Medication Side Effects in Psychiatric Treatment

Medication consultation, side effects

Hello, Doctor: I have been diagnosed with autonomic nervous system dysfunction due to persistent symptoms of dizziness and headaches.
Initially, the doctor prescribed one tablet of Clonazepam at bedtime, but after four weeks, the side effects became significant and there was no improvement.
Later, I switched to Venlafaxine, taking one tablet in the morning and one in the evening, but I experienced visual disturbances during the day, so the daytime dosage was reduced to half a tablet.
After five weeks on this regimen, although the side effects were milder, my dizziness, headaches, and tension did not improve and even seemed to worsen slightly.
Eventually, I considered switching to Duloxetine, but I hesitated due to concerns about adapting to potential side effects.
Two years ago, another doctor had me take Escitalopram for a year, which I found to be effective with no significant side effects, and my symptoms improved significantly after a few months of treatment.
I would like to ask the doctor: 1.
What are the differences between Escitalopram and Duloxetine? Is there a difference in the intensity and frequency of side effects? 2.
What considerations do doctors typically have when choosing between SNRI and SSRI medications (or vice versa)? Thank you for your response!

Mona, 20~29 year old female. Ask Date: 2021/10/09

Dr. Zhang Gengjia reply Psychiatry

Dear Sir/Madam,
From your letter, it is evident that you are experiencing discomfort and distress due to dizziness, headaches, and the stress associated with autonomic nervous system dysfunction.
Whether this is indeed autonomic nervous system dysfunction requires a professional diagnosis from a physician.
1.
Facing an uncertain future, autonomic nervous system dysfunction is a common condition in modern individuals.
It is a chronic illness that requires long-term treatment for recovery.
2.
Autonomic nervous system dysfunction is a chronic condition characterized by episodes of exacerbation, remission, recovery, and relapse.
More than half of patients may experience a recurrence of symptoms even after they have improved.
Due to individual differences in physiology, it may take time to determine the most suitable medication, and it is not possible to simply attribute effectiveness to any one medication.
Please be patient and cooperate with your physician.
3.
Regarding SNRI or SSRI medications, each type may have side effects.
It is advisable to note the duration and frequency of any adverse symptoms you experience and discuss them with your physician.
4.
In addition to medication and psychotherapy, repetitive transcranial magnetic stimulation (rTMS) is a non-invasive, anesthesia-free, highly safe treatment option that does not require hospitalization.
It can improve anxiety and depressive moods.
For patients with treatment-resistant depression or poor medication response, rTMS treatment has shown significant improvement in depressive symptoms.
Our clinic is open Monday to Friday, both morning and afternoon.
I recommend that you consider visiting the clinic for a personal evaluation of your symptoms by a physician, so that we can collaboratively discuss the best course of action for you.
Wishing you mental and physical well-being.
Sincerely,
Dr.
Chang Geng-Jia
Department of Psychiatry

Reply Date: 2021/10/09

More Info

Understanding medication side effects in psychiatric treatment is crucial for patients who are navigating their mental health journey. Your experience with various medications highlights the complexities involved in finding the right treatment. Let's break down your questions regarding the medications you mentioned, particularly focusing on the differences between Escitalopram (易思坦) and Duloxetine (千憂解), as well as the considerations behind prescribing SNRI versus SSRI medications.

1. Differences Between Escitalopram and Duloxetine
Escitalopram (Lexapro) is a selective serotonin reuptake inhibitor (SSRI) that primarily increases serotonin levels in the brain. It is commonly prescribed for depression and anxiety disorders. The side effects of SSRIs can include nausea, insomnia, sexual dysfunction, and, in some cases, increased anxiety during the initial treatment phase. However, many patients find that these side effects diminish over time as their bodies adjust to the medication.

Duloxetine (Cymbalta), on the other hand, is a serotonin-norepinephrine reuptake inhibitor (SNRI). It not only increases serotonin levels but also norepinephrine, which can help with pain management as well as mood disorders. Common side effects of Duloxetine may include dry mouth, fatigue, dizziness, and increased sweating. Some patients may experience withdrawal symptoms if they stop taking it abruptly, which is a consideration when switching medications.

In terms of the intensity and frequency of side effects, it can vary widely among individuals. Generally, SNRIs like Duloxetine may have a broader range of side effects due to their dual action on serotonin and norepinephrine. However, some patients may tolerate them better than SSRIs, depending on their unique biochemistry and the specific nature of their symptoms.

2. Considerations for Prescribing SNRI vs. SSRI
When a physician decides between prescribing an SNRI or an SSRI, several factors come into play:
- Patient History: If a patient has previously responded well to a particular class of medication, such as SSRIs, a doctor might lean towards that option. Conversely, if a patient has not responded to SSRIs or has experienced intolerable side effects, an SNRI may be considered.

- Symptom Profile: The specific symptoms being treated can influence the choice. For example, if a patient presents with significant anxiety and depression, an SSRI might be preferred. However, if the patient also experiences chronic pain or has symptoms of fibromyalgia, an SNRI like Duloxetine may be more beneficial due to its pain-relieving properties.

- Side Effect Tolerance: Some patients may have a history of adverse reactions to SSRIs, making SNRIs a more suitable option. Conversely, if a patient has had issues with increased blood pressure or heart rate, an SNRI might be avoided.

- Pharmacological Considerations: The pharmacokinetics and pharmacodynamics of the medications also play a role. For instance, SSRIs generally have a more favorable side effect profile for long-term use, while SNRIs may require more careful monitoring due to potential increases in blood pressure.

Conclusion
Your experience with medication adjustments is not uncommon in psychiatric treatment. It’s essential to maintain open communication with your healthcare provider about any side effects you experience, as they can often adjust dosages or switch medications to find a more suitable option. The goal is to achieve a balance where the benefits of the medication outweigh the side effects, leading to improved mental health and quality of life.

If you have concerns about starting Duloxetine after your experience with other medications, it’s important to discuss these with your doctor. They can provide guidance tailored to your specific situation, including potential strategies to manage side effects or alternative treatment options. Remember, finding the right medication can take time, and it’s perfectly okay to seek a second opinion or further clarification from your healthcare provider.

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