PAC 610 Module 7 Side Effects, Interactions and Adherence Example

After the Prescription: Interactions, Withdrawal and Why People Stop Taking Their Medication

Student Name

Psychology and Addiction Studies Program, Aspen University

PAC 610: Psychopharmacology

Instructor Name

Month Day, Year

After the Prescription: Interactions, Withdrawal and Why People Stop Taking Their Medication

Rosa and Ben, clients of the fictional Knoxville program Ridgeview Recovery Center, showed up one Thursday with problems that began after their prescriptions were written. Rosa, forty, has taken escitalopram for depression for two years. After a fall at work, an urgent care clinic prescribed tramadol for her back. Two days later she arrived at group restless, sweating heavily, with shaking hands and jerking legs, saying she felt "wired and sick." Ben, thirty-three, had taken paroxetine for anxiety but stopped it suddenly a week earlier because he was tired of the sexual side effects. He felt dizzy, irritable and described "zaps" in his head when he moved his eyes, and he worried these were cravings for the drugs he used to take. Both situations, and the broader problem of how often people do not take medication as prescribed, are the subject of this paper.

Serotonin Syndrome

Boyer and Shannon (2005) reviewed serotonin syndrome, a reaction caused by excess serotonin activity in the nervous system. They described it as a spectrum ranging from mild to life-threatening, involving three groups of features: changes in mental state, such as agitation and confusion; autonomic overactivity, such as sweating, rapid heart rate, fever and diarrhea; and neuromuscular abnormalities, such as tremor, muscle rigidity, overactive reflexes and clonus, rhythmic involuntary muscle jerking. Symptoms usually appear within hours of starting a new drug or raising a dose. The syndrome most often results from combining drugs that increase serotonin: antidepressants, especially with monoamine oxidase inhibitors; certain opioids, including tramadol, meperidine and methadone; the cough medicine dextromethorphan; the antibiotic linezolid; and drugs such as MDMA. Boyer and Shannon emphasized that the syndrome is often missed because its milder forms are mistaken for anxiety or other illness, and that stopping the causative drugs and getting medical care are the first steps.

Rosa's symptoms began two days after adding tramadol, a serotonergic opioid, to escitalopram, and included agitation, sweating, tremor and jerking legs. Her counselor is not qualified to diagnose serotonin syndrome and does not need to be. The combination of a recent new drug and these symptoms is enough to treat the situation as urgent.

Antidepressant Withdrawal

Davies and Read (2019) systematically reviewed studies of withdrawal effects after people stopped or reduced antidepressants. Across studies, more than half of people who stopped experienced withdrawal effects. Among those who reported on severity, nearly half described their symptoms as severe. And withdrawal frequently lasted longer than two weeks, sometimes for months. The authors argued that guidelines then in use, which described withdrawal as typically mild and brief, did not reflect the evidence. Symptoms commonly include dizziness, flu-like feelings, insomnia, irritability, anxiety and electric-shock sensations. They are more common with antidepressants that leave the body quickly, such as paroxetine and venlafaxine, and after abrupt stopping.

How Often People Do Not Take Medication as Prescribed

Osterberg and Blaschke (2005) reviewed adherence, the extent to which people take medication as prescribed. In clinical trials, which tend to enroll motivated participants, average adherence among people with chronic conditions was only around half to three quarters. Adherence often improved in the days before and after appointments and fell away between them. Reasons included side effects, complex dosing schedules, cost, poor understanding of the illness or treatment, lack of perceived benefit, beliefs about medication, depression and a poor relationship with the prescriber. The authors noted that clinicians are often poor at detecting nonadherence and that simple, nonjudgmental questions about missed doses work better than assumptions.

Lacro et al. (2002) reviewed studies of medication adherence in schizophrenia and found that, on average, about four in ten patients were nonadherent. Consistent risk factors included poor insight into the illness, negative attitudes toward medication, previous nonadherence, substance abuse, shorter duration of illness, inadequate discharge planning or aftercare and a weaker therapeutic alliance. Several of these factors, notably substance use and the alliance, are areas where counseling can help.

Improving Adherence

Osterberg and Blaschke described approaches that help: simplifying dosing to once daily where possible, explaining clearly what the medication is for and what to expect, asking about missed doses without blame, addressing side effects promptly and involving the person in decisions. Counselors can contribute to several of these. They can ask about medication routinely, notice when a client seems to have stopped and help the client voice concerns to the prescriber rather than quietly stopping.

Warning Signs and Responses

Applying the Evidence to Rosa

Rosa's counselor recognized the timing and symptoms, asked Rosa about all her medications and learned about the tramadol. Because her symptoms were moderate and she was alert, the counselor arranged, with Rosa's consent, for the program's nurse practitioner to see her immediately; the nurse practitioner sent her to the emergency department. Had Rosa been confused, feverish or rigid, the counselor would have called emergency services directly. Afterward, the counselor encouraged Rosa to tell every prescriber about all the medications she takes and suggested she keep a written list.

Applying the Evidence to Ben

Ben's symptoms fit discontinuation effects from paroxetine, a drug with a short half-life that he had stopped abruptly. His counselor reassured him that the head "zaps" and dizziness were common withdrawal effects of the medication, not cravings for drugs, and with his consent contacted the prescriber, who discussed restarting at a low dose and tapering slowly or trying a different medication. The counselor also explored the reason Ben stopped: sexual side effects, a common and often unspoken reason for nonadherence that he had never mentioned to his prescriber. Helping him raise it is part of the solution.

Conclusion

Many problems with psychiatric medication arise after the prescription is written: dangerous interactions such as serotonin syndrome, withdrawal effects that are more common and lasting than once thought and widespread nonadherence driven by side effects, beliefs and circumstances. Counselors see clients often and are well placed to notice these problems. Their role is to recognize warning signs, respond at the right level of urgency, explore reasons for nonadherence without judgment and connect clients with prescribers.

References

Boyer, E. W., & Shannon, M. (2005). The serotonin syndrome. New England Journal of Medicine, 352(11), 1112-1120. https://doi.org/10.1056/NEJMra041867

Davies, J., & Read, J. (2019). A systematic review into the incidence, severity and duration of antidepressant withdrawal effects: Are guidelines evidence-based? Addictive Behaviors, 97, 111-121. https://doi.org/10.1016/j.addbeh.2018.08.027

Lacro, J. P., Dunn, L. B., Dolder, C. R., Leckband, S. G., & Jeste, D. V. (2002). Prevalence of and risk factors for medication nonadherence in patients with schizophrenia: A comprehensive review of recent literature. Journal of Clinical Psychiatry, 63(10), 892-909. https://doi.org/10.4088/JCP.v63n1007

Osterberg, L., & Blaschke, T. (2005). Adherence to medication. New England Journal of Medicine, 353(5), 487-497. https://doi.org/10.1056/NEJMra050100