Appendix A: Psychiatric Drugs

Introduction

Of course there are handbooks for doctors and health professionals. Principal among these is the Compendium of Pharmaceuticals and Specialites, commonly knows as the "CPS" (which you will find in the bibliography to this manual). While the CPS is complete and detailed, it's also hard to decode. It's hundreds of pages long, the print is tiny and intimidating, and the language is technical. We needed information that was presented in a more friendly way; we also needed information that people could take home with them.

To fill this need, we developed a set of "psychiatric drug sheets." These two to four page handouts cover individual drugs, providing the essential information about indications, dosages, precautions, and side effects. We also included several other handouts on related topics, such as the general classes of drugs, tardive dyskinesia, general precautions for using psychiatric drugs, and how to stop taking them if one wants to. These sheets are assembled into a loose-leaf binder. The format allows us to add new sheets as we develop them and as new drugs are brought onto the market, and to modify existing sheets as need be.

The information in the sheets is a translation of information mainly from the CPS and two other professional publications. We have done our best to keep it free of any bias, and the information in the drug sheets does not necessarily reflect SOS's opinions about the drugs or their use and effects. Our intention is to provide the information in a straightforward, clear way that can be understood by the average person. Of course we haven't been able to reproduce all of the detail of the professional handbooks, but we have tried to give a fair and complete picture of each drug.

This appendix contains the sheets on the general topics and the individual sheets on the most common drugs. Space limitations in this manual prevent us from including all of the sheets; you can order a complete set from SOS (details appear in the bibliography).

We believe that the information in these sheets is absolutely essential. Very, very few psychiatric patients know about the effects and risks of the medication they take. As you look through the sheets, you may be surprised at the range of serious side effects that are common with these drugs. In working with psychiatrized women, we feel that it's tremendously important that transition house staff have a real acquaintance with psychiatric drugs and their effects. We also feel that it's equally important for you to be able to pass this information along to psychiatrized women.

We encourage you to photocopy these sheets and hand them out to women you work with. You may have some apprehension that what they find in the drug sheets will be alarming. We agree that much of it is unsettling, but women who take these drugs -- or who are being urged to begin taking them -- have a right to know about them. To be able to make informed choices about their bodies, they need to have information.

As you look through the sheets for the individual drugs, you will see that they follow a standard format. First, you'll find the trade name of the drug, along with its generic name, and information that allows you to identify the drug by the form of the tablet or capsule.

The usual dosages are listed next. This is important; in our experience, these drugs are often prescribed at levels much higher than those recommended by the manufacturer. The dosage information in the drug sheets may help you determine if a woman's dosage is in the recommended range.

Next is a listing of conditions for which the drug is prescribed -- the "indications," in other words. There is then a list of contraindications. These are conditions under which the drug should not be used or should be used with caution. This list also shows what a patient should not be doing while taking this medication. Note that many of these medications set strict conditions about certain kinds of foods or other drugs. This information can also be very useful in helping a woman who may not have been told that she can't drink alcohol, say, or eat certain things while taking a given drug.

A listing of the drug's side effects comes next. We have broken these down into effects that happen often, sometimes, or rarely. This section translates the technical language of the CPS and other handbooks into descriptions that are easy to understand. In looking at the list of a drug's side effects, we'd like you to notice a couple of things. One is that many of these drugs produce side effects that might interfere with a woman's ability to adjust to the transition house setting. Many drugs commonly cause sleep disturbances, anxiety, restlessness, difficulty in concentrating, and so on. All of these are things that can make it much harder for an abused woman to deal with and adjust to her situation.

The other point we want to make is that many of these side effects are the very signs that make other people see a psychiatrized person as "crazy." Please keep this in mind when working with a psychiatrized woman who is taking medication. If she behaves in an agitated, lethargic, or seemingly strange way, it may very well be the effect of the drugs she is taking.

As we have said often in this manual, we hope that this information will better allow you to offer understanding and support to the psychiatrized women you work with. A familiarity with psychiatric drugs, their dangers, and their effects will help you to empathize with a psychiatrized woman and her experiences. And the information contained in this section can allow her to make knowledgable choices about how she wishes to exercise her right to control of her body.

This appendix contains the following information:

• a list of the drugs covered by the current SOS drug sheets
• a listing of the generic names and equivalent brand names of the drugs in the SOS drug sheets
• general precautions for using psychiatric drugs
• general information on the main classes of psychiatric drugs
• an information sheet on tardive dyskinesia, a permanent, very serious, and common side effect of major tranquilizers
• information on what's involved in quitting psychiatric medication
• individual information sheets on nine common psychiatric drugs

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Second Opinion Society Drug Information Sheets

Drugs marked with an asterisk are included in this appendix. A complete set of drug sheets in a loose leaf binder is available from the Second Opinion Society for $25. To order please contact us at sos@yukon.net, or phone us at (867) 667-2037, or write to: Second Opinion Society, 708 Black Street, Whitehorse, Yukon Y1A 2N8.

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Corresponding Drug Names

(Names in brackets are generic names)

Many psychiatric drugs have several names, as well as a generic name. This list shows the various names for the common psychiatric drugs currently covered by the SOS drug information sheets. It is not a complete list of all psychiatric drugs.

AKINETON:	(Biperiden)
ANAFRANIL:	(Clomipramine)
ASENDIN:	(Amoxapine)
AVENTYL:	(Nortriptyline)
CHLORPROMAZINE:	Thorazine, Largactil, Chlorpromanyl, Novo- Chlorpromazine
CLOZARIL:	(Clozapine)
COGENTIN:	(Benztropine Mesylate), Apo Benztropine, PMS Benztropine
DESYREL:	(Trazodone)
ELAVIL:	(Amitriptyline), Levate, Apo Amitriptyline, Novotriptyn, PMS Amitripyline
ELDEPRYL:	(Selegiline), SD Deprenyl
FLUANXOL:	(Flupenthixol dihydrochloride), (Flupenthixol decanoate)
FLUPHENAZINE:	Modecate, Apo Fluphenazine, Permitil, Moditen
HALDOL LA:	(Haloperidol), Apo Haloperidol, Novo Peridol, Peridol, PMS Haloperidol
KEMADRIN:	(Procyclidine), PMS Procyclidine, Procyclid
LITHIUM:	(Lithium Carbonate), Lithane, Carbolith, Duralith, Lithane, Lithizine
LUVOX:	(Fluvoxamine maleate)
MARPLAN:	(Isocarboxazid)
MELLARIL:	(Thioridazine), Apo Thioridazine, Novo Ridazine, PMS Thioridazine
NARDIL:	(Phenelzine)
NEULEPTIL:	(Pericyazine)
NORPRAMIN:	(Desipramine), Pertofrane
NOZINAN:	(Methotrimeprazine)
ORAP:	(Pimozide)
PARNATE:	(Tranylcypromine)
PARSITAN:	(Ethopropazine), Profenamine
PIPORTIL L4:	(Pipotiazine)
PROMAZINE:	(Promazine)
PROZAC:	(Fluoxetine)
RITALIN:	(Methylphenidate), Ritalin SR
RISPERDAL:	(Risperidone)
SERENTIL:	(Mesoridazine)
SINEQUAN:	(Doxepin), Novo-Doxepin, Triadapin
STELAZINE:	(Trifluoperazine), Apo Trifluoperazine, PMS Trifluoperazine, Terfluzine, Novo Flurazine, Solazine
STEMETIL:	(Prochlorperazine), Prorazin, PMS Prochlorperazine
SURMONTIL:	(Trimipramine), Apo-Trimip, Novo-Trimpramine, Rhotrimine
TEGRETOL:	(Carbamazepine), Apo Carbamazepine, Mazepine, Novocarbamaz, PMS Carbamazepine
TOFRANIL:	(Imipramine HCl), Apo Imipramine, Impril, Novopramine, PMS Imipramine
TRILAFON:	(Perphenazine), Apo Perphenazine, PMS Perphenazine
TRIPTIL:	(Protriptyline HCl)
VALIUM:	(Diazepam), Apo Diazepam, Diazemuls, Novodipam, PMS Diazepam, Vivol
XANAX:	(Alprazolam), Apo Alpraz, Novo Alprazol, Nu-Alpraz
ZOLOFT:	(Sertraline)

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General Precautions for Taking Psychiatric Drugs

1. You should have a complete medical examination before taking any psychiatric drug.

2. You should have a periodical medical exam while taking psychiatric drugs, because each drug has the potential of damaging certain parts of your body.

3. Psychiatric drugs are more dangerous if you use alcohol.

4. If you have any other medical conditions (such as high blood pressure, diabetes, etc.), psychiatric drugs are more dangerous.

5. When combined with other prescription drugs or street drugs, psychiatric drugs can be very dangerous or even lethal.

6. Everyone reacts differently to various drugs and dosages.

7. Don't use more than the prescribed dose.

8. If you forget a dose, just skip it. Don't take a double dose.

9. Keep all drugs out of children's reach.

10. Throw out all drugs which have passed their expiration date.

11. Psychiatric drugs often cause tiredness, drowsiness, and reduced concentration. Avoid driving, operating machinery, etc.

12. Psychiatric drugs may affect your sleep, cause nightmares, and so on -- this is more likely when they are taken at night.

13. Psychiatric drugs commonly affect sexuality. Common side effects are reduced sexual interest, inability to have orgasms, etc.

14. Psychiatric drugs can upset the menstrual cycle.

15. Pregnant women should avoid psychiatric drugs.

16. The elderly are at more risk of suffering brain damage from psychiatric drugs.

17. Psychiatric drugs can sometimes cause the opposite effect from what they are supposed to. People can become confused or agitated or freak out from using psychiatric drugs, which is often seen as another sign of mental illness. Stop taking the drugs or at least reduce your intake if you suffer such effects.

18. "Depression" -- lethargy, apathy, hopelessness -- is often caused by psychiatric drugs. Suicidal feelings can also result from debilitating effects of psychiatric drugs.

19. Psychiatric drugs can directly cause death.

20. Take psychiatric drugs as prescribed. If you stop and start taking them, you will experience withdrawal symptoms every time.

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Major Classes of Psychiatric Drugs

Antidepressants

Antidepressants are prescribed for "depression". Symptoms of depression include low energy, unhappiness, anxiety, grief, sleeplessness, loss of appetite, loss of sexual interest, tearfulness and apathy.

Note that these are the very same symptoms which major tranquilizers, antidepressants, and lithium often produce.

Antidepressants actually have a depressant effect on the brain and thereby dull the depression. They have a deadening effect on all emotions; one feels everything less, including less depression, which many people find very unpleasant.

Minor Tranquilizers

The minor tranquilizers -- also known as anti-anxiety drugs -- are used to treat "minor mental disorders." These are conditions that involve anxiety or stress. They include generalized anxiety, nervousness, tension, sleep disorders, and medical problems related to stress such as ulcers. Doctors also prescribe these drugs to relieve the stress caused by other medical conditions such as heart disease.

These drugs are very similar to barbiturates, the most common form of sleeping pills. They are sedative-hypnotics, with depressant effects.

The minor tranquilizers, which include some very widely-prescribed drugs like Valium and Ativan, are psychologically and physically very addictive. They should never be used for long periods of time, and sudden withdrawal can be very dangerous.

Neuroleptics (Major Tranquilizers)

The neuroleptics are psychiatry's most powerful drugs. They are typically prescribed to people labelled as schizophrenic, psychotic or manic-depressive.

"Neuroleptic" means "nerve seizing," and describes the semi-paralyzing effect these drugs have on the brain and nervous system.

Psychiatrists claim that neuroleptics can suppress symptoms such as confusion, delusions, hallucinations, withdrawal, excitability, extreme anxiety, uncooperativeness, aggressiveness, and violence.

After their introduction, neuroleptics quickly became the major control method in all psychiatric institutions, for the most part replacing barbiturates, insulin shock, electroshock, and lobotomy. Neuroleptics may be administered as pills, in liquids, or by injection. They are often given in doses far higher than those recommended by the drug companies, in order to restrain or incapacitate patients labelled as "uncontrollable" -- a "chemical strait jacket."

Antiparkinsonians

These are given to reduce disturbing muscular effects caused by neuroleptics, such as muscle cramps, shaking, muscle rigidity, and restlessness.

Note that they don't have any effect on the impact of the neuroleptics on the brain and they don't reduce the risk of tardive dyskinesia, a permanent and debilitating side effect of neuroleptics and sometimes antidepressants

Antiparkinsonians have very harmful side effects, and should only be used if serious muscles problems occur.

If while taking a neuroleptic drug you do develop sudden painful muscle cramps, make sure you get an injection of an antiparkinsonian drug as soon as possible; it will provide immediate relief.

Lithium

Lithium is given to control so called excited and agitated states, often in people labelled "manic-depressive," or suffering from "bi-polar disorder" or a "mood disorder."

For many people lithium is used as a lifetime maintenance treatment, like insulin for diabetes. The theory is that lithium supposedly corrects an internal biochemical imbalance.

Lithium is an extremely poisonous substance often causing major kidney damage. It also becomes very dangerous when too much is accumulated in the body, so extreme care and regular monitoring are needed to control the dosage.

It usually take several weeks for the full effect to develop.

Other drugs, especially neuroleptics, are often prescribed during an initial period, which creates a risk of serious drug interactions.

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Tardive Dyskinesia

What is tardive dyskinesia?

Tardive dyskinesia (TD) is a neurological disorder, indicating brain damage, caused by the use of neuroleptic or antipsychotic drugs such as Thorazine, Stelazine, Haldol, and Modecate. These drugs are generally prescribed by psychiatrists for people labelled mentally disordered.

TD is usually permanent. It consists of various uncontrollable, grotesque movements of the body, primarily the face, mouth, and tongue.

The condition frequently develops after one or two years of regular drug use, but it can start as early as two or three months after drug treatment begins.

The symptoms usually appear after a patient stops taking the medication, because the medication itself masks or suppresses the very symptoms that it causes.

There is no cure.

Roughly 25 to 50 percent of people taking these drugs have developed or will develop TD. Critics of psychiatric medication claim that there is now a world-wide epidemic of TD, with at least 25,000,000 sufferers.

Patients are generally not informed about this serious risk, which both the psychiatric profession and the multinational drug companies covered up for many years.

Prevention of tardive dyskinesia

1. If you take neuroleptics (major tranquilizers), use them in small doses for short periods of time.

2. While you are taking the drugs, have a thorough neurological examination by a doctor -- preferably a neurologist who is familiar with TD -- every three months.

3. Don't use neuroleptics for more than a few weeks to three months without taking a break. Taking a "drug holiday" allows you to see if the early signs of TD will appear. For example, at least four times a year, withdraw gradually and stay drug-free for two weeks to a month and watch for any TD symptoms. At this time, you should also have an examination by a doctor who knows about TD. If you have suffered any brain damage, the abnormal muscle movements of TD will start during or shortly after drug withdrawal. If such movements appear, do not start taking the neuroleptics again.

4. Whenever you stop taking neuroleptic drugs, decrease your dosage gradually. Some experts think this may reduce the risk of developing TD.

5. Avoid long-acting injections of neuroleptics, like Prolixin Decanoate. All neuroleptics carry the risk of TD, but the risk appears greater with the longer-acting forms of administration.

6. Remember that the best way to avoid TD is to not take neuroleptic medication. Try to find other ways of dealing with your problems.

7. CAUTION! If you have been taking these drugs for more than a month, do not stop taking them all at once. This can cause even more serious drug withdrawal problems. If you want to stop taking these drugs, gradual withdrawal, lifestyle adjustments, and medical supervision are recommended.

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Quitting psychiatric drugs

Introduction

A woman may have a variety of reasons for wanting to stop taking psychiatric medication. She may want to be free of the dulling effect that most psychiatric drugs cause, or of more serious side effects that she may be suffering. She may be worried about the long-term effects of the drugs, including tardive dyskinesia. Or she may be wanting to make a major change in her life by freeing herself from a dependence on powerful medication.

But whatever her motivation, she has a right to free herself from using medication. There may well be situations in which you don't agree with a woman who wants to stop taking psychiatric medication, or you may be scared that doing so will do her serious harm. But it is her right, and she probably has sound reasons for wanting to stop using the drugs. After all, she is the one who has to live with the effects of the medication, and she is the only one who knows how the medication really affects her.

You can support her by helping her make informed choices about her options. You can give her information about her medication and its effects. You can also give her information about getting off the drugs, and you can support her in carrying out her choice in a safe way.

That safety may be the most important support that you can provide. Remember, you have little influence over what she does after she leaves the transition house. She may stop her medication cold, without information or support, and put herself in serious danger. The symptoms of too-rapid withdrawal from psychiatric drugs include extreme nausea, anxiety, insomnia, restlessness, muscular reactions, and strange behaviour. In the case of minor tranquilizers and sedatives, the reactions to sudden withdrawal can be life-threatening.

You can support her in struggling with these issues and making an informed choice. But remember that you are dealing with something that is her right. If you pass judgement on her wishes, you won't be helping her find out what is really best for her. And she may simply stop her medication anyway, without the information and support she needs.

Finally, a woman who wants to stop taking psychiatric medication should have the support of a sympathetic doctor. By sympathetic we mean a doctor who is willing to accept a woman's right to choose her own path and work with her in getting off the medication. This is the best way, to have the active involvement of a doctor who can help plan and monitor a woman's withdrawal from psychiatric medication.

Note that many detox centres and drug abuse programs help people to stop taking minor tranquilizers and sedatives, but not neuroleptics and antidepressants.

What follows is an overview of the basics. It will help you and women you work with understand what's involved in the process, and how one goes about it.

The basic principles

There are some basic principles that a woman has to follow to stop taking psychiatric drugs safely. Familiarize yourself with them, and make sure that any woman you work with who wants to stop her medication is familiar with them, too.

• don't try to stop taking psychiatric drugs without support

• if at all possible, find a supportive doctor to supervise the process

• never stop taking psychiatric drugs abruptly -- going "cold turkey" can lead to serious withdrawal symptoms and can be life-threatening

• the best way to stop is to reduce the dosage gradually; by withdrawing gradually and carefully it may be possible to minimize withdrawal symptoms

• withdrawal from sedatives and minor tranquilizers can be extremely dangerous

• withdrawal symptoms don't necessarily start immediately; they may begin anywhere from 8 hours to several days after quitting

• the time it takes for withdrawal symptoms to set in and their severity varies from person to person, and depends on how long you have been taking the drugs, your dosage, your overall health, your body weight, and so on.

1. Find a supportive doctor who will work out a withdrawal schedule with you and monitor your progress. Other psychiatric survivors or a survivors' group might be able to suggest a doctor.

2. Have a living situation that is as stable as possible.

3. Organize support from friends, family, survivor groups, the local women's centre, and/or counsellors.

4. Withdraw from the drugs as gradually as you can.

5. Find out as much as you can about the process so that you will be prepared for the withdrawal symptoms.

6. Don't expect to feel much difference in the first few days.

7. Realize that your body and mind are going through a difficult experience.

8. Make sure you get enough sleep. Difficulty in sleeping is a common problem; it's important that you get at least 6 hours of sleep a night. Use herbal remedies for sleep, and try yoga, meditation, massage, etc. But if nothing else helps, it's worth taking sleeping pills just for this short period.

9. Stop using stimulants like coffee, sugar, chocolate, alcohol, or street drugs.

10. Eat the healthiest diet you can to help your body purify itself. Vegetables, fruit, nuts, and grains are important; eat as little red meat as you can, and avoid junk food.

11. You will have more physical energy as your body gets away from the drugs. Physical exercise will help you stay calm, and will be very helpful if your energy seems to be getting out of control. Try to start exercising, swimming, hiking, or bicycling. But start gradually.

Remember, psychiatric drugs should never be stopped abruptly! The more slowly you can withdraw, the less bad effects you will suffer. The best plan is to work out a schedule with your doctor that best suits your situation.

Standard practice is to reduce your dosage by 10 percent per week, monitoring your progress at every step. The first week, you would reduce your dosage by ten percent. Try that for the first week, and then see how you are doing. If you feel OK, reduce the dosage by another 10 percent. Try that for a week, and see if you feel OK.

If you reach a point where you don't feel OK, don't reduce your dosage by another 10 percent. Stay at the same reduced level for another week, or until you do feel fine. Then reduce by another 10 percent and continue with the process. Some steps might be more difficult than others; take your time.

For example, if you are taking 200mg of Chlorpromazine a day, reduce by 10 percent -- 20mg -- to 180mg per day. Try that level for a week. The next reduction would be to 160mg a day for a week (or longer), then 140mg a day, and so on.

If you are taking more than one medication at a time, it's best to stop them one by one. If you are taking a neuroleptic (major tranquilizer) and an anticonvulsive drug (anti-Parkinsonian) at the same time, which is common, withdraw from the neuroleptic first. However, if you are taking more than one medication, this is a situation where it is definitely best to have a doctor working with you.

Withdrawal effects by drug class

If you are working with a woman who wants to stop taking psychiatric drugs, it's important to be familiar with the typical reactions or symptoms of withdrawal. These vary, depending on the person, how long she's been taking the drug, her dosage, and the type of drug.

Different classes of drugs bring on different withdrawal reactions. Some of these reactions may be disturbing and hard to witness but not really dangerous. Others may be life-threatening.

A familiarity with drug withdrawal reactions will help you in working with any woman who is taking psychiatric medication. Many patients don't take their medications as prescribed; they will alter their dosage, increasing or decreasing the amount they take. Or they will miss a day's medication, and then catch up by taking twice as much the next day. By mistakenly taking too little medication, they may bring on the early stages of withdrawal. Mysterious physical and emotional complaints may actually be signs that they are not taking their medication as prescribed.

Even when a woman is taking her medication as prescribed, she may experience the beginnings of a withdrawal reaction as a dose begins to wear off. For example, a woman who is taking a minor tranquilizer may find herself feeling agitated and restless before she is to take her next prescribed dose.

In both cases, these signs are the results of the early stages of withdrawal. It may seem like the agitation, anxiety, or physical discomfort are signs of a woman's "mental illness" or a sign that she really does need the medication she's taking. However, her complaints may actually be due to the physical effects of the beginning stages of drug withdrawal.

Listed below are the main classes of psychiatric medication, along with the withdrawal reactions that are most common with each of them.

Antidepressants and neuroleptics

• flu-like syndrome with headache, muscle aches, chills, nausea, vomiting, diarrhea, and loss of appetite

• muscular reactions such as uncontrollable rhythmic movements and tremors (these are more severe with neuroleptics)

• insomnia, emotional distress, feeling like one is "going crazy"

Lithium

• less side effects generally than other classes

• insomnia, anxiety, irritability

Minor tranquilizers, sedatives

• sudden withdrawal can result in life-threatening seizures; withdrawal must be very gradual

• seizures common in early stages of withdrawal

• other reactions can include flu-like syndrome (see above), muscle tics, restlessness, and anxiety

• withdrawal symptoms usually take a few days to develop, but can occur immediately and get worse during the first week

1. Respect the woman's right to make her own choices.

2. Be informed about the process of withdrawing from psychiatric drugs.

3. Be familiar with the withdrawal symptoms so that you can stay clearheaded and not panic.

4. Help keep people who disapprove of what the woman is doing from interfering in the process.

5. Remind the woman to get enough sleep.

6. Make sure she gets enough to eat. Help her prepare food, as she may be too nervous to cook on her own.

7. Help her get in touch with other people who will support her.

8. Don't be misled by the withdrawal symptoms, thinking that they are signs of her "illness." Be patient; it takes time to withdraw from the drugs and adjust to life without them.

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