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General
Potential side effects of psychotropic medications (with handouts for each medication)
Cardiovascular risk screening form
How common are side effects of antidepressants?
Side effects: what’s the big deal?
Side Effects: Test Your Knowledge
How to assess persons who are “sensitive to medications.”
How to manage a person who is “sensitive to medications”
Dose reduction to manage adverse effects
Some medications have a low “therapeutic index”. What’ exactly is that?
Knowledge is power: Effective strategies for educating patients about potential adverse effects
How to identify potentially significant side effects hidden behind “misleading means”
Can medication X cause side effect Y?
What are boxed warnings (so-called “black box warnings”)
What to do about boxed warnings
Some medications have a low “therapeutic index”. What’ exactly is that?
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: Treatment
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?
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
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
Diarrhea
Discontinuation syndromes (withdrawal)
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”
Dopamine agonist withdrawal syndrome (DAWS)
Cholinergic rebound syndrome
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
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?
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
How exactly to use topical minoxidil foam
Can patchy hair loss be due to an antidepressant?
Does any antidepressant have a lower or higher risk of causing hair loss?
Headache
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
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
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?
How should lithium-induced hypothyroidism be managed?
Infertility
Insomnia
Kidney stones
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
Antidepressants
Antidepressants can injure the liver, some more than others
How to use antidepressants in persons with liver disease
Second-generation antipsychotics
Loss of appetite (Anorexia)
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)
Is it true that mirtazapine (Remeron®) can cause agranulocytosis?
How to use lithium to treat neutropenia
Benign ethnic neutropenia (BEN)
Clozapine REMS program
Why we sometimes specifically order a “Complete Blood Count with Differential”
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
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
Psychiatric and behavioral side effects
Which SSRIs are more sedating or more activating?
In whom can antidepressants increase the risk of suicidality?
What can we do about suicidality associated with antidepressants?
Emotional blunting/ flattening (numbing, dulling, apathy)
Management of antidepressant-induced emotional blunting/ flattening (numbing, dulling, indifference)
Can lamotrigine cause psychiatric side effects?
Can isotretinoin (Accutane®, Roaccutane®) cause depression or suicidality?
What do published studies on isotretinoin and depression/ suicidality show?
QT prolongation and other ECG changes
How to look up whether a drug can cause QTc prolongation or torsades
Three SSRIs that may cause QT prolongation
Doesn’t escitalopram cause QTc prolongation?
Can mirtazapine increase the risk of QT prolongation?
Antipsychotics and QTc prolongation
When to get an ECG when prescribing an antipsychotic
Antibiotics, antipsychotics, and QTc prolongation
Lithium’s effects on the electrocardiogram (ECG, EKG)
What to do about the risk of arrhythmias with lamotrigine
Do modafinil/ armodafinil need cardiovascular monitoring?
What to do about the risk of QT prolongation with methadone
Ondansetron (Zofran®), QT prolongation, and psychotropic medications
Does buprenorphine cause QT prolongation and torsades de pointes?
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)
Can psychedelics cause 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?
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®)
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