood pressure instruments?
How to correctly measure blood pressure
Tamsulosin (Flomax®) and psychiatric medications: What to watch for
Pancreatitis
Pancreatitis: A very short primer specifically for mental health clinicians
Valproate-induced pancreatitis
Which antipsychotics are more likely to cause pancreatitis and what should we do about this?
Can antidepressants cause pancreatitis?
Parkinsonism
Parkinsonism—Clinical features and causes
Antipsychotic-induced parkinsonism clinical features
Is lumateperone less likely to cause extrapyramidal symptoms (including parkinsonism or akathisia)?
Medication-induced tremors: An overview
How to examine a person with tremors
Tips on differentiating between antipsychotic-induced parkinsonism and Parkinson’s disease
What we know about VMAT2-inhibitor-induced parkinsonism
Can valproate cause parkinsonism?
Can buspirone cause dyskinesia or parkinsonism?
Can lithium cause parkinsonism?
Parkinsonism—Prevention and Management
Can we prevent neuroleptic-induced parkinsonism?
Tips on treating antipsychotic-induced parkinsonism
Does dose reduction work for neuroleptic-induced parkinsonism?
Anticholinergic medications in mental health: Menu of options
Clinically-important differences between anticholinergic medications
For how long should anticholinergics be given for antipsychotic-induced parkinsonism?
Amantadine for antipsychotic-induced parkinsonism
Amantadine (Symmetrel): Basic information
Pharmacogenomics of side effects
Serotonin transporter promoter region
Serotonin transporter linked polymorphic region (5-HTTLPR)
5-HTTLPR and efficacy of antidepressants
5-HTTLPR and adverse effects of antidepressants
5-HTTLPR and antidepressant-induced mania
Serotonergic receptors
Serotonin 2A receptor gene (HTR2A) polymorphisms and adverse effects
HTR2C polymorphisms and medication-induced weight gain
Blood-brain barrier/ P-glycoprotein
Cytochrome P450 enzymes
HLA gene testing
Melanocortin 4 receptor (MC4R)
Commercially-available pharmacogenomic tests
Polycystic ovary syndrome (PCOS)
Polyuria/ Diabetes insipidus
Lithium-induced polyuria and diabetes insipidus
Lithium-induced polyuria and diabetes insipidus: Evaluation
Lithium-induced polyuria and diabetes insipidus: Treatment
Priapism
What risk factors to look for in patients with a history of priapism
Which antipsychotics may have a lower risk of priapism?
How and why to compare antipsychotics’ affinity for alpha-1 receptors
How to reduce the risk of priapism due to trazodone
Medication-induced priapism of the clitoris
Psychiatric and behavioral side effects—Miscellaneous
Also see: Suicidality; Mania or hypomania; Psychosis
Emotional blunting
Emotional blunting/ flattening (numbing, dulling, apathy)
Management of antidepressant-induced emotional blunting/ flattening (numbing, dulling, indifference)
Psychiatric and behavioral side effects—Miscellaneous
Which SSRIs are more sedating or more activating?
Can lamotrigine cause psychiatric side effects?
Psychosis
QT prolongation and other ECG changes
QT prolongation and other ECG changes—General articles
How to look up whether a drug can cause QTc prolongation or torsades
QT prolongation and other ECG changes—Antidepressants
Three SSRIs that may cause QT prolongation
Doesn’t escitalopram cause QTc prolongation?
Can mirtazapine increase the risk of QT prolongation?
QT prolongation and other ECG changes—Antipsychotics
Antipsychotics and QTc prolongation
When to get an ECG when prescribing an antipsychotic
Antibiotics, antipsychotics, and QTc prolongation
QT prolongation and other ECG changes—Buprenorphine
Does buprenorphine cause QT prolongation and torsades de pointes?
QT prolongation and other ECG changes—Lamotrigine
What to do about the risk of arrhythmias with lamotrigine
QT prolongation and other ECG changes—Lithium
Lithium’s effects on the electrocardiogram (ECG, EKG)
QT prolongation and other ECG changes—Methadone
What to do about the risk of QT prolongation with methadone
QT prolongation and other ECG changes—Modafinil/ Armodafinil
Do modafinil/ armodafinil need cardiovascular monitoring?
QT prolongation and other ECG changes—Ondansetron
Ondansetron (Zofran®), QT prolongation, and psychotropic medications
Rash—see “Skin reactions”
Raynaud's phenomenon or syndrome
Renal impairment
Lithium-induced renal impairment: Clinical recommendations
Case: Rising serum creatinine in a patient on lithium
Case: Elevated serum creatinine that remained stable for many years
Which preparation of lithium is less likely to harm the kidneys?
Seizures
Antidepressants and seizures
Bupropion and seizures: the facts and the myths
Is a history of seizures in early childhood a contraindication to using bupropion?
What factors can increase the risk of seizures with bupropion?
Key information about seizures with clozapine
Transcranial Magnetic Stimulation (TMS): Risk of seizures
Serotonin toxicity (syndrome)
How to recognize serotonin toxicity (syndrome)
How to make the diagnosis of serotonin toxicity (syndrome)
How to distinguish between serotonin toxicity and NMS
How is serotonin toxicity managed?
Can psychedelics cause serotonin toxicity (syndrome)?
Sexual side effects
General articles
How often does antidepressant-induc
Trazodone and priapism
Beta-blockers can worsen or improve erectile dysfunction
Evaluation of sexual side effects
Arizona Sexual Experiences Scale (ASEX)
An introduction to the Changes in Sexual Functioning Questionnaire (CSFQ)
How to administer, score, and interpret the Changes in Sexual Functioning Questionnaire (CSFQ)
Which laboratory tests in men with erectile dysfunction?
Management of sexual side effects
Management of antidepressant-induced sexual dysfunction
Does bupropion treat antidepressant-induced sexual dysfunction?
PsychopharMYTH: “Vortioxetine does not cause sexual dysfunction”
How to reduce the risk of erectile dysfunction
Management of sexual dysfunction: Interview with Anita Clayton, MD
Which PDE-5 inhibitor for erectile dysfunction?
How long before sexual activity should PDE-5 inhibitors be taken?
Cyproheptadine (Periactin®) for antidepressant-induced sexual dysfunction (ADISD)?
Transdermal testosterone for hypoactive sexual desire disorder in postmenopausal women
Flibanserin (Addyi®)
Flibanserin (Addyi®)
Flibanserin (Addyi®): Basic Information
Flibanserin (Addyi®) for hypoactive sexual desire disorder in postmenopausal women
Flibanserin (Addyi®): Systematic list of references
Sialorrhea—see “Hypersalivation (Sialorrhea)”
Skin reactions
How common are benign and serious rashes with lamotrigine?
Dermatological precautions when starting lamotrigine
Restarting lamotrigine
Restarting lamotrigine: how many days?
Restarting lamotrigine: A case study
Is it a benign or dangerous skin rash?
Non-drug causes of Stevens-Johnson Syndrome (SJS)/Toxic Epidermal Necrolysis (TEN)
Do past infections increase the risk of Stevens-Johnson Syndrome (SJS) / Toxic Epidermal Necrolysis (TEN)?
Lithium and acne: Evaluation and management
Acneiform eruption associated with lamotrigine
Rash, irritation, or itching with transdermal patches
What to do about skin rash on SSRIs
Also see: Oral sores in a patient on lamotrigine
Suicidality
What can we do about suicidality associated with antidepressants?
In whom can antidepressants increase the risk of suicidality?
Can isotretinoin (Accutane®, Roaccutane®) cause depression or suicidality?
What do published studies on isotretinoin and depression/ suicidality show?
Tachycardia
Tardive dyskinesia
Screening and Evaluation
How EXACTLY to screen for tardive dyskinesia
Abnormal Involuntary Movement Scale
Abnormal Involuntary Movement Scale (AIMS): Examination procedure
How to do an AIMS examination via telepsychiatry
Abnormal Involuntary Movement Scale (AIMS): Scoring instructions
AIMS-original in Guy (1976)—PDF download, for reference only
Tips on “informal” evaluation for involuntary movements
“Masked” dyskinesia versus “withdrawal-emergent” dyskinesia
Tips on diagnosing tardive dyskinesia
Risk factors
Is TD less likely with second-generation (“atypical”) antipsychotics?
Does any atypical antipsychotic have a lower risk of tardive dyskinesia?
Antidepressant-induced tardive dyskinesia
Management
Management of tardive dyskinesia: First-line options
Management of tardive dyskinesia: Second-line options
What is VMAT2 and what do VMAT2 inhibitors do?
Comparing the VMAT2 inhibitors
An Expert answers YOUR questions about tardive dyskinesia
Is tardive dyskinesia reversible if the antipsychotic is stopped?
Valbenazine (Ingrezza®): Basic information
Deutetrabenazine (Austedo®): Basic Information
Does vitamin E work for tardive dyskinesia?
Vitamin E: Potential adverse effects and drug interactions
Testicular pain
Teratogenicity
Potential risks of second-generation (atypical) antipsychotics in pregnancy
Is the use of lamotrigine during pregnancy safe?
Does methylphenidate during pregnancy increase the risk of congenital malformations?
Pregnancy and psychotropic medications: Online resources
Does this medication increase the risk of bad outcomes in pregnancy?
What are the possible risks of using lurasidone (Latuda®) during pregnancy?
Pregnancy registries
Encourage pregnant women on an antiepileptic drug to enroll in these registries
Thrombocytopenia
When do we need to worry about a low platelet count (thrombocytopenia)?
Drug-induced thrombocytopenia: A primer for mental health clinicians
Can thrombocytopenia be due to alcohol use?
What to do if a patient develops thrombocytopenia during treatment with valproate
Tinnitus
Why tinnitus is important for mental health clinicians
Key things to ask about if a patient complains of tinnitus
Tinnitus associated with antidepressant medications
Tremors
Medication-induced tremors: An overview
How to examine a person with tremors
How to monitor change in the severity of a tremor
Lithium-induced benign tremor: Introduction
Lithium-induced benign tremor: Clinical features
Lithium-induced benign tremor: Evaluation
Lithium-induced benign tremor: Treatment
Beta-blockers for lithium-induced benign tremor
Antiepileptic medications for lithium-induced benign tremor?
Vitamin B6 for lithium-induced benign tremor?
Urinary hesitancy/retention
Urinary hesitancy or retention due to atomoxetine
How to manage medication-induced urinary hesitancy/retention.
Urinary incontinence
Weight gain/Metabolic adverse effects
General
Should we prescribe medications for weight loss?
Why it is important to treat obesity
Medications for the treatment of obesity: Overview
Metabolic side effects—Antidepressants
Why I don’t usually prescribe paroxetine (Paxil®)
Which causes more weight gain—venlafaxine or duloxetine?
Any reassuring facts about weight gain with antidepressants?
Myth or Fact? Our verdict on common beliefs about antidepressants and weight gain
Check weight after one month on an antidepressant; take action if…
Especially if there is any data on the relative impact on weight of different medications i.e. which is least likely to cause weight gain, etc.
Let me start with the most clinically important facts: Overall, we should use bupropion more often–it has been convincingly shown to not cause any more weight gain than that which can occur with a placebo. And, we should avoid paroxetine if at all possible because it has been shown to cause more weight gain than the other SSRIs. Please see Why I don’t usually prescribe paroxetine (Paxil®)
More to follow.
Hello, could you compare what is known about SSRIs/SNRIs (other than paroxetine) and weight gain side effects (rates of people experiencing weight gain, amount of weight gain over what period of time, etc) for a patient with many specific questions about this issue and a lot of anxiety starting medication?
Hello Sir, Can you please also cover Headache as a side effect. What should be the strategy if patients starts getting headache as side effect?
Dr. Kulkarni: There is not much to say about headache as a side effect. The cause of the headache should be determined, of course. For example, could it be due to hypertension, migraine, etc? For our article about headache due to lamotrigine, please see https://simpleandpractical.com/lamotrigine-headache/
Can you please cover rhabdomyolysis and schizophrenia treatment after a patient has had rhabdomyolysis due to psychotropics? What psychotropics are more favorable and not to be given after? Thank you