Phobia Medications

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ALPHABETICAL LIST OF MEDICATIONS
GENERAL MEDICATION INFORMATION
Adapin (DOPEXIN)

Anafranil (CLOMIPRAMINE)

Asendin (AMOXAPINE)

Ativan Oral (LORAZEPAM)

Aventyl HCl (NORTRIPTYLINE)

BuSpar Oral (BUSPIRONE)

Celexa Oral (CITALOPRAM)

Cymbalta (DULOXETINE)

Effexor Oral (VENLAFAXINE)

Elavil (AMITRIPTYLINE)

Emsam (SELEGILINE)

Endep (AMITRIPTYLINE)

Lexapro Oral (ESCITALOPRAM)

Ludiomil (MAPROTILINE)

Marplan (ISOCARBOXAZID)

Nardil (PHENELZINE)

Norpramin (DESIPRAMINE)

Pamelor (NORTRIPTYLINE)

Parnate (TRANYLCYPROMINE)

Paxil CR Oral (PAROXETINE)

Pexeva (PAROXETINE)

Prozac Oral

Remeron Oral (MIRTAZAPINE)

Sinequan (DOXEPIN)

Tofranil (IMIPRAMINE)

Vivactil (PROTRIPTYLINE)

Wellbutrin Oral (BUPROPION)

Xanax XR Oral (ALPRAZOLAM)

Zoloft Oral (SERTRALINE)

Making Sense of Antidepressants

Making sense of Antipsychotics

Making sense of Herbal Remedies

Drugs for attention deficit hyperactivity disorder (ADHD)

Making sense of Sleeping Pills and Minor Tranquillisers

General information about the use of medicines

Prozac Oral

Generic Name: FLUOXETINE - ORAL
Pronounced: (flew-OX-eh-teen)

Uses and How to Use
Precautions and side affects
Dosage and storage

Uses and How to Use

Prozac Oral Uses
Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) used to treat depression, anxiety disorders (panic attacks), obsessive-compulsive disorder (OCD), a certain eating disorder (bulimia), and a severe form of premenstrual syndrome (premenstrual dysphoric disorder).

SSRIs work by helping to restore the balance of certain natural substances in the brain (neurotransmitters such as serotonin). Fluoxetine may improve your mood, sleep, appetite, and energy level and may help restore your interest in daily living. It may decrease anxiety/unreasonable fears, persistent/troubling thoughts (obsessions), and unwanted urges that keep returning (compulsions). It may decrease the number and severity of panic attacks. Fluoxetine may lessen premenstrual symptoms such as irritability, increased appetite, and depression. It may decrease bingeing and purging behaviors in bulimia.

How To Use Prozac Oral
Read the Medication Guide provided by your pharmacist before you start using fluoxetine and each time you get a refill. If you have any questions, consult your doctor or pharmacist.

Take this medication by mouth with or without food, usually once daily or as directed by your doctor. This medication may make you either sleepy or wakeful. Therefore, depending on how this medication affects you, your doctor may direct you to take the entire dose once daily in either the morning or evening. If you are taking this medication twice a day, your doctor may direct you to take it in the morning and at noon.

If you are taking fluoxetine for premenstrual problems, your doctor may direct you to take it every day of the month or just for the 2 weeks before your period through the first full day of your period. To help you remember, mark your calendar.

If you are using the liquid form of this medication, measure the dose carefully using a special measuring device/spoon. Do not use a household spoon because you may not get the correct dose.

The dosage is based on your medical condition and response to treatment. To reduce your risk of side effects, your doctor may start you at a low dose and gradually increase your dose. Follow your doctor's instructions carefully. Do not take more or less medication or take it more frequently than prescribed. Your condition will not improve any faster, and your risk of side effects will increase. Use this medication regularly in order to get the most benefit from it. To help you remember, use it at the same time(s) each day.

It is important to continue taking this medication as prescribed even if you feel well. Do not stop taking this medication without first consulting your doctor. Some conditions may become worse when the drug is abruptly stopped. Your dose may need to be gradually decreased.

You should see some improvement in 1 to 2 weeks. It may take several weeks before you feel the full benefit.

Tell your doctor if your condition does not improve or if it worsens.

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Precautions and Side Effects

Prozac Oral Warning

Antidepressant medications are used to treat a variety of conditions, including depression and other mental/mood disorders. These medications can help prevent suicidal thoughts/attempts and provide other important benefits. However, studies have shown that a small number of people (especially children/teenagers) who take antidepressants for any condition may experience worsening depression, other mental/mood symptoms, or suicidal thoughts/attempts. Therefore, it is very important to talk with the doctor about the risks and benefits of antidepressant medication (especially for children/teenagers), even if treatment is not for a mental/mood condition.

Tell the doctor immediately if you notice worsening depression/other psychiatric conditions, unusual behavior changes (including possible suicidal thoughts/attempts), or other mental/mood changes (including new/worsening anxiety, panic attacks, trouble sleeping, irritability, hostile/angry feelings, impulsive actions, severe restlessness, very rapid speech). Be especially watchful for these symptoms when a new antidepressant is started or when the dose is changed.

Prozac Oral Side Effects

See also Warning section.

Nausea, drowsiness, dizziness, anxiety, trouble sleeping, loss of appetite, weakness, tiredness, sweating, or yawning may occur. If any of these effects persist or worsen, tell your doctor promptly.

Remember that your doctor has prescribed this medication because he or she has judged that the benefit to you is greater than the risk of side effects. Many people using this medication do not have serious side effects.

Tell your doctor immediately if any of these unlikely but serious side effects occur:

unusual or severe mental/mood changes (e.g., agitation, unusual high energy/excitement, thoughts of suicide)
uncontrolled movements (e.g., of the lips/tongue)
shakiness (tremor)
restlessness
inability to keep still
decreased interest in sex
changes in sexual ability
blurred vision
numbness/tingling

Tell your doctor immediately if any of these rare but very serious side effects occur:

bloody/black/tarry stools
vomit that looks like coffee grounds
easy bruising/bleeding
fainting
fast/irregular heartbeat
muscle weakness/spasm
seizures
change in amount of urine

This medication may rarely cause a very serious condition called serotonin syndrome. The risk increases when this medication is used with certain other drugs such as "triptans" used to treat migraine headaches (e.g., sumatriptan, eletriptan), certain antidepressants including other SSRIs (e.g., citalopram, paroxetine) and SNRIs (e.g., duloxetine, venlafaxine), lithium, tramadol, tryptophan, or a certain drug to treat obesity (sibutramine). See also Drug Interactions section. Before taking this drug, tell your doctor if you take any of these medications. Serotonin syndrome may be more likely when you start or increase the dose of any of these medications. Seek immediate medical attention if you develop some of the following symptoms:

hallucinations
unusual restlessness
loss of coordination
fast heartbeat
severe dizziness
unexplained fever
severe nausea/vomiting/diarrhea
twitchy muscles

For males, in the very unlikely event you have a painful or prolonged erection lasting 4 or more hours, stop using this drug and seek immediate medical attention, or permanent problems could occur.

A very serious allergic reaction to this drug is rare. However, seek immediate medical attention if you notice any symptoms of a serious allergic reaction, including:

rash
itching
swelling
severe dizziness
trouble breathing

If you notice other effects not listed above, contact your doctor or pharmacist.

Prozac Oral Precautions
Before taking fluoxetine, tell your doctor or pharmacist if you are allergic to it; or if you have any other allergies.

Before using this medication, tell your doctor or pharmacist your medical history, especially of:

personal or family history of bipolar/manic-depressive disorder
personal or family history of suicide attempts
liver problems
diabetes
low sodium in the blood
severe loss of body water (dehydration)
seizures
stomach/intestinal ulcers

This drug may make you dizzy or drowsy. Use caution while driving, using machinery, or doing any other activity that requires alertness. Avoid alcoholic beverages.

If you have diabetes, fluoxetine may affect your blood sugar levels. Monitor your blood sugar regularly and share the results with your doctor. Your doctor may need to adjust your medication, diet, and exercise when you start or stop fluoxetine. Liquid forms of this product may contain sugar and/or alcohol. Caution is advised if you have diabetes, alcohol dependence, or liver disease. Ask your doctor or pharmacist about using this product safely.

Caution is advised when using this product in the elderly because they may be more sensitive to its effects. The elderly are more likely to lose too much salt (hyponatremia), especially if they are also taking "water pills" (diuretics) with this medication.

This medication is not recommended for use during pregnancy. It may harm an unborn baby. Also, babies born to mothers who have used this drug during the last 3 months of pregnancy may infrequently develop withdrawal symptoms such as feeding/breathing difficulties, seizures, muscle stiffness, or constant crying. If you notice any of these symptoms in your newborn, tell the doctor promptly.

Since untreated depression can be a serious condition, do not stop taking this medication unless directed by your doctor. If you are planning pregnancy, become pregnant, or think you may be pregnant, immediately discuss the benefits and risks of using this medication during pregnancy with your doctor.

This drug may pass into breast milk and could have undesirable effects on a nursing infant. Therefore, breast-feeding is not recommended while using this drug. Consult your doctor before breast-feeding.

Prozac Oral Drug Interactions
Your doctor or pharmacist may already be aware of any possible drug interactions and may be monitoring you for them. Do not start, stop, or change the dosage of any medicine before checking with your doctor or pharmacist first.

Fluoxetine can stay in your body for many weeks after your last dose and may interact with many other medications. Before using any medication, tell your doctor or pharmacist if you have taken fluoxetine in the previous 5 weeks.

Certain medications taken with fluoxetine could result in serious (rarely fatal) drug interactions. Avoid taking MAO inhibitors (e.g., furazolidone, isocarboxazid, linezolid, moclobemide, phenelzine, procarbazine, rasagiline, selegiline, tranylcypromine) with fluoxetine for 2 weeks before, during treatment, and at least 5 weeks after your last dose of fluoxetine. Consult your doctor or pharmacist for additional information.

The following medications should not be used with fluoxetine and for 5 weeks after your last dose of fluoxetine because very serious (possibly fatal) interactions may occur:

pimozide
sibutramine
thioridazine

If you are currently using any of these medications listed above, tell your doctor or pharmacist before starting fluoxetine.

Before using fluoxetine, tell your doctor or pharmacist of all prescription and nonprescription/herbal products you may use, especially of:

drugs removed from your body by certain liver enzymes (e.g., carbamazepine, cimetidine, phenytoin, vinblastine, drugs for anxiety such as alprazolam and diazepam, antipsychotics such as aripiprazole/clozapine/haloperidol/perphenazine, antiarrhythmics such as propafenone/flecainide, TCA antidepressants such as desipramine/imipramine)
fosamprenavir/ritonavir
metoprolol
"water pills" (diuretics such as furosemide)
drugs that can cause bleeding/bruising (e.g., aspirin, antiplatelet drugs such as clopidogrel, NSAIDs such as ibuprofen, "blood thinners" such as heparin/warfarin)
Aspirin can increase the risk of bleeding when used with this medication (see above). If your doctor has directed you to take low-dose aspirin for heart attack or stroke prevention (usually at dosages of 81-325 milligrams a day), you should continue taking it unless your doctor instructs you otherwise. Discuss the risks and benefits with your doctor.

Also tell your doctor if you take any other drugs that increase serotonin, such as bromocriptine, buspirone, dextromethorphan, lithium, meperidine, propoxyphene, phentermine, SSRIs, SNRIs, tryptophan, St. John's wort, drugs used to treat migraines such as "triptans" and dihydroergotamine, street drugs such as MDMA/"ecstasy," amphetamine.

Tell your doctor or pharmacist if you also take drugs that cause drowsiness, such as certain antihistamines (e.g., diphenhydramine), anti-seizure drugs (e.g., carbamazepine), medicine for sleep or anxiety (e.g., lorazepam, zolpidem), muscle relaxants, narcotic pain relievers (e.g., codeine), psychiatric medicines (e.g., chlorpromazine, quetiapine, nortriptyline, trazodone).

Check the labels on all your medicines (e.g., cough-and-cold products) because they may contain ingredients that cause drowsiness. Dextromethorphan is a commonly used cough medication and may interact with fluoxetine. Ask your pharmacist about using those products safely.

Cimetidine is a nonprescription drug that is commonly used to treat extra stomach acid. Because it may cause undesirable interactions when used with fluoxetine, ask your pharmacist about other products to treat stomach acid.

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Dosage and Storage

Prozac Oral Overdose

If overdose is suspected, contact your local poison control center or emergency room immediately. US residents can call the US National Poison Hotline at 1-800-222-1222. Canada residents can call a provincial poison control center. Symptoms of overdose may include: irregular heartbeat, fainting, severe dizziness, seizures.

Prozac Oral Missed Dose If you miss a dose, take it as soon as you remember. If it is near the time of the next dose, skip the missed dose and resume your usual dosing schedule. Do not double the dose to catch up.

Prozac Oral Notes
Do not share this medication with others.

Psychiatric/medical check-ups should be done periodically to monitor your progress or check for side effects. Consult your doctor for more details.

Prozac Oral Storage
Store at room temperature between 59-86 degrees F (15-30 degrees C) away from light and moisture. Do not store in the bathroom. Keep all medicines away from children and pets. Different brands may have different storage instructions. Check the product label or ask your pharmacist how to store your particular product.

Properly discard this product when it is expired or no longer needed. Consult your pharmacist or local waste disposal company for more details about how to safely discard your product.

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Celexa Oral (CITALOPRAM)

Generic Name: CITALOPRAM - ORAL
Pronounced: (sye-TAL-oh-pram)

Uses and How to Use
Precautions and Side Effects
Dosage and Storage
 

Uses and How to Use
 

Celexa Oral Uses
Citalopram is an antidepressant (selective serotonin reuptake inhibitor-SSRI) used to treat depression. It works by restoring the balance of certain natural substances (neurotransmitters such as serotonin) in the brain. Citalopram may improve your feelings of well-being and energy level.

How To Use Celexa Oral
Read the Medication Guide provided by your pharmacist before you start using citalopram and each time you get a refill. If you have any questions, consult your doctor or pharmacist.

Take this medication once daily in the morning or evening, with or without food or as directed by your doctor. The dosage is based on your medical condition and response to treatment. If you are using the liquid form of this medication, measure the dose carefully using a special measuring device/spoon. Do not use a household spoon because you may not get the correct dose.

To reduce your risk of side effects, your doctor may direct you to start taking this drug at a low dose and gradually increase your dose. Follow your doctor's instructions carefully. Do not take more or less medication or take it more frequently than prescribed. Your condition will not improve any faster, and your risk of side effects will increase. Use this medication regularly in order to get the most benefit from it. To help you remember, use it at the same time each day.

It is important to continue taking this medication even if you feel well. Do not stop taking this medication without consulting your doctor. Some conditions may become worse when the drug is suddenly stopped. Your dose may need to be gradually decreased.

This medication may cause dependence, especially if it has been used regularly for an extended time or if it has been used in high doses. In such cases, withdrawal reactions (e.g., nervousness, headache, numbness, tingling, trouble sleeping, nightmares) may occur if you suddenly stop this drug. To prevent withdrawal when stopping extended/regular treatment with this drug, gradually reduce the dosage as directed. Consult your doctor or pharmacist for more details, and report any withdrawal reactions immediately.

It may take 1 to 2 weeks to feel a benefit from this drug and 4 weeks to feel the full benefit of this medication. Tell your doctor if your condition persists or worsens.

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Precautions and Side Effects

Celexa Oral Warning
Antidepressant medications are used to treat a variety of conditions, including depression and other mental/mood disorders. These medications can help prevent suicidal thoughts/attempts and provide other important benefits. However, studies have shown that a small number of people (especially children/teenagers) who take antidepressants for any condition may experience worsening depression, other mental/mood symptoms, or suicidal thoughts/attempts. Therefore, it is very important to talk with the doctor about the risks and benefits of antidepressant medication (especially for children/teenagers), even if treatment is not for a mental/mood condition.

Tell the doctor immediately if you notice worsening depression/other psychiatric conditions, unusual behavior changes (including possible suicidal thoughts/attempts), or other mental/mood changes (including new/worsening anxiety, panic attacks, trouble sleeping, irritability, hostile/angry feelings, impulsive actions, severe restlessness, very rapid speech). Be especially watchful for these symptoms when a new antidepressant is started or when the dose is changed.

Celexa Oral Side Effects

Nausea, dry mouth, trouble sleeping, loss of appetite, weakness, tiredness, drowsiness, dizziness, increased sweating, blurred vision, or yawning may occur. If any of these effects persist or worsen, tell your doctor promptly.

Remember that your doctor has prescribed this medication because he or she has judged that the benefit to you is greater than the risk of side effects. Many people using this medication do not have serious side effects.

Tell your doctor immediately if any of these unlikely but serious side effects occur:

unusual or severe mental/mood changes (e.g., nervousness, unusual high energy/excitement, rare thoughts of suicide)
shakiness (tremor)
decreased interest in sex
changes in sexual ability

Tell your doctor immediately if any of these rare but very serious side effects occur:

stomach pain
fainting
bloody/black/tarry stools
vomit that looks like coffee grounds
easy bruising/bleeding
muscle weakness/cramps
seizures
fast/irregular/pounding heartbeat
difficulty urinating
change in the amount of urine

This medication may rarely cause a very serious condition called serotonin syndrome. The risk increases when this medication is used with certain other drugs such as "triptans" used to treat migraine headaches (e.g., sumatriptan, eletriptan), certain antidepressants including other SSRIs (e.g., fluoxetine, paroxetine) and SNRIs (e.g., venlafaxine), lithium, tramadol, tryptophan, or a certain drug to treat obesity (sibutramine). See also Drug Interactions section. Before taking this drug, tell your doctor if you take any of these medications. Serotonin syndrome may be more likely when you start or increase the dose of any of these medications. Seek immediate medical attention if you develop some of the following symptoms:

hallucinations
restlessness
loss of coordination
fast heartbeat
severe dizziness
unexplained fever
severe nausea/vomiting/diarrhea
twitchy muscles

For males, in the very unlikely event you have a painful or prolonged erection lasting 4 or more hours, stop using this drug and seek immediate medical attention, or permanent problems could occur.

A very serious allergic reaction to this drug is rare. However, seek immediate medical attention if you notice any symptoms of a serious allergic reaction, including:

rash
itching
swelling
severe dizziness
trouble breathing

If you notice other effects not listed above, contact your doctor or pharmacist.

Celexa Oral Precautions
Before taking citalopram, tell your doctor or pharmacist if you are allergic to it; or to escitalopram; or if you have any other allergies.

Before using this medication, tell your doctor or pharmacist your medical history, especially of:

personal or family history of psychiatric disorders (e.g., bipolar/manic-depressive disorder)
personal or family history of suicide attempts
bleeding problems
liver disease
seizures
severe kidney disease
stomach bleeding
severe loss of body water (dehydration)
low sodium in the blood (hyponatremia)

This drug may make you dizzy or drowsy. Use caution while driving, using machinery, or doing any other activity that requires alertness. Avoid alcoholic beverages.

Caution is advised when using this drug in the elderly because they may be more sensitive to its effects. The elderly are more likely to lose too much salt (hyponatremia), especially if they are also taking "water pills" (diuretics) with this medication.

This medication is not recommended for use during pregnancy. It may harm an unborn baby. Also, babies born to mothers who have used this drug during the last 3 months of pregnancy may infrequently develop withdrawal symptoms such as feeding/breathing difficulties, seizures, muscle stiffness, or constant crying. If you notice any of these symptoms in your newborn, tell the doctor promptly.

Since untreated depression can be a serious condition, do not stop taking this medication unless directed by your doctor. If you are planning pregnancy, become pregnant, or think you may be pregnant, immediately discuss the benefits and risks of using this medication during pregnancy with your doctor.

This medication passes into breast milk and may have undesirable effects on a nursing infant. Breast-feeding is not recommended while using this drug. Consult your doctor before breast-feeding.

Celexa Oral Drug Interactions
Your doctor or pharmacist may already be aware of any possible drug interactions and may be monitoring you for them. Do not start, stop, or change the dosage of any medicine before checking with your doctor or pharmacist first.

Taking certain medications with this product could result in serious (rarely fatal) drug interactions. Avoid taking MAO inhibitors (e.g., furazolidone, isocarboxazid, linezolid, moclobemide, phenelzine, procarbazine, rasagiline, selegiline, tranylcypromine) with citalopram for 2 weeks before treatment, during treatment, or for 2 weeks after your last dose of citalopram.

This drug should not be used with the following medications because very serious interactions may occur:

pimozide
tryptophan
weight loss drugs (e.g., sibutramine, phentermine)

If you are currently using any of these medications, tell your doctor or pharmacist before starting citalopram.

Before using this medication, tell your doctor or pharmacist of all prescription and nonprescription/herbal products you may use, especially of:

cimetidine
metoprolol
"water pills" (diuretics such as furosemide)
drugs that can cause bleeding/bruising (e.g., aspirin, antiplatelet drugs such as clopidogrel, NSAIDs such as ibuprofen, "blood thinners" such as heparin/warfarin)

Aspirin can increase the risk of bleeding when used with this medication (see above). If your doctor has directed you to take low-dose aspirin for heart attack or stroke prevention (usually at dosages of 81-325 milligrams a day), you should continue taking it unless your doctor instructs you otherwise. Discuss the risks and benefits with your doctor.

Also tell your doctor if you take any other drugs that increase serotonin, such as buspirone, dextromethorphan, lithium, meperidine, propoxyphene, phentermine, other SSRIs (e.g., paroxetine), SNRIs (e.g., duloxetine), tryptophan, St. John's wort, drugs used to treat migraines such as "triptans" and dihydroergotamine, street drugs such as MDMA/"ecstasy," amphetamine. (See also Side Effects section.)

Tell your doctor or pharmacist if you also take drugs that cause drowsiness, such as certain antihistamines (e.g., diphenhydramine), anti-seizure drugs (e.g., carbamazepine), medicine for sleep or anxiety (e.g., lorazepam, zolpidem), muscle relaxants, narcotic pain relievers (e.g., codeine), psychiatric medicines (e.g., chlorpromazine, quetiapine, nortriptyline, trazodone). Check the labels on all your medicines (e.g., cough-and-cold products) because they may contain ingredients that cause drowsiness.

Cimetidine is a nonprescription drug that is commonly used to treat extra stomach acid. Because it may cause undesirable interactions when used with citalopram, ask your pharmacist about other products to treat stomach acid.

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Dosage and Storage

Celexa Oral Missed Dose
If you miss a dose, take it as soon as you remember. If it is near the time of the next dose, skip the missed dose and resume your usual dosing schedule. Do not double the dose to catch up.

Celexa Oral Notes
Do not share this medication with others.

Psychiatric/medical check-ups and possibly lab tests should be done periodically to monitor your progress or check for side effects. Consult your doctor for more details.

Celexa Oral Storage
Store at room temperature at 77 degrees F (25 degrees C) away from light and moisture. Brief storage between 59-86 degrees F (15-30 degrees C) is permitted. Do not store in the bathroom. Keep all medicines away from children and pets.

Properly discard this product when it is expired or no longer needed. Consult your pharmacist or local waste disposal company for more details about how to safely discard your product.

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Lexapro Oral (ESCITALOPRAM)

Generic Name: ESCITALOPRAM - ORAL
Pronounced: (es-sye-TAL-oh-pram)

Uses and How to Use
Precautions and side affects
Dosage and Storage
 

Uses and How to Use

Lexapro Oral Uses
Escitalopram is an antidepressant (selective serotonin reuptake inhibitor-SSRI) used to treat depression and anxiety. It works by restoring the balance of certain natural substances (neurotransmitters such as serotonin) in the brain. Escitalopram may improve your feelings of well-being and energy level and decrease nervousness.

How To Use Lexapro Oral
Read the Medication Guide provided by your pharmacist before you start using escitalopram and each time you get a refill. If you have any questions, consult your doctor or pharmacist.

Take this medication once daily in the morning or evening, with or without food or as directed by your doctor. The dosage is based on your medical condition and response to treatment. If you are using the liquid form of this medication, measure the dose carefully using a special measuring device/spoon. Do not use a household spoon because you may not get the correct dose.

To reduce your risk of side effects, your doctor may direct you to start taking this drug at a low dose and gradually increase your dose. Follow your doctor's instructions carefully. Do not take more or less medication or take it more frequently than prescribed. Your condition will not improve any faster, and your risk of side effects will increase. Use this medication regularly in order to get the most benefit from it. To help you remember, use it at the same time each day.

It is important to continue taking this medication even if you feel well. Do not stop taking this medication without consulting your doctor. Some conditions may become worse when the drug is suddenly stopped. Your dose may need to be gradually decreased.

This medication may cause dependence, especially if it has been used regularly for an extended time or if it has been used in high doses. In such cases, withdrawal reactions (e.g., nervousness, headache, numbness, tingling, trouble sleeping, confusion) may occur if you suddenly stop this drug. To prevent withdrawal when stopping extended/regular treatment with this drug, gradually reduce the dosage as directed. Consult your doctor or pharmacist for more details, and report any withdrawal reactions immediately.

It may take 1 to 2 weeks to feel a benefit from this drug and 4 weeks to feel the full benefit of this medication. Tell your doctor if your condition persists or worsens.

BACK TO TOP

BACK TO INDEX

Precautions and Side Effects

Lexapro Oral Warning
Antidepressant medications are used to treat a variety of conditions, including depression and other mental/mood disorders. These medications can help prevent suicidal thoughts/attempts and provide other important benefits. However, studies have shown that a small number of people (especially children/teenagers) who take antidepressants for any condition may experience worsening depression, other mental/mood symptoms, or suicidal thoughts/attempts. Therefore, it is very important to talk with the doctor about the risks and benefits of antidepressant medication (especially for children/teenagers), even if treatment is not for a mental/mood condition.

Tell the doctor immediately if you notice worsening depression/other psychiatric conditions, unusual behavior changes (including possible suicidal thoughts/attempts), or other mental/mood changes (including new/worsening anxiety, panic attacks, trouble sleeping, irritability, hostile/angry feelings, impulsive actions, severe restlessness, very rapid speech). Be especially watchful for these symptoms when a new antidepressant is started or when the dose is changed.

Lexapro Oral Side Effects

Nausea, dry mouth, trouble sleeping, loss of appetite, weakness, tiredness, drowsiness, dizziness, increased sweating, or yawning may occur. If any of these effects persist or worsen, tell your doctor promptly.

Remember that your doctor has prescribed this medication because he or she has judged that the benefit to you is greater than the risk of side effects. Many people using this medication do not have serious side effects.

Tell your doctor immediately if any of these unlikely but serious side effects occur:

unusual or severe mental/mood changes (e.g., nervousness, unusual high energy/excitement, rare thoughts of suicide)
shakiness (tremor)
decreased interest in sex
changes in sexual ability

Tell your doctor immediately if any of these rare but very serious side effects occur:

stomach pain
fainting
bloody/black/tarry stools
vomit that looks like coffee grounds
easy bruising/bleeding
muscle weakness/cramps
seizures
irregular/pounding heartbeat
change in the amount of urine

This medication may rarely cause a very serious condition called serotonin syndrome. The risk increases when this medication is used with certain other drugs such as "triptans" used to treat migraine headaches (e.g., sumatriptan, eletriptan), certain antidepressants including other SSRIs (e.g., fluoxetine, citalopram) and SNRIs (e.g., venlafaxine), lithium, tramadol, tryptophan, or a certain drug to treat obesity (sibutramine). See also Drug Interactions section. Before taking this drug, tell your doctor if you take any of these medications. Serotonin syndrome may be more likely when you start or increase the dose of any of these medications. Seek immediate medical attention if you develop some of the following symptoms:

hallucinations
restlessness
loss of coordination
fast heartbeat
severe dizziness
unexplained fever
severe nausea/vomiting/diarrhea
twitchy muscles

For males, in the very unlikely event you have a painful or prolonged erection lasting 4 or more hours, stop using this drug and seek immediate medical attention, or permanent problems could occur.

A very serious allergic reaction to this drug is rare. However, seek immediate medical attention if you notice any symptoms of a serious allergic reaction, including:

rash
itching
swelling
severe dizziness
trouble breathing

If you notice other effects not listed above, contact your doctor or pharmacist.

Lexapro Oral Precautions
Before taking escitalopram, tell your doctor or pharmacist if you are allergic to it; or to citalopram; or if you have any other allergies.

Before using this medication, tell your doctor or pharmacist your medical history, especially of:

personal or family history of psychiatric disorders (e.g., bipolar/manic-depressive disorder)
personal or family history of suicide attempts
bleeding problems
liver disease
seizures
severe kidney disease
stomach bleeding
severe loss of body water (dehydration)
low sodium in the blood (hyponatremia)

This drug may make you dizzy or drowsy. Use caution while driving, using machinery, or doing any other activity that requires alertness. Avoid alcoholic beverages.

Caution is advised when using this drug in the elderly because they may be more sensitive to its effects. The elderly are more likely to lose too much salt (hyponatremia), especially if they are also taking "water pills" (diuretics) with this medication.

This medication is not recommended for use during pregnancy. It may harm an unborn baby. Also, babies born to mothers who have used this drug during the last 3 months of pregnancy may infrequently develop withdrawal symptoms such as feeding/breathing difficulties, seizures, muscle stiffness, or constant crying. If you notice any of these symptoms in your newborn, tell the doctor promptly.

Since untreated depression can be a serious condition, do not stop taking this medication unless directed by your doctor. If you are planning pregnancy, become pregnant, or think you may be pregnant, immediately discuss the benefits and risks of using this medication during pregnancy with your doctor.

This medication passes into breast milk and may have undesirable effects on a nursing infant. Breast-feeding is not recommended while using this drug. Consult your doctor before breast-feeding.

Lexapro Oral Drug Interactions
Your doctor or pharmacist may already be aware of any possible drug interactions and may be monitoring you for them. Do not start, stop, or change the dosage of any medicine before checking with your doctor or pharmacist first.

Taking certain medications with this product could result in serious (rarely fatal) drug interactions. Avoid taking MAO inhibitors (e.g., furazolidone, isocarboxazid, linezolid, moclobemide, phenelzine, procarbazine, rasagiline, selegiline, tranylcypromine) with escitalopram for 2 weeks before treatment, during treatment, or for 2 weeks after your last dose of escitalopram.

This drug should not be used with the following medications because very serious interactions may occur:

pimozide
tryptophan
weight loss drugs (e.g., sibutramine, phentermine)

If you are currently using any of these medications, tell your doctor or pharmacist before starting escitalopram.

Before using this medication, tell your doctor or pharmacist of all prescription and nonprescription/herbal products you may use, especially of:

desipramine
metoprolol
"water pills" (diuretics such as furosemide)
drugs that can cause bleeding/bruising (e.g., aspirin, antiplatelet drugs such as clopidogrel, NSAIDs such as ibuprofen, "blood thinners" such as heparin/warfarin)

Aspirin can increase the risk of bleeding when used with this medication (see above). If your doctor has directed you to take low-dose aspirin for heart attack or stroke prevention (usually at dosages of 81-325 milligrams a day), you should continue taking it unless your doctor instructs you otherwise. Discuss the risks and benefits with your doctor.

Also tell your doctor if you take any other drugs that increase serotonin, such as buspirone, dextromethorphan, lithium, meperidine, propoxyphene, phentermine, other SSRIs (e.g., paroxetine), SNRIs (e.g., duloxetine), tryptophan, St. John's wort, drugs used to treat migraines such as "triptans" and dihydroergotamine, street drugs such as MDMA/"ecstasy," amphetamine. (See also Side Effects section.)

Tell your doctor or pharmacist if you also take drugs that cause drowsiness, such as certain antihistamines (e.g., diphenhydramine), anti-seizure drugs (e.g., carbamazepine), medicine for sleep or anxiety (e.g., lorazepam, zolpidem), muscle relaxants, narcotic pain relievers (e.g., codeine), psychiatric medicines (e.g., chlorpromazine, quetiapine, nortriptyline, trazodone). Check the labels on all your medicines (e.g., cough-and-cold products) because they may contain ingredients that cause drowsiness.

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Dosage and Storage

Lexapro Oral Missed Dose
If you miss a dose, take it as soon as you remember. If it is near the time of the next dose, skip the missed dose and resume your usual dosing schedule. Do not double the dose to catch up.

Lexapro Oral Notes
Do not share this medication with others.

Psychiatric/medical check-ups and possibly lab tests should be done periodically to monitor your progress or check for side effects. Consult your doctor for more details.

Lexapro Oral Storage
Store at room temperature at 77 degrees F (25 degrees C) away from light and moisture. Brief storage between 59-86 degrees F (15-30 degrees C) is permitted. Do not store in the bathroom. Keep all medicines away from children and pets.

Properly discard this product when it is expired or no longer needed. Consult your pharmacist or local waste disposal company for more details about how to safely discard your product.

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Zoloft Oral (SERTRALINE)

Generic Name: SERTRALINE LIQUID CONCENTRATE - ORAL
Pronounced: (SER-truh-leen)

Uses and How to Use
Precautions and side affects
Dosage and Storage

Uses and How to Use

Zoloft Oral Uses
Sertraline is used to treat depression, panic attacks, obsessive compulsive disorders, post-traumatic stress disorder, social anxiety disorder (social phobia), and a severe form of premenstrual syndrome (premenstrual dysphoric disorder). It is known as a selective serotonin reuptake inhibitor (SSRI).

This medication may improve your mood, sleep, appetite, and energy level and may help restore your interest in daily living. It may decrease fear, anxiety, unwanted thoughts, and the number of panic attacks. It may also reduce the urge to perform repeated tasks (compulsions such as hand-washing, counting, and checking) that interfere with daily living. This medication works by helping to restore the balance of certain natural chemicals (neurotransmitters such as serotonin) in the brain.

How To Use Zoloft Oral
Read the Medication Guide (US) or Patient Information Leaflet (Canada) available from your pharmacist before you start using sertraline and each time you get a refill. If you have any questions, consult your doctor or pharmacist.

This liquid medication must be mixed with another fluid before use. Remove the prescribed amount of liquid medication from the bottle with the dropper provided. Mix the medication with half a cup (4 ounces or 120 milliliters) of water, ginger ale, lemon-lime soda, lemonade, or orange juice. Do not use any other fluid for mixing this drug. The mixture may appear cloudy. This is normal and harmless.

Mix each dose just before taking it. Do not prepare a supply for future use.

Take this medication/liquid mixture by mouth, usually once daily with or without food or as directed by your doctor. This medication may make you sleepy or wakeful. Therefore, depending on how this medication affects you, your doctor may direct you to take the entire dose once daily either in the morning or evening.

If you are taking this medication for premenstrual problems, your doctor may direct you to take this drug every day of the month or just for the 2 weeks before your period through the first full day of your period.

The dosage is based on your medical condition and response to therapy. Follow your doctor's instructions carefully. Do not take more or less medication or take it more frequently than prescribed. Your condition will not improve any faster and your risk of side effects will increase. Use this medication regularly in order to get the most benefit from it. To help you remember, use it at the same time each day.

It is important to continue taking this medication as prescribed even if you feel well. Do not stop taking this medication without consulting your doctor. Some conditions may become worse when this drug is abruptly stopped. Your dose may need to be gradually decreased to reduce side effects. Consult your doctor or pharmacist for more details.

It may take up to 4 weeks before the full benefit of this drug takes effect.

Inform your doctor if your condition persists.

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Precautions and Side Effects

Zoloft Oral Warning
Antidepressant medications are used to treat a variety of conditions, including depression and other mental/mood disorders. These medications can help prevent suicidal thoughts/attempts and provide other important benefits. However, studies have shown that a small number of people (especially children/teenagers) who take antidepressants for any condition may experience worsening depression, other mental/mood symptoms, or suicidal thoughts/attempts. Therefore, it is very important to talk with the doctor about the risks and benefits of antidepressant medication (especially for children/teenagers), even if treatment is not for a mental/mood condition.
 

Tell the doctor immediately if you notice worsening depression/other psychiatric conditions, unusual behavior changes (including possible suicidal thoughts/attempts), or other mental/mood changes (including new/worsening anxiety, panic attacks, trouble sleeping, irritability, hostile/angry feelings, impulsive actions, severe restlessness, very rapid speech). Be especially watchful for these symptoms when a new antidepressant is started or when the dose is changed.

Zoloft Oral Side Effects
See also Warning section.

Nausea, dizziness, dry mouth, loss of appetite, increased sweating, drowsiness, diarrhea, upset stomach, or trouble sleeping may occur. If any of these effects persist or worsen, notify your doctor or pharmacist promptly.

Remember that your doctor has prescribed this medication because the benefit to you is greater than the risk of side effects. Many people using this medication do not have serious side effects.

Tell your doctor immediately if any of these unlikely but serious side effects occur:

unusual or severe mental/mood changes (e.g., agitation, nervousness, suicidal thoughts)
decrease in sexual ability (ejaculation delay)
decreased interest in sex
uncontrollable shaking (tremor)
unusual weight loss

Tell your doctor immediately if any of these highly unlikely but very serious side effects occur:

easy bruising/bleeding
persistent nausea/vomiting
severe stomach/abdominal pain
black stools
seizures
change in the amount of urine
dark urine
vomit that looks like coffee grounds
yellowing eyes/skin

This medication may rarely cause a very serious condition called serotonin syndrome. The risk increases when this medication is used with certain other drugs such as "triptans" used to treat migraine headaches (e.g., sumatriptan, eletriptan), certain antidepressants including other SSRIs (e.g., citalopram, paroxetine) and SNRIs (e.g., duloxetine, venlafaxine), lithium, tramadol, tryptophan, or a certain drug to treat obesity (sibutramine). Before taking this drug, tell your doctor if you take any of these medications. Serotonin syndrome may be more likely when you start or increase the dose of any of these medications. Seek immediate medical attention if you develop some of the following symptoms:

hallucinations
unusual restlessness
loss of coordination
fast heartbeat
severe dizziness
unexplained fever
severe nausea/vomiting/diarrhea
twitchy muscles

For males, in the very unlikely event you have a painful or prolonged erection lasting 4 or more hours, stop using this drug and seek immediate medical attention, or permanent problems could occur.

A very serious allergic reaction to this drug is unlikely, but seek immediate medical attention if it occurs. Symptoms of a serious allergic reaction may include:

rash
itching
swelling
severe dizziness
trouble breathing

If you notice other effects not listed above, contact your doctor or pharmacist.

Zoloft Oral Precautions
Before taking sertraline, tell your doctor or pharmacist if you are allergic to it; or to latex; or if you have any other allergies.

Before using this medication, tell your doctor or pharmacist your medical history, especially of:

personal or family history of psychiatric disorder (e.g., bipolar/manic-depressive disorder)
personal or family history of suicide attempts
kidney disease
liver disease
seizures
thyroid disease (e.g., hypothyroidism)

This liquid medication contains alcohol. Caution is advised if you have diabetes, alcohol dependence, or liver disease. Some medications (e.g., metronidazole, disulfiram) can cause a serious reaction when combined with alcohol. Ask your doctor or pharmacist about the safe use of this product.

This drug may make you drowsy; use caution engaging in activities requiring alertness such as driving or using machinery. Avoid alcoholic beverages.

Caution is advised when using this drug in the elderly because they may be more sensitive to the side effects of the drug. The elderly are also more likely to develop a type of mineral imbalance (hyponatremia), especially if they are also taking "water pills" (diuretics) with this medication.

Caution is advised when using this drug in children because they may be more sensitive to the side effects of the drug, especially loss of appetite and weight loss. It is important to monitor weight and growth in children who are taking this drug.

This medication is not recommended for use during pregnancy. It may harm an unborn baby. Also, babies born to mothers who have used this drug during the last 3 months of pregnancy may infrequently develop withdrawal symptoms such as feeding/breathing difficulties, seizures, muscle stiffness, or constant crying. If you notice any of these symptoms in your newborn, tell the doctor promptly.

Since untreated depression can be a serious condition, do not stop taking this medication unless directed by your doctor. If you are planning pregnancy, become pregnant, or think you may be pregnant, immediately discuss the benefits and risks of using this medication during pregnancy with your doctor.

This drug passes into breast milk and may have undesirable effects on a nursing infant. Consult your doctor before breast-feeding.

Zoloft Oral Drug Interactions
See also Precautions.

Your doctor or pharmacist may already be aware of any possible drug interactions and may be monitoring you for them. Do not start, stop or change the dosage of any medicine before checking with them first.

Avoid taking MAO inhibitors (e.g., furazolidone, isocarboxazid, linezolid, moclobemide, phenelzine, procarbazine, selegiline, tranylcypromine) within 2 weeks before, during, and after treatment with this medication. In some cases a serious, possibly fatal drug interaction may occur.

This drug should also not be used with the following medications because very serious interactions may occur:

pimozide
sibutramine

If you are currently using any of these medications, tell your doctor or pharmacist before starting sertraline.

Before using this medication, tell your doctor or pharmacist of all prescription and nonprescription/herbal products you may use, especially of:

drugs for diabetes (e.g., insulin, tolbutamide)
other antidepressants (e.g., SSRIs such as citalopram/fluvoxamine, TCAs such as amitriptyline/desipramine, other types such as venlafaxine/nefazodone/trazodone)
drugs which can cause bleeding/bruising (e.g., anticoagulants such as heparin and warfarin, anti-platelet drugs including aspirin/NSAIDs such as ibuprofen)
buspirone
dextromethorphan
certain herbal/supplement products (e.g., melatonin, St John's wort, tryptophan)
lithium
drugs for migraine (e.g., dihydroergotamine, "triptans" such as sumatriptan)
stimulants such as amphetamines/phentermine
street drugs such as MDMA ("ecstasy")

Sertraline can affect the removal of other drugs from your body by affecting certain liver enzymes. These affected drugs include cimetidine, cisapride, clozapine, and certain drugs for heart rhythm such as flecainide/propafenone, among others. Consult your doctor or pharmacist for more details.

Also report the use of drugs which might increase seizure risk (decrease seizure threshold) when combined with this medication such as bupropion, isoniazid (INH), theophylline, or tramadol, among others. Consult your doctor or pharmacist for details.

Tell your doctor or pharmacist if you also take drugs that cause drowsiness such as: certain antihistamines (e.g., diphenhydramine), anti-seizure drugs (e.g., carbamazepine, phenytoin), medicine for sleep or anxiety (e.g., alprazolam, diazepam, zolpidem), muscle relaxants, narcotic pain relievers (e.g., codeine, meperidine), psychiatric medicines (e.g., chlorpromazine, risperidone, thioridazine).

Check the labels on all your medicines (e.g., cough-and-cold products) because they may contain drowsiness-causing ingredients, pain relievers/fever reducers (NSAIDs such as aspirin, ibuprofen, or naproxen) or the cough suppressant dextromethorphan. Ask your pharmacist about the safe use of those products.

Low-dose aspirin, as prescribed by your doctor for specific medical reasons such as heart attack or stroke prevention (usually at dosages of 81-325 mg per day), should be continued. Consult your doctor or pharmacist for more details.

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Dosage and Storage

Zoloft Oral Missed Dose
If you miss a dose, take it as soon as you remember. If it is near the time of the next dose, skip the missed dose and resume your usual dosing schedule. Do not double the dose to catch up.

Zoloft Oral Notes
Psychiatric/medical checkups (and possibly laboratory tests) should be done regularly to monitor your progress and check for side effects. Consult your doctor for more details.

Do not share this medication with others.

Zoloft Oral Storage
Store at room temperature at 77 degrees F (25 degrees C) away from light and moisture. Brief storage between 59-86 degrees F (15-30 degrees C) is permitted. Do not store in the bathroom. Keep all medicines away from children and pets.

Properly discard this product when it is expired or no longer needed. Consult your pharmacist or local waste disposal company for more details about how to safely discard your product.

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Remeron Oral (MIRTAZAPINE)

Generic Name: MIRTAZAPINE - ORAL
Pronounced: (mer-TAZE-uh-peen)

Uses and How to Use
Precautions and Side Effects
Dosage and Storage

Uses and How to Use

Remeron Oral Uses
Mirtazapine is used to treat depression. It improves mood and feelings of well-being. Mirtazapine is an antidepressant that works by restoring the balance of natural chemicals (neurotransmitters) in the brain.

How To Use Remeron Oral
Read the Medication Guide provided by your pharmacist before you start using mirtazapine and each time you get a refill because new information may be available. If you have any questions regarding the information, consult your doctor or pharmacist.

Take this medication by mouth, with or without food, usually once daily at bedtime or as directed by your doctor. The dosage is based on your medical condition and response to therapy, but should not exceed 45 milligrams per day.

Use this medication regularly in order to get the most benefit from it. Remember to use it at the same time each day. It may take between 1-4 weeks to notice improvement in your symptoms. Therefore, do not increase your dose or take it more often than prescribed.

It is important to continue taking this medication even if you feel well. Do not stop taking this medication without consulting your doctor. Some conditions may become worse when the drug is abruptly stopped. Your dose may need to be gradually decreased.

Inform your doctor if your condition persists or worsens.

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Precautions and Side Effects

Remeron Oral Warning
Antidepressant medications are used to treat a variety of conditions, including depression and other mental/mood disorders. These medications can help prevent suicidal thoughts/attempts and provide other important benefits. However, studies have shown that a small number of people (especially children/teenagers) who take antidepressants for any condition may experience worsening depression, other mental/mood symptoms, or suicidal thoughts/attempts. Therefore, it is very important to talk with the doctor about the risks and benefits of antidepressant medication (especially for children/teenagers), even if treatment is not for a mental/mood condition.

Tell the doctor immediately if you notice worsening depression/other psychiatric conditions, unusual behavior changes (including possible suicidal thoughts/attempts), or other mental/mood changes (including new/worsening anxiety, panic attacks, trouble sleeping, irritability, hostile/angry feelings, impulsive actions, severe restlessness, very rapid speech). Be especially watchful for these symptoms when a new antidepressant is started or when the dose is changed.

Remeron Oral Side Effects
See also the Warning section.

Dizziness, drowsiness, lightheadedness, increased appetite, weight gain, dry mouth, or constipation may occur. If any of these effects persist or worsen, notify your doctor or pharmacist promptly.

To relieve dry mouth, suck on (sugarless) hard candy or ice chips, chew (sugarless) gum, drink water or use a saliva substitute.

Remember that your doctor has prescribed this medication because the benefit to you is greater than the risk of side effects. Many people using this medication do not have serious side effects.

Tell your doctor immediately if any of these unlikely but serious side effects occur:

swelling of the hands/feet
shaking (tremor)
confusion

Tell your doctor immediately if any of these rare but very serious side effects occur:

unusual or severe mental/mood changes
signs of infection (e.g., fever, persistent sore throat)

A very serious allergic reaction to this drug is unlikely, but seek immediate medical attention if it occurs. Symptoms of a serious allergic reaction may include:

rash
itching
swelling
severe dizziness
trouble breathing

If you notice other effects not listed above, contact your doctor or pharmacist.

Remeron Oral Precautions
Before taking this medication, tell your doctor or pharmacist if you are allergic to it, or if you have any other allergies.

Before using this medication, tell your doctor or pharmacist your medical history, especially of:

history or family history of psychiatric disorders (e.g., bipolar/manic-depressive disorder)
history or family history of suicide attempts
liver disease
kidney disease
seizures
high blood cholesterol or triglyceride levels
heart disease (e.g., recent heart attack, angina)
stroke
severe loss of body fluids (dehydration)
low blood pressure

This drug may make you dizzy or drowsy; use caution engaging in activities requiring alertness such as driving or using machinery. Limit alcoholic beverages and ask your doctor about the safe use of alcohol.

To minimize dizziness and lightheadedness, get up slowly when rising from a seated or lying position.

Caution is advised when using this drug in the elderly because they may be more sensitive to its effects, especially drowsiness.

This medication should be used only when clearly needed during pregnancy. Discuss the risks and benefits with your doctor.

If this medication is used during the last 3 months of pregnancy, infrequently your newborn may develop symptoms including feeding or breathing difficulties, seizures, muscle stiffness, jitteriness, or constant crying. However, do not stop taking this medication unless your doctor directs you to do so. Report any such symptoms to your doctor promptly.

It is not known whether this drug passes into breast milk. Consult your doctor before breast-feeding.

Remeron Oral Drug Interactions
Your healthcare professionals (e.g., doctor or pharmacist) may already be aware of any possible drug interactions and may be monitoring you for it. Do not start, stop, or change the dosage of any medicine before checking with them first.

This drug should not be used with the following medications because very serious interactions may occur:

cisapride

If you are currently using any of these medications listed above, tell your doctor or pharmacist before starting mirtazapine.

Avoid taking MAO inhibitors (e.g., furazolidone, isocarboxazid, linezolid, moclobemide, phenelzine, procarbazine, selegiline, tranylcypromine) within 2 weeks before or after treatment with this medication. In some cases a serious, possibly fatal, drug interaction may occur.

Before using this medication, tell your doctor or pharmacist of all prescription and nonprescription/herbal products you may use, especially of:

bupropion
sibutramine
drugs that lower blood pressure (e.g., ACE inhibitors, calcium channel blockers, "water pills"/diuretics)

Tell your doctor or pharmacist if you also take drugs that cause drowsiness such as:

certain antihistamines (e.g., diphenhydramine)
anti-anxiety drugs (e.g., diazepam)
anti-seizure drugs (e.g., carbamazepine)
medicine for sleep (e.g., sedatives)
muscle relaxants
narcotic pain relievers (e.g., codeine)
psychiatric medicines (e.g., phenothiazines such as chlorpromazine, or tricyclics such as amitriptyline)
tranquilizers

Check the labels on all your medicines (e.g., cough-and-cold products) because they may contain drowsiness-causing ingredients. Ask your pharmacist about the safe use of those products.

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Dosage and Storage

Remeron Oral Missed Dose
If you miss a dose, use it as soon as you remember. If it is near the time of the next dose, skip the missed dose and resume your usual dosing schedule. Do not double the dose to catch up.

Remeron Oral Notes
Psychiatric/medical checkups (and possibly laboratory tests) must be done periodically to monitor your progress and check for side effects. Consult your doctor for more details.

Do not share this medication with others.

Remeron Oral Storage
Store at room temperature (77 degrees F or 25 degrees C) away from light and moisture. Brief storage between 59-86 degrees F (15-30 degrees C) is permitted. Do not store in the bathroom. Keep all medicines away from children and pets.

Properly discard this product when it is expired or no longer needed. Consult your pharmacist or local waste disposal company for more details about how to safely discard your product.

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Ativan oral (LORAZEPAM)

Generic Name: LORAZEPAM - ORAL
Pronounced: (lor-AYE-zeh-pam)

Uses and How to Use
Precautions and Side Effects
Dosage and Storage

Uses and How to Use

Ativan Oral Uses

This medication is used to treat anxiety. Lorazepam belongs to a class of drugs known as benzodiazepines which act on the brain and nerves (central nervous system) to produce a calming effect. This drug works by enhancing the effects of a certain natural chemical in the body (GABA).

How To Use Ativan Oral

Take this medication by mouth with or without food as directed by your doctor. Dosage is based on your medical condition and response to therapy.

If directed by your doctor, use this medication regularly in order to get the most benefit from it. To help you remember, use it at the same time(s) each day.

This medication may cause dependence, especially if it has been used regularly for an extended time (more than 1-4 weeks), if it has been used in high doses, or if you have a history of alcoholism, drug abuse, or personality disorder. In such cases, if you suddenly stop this drug, withdrawal reactions may occur. Such reactions can include seizures, trouble sleeping, mental/mood changes, increased reactions to noise/touch/light, nausea, vomiting, diarrhea, loss of appetite, stomach pain, hallucinations, numbness/tingling of arms and legs, muscle pain, fast heartbeat, short-term memory loss, and very high fever. Report any such reactions to your doctor immediately. When stopping extended, regular treatment with this drug, gradually reducing the dosage as directed will help prevent withdrawal reactions. Consult your doctor or pharmacist for more details.

Though it is very unlikely to occur, this medication can also result in abnormal drug-seeking behavior (addiction/habit forming). Do not increase your dose, take it more frequently, or use it for a longer time than prescribed. Properly stop the medication when so directed. This will lessen the chances of becoming addicted.

Do not suddenly stop using this drug without your doctor's approval. Some conditions may become worse when the drug is abruptly stopped. Your dose may need to be gradually decreased.

When used for an extended time, this medication may not work as well and may require different dosing. Talk with your doctor if this medication stops working well. Do not increase your dose without first talking to your doctor.

Inform your doctor if your condition persists or worsens.

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Precautions and Side Effects

Ativan Oral Side Effects

Drowsiness, dizziness, loss of coordination, headache, nausea, blurred vision, change in sexual interest/ability, hair loss, constipation, heartburn, or change in appetite may occur. If any of these effects persist or worsen, notify your doctor or pharmacist promptly.

Remember that your doctor has prescribed this medication because the benefit to you is greater than the risk of side effects. Many people using this medication do not have serious side effects.

Tell your doctor immediately if any of these unlikely but serious side effects occur:

memory loss
shaking
difficult/slurred speech
vision changes
mental/mood changes (e.g., depression, including rare thoughts of suicide)
trouble breathing (especially during sleep)
stomach/abdominal pain
yellowing of skin/eyes
dark urine
seizures
easy bruising/bleeding
signs of infection (e.g., fever, persistent sore throat)
unusual weakness
low body temperature

A very serious allergic reaction to this drug is unlikely, but seek immediate medical attention if it occurs. Symptoms of a serious allergic reaction may include:

rash
itching
swelling
severe dizziness
trouble breathing

If you notice other effects not listed above, contact your doctor or pharmacist.

Ativan Oral Precautions

Before taking lorazepam, tell your doctor or pharmacist if you are allergic to it; or to other benzodiazepines (e.g., diazepam, alprazolam, clonazepam); or if you have any other allergies.

This medication should not be used if you have certain medical conditions. Before using this medicine, consult your doctor or pharmacist if you have:

narrow-angle glaucoma

Before using this medication, tell your doctor or pharmacist your medical history, especially of:

heart disease
kidney disease
liver disease
severe lung/breathing problems (chronic obstructive pulmonary disorder-COPD, sleep apnea)
mental/mood disorders (e.g., depression, psychosis)
another type of glaucoma (open-angle type)
muscle weakness
drug/alcohol abuse

This drug may make you dizzy or drowsy or cause blurred vision; use caution engaging in activities requiring alertness or clear vision such as driving or using machinery. Avoid alcoholic beverages.

Before having surgery, tell your doctor or dentist that you are using this medication.

The elderly may be more sensitive to the effects of this drug, especially drowsiness and unsteadiness. Also, the elderly may not experience relief of anxiety with lorazepam. It may have the opposite effect on the elderly, causing mental/mood changes, sleeping problems, increase in sexual interest, or hallucinations.

Children may not experience relief of anxiety with lorazepam. It may have the opposite effect on children, causing agitation, shaking, or hallucinations.

This medication is not recommended for use during pregnancy. It may harm an unborn baby. Infants born to mothers who took this drug during the last weeks before delivery have had withdrawal symptoms, including unusual drowsiness, slowed breathing, and feeding problems. Consult your doctor for more details

This drug passes into breast milk and could have undesirable effects on a nursing infant. Breast-feeding is not recommended while using this drug. Consult your doctor before breast-feeding.

Ativan Oral Drug Interactions
Your healthcare professionals (e.g., doctor or pharmacist) may already be aware of any possible drug interactions and may be monitoring you for it. Do not start, stop or change the dosage of any medicine before checking with them first.

This drug should not be used with the following medication because a very serious interactions may occur:

sodium oxybate (also known as gamma hydroxybutyrate or GHB)

If you are currently using this medication listed above, tell your doctor or pharmacist before starting lorazepam.

Before using this medication, tell your doctor or pharmacist of all prescription and nonprescription/herbal products you may use, especially of:

aminophylline
clozapine
kava
probenecid
theophylline
valproate

Tell your doctor or pharmacist if you also take drugs that cause drowsiness such as: certain antihistamines (e.g., diphenhydramine), anti-seizure drugs (e.g., carbamazepine), medicine for sleep or anxiety (e.g., alprazolam, diazepam, zolpidem), muscle relaxants, narcotic pain relievers (e.g., codeine), psychiatric medicines (e.g., chlorpromazine, risperidone, amitriptyline, trazodone).

Check the labels on all your medicines (e.g., cough-and-cold products) because they may contain drowsiness-causing ingredients. Ask your pharmacist about the safe use of those products.

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Dosage and Storage

Ativan Oral Missed Dose
If you miss a dose and are taking more than 1 dose daily, do not take it if it is almost time for the next dose. Instead, skip the missed dose and resume your usual dosing schedule. Do not double the dose to catch up. If you take it once daily at bedtime and miss a dose, do not take it the following morning. Call your doctor to find out what to do.

Ativan Oral Notes
Lifestyle changes such as starting a stress reduction program may increase the effectiveness of this medicine. Talk to your doctor or pharmacist about lifestyle changes that might benefit you.

Do not share this medication with others. It is against the law.

Laboratory and/or medical tests (e.g., blood counts, liver function tests) should be performed periodically to monitor your progress or check for side effects. Consult your doctor for more details.

Ativan Oral Storage
Store at room temperature between 68-77 degrees F (20-25 degrees C) away from light and moisture. Do not store in the bathroom. Keep all medicines away from children and pets.

Properly discard this product when it is expired or no longer needed. Consult your pharmacist or local waste disposal company for more details about how to safely discard your product.

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Wellbutrin Oral (BUPROPION)

Generic Name: BUPROPION - ORAL
Pronounced: (byou-PRO-pee-on)

Uses and How to Use
Precautions and Side Effects
Dosage and Storage

Uses and How to Use

Wellbutrin Oral Uses
Bupropion is used to treat depression. It can improve your mood and feelings of well-being. It may work by helping to restore the balance of certain natural chemicals (neurotransmitters) in your brain.

The sustained release form of bupropion is also used to help people quit smoking by decreasing cravings and nicotine withdrawal effects.

How To Use Wellbutrin Oral
Read the Patient Information Leaflet and Medication Guide available from your pharmacist before you start using bupropion and each time you get a refill. Consult your doctor or pharmacist if you have any questions.

Take this medication by mouth, with or without food, usually three times daily. If stomach upset occurs, you may take this drug with food. It is important to take your doses at least 6 hours apart or as directed by your doctor to decrease your risk of having a seizure.

Do not take more or less medication or take it more frequently than prescribed. Taking more than the recommended dose of bupropion may increase your risk of having a seizure. Do not take more than 150 milligrams as a single dose, and do not take more than 450 milligrams per day.

Your dosage is based on your medical condition and response to therapy. Your dose may be slowly increased to limit side effects such as sleeplessness, and to decrease the risk of seizures. To avoid trouble sleeping, do not take this medication too close to bedtime. Let your doctor know if sleeplessness becomes a problem.

Use this medication regularly in order to get the most benefit from it. To help you remember, use it at the same times each day.

Do not stop taking this medication without consulting your doctor. Some conditions may become worse when the drug is suddenly stopped. Your dose may need to be gradually decreased.

It may take 4 or more weeks before you notice the full benefit of this drug. Continue to take this medication as directed by your doctor even after you feel better. Talk to your doctor if your condition does not improve or if it worsens.

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Precautions and Side Effects

Wellbutrin Oral Warning
Antidepressant medications are used to treat a variety of conditions, including depression and other mental/mood disorders. These medications can help prevent suicidal thoughts/attempts and provide other important benefits. However, studies have shown that a small number of people (especially children/teenagers) who take antidepressants for any condition may experience worsening depression, other mental/mood symptoms, or suicidal thoughts/attempts. Therefore, it is very important to talk with the doctor about the risks and benefits of antidepressant medication (especially for children/teenagers), even if treatment is not for a mental/mood condition.

Tell the doctor immediately if you notice worsening depression/other psychiatric conditions, unusual behavior changes (including possible suicidal thoughts/attempts), or other mental/mood changes (including new/worsening anxiety, panic attacks, trouble sleeping, irritability, hostile/angry feelings, impulsive actions, severe restlessness, very rapid speech). Be especially watchful for these symptoms when a new antidepressant is started or when the dose is changed.

Wellbutrin Oral Side Effects
See also the How to Use, Precautions, and Warning sections.

Nausea, vomiting, dry mouth, headache, constipation, increased sweating, joint aches, sore throat, blurred vision, strange taste in the mouth, or dizziness may occur. If any of these effects persist or worsen, notify your doctor or pharmacist promptly.

Remember that your doctor has prescribed this medication because the benefit to you is greater than the risk of side effects. Many people using this medication do not have serious side effects.

Tell your doctor immediately if any of these unlikely but serious side effects occur:

chest pain
fainting
fast/pounding/irregular heartbeat
hearing problems
ringing in the ears
severe headache
mental/mood changes (e.g., agitation, anxiety, confusion, hallucinations)
uncontrolled movements (tremor)
unusual weight loss or gain

Tell your doctor immediately if any of these rare but very serious side effects occur:

muscle pain/tenderness/weakness
change in the amount of urine

This drug may infrequently cause seizures. Seek immediate medical attention if you experience a seizure. If you have a seizure while taking bupropion, you should not take this drug again.

A very serious allergic reaction to this drug is unlikely, but seek immediate medical attention if it occurs. Symptoms of a serious allergic reaction include:

rash
itching
swelling
severe dizziness
trouble breathing

Wellbutrin Oral Precautions
See also the How to Use and Warning sections.

Before taking bupropion, tell your doctor or pharmacist if you are allergic to it; or if you have any other allergies.

This medication should not be used if you have certain medical conditions. Before using this medicine, consult your doctor or pharmacist if you have or have had:

seizures
eating disorders (e.g., bulimia, anorexia nervosa)

This medication should not be used if you are suddenly stopping regular use of sedatives (e.g., benzodiazepines such as lorazepam) or alcohol. Doing so may increase your risk of seizures. Large amounts of alcohol may also increase your risk of seizures and dizziness. Discuss your use of these products with your doctor.

Before using this medication, tell your doctor or pharmacist your medical history, especially of:

alcohol/drug dependence (including benzodiazepines, narcotic pain medicines, cocaine and stimulants)
brain tumor
diabetes
head injury
heart disease (e.g., congestive heart failure, high blood pressure, recent heart attack)
kidney problems
liver problems (e.g., cirrhosis)
personal or family history of psychiatric disorder (e.g., bipolar/manic-depressive disorder)
personal or family history of suicide thoughts/attempts
intent to quit smoking

Though uncommon, depression can lead to thoughts or attempts of suicide. Tell your doctor immediately if you have any suicidal thoughts, worsening depression, or any other mental/mood changes (including new or worsening anxiety, agitation, panic attacks, trouble sleeping, irritability, hostile/angry feelings, impulsive actions, severe restlessness, rapid speech, unusual behavior changes). Keep all medical appointments so your doctor can monitor your progress closely and adjust or change your medication if needed.
 

This drug may make you dizzy or affect your coordination; use caution engaging in activities requiring alertness such as driving or using machinery. Avoid or limit alcoholic beverages.

Kidney function declines as you grow older. This medication is removed by the kidneys. Therefore, elderly people may be more sensitive to this drug and to side effects.

This medication should be used only when clearly needed during pregnancy. Discuss the risks and benefits with your doctor. Infrequently, newborns whose mothers have used certain newer antidepressants during the last 3 months of pregnancy may develop symptoms including persistent feeding or breathing difficulties, jitteriness, seizures or constant crying. Promptly report any such symptoms to the doctor. However, do not stop taking this medication unless your doctor directs you to do so.

This medication passes into breast milk and may have undesirable effects on a nursing infant. Breast-feeding while using this drug is not recommended. Consult your doctor before breast-feeding.

Wellbutrin Oral Drug Interactions
Your healthcare professionals (e.g., doctor or pharmacist) may already be aware of any possible drug interactions and may be monitoring you for it. Do not start, stop or change the dosage of any medicine before checking with them first.

This drug should not be used with the following medications because very serious interactions may occur:

certain x-ray dyes such as iomeprol
other medications containing bupropion (e.g., drugs for smoking cessation)
sibutramine
thioridazine

If you are currently using any of these medications, tell your doctor or pharmacist before starting bupropion.

Avoid taking MAO inhibitors (e.g., furazolidone, isocarboxazid, linezolid, moclobemide, phenelzine, procarbazine, selegiline, tranylcypromine) within 2 weeks before or after treatment with this medication. In some cases a serious, possibly fatal, drug interaction may occur.

Before using this medication, tell your doctor or pharmacist of all prescription and nonprescription/herbal products you may use, especially of:

amantadine
diabetes medications (e.g., glipizide, glyburide, insulin)
certain HIV drugs (e.g., efavirenz, nelfinavir, ritonavir)
levodopa
nicotine products (e.g., patches, gum)
regular use of sedatives (e.g., alcohol, alprazolam)
stimulants (e.g., amphetamine, cocaine, "ecstasy," ephedrine)
warfarin

Also tell your doctor if you are taking drugs which may be affected by certain liver enzymes such as antidepressants (e.g., desipramine, paroxetine, fluoxetine), antiarrhythmics (e.g., propafenone and flecainide), antipsychotics (e.g., haloperidol, risperidone), beta blockers (e.g., metoprolol), orphenadrine, cyclophosphamide, thiotepa, carbamazepine, phenobarbital or phenytoin.

Report the use of drugs that might increase seizure risk (decrease seizure threshold) when combined with bupropion, such as antipsychotics (e.g., chlorpromazine), corticosteroids (e.g., prednisone), tricyclic antidepressants (e.g., amitriptyline), or theophylline, among others. Consult your doctor or pharmacist for details.

Large amounts of caffeine and other stimulants, such as those found in weight loss and cold/sinus medications, can increase the chance of seizures with this drug. Check the labels on all your nonprescription/prescription/herbal medicines (e.g., cough-and-cold products, diet aids) for caffeine and other stimulants (e.g., ephedra). Consult your doctor or pharmacist.

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Dosage and Storage

Wellbutrin Oral Missed Dose
If you miss a dose, skip the missed dose and resume your usual dosing schedule. Do not double the dose to catch up.

Wellbutrin Oral Notes
Do not share this medication with others.

Psychiatric/medical checkups or tests such as blood pressure monitoring may be performed periodically to monitor your progress or check for side effects. Consult your doctor for more details.

Wellbutrin Oral Storage
Store at room temperature between 59-77 degrees F (15-25 degrees C) away from light and moisture. Bupropion tablets may have a strange odor. This is normal and the medication is still okay to use. Do not store in the bathroom. Keep all medicines away from children and pets.

Properly discard this product when it is expired or no longer needed. Consult your pharmacist or local waste disposal company for more details about how to safely discard your product.

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Xanax XR Oral (ALPRAZOLAM)

Generic Name: ALPRAZOLAM EXTENDED RELEASE - ORAL
Pronounced: (al-PRAZ-oh-lam)

Uses and How to Use
Precautions and Side Effects
Dosage and Storage

Uses and How to Use

Xanax XR Oral Uses
This medication is used to treat the panic and anxiety symptoms associated with panic disorder. Alprazolam belongs to a class of medications called benzodiazepines which act on the brain and nerves (central nervous system) to produce a calming effect. It works by enhancing the effects of a certain natural chemical in the body (GABA).

How To Use Xanax XR Oral
Take this medication by mouth once daily usually in the morning; or as directed by your doctor. This medication should be swallowed whole; do not crush or chew the tablets.

This medication may cause dependence, especially if it has been used regularly for an extended period of time, or if it has been used in high doses. In such cases, if you suddenly stop this drug, withdrawal reactions including seizures may occur. Report any such reactions to your doctor immediately. When stopping extended, regular treatment with this drug, the dosage should be gradually reduced as directed to help prevent withdrawal reactions. Consult your doctor or pharmacist for more details.

Though it is very unlikely to occur, this medication can also result in abnormal drug-seeking behavior (addiction/habit-forming). Do not increase your dose, take it more frequently, or use it for a longer period of time than prescribed. Properly stop the medication when so directed. This will lessen the chances of becoming addicted.

When used for an extended period, this medication may not work as well and may require different dosing. Talk with your doctor if this medication stops working well.

Inform your doctor if your condition persists or worsens.

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Precautions and Side Effects

Xanax XR Oral Side Effects
Drowsiness, dizziness, headache, tiredness, clumsiness, decreased interest in sex, decreased appetite, nausea, constipation, or joint pain may occur. If any of these effects persist or worsen, notify your doctor or pharmacist promptly.

Remember that your doctor has prescribed this medication because the benefit to you is greater than the risk of side effects. Many people using this medication do not have serious side effects.

Tell your doctor immediately if any of these serious side effects occur:

mental/mood changes
confusion
slurred speech or difficulty speaking
difficulty remembering things

An allergic reaction to this drug is unlikely, but seek immediate medical attention if it occurs. Symptoms of an allergic reaction include:

rash
itching
swelling
severe dizziness
trouble breathing

If you notice other effects not listed above, contact your doctor or pharmacist.

Xanax XR Oral Precautions
Before taking alprazolam, tell your doctor or pharmacist if you are allergic to it; or to other benzodiazepines (e.g., diazepam, lorazepam); or if you have any other allergies.

Before using this medication, tell your doctor or pharmacist your medical history, especially of:

kidney disease
liver disease
severe lung/breathing problems (e.g., COPD, sleep apnea)
drug or alcohol abuse

This drug may make you dizzy or drowsy; use caution engaging in activities requiring alertness such as driving or using machinery. Limit alcoholic beverages.

Caution is advised when using this drug in the elderly because they may be more sensitive to its side effects, especially loss of coordination and drowsiness.

This medication is not recommended for use during pregnancy due to the potential for harm to an unborn baby. Consult your doctor for more details.

This drug passes into breast milk and may have undesirable effects on a nursing infant. Therefore, breast-feeding while using this medication is not recommended. Consult your doctor before breast-feeding.

Xanax XR Oral Drug Interactions

Your healthcare professionals (e.g., doctor or pharmacist) may already be aware of any possible drug interactions and may be monitoring you for it. Do not start, stop or change the dosage of any medicine before checking with them first.

This drug should not be used with the following medications because very serious interactions may occur:

certain azole antifungals (e.g., itraconazole, ketoconazole)
delavirdine
indinavir
sodium oxybate

If you are currently using any of these medications, tell your doctor or pharmacist before starting alprazolam.

Before using this medication, tell your doctor or pharmacist of all prescription and nonprescription/herbal products you may use, especially of:

clozapine
digoxin
disulfiram
kava

Tell your doctor or pharmacist if you take drugs that affect the removal of alprazolam from your system (CYP 3A4 substrates, inhibitors and inducers) such as:

other azole antifungals (e.g., fluconazole, voriconazole)
certain anti-depressants (e.g., fluoxetine, fluvoxamine, nefazodone)
certain anti-seizure medications (e.g., phenytoin, phenobarbital)
cimetidine
macrolide antibiotics (e.g., erythromycin, clarithromycin)
rifamycins (e.g., rifampin)
ritonavir
St John's wort

Tell your doctor or pharmacist if you take drugs that cause drowsiness such as: antihistamines that cause drowsiness (e.g., diphenhydramine), anti-seizure drugs (e.g., carbamazepine), medicine for sleep (e.g., sedatives), muscle relaxants, narcotic pain relievers (e.g., codeine), psychiatric medicines (e.g., phenothiazines such as chlorpromazine, tricyclic anti-depressants such as amitriptyline), tranquilizers.

Check the labels on all your medicines (e.g., cough-and-cold products) because they may contain ingredients which cause drowsiness. Ask your pharmacist about the safe use of those products.

Cigarette smoking decreases blood levels of this medication (through liver enzyme induction). Tell your doctor if you smoke or if you have recently stopped smoking because your dose may need to be adjusted.

Do not start or stop any medicine without doctor or pharmacist approval.

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Dosage and Storage

Xanax XR Oral Missed Dose
If you miss a dose, take it as soon as you remember. If it is near the time of the next dose, skip the missed dose and resume your usual dosing schedule. Do not double the dose to catch up.

Xanax XR Oral Notes
Do not share this medication with others. It is against the law.

If this drug is used for an extended period of time, laboratory and/or medical tests (e.g., liver function tests, complete blood count) may be performed periodically to check for side effects. Consult your doctor for more details.

Xanax XR Oral Storage
Store at room temperature (77 degrees F or 25 degrees C) away from light and moisture. Brief storage between 59-86 degrees F (15-30 degrees C) is permitted. Do not store in the bathroom. Keep all medicines away from children and pets.

Properly discard this product when it is expired or no longer needed. Consult your pharmacist or local waste disposal company for more details about how to safely discard your product.

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Paxil CR Oral (PAROXETINE)

Generic Name: PAROXETINE CONTROLLED-RELEASE - ORAL
Pronounced: (pair-OX-eh-teen)

Uses and How to Use
Precautions and Side Effects
Dose and Storage

Uses and How to Use

Paxil CR Oral Uses
Paroxetine is a selective serotonin reuptake inhibitor (SSRI) used to treat depression, panic attacks, obsessive-compulsive disorder (OCD), anxiety disorders, post-traumatic stress disorder, and a severe form of premenstrual syndrome (premenstrual dysphoric disorder).

SSRIs work by helping to restore the balance of certain natural substances in the brain (neurotransmitters such as serotonin). Paroxetine may improve your mood, sleep, appetite, and energy level and may help restore your interest in daily living. It may decrease anxiety/unreasonable fears, persistent/troubling thoughts (obsessions), and unwanted urges that keep returning (compulsions). It may decrease the number and severity of panic attacks. Paroxetine may lessen premenstrual symptoms such as irritability, increased appetite, and depression.

How To Use Paxil CR Oral
Read the Medication Guide provided by your pharmacist before you start using paroxetine and each time you get a refill. If you have any questions, consult your doctor or pharmacist.

Take this medication by mouth with or without food, usually once daily or as directed by your doctor. This medication may make you either sleepy or wakeful. Therefore, depending on how this medication affects you, your doctor may direct you to take the entire dose once daily in either the morning or evening. Swallow the medication whole. Do not crush or chew this medication.

The dosage is based on your medical condition and response to treatment. To reduce your risk of side effects, your doctor may start you at a low dose and gradually increase your dose. Follow your doctor's instructions carefully. Do not take more or less medication or take it more frequently than prescribed. Your condition will not improve any faster and your risk of side effects will increase. Use this medication regularly in order to get the most benefit from it. To help you remember, use it at the same time each day.

If you are taking paroxetine for premenstrual problems, your doctor may direct you to take it every day of the month or just for the 2 weeks before your period through the first full day of your period.

It is important to continue taking this medication as prescribed even if you feel well. Do not stop taking this medication without first consulting your doctor.

This medication may cause dependence, especially if it has been used regularly for an extended time or if it has been used in high doses. In such cases, withdrawal reactions (e.g., mood swings, headache, tiredness, sleep changes, "shock-like" feelings) may occur if you suddenly stop this drug. To prevent withdrawal when stopping extended/regular treatment with this drug, gradually reduce the dosage as directed. Consult your doctor or pharmacist for more details. Report any withdrawal reactions or worsening symptoms immediately.

You should see some improvement in 1 to 2 weeks. It may take several weeks before you feel the full benefit.

Tell your doctor if your condition does not improve or if it worsens.

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Precautions and Side Effects

Paxil CR Oral Warning
Antidepressant medications are used to treat a variety of conditions, including depression and other mental/mood disorders. These medications can help prevent suicidal thoughts/attempts and provide other important benefits. However, studies have shown that a small number of people (especially children/teenagers) who take antidepressants for any condition may experience worsening depression, other mental/mood symptoms, or suicidal thoughts/attempts. Therefore, it is very important to talk with the doctor about the risks and benefits of antidepressant medication (especially for children/teenagers), even if treatment is not for a mental/mood condition.

Tell the doctor immediately if you notice worsening depression/other psychiatric conditions, unusual behavior changes (including possible suicidal thoughts/attempts), or other mental/mood changes (including new/worsening anxiety, panic attacks, trouble sleeping, irritability, hostile/angry feelings, impulsive actions, severe restlessness, very rapid speech). Be especially watchful for these symptoms when a new antidepressant is started or when the dose is changed.

Paxil CR Oral Side Effects

Nausea, drowsiness, dizziness, trouble sleeping, loss of appetite, weakness, tiredness, dry mouth, sweating, yawning, or headache may occur. If any of these effects persist or worsen, tell your doctor promptly.

Remember that your doctor has prescribed this medication because he or she has judged that the benefit to you is greater than the risk of side effects. Many people using this medication do not have serious side effects.

Tell your doctor immediately if any of these unlikely but serious side effects occur:

unusual or severe mental/mood changes (e.g., agitation, thoughts of suicide)
shakiness (tremor)
restlessness
inability to keep still
decreased interest in sex
changes in sexual ability
blurred vision
numbness/tingling

Tell your doctor immediately if any of these rare but very serious side effects occur:

bloody/black/tarry stools
vomit that looks like coffee grounds
easy bruising/bleeding
fainting
fast/irregular heartbeat
muscle weakness/spasm
seizures
change in amount of urine

This medication may rarely cause a very serious condition called serotonin syndrome. The risk increases when this medication is used with certain other drugs such as "triptans" used to treat migraine headaches (e.g., sumatriptan, eletriptan), certain antidepressants including other SSRIs (e.g., citalopram, fluoxetine) and SNRIs (e.g., duloxetine, venlafaxine), lithium, tramadol, tryptophan, or a certain drug to treat obesity (sibutramine). Before taking this drug, tell your doctor if you take any of these medications. Serotonin syndrome may be more likely when you start or increase the dose of any of these medications. Seek immediate medical attention if you develop some of the following symptoms:

hallucinations
unusual restlessness
loss of coordination
fast heartbeat
severe dizziness
unexplained fever
severe nausea/vomiting/diarrhea
twitchy muscles

For males, in the very unlikely event you have a painful or prolonged erection lasting 4 or more hours, stop using this drug and seek immediate medical attention, or permanent problems could occur.

A very serious allergic reaction to this drug is rare. However, seek immediate medical attention if you notice any symptoms of a serious allergic reaction, including:

rash
itching
swelling
severe dizziness
trouble breathing

If you notice other effects not listed above, contact your doctor or pharmacist.

Paxil CR Oral Precautions
Before taking paroxetine, tell your doctor or pharmacist if you are allergic to it; or if you have any other allergies.

Before using this medication, tell your doctor or pharmacist your medical history, especially of:

personal or family history of bipolar/manic-depressive disorder
personal or family history of suicide attempts
liver problems
kidney problems
low sodium in the blood
severe loss of body water (dehydration)
seizures
stomach/intestinal ulcers
glaucoma (narrow-angle type)

This drug may make you dizzy or drowsy. Use caution while driving, using machinery, or doing any other activity that requires alertness. Avoid alcoholic beverages.

Caution is advised when using this product in the elderly because they may be more sensitive to its effects. The elderly are more likely to lose too much salt (hyponatremia), especially if they are also taking "water pills" (diuretics) with this medication.

This medication is not recommended for use during pregnancy. It may harm an unborn baby. Also, babies born to mothers who have used this drug during the last 3 months of pregnancy may infrequently develop withdrawal symptoms such as feeding/breathing difficulties, seizures, muscle stiffness, or constant crying. If you notice any of these symptoms in your newborn, tell the doctor promptly.

Since untreated depression can be a serious condition, do not stop taking this medication unless directed by your doctor. If you are planning pregnancy, become pregnant, or think you may be pregnant, immediately discuss the benefits and risks of using this medication during pregnancy with your doctor.

This drug passes into breast milk. Consult your doctor before breast-feeding.

Paxil CR Oral Drug Interactions
Your doctor or pharmacist may already be aware of any possible drug interactions and may be monitoring you for them. Do not start, stop, or change the dosage of any medicine before checking with your doctor or pharmacist first.

Certain medications taken with this product could result in serious (rarely fatal) drug interactions. Avoid taking sibutramine or MAO inhibitors (e.g., furazolidone, isocarboxazid, linezolid, moclobemide, phenelzine, procarbazine, rasagiline, selegiline, tranylcypromine) for 2 weeks before, during, or after treatment with this medication. Consult your doctor or pharmacist for additional information.

This drug should not be used with the following medications because very serious (possibly fatal) interactions may occur:

pimozide
sibutramine
thioridazine

If you are currently using any of these medications listed above, tell your doctor or pharmacist before starting paroxetine.

Before using this medication, tell your doctor or pharmacist of all prescription and nonprescription/herbal products you may use, especially of:

drugs removed from your body by certain liver enzymes (e.g., aripiprazole, atomoxetine, fluoxetine, phenothiazines, procyclidine, risperidone, tamoxifen, antiarrhythmics such as propafenone, flecainide, TCA antidepressants such as desipramine, amitriptyline)
cimetidine
digoxin
fosamprenavir/ritonavir
metoprolol
quinidine
theophylline
tramadol
"water pills" (diuretics such as furosemide)
drugs that can cause bleeding/bruising (e.g., aspirin, antiplatelet drugs such as clopidogrel, NSAIDs such as ibuprofen, "blood thinners" such as heparin, warfarin)

Aspirin can increase the risk of bleeding when used with this medication (see above). If your doctor has directed you to take low-dose aspirin for heart attack or stroke prevention (usually at dosages of 81-325 milligrams a day), you should continue taking it unless your doctor instructs you otherwise. Discuss the risks and benefits with your doctor.

Also tell your doctor if you take any other drugs that increase serotonin, such as bromocriptine, buspirone, dextromethorphan, lithium, meperidine, propoxyphene, phentermine, SSRIs, SNRIs, tryptophan, St. John's wort, drugs used to treat migraines such as "triptans" and dihydroergotamine, street drugs such as MDMA/"ecstasy," amphetamine. (See also Side Effects section.)

Tell your doctor or pharmacist if you also take drugs that cause drowsiness such as: certain antihistamines (e.g., diphenhydramine), anti-seizure drugs (e.g., carbamazepine), medicine for sleep or anxiety (e.g., alprazolam, diazepam, zolpidem), muscle relaxants, narcotic pain relievers (e.g., codeine), psychiatric medicines (e.g., chlorpromazine, quetiapine, nortriptyline, trazodone).

Check the labels on all your medicines (e.g., cough-and-cold products) because they may contain ingredients that cause drowsiness. Ask your pharmacist about using those products safely.

Cimetidine is a nonprescription drug that is commonly used to treat extra stomach acid. Because it may cause undesirable interactions when used with paroxetine, ask your pharmacist about other products to treat stomach acid.

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Dosage and Storage

Paxil CR Oral Missed Dose
If you miss a dose, take it as soon as you remember. If it is near the time of the next dose, skip the missed dose and resume your usual dosing schedule. Do not double the dose to catch up.

Paxil CR Oral Notes
Do not share this medication with others.

Psychiatric/medical check-ups should be done periodically to monitor your progress or check for side effects. Consult your doctor for more details.

Paxil CR Oral Storage
Store at room temperature at or below 77 degrees F (25 degrees C) away from light and moisture. Do not store in the bathroom. Keep all medicines away from children and pets.

Properly discard this product when it is expired or no longer needed. Consult your pharmacist or local waste disposal company for more details about how to safely discard your product.

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Effexor Oral (VENLAFAXINE)

Generic Name: VENLAFAXINE - ORAL
Pronounced: (ven-luh-FAX-een)

Uses and How to Use
Precautions and Side Effects
Dose and Storage
 

Uses and How to Use

Effexor Oral Uses
Venlafaxine is an antidepressant (serotonin-norepinephrine reuptake inhibitor type-SNRI) used in the treatment of depression and anxiety. It works by restoring the balance of natural substances (neurotransmitters such as serotonin and norepinephrine) in the brain. Venlafaxine may decrease nervousness and improve your mood, feelings of well-being, and energy level.

How To Use Effexor Oral
Read the Medication Guide provided by your pharmacist before you start using venlafaxine and each time you get a refill. If you have any questions, consult your doctor or pharmacist.

Take this medication with food, usually 2 to 3 times daily or as directed by your doctor. Dosage is based on your medical condition and response to treatment. The usual maximum dose for an adult is 375 milligrams each day.

To reduce your risk of side effects, your doctor may direct you to start taking this drug at a low dose and gradually increase your dose. Follow your doctor's instructions carefully. Do not take more or less medication or take it more frequently than prescribed. Your condition will not improve any faster, and your risk of side effects will increase. Use this medication regularly in order to get the most benefit from it. To help you remember, use it at the same times each day.

It is important to continue taking this medication even if you feel well. Do not stop taking this medication without consulting your doctor. Some conditions may become worse when the drug is suddenly stopped. Your dose may need to be gradually decreased.

This medication may cause dependence, especially if it has been used regularly for an extended time or if it has been used in high doses. In such cases, withdrawal reactions (e.g., nausea, vomiting, headache, numbness, tingling, nightmares) may occur if you suddenly stop this drug. To prevent withdrawal when stopping extended/regular treatment with this drug, gradually reduce the dosage as directed. Consult your doctor or pharmacist for more details, and report any withdrawal reactions immediately.

It may take several weeks to feel the full benefit of this medication. Tell your doctor if your condition persists or worsens.
 

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Precautions and Side Effects

Effexor Oral Warning
Antidepressant medications are used to treat a variety of conditions, including depression and other mental/mood disorders. These medications can help prevent suicidal thoughts/attempts and provide other important benefits. However, studies have shown that a small number of people (especially children/teenagers) who take antidepressants for any condition may experience worsening depression, other mental/mood symptoms, or suicidal thoughts/attempts. Therefore, it is very important to talk with the doctor about the risks and benefits of antidepressant medication (especially for children/teenagers), even if treatment is not for a mental/mood condition.

Tell the doctor immediately if you notice worsening depression/other psychiatric conditions, unusual behavior changes (including possible suicidal thoughts/attempts), or other mental/mood changes (including new/worsening anxiety, panic attacks, trouble sleeping, irritability, hostile/angry feelings, impulsive actions, severe restlessness, very rapid speech). Be especially watchful for these symptoms when a new antidepressant is started or when the dose is changed.

Effexor Oral Side Effects

Headache, drowsiness, dizziness, nausea, weakness, dry mouth, constipation, loss of appetite, weight loss, blurred vision, tiredness, nervousness, trouble sleeping, sweating, or yawning may occur. If any of these effects persist or worsen, tell your doctor promptly.

Venlafaxine may increase blood pressure. Your blood pressure should be checked regularly while you are taking this medication.

Remember that your doctor has prescribed this medication because he or she has judged that the benefit to you is greater than the risk of side effects. Many people using this medication do not have serious side effects.

Tell your doctor immediately if any of these unlikely but serious side effects occur:

fainting
severe/pounding headache
unusual or severe mental/mood changes (e.g., extreme anxiety, unusual high energy/excitement, rare thoughts of suicide)
shakiness (tremor)
decreased interest in sex
changes in sexual ability
difficulty urinating
change in the amount of urine

Tell your doctor immediately if any of these rare but very serious side effects occur:

stomach/abdominal pain
chest pain
persistent cough
shortness of breath
bloody/black/tarry stools
vomit that looks like coffee grounds
easy bruising/bleeding
fast/irregular/pounding heartbeat
muscle weakness/cramps
yellowing eyes/skin
dark urine
seizures
unusual tiredness

This medication may rarely cause a very serious condition called serotonin syndrome. The risk increases when this medication is used with certain other drugs such as "triptans" used to treat migraine headaches (e.g., sumatriptan, eletriptan), certain antidepressants including SSRIs (e.g., citalopram, paroxetine) and other SNRIs (e.g., duloxetine), lithium, tramadol, tryptophan, or a certain drug to treat obesity (sibutramine). See also Drug Interactions section. Before taking this drug, tell your doctor if you take any of these medications. Serotonin syndrome may be more likely when you start or increase the dose of any of these medications. Seek immediate medical attention if you develop some of the following symptoms:

hallucinations
restlessness
loss of coordination
fast heartbeat
severe dizziness
unexplained fever
severe nausea/vomiting/diarrhea
twitchy muscles

For males, in the very unlikely event you have a painful or prolonged erection lasting 4 or more hours, stop using this drug and seek immediate medical attention, or permanent problems could occur.

A very serious allergic reaction to this drug is rare. However, seek immediate medical attention if you notice any symptoms of a serious allergic reaction, including:

rash
itching
swelling
severe dizziness
trouble breathing

If you notice other effects not listed above, contact your doctor or pharmacist.

Effexor Oral Precautions
Before taking venlafaxine, tell your doctor or pharmacist if you are allergic to it; or if you have any other allergies.

Before using this medication, tell your doctor or pharmacist your medical history, especially of:

personal or family history of psychiatric disorders (e.g., bipolar/manic-depressive disorder)
personal or family history of suicide attempts
bleeding problems
severe loss of body water (dehydration)
glaucoma
high blood pressure
heart problems (e.g., chest pain, irregular heartbeat, heart failure, heart attack)
high cholesterol
kidney disease
liver disease
seizure disorder
thyroid problems
low sodium in the blood (e.g., hyponatremia)

This drug may make you dizzy or drowsy. Use caution while driving, using machinery, or doing any other activity that requires alertness. Avoid alcoholic beverages.

Caution is advised when using this product in the elderly because they may be more sensitive to its effects. The elderly are more likely to lose too much salt (hyponatremia), especially if they are also taking "water pills" (diuretics) with this medication.

Caution is advised when using this drug in children because it may affect weight, growth rate, and final height. Consult your doctor or pharmacist for more details.

This medication is not recommended for use during pregnancy. It may harm an unborn baby. Also, babies born to mothers who have used this drug during the last 3 months of pregnancy may infrequently develop withdrawal symptoms such as feeding/breathing difficulties, seizures, muscle stiffness, or constant crying. If you notice any of these symptoms in your newborn, tell the doctor promptly.

Since untreated depression can be a serious condition, do not stop taking this medication unless directed by your doctor. If you are planning pregnancy, become pregnant, or think you may be pregnant, immediately discuss the benefits and risks of using this medication during pregnancy with your doctor.

This medication passes into breast milk and may have undesirable effects on a nursing infant. Breast-feeding is not recommended while using this drug. Consult your doctor before breast-feeding.

Effexor Oral Drug Interactions
Your doctor or pharmacist may already be aware of any possible drug interactions and may be monitoring you for them. Do not start, stop, or change the dosage of any medicine before checking with your doctor or pharmacist first.

Taking certain medications with this product could result in serious (rarely fatal) drug interactions. Avoid taking MAO inhibitors (e.g., furazolidone, isocarboxazid, linezolid, moclobemide, phenelzine, procarbazine, rasagiline, selegiline, tranylcypromine) with venlafaxine for 2 weeks before treatment, during treatment, and at least 7 days after your last dose of venlafaxine. Consult your doctor or pharmacist for more information.

This drug should also not be used with the following medications because very serious (possibly fatal) interactions may occur:

weight loss drugs (e.g., sibutramine, phentermine)
tryptophan

If you are currently using any of these medications, tell your doctor or pharmacist before starting venlafaxine.

Certain drugs that may affect the heart rhythm (QTc prolongation in the EKG) include amiodarone, dofetilide, pimozide, quinidine, sotalol, procainamide, thioridazine, and erythromycin, among others. Venlafaxine may increase the risk of this effect. QTc prolongation can infrequently result in a serious (rarely fatal) irregular heartbeat. Consult your doctor or pharmacist for more details and for instructions on how you may reduce this risk of this effect.

Before using this medication, tell your doctor or pharmacist of all prescription and nonprescription/herbal products you may use, especially of:

drugs removed from your body by certain liver enzymes (e.g., antipsychotics such as clozapine/ haloperidol, HIV medications such as indinavir, tricyclic antidepressants-TCAs such as desipramine)
drugs affecting liver enzymes that remove venlafaxine from your body (e.g., cimetidine, azole antifungals such as ketoconazole, itraconazole)
"water pills" (diuretics such as furosemide)
drugs that can cause bleeding/bruising (e.g., aspirin, antiplatelet drugs such as clopidogrel, NSAIDs such as ibuprofen, "blood thinners" such as heparin/warfarin)

Aspirin can increase the risk of bleeding when used with this medication (see above). If your doctor has directed you to take low-dose aspirin for heart attack or stroke prevention (usually at dosages of 81-325 milligrams a day), you should continue taking it unless your doctor instructs you otherwise. Discuss the risks and benefits with your doctor.

Also tell your doctor if you take any other drugs that increase serotonin, such as buspirone, dextromethorphan, lithium, meperidine, propoxyphene, SSRIs, other SNRIs, St. John's wort, drugs used to treat migraines such as "triptans" and dihydroergotamine, street drugs such as MDMA/"ecstasy," amphetamine. (See also Side Effects section.)

Tell your doctor or pharmacist if you also take drugs that cause drowsiness such as: certain antihistamines (e.g., diphenhydramine), anti-seizure drugs (e.g., carbamazepine), medicine for sleep or anxiety (e.g., alprazolam, diazepam, zolpidem), muscle relaxants, narcotic pain relievers (e.g., codeine), psychiatric medicines (e.g., chlorpromazine, risperidone, amitriptyline, trazodone). Check the labels on all your medicines (e.g., allergy, cough-and-cold products) because they may contain ingredients that cause drowsiness. Ask your pharmacist about using those products safely.

Cimetidine is a nonprescription drug that is commonly used to treat extra stomach acid. Because it may cause undesirable interactions when used with venlafaxine, ask your pharmacist about other products to treat stomach acid.

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Dosage and Storage

Paxil CR Oral Missed Dose
If you miss a dose, take it as soon as you remember. If it is near the time of the next dose, skip the missed dose and resume your usual dosing schedule. Do not double the dose to catch up.

Effexor Oral Notes
Do not share this medication with others.

Psychiatric/medical check-ups or lab tests (e.g., blood pressure, cholesterol, growth monitoring in children) should be done periodically to monitor your progress or check for side effects. Consult your doctor for more details.

Effexor Oral Storage
Store at room temperature between 68-77 degrees F (20-25 degrees C) away from light and moisture. Do not store in the bathroom. Keep all medicines away from children and pets.

Properly discard this product when it is expired or no longer needed. Consult your pharmacist or local waste disposal company for more details about how to safely discard your product.

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Elavil (AMITRIPTYLINE)

Generic Name: amitriptyline (a mee TRIP ti leen)
Brand Names: Elavil, Endep, Vanatrip

What is Elavil?
What is the most important information I should know about Elavil?
What should I discuss with my healthcare provider before taking Elavil?
How should I take Elavil?
What happens if I miss a dose?
What happens if I overdose?
What should I avoid while taking Elavil?
Elavil side effects
What other drugs will affect Elavil?
Where can I get more information?
What does my medication look like?

What is Elavil?

Elavil is in a group of drugs called tricyclic antidepressants. Elavil affects chemicals in the brain that may become unbalanced.

Elavil is used to treat symptoms of depression.

Elavil may also be used for purposes other than those listed in this medication guide.

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What is the most important information I should know about Elavil?

Do not use Elavil if you are allergic to amitriptyline, or if you have recently had a heart attack. Do not use Elavil if you have taken cisapride (Propulsid) or used an MAO inhibitor such as isocarboxazid (Marplan), phenelzine (Nardil), rasagiline (Azilect), selegiline (Eldepryl, Emsam), or tranylcypromine (Parnate) within the past 14 days.
You may have thoughts about suicide when you first start taking an antidepressant, especially if you are younger than 24 years old. Your doctor will need to check you at regular visits for at least the first 12 weeks of treatment.

Call your doctor at once if you have any new or worsening symptoms such as: mood or behavior changes, anxiety, panic attacks, trouble sleeping, or if you feel impulsive, irritable, agitated, hostile, aggressive, restless, hyperactive (mentally or physically), more depressed, or have thoughts about suicide or hurting yourself.

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What should I discuss with my healthcare provider before taking Elavil?

Do not use this medication if you are allergic to Elavil, or if you have recently had a heart attack. Do not use Elavil if you have taken cisapride (Propulsid) or used an MAO inhibitor such as isocarboxazid (Marplan), phenelzine (Nardil), rasagiline (Azilect), selegiline (Eldepryl, Emsam), or tranylcypromine (Parnate) within the past 14 days. Serious, life-threatening side effects can occur if you take Elavil before the MAO inhibitor has cleared from your body.
Before taking Elavil, tell your doctor if you are allergic to any drugs, or if you have:

heart disease;

a history of heart attack, stroke, or seizures;

bipolar disorder (manic-depression);

schizophrenia or other mental illness;

diabetes (Elavil may raise or lower blood sugar);

overactive thyroid;

glaucoma; or

problems with urination.

If you have any of these conditions, you may not be able to use Elavil, or you may need a dosage adjustment or special tests during treatment.

You may have thoughts about suicide when you first start taking an antidepressant, especially if you are younger than 24 years old. Tell your doctor if you have worsening symptoms of depression or suicidal thoughts during the first several weeks of treatment, or whenever your dose is changed.

Your family or other caregivers should also be alert to changes in your mood or symptoms. Your doctor will need to check you at regular visits for at least the first 12 weeks of treatment.

FDA pregnancy category C. Elavil may be harmful to an unborn baby. Tell your doctor if you are pregnant or plan to become pregnant during treatment. Elavil can pass into breast milk and may harm a nursing baby. Do not use Elavil without telling your doctor if you are breast-feeding a baby. Do not give Elavil to anyone under 18 years old without the advice of a doctor.

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How should I take Elavil?

Take Elavil exactly as it was prescribed for you. Do not take the medication in larger amounts, or take it for longer than recommended by your doctor. Follow the directions on your prescription label.

If you need to have any type of surgery, tell the surgeon ahead of time that you are taking Elavil. You may need to stop using the medicine for a short time.

Do not stop using Elavil without first talking to your doctor. You may need to use less and less before you stop the medication completely. Stopping this medication suddenly could cause you to have unpleasant side effects. It may take up to 4 weeks of using this medicine before your symptoms improve. For best results, keep using the medication as directed. Talk with your doctor if your symptoms do not improve after 4 weeks of treatment. Store Elavil at room temperature away from moisture and heat.

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What happens if I miss a dose?

Take the missed dose as soon as you remember. If it is almost time for your next dose, skip the missed dose and take the medicine at the next regularly scheduled time. Do not take extra medicine to make up the missed dose.

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What happens if I overdose?

Seek emergency medical attention if you think you have used too much of this medicine. An overdose of Elavil can be fatal.
Symptoms of an Elavil overdose may include uneven heartbeats, extreme drowsiness, confusion, agitation, vomiting, blurred vision, feeling hot or cold, sweating, muscle stiffness, feeling light-headed, fainting, seizure (convulsions), or coma.

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What should I avoid while taking Elavil?

Avoid drinking alcohol. It can cause dangerous side effects when taken together with Elavil.
Avoid using other medicines that make you sleepy (such as cold medicine, pain medication, muscle relaxers, medicine for seizures, or other antidepressants).

Grapefruit and grapefruit juice may interact with Elavil. Discuss the use of grapefruit products with your doctor before increasing or decreasing the amount of grapefruit products in your diet.

Elavil can cause side effects that may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be awake and alert. Avoid exposure to sunlight or artificial UV rays (sunlamps or tanning beds). Elavil can make your skin more sensitive to sunlight and sunburn may result. Use a sunscreen (minimum SPF 15) and wear protective clothing if you must be out in the sun.

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Elavil side effects

Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat.
Call your doctor at once if you have any new or worsening symptoms such as: mood or behavior changes, anxiety, panic attacks, trouble sleeping, or if you feel impulsive, irritable, agitated, hostile, aggressive, restless, hyperactive (mentally or physically), more depressed, or have thoughts about suicide or hurting yourself.

Call your doctor at once if you have any of these serious side effects:
fast, pounding, or uneven heart rate, chest pain or heavy feeling, pain spreading to the arm or shoulder, nausea, sweating, general ill feeling;

sudden numbness or weakness, especially on one side of the body;

sudden headache, confusion, problems with vision, speech, or balance;

hallucinations, or seizures (convulsions), feeling light-headed, fainting;

restless muscle movements in your eyes, tongue, jaw, or neck, uncontrollable shaking or tremor;

skin rash, severe tingling, numbness, pain, muscle weakness;

easy bruising or bleeding;

extreme thirst with headache, nausea, vomiting, and weakness; or

urinating less than usual or not at all.

Less serious side effects may be more likely to occur, such as:

nausea, vomiting, constipation, diarrhea, loss of appetite;

dry mouth, unpleasant taste;

feeling dizzy, drowsy, or tired;

trouble concentrating;

nightmares;

blurred vision, headache, ringing in your ears;

breast swelling (in men or women); or

decreased sex drive, impotence, or difficulty having an orgasm.

Side effects other than those listed here may also occur. Talk to your doctor about any side effect that seems unusual or that is especially bothersome.

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What other drugs will affect Elavil?

Before taking Elavil, tell your doctor if you have used an "SSRI" antidepressant in the past 5 weeks, such as citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac, Sarafem), fluvoxamine (Luvox), paroxetine (Paxil), or sertraline (Zoloft).

Before taking Elavil, tell your doctor if you are currently using any of the following drugs:

cimetidine (Tagamet);

guanethidine (Ismelin);

disulfiram (Antabuse); or

heart rhythm medications such as flecainide (Tambocor), propafenone (Rhythmol), or quinidine (Cardioquin, Quinidex, Quinaglute).

If you are using any of these drugs, you may not be able to use Elavil, or you may need dosage adjustments or special tests during treatment.

There are many other medicines that can interact with Elavil. Tell your doctor about all the prescription and over-the-counter medications you use. This includes vitamins, minerals, herbal products, and drugs prescribed by other doctors. Do not start using a new medication without telling your doctor. Keep a list with you of all the medicines you use and show this list to any doctor or other healthcare provider who treats you.

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Where can I get more information?

Your pharmacist has information about Elavil written for health professionals that you may read.

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What does my medication look like?

Amitriptyline is available with a prescription generically and under the brand names Elavil, Endep and Vanatrip. Other brand or generic formulations may also be available. Ask your pharmacist any questions you have about this medication, especially if it is new to you.

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Asendin (AMOXAPINE)

Asendin

Generic Name: amoxapine (a MOX a peen)
Brand Names: Asendin

What is Asendin?
What is the most important information I should know about Asendin?
What should I discuss with my healthcare provider before taking Asendin?
How should I take Asendin?
What happens if I miss a dose?
What happens if I overdose?
What should I avoid while taking Asendin?
Asendin side effects
What other drugs will affect Asendin?
Where can I get more information?
What does my medication look like?

What is Asendin?

Amoxapine is in a group of drugs called tricyclic antidepressants. Amoxapine affects chemicals in the brain that may become unbalanced.

Amoxapine is used to treat symptoms of depression, anxiety, or agitation.

Amoxapine may also be used for purposes other than those listed in this medication guide.

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What is the most important information I should know about Asendin?

Do not use this medication if you are allergic to amoxapine, or if you have recently had a heart attack. Do not use amoxapine if you have used an MAO inhibitor such as isocarboxazid (Marplan), phenelzine (Nardil), rasagiline (Azilect), selegiline (Eldepryl, Emsam), or tranylcypromine (Parnate) within the past 14 days.
You may have thoughts about suicide when you first start taking an antidepressant, especially if you are younger than 24 years old. Your doctor will need to check you at regular visits for at least the first 12 weeks of treatment.

Call your doctor at once if you have any new or worsening symptoms such as: mood or behavior changes, anxiety, panic attacks, trouble sleeping, or if you feel impulsive, irritable, agitated, hostile, aggressive, restless, hyperactive (mentally or physically), more depressed, or have thoughts about suicide or hurting yourself.

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What should I discuss with my healthcare provider before taking Asendin?

Do not use this medication if you are allergic to amoxapine, or if you have recently had a heart attack. Do not use amoxapine if you have used an MAO inhibitor such as isocarboxazid (Marplan), phenelzine (Nardil), rasagiline (Azilect), selegiline (Eldepryl, Emsam), or tranylcypromine (Parnate) within the past 14 days. Serious, life-threatening side effects can occur if you take amoxapine before the MAO inhibitor has cleared from your body.
Before taking amoxapine, tell your doctor if you are allergic to any drugs, or if you have:

heart disease;

a history of heart attack, stroke, or seizures;

kidney disease;

schizophrenia or other mental illness;

diabetes (amoxapine may raise or lower blood sugar);

glaucoma; or

problems with urination.

If you have any of these conditions, you may not be able to use amoxapine, or you may need a dosage adjustment or special tests during treatment.

You may have thoughts about suicide when you first start taking an antidepressant, especially if you are younger than 24 years old. Tell your doctor if you have worsening symptoms of depression or suicidal thoughts during the first several weeks of treatment, or whenever your dose is changed.

Your family or other caregivers should also be alert to changes in your mood or symptoms. Your doctor will need to check you at regular visits for at least the first 12 weeks of treatment.

FDA Pregnancy Category C. This medication may be harmful to an unborn baby. Tell your doctor if you are pregnant or plan to become pregnant during treatment. Amoxapine can pass into breast milk and may harm a nursing baby. Do not use this medication without telling your doctor if you are breast-feeding a baby. Older adults may be more likely to have side effects from this medicine. Do not give this medication to anyone under 18 years old without the advice of a doctor.

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How should I take Asendin?

Take this medication exactly as it was prescribed for you. Do not take the medication in larger amounts, or take it for longer than recommended by your doctor. Your doctor may occasionally change your dose to make sure you get the best results from this medication. Follow the directions on your prescription label.

It may take up to 3 weeks of using this medicine before your symptoms improve. For best results, keep using the medication as directed. Talk with your doctor if your symptoms do not improve after 3 weeks of treatment. Store amoxapine at room temperature away from moisture and heat.

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What happens if I miss a dose?

Take the missed dose as soon as you remember. If it is almost time for your next dose, skip the missed dose and take the medicine at the next regularly scheduled time. Do not take extra medicine to make up the missed dose.

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What happens if I overdose?

Seek emergency medical attention if you think you have used too much of this medicine. An overdose of amoxapine can be fatal.
Symptoms of an amoxapine overdose may include uneven heartbeats, increase or decrease in urination, drowsiness, agitation, confusion, hallucinations, seizure (convulsions), or coma.

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What should I avoid while taking Asendin?

Avoid drinking alcohol. It can cause dangerous side effects when taken together with amoxapine.
Avoid using other medicines that make you sleepy (such as cold medicine, pain medication, muscle relaxers, medicine for seizures, or other antidepressants). They can add to sleepiness caused by amoxapine.

Grapefruit and grapefruit juice may interact with amoxapine. Discuss the use of grapefruit products with your doctor before increasing or decreasing the amount of grapefruit products in your diet.

Amoxapine can cause side effects that may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be awake and alert. Avoid exposure to sunlight or artificial UV rays (sunlamps or tanning beds). Amoxapine can make your skin more sensitive to sunlight and sunburn may result. Use a sunscreen (minimum SPF 15) and wear protective clothing if you must be out in the sun.

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Asendin side effects

Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat.
Call your doctor at once if you have any new or worsening symptoms such as: mood or behavior changes, anxiety, panic attacks, trouble sleeping, or if you feel impulsive, irritable, agitated, hostile, aggressive, restless, hyperactive (mentally or physically), more depressed, or have thoughts about suicide or hurting yourself.

Call your doctor at once if you have any of these serious side effects:
fast, pounding, or uneven heart rate;

chest pain or heavy feeling, pain spreading to the arm or shoulder, nausea, sweating, general ill feeling;

sudden numbness or weakness, especially on one side of the body;

sudden headache, confusion, problems with vision, speech, or balance;

feeling light-headed, fainting;

restless muscle movements in your eyes, tongue, jaw, or neck;

tremors or uncontrollable shaking; or

fever with confusion, muscle stiffness, sweating, and fast or uneven heartbeats.

Less serious side effects may be more likely to occur, such as:

nausea, vomiting, stomach pain, constipation, diarrhea;

dry mouth, unpleasant taste;

increased appetite, weight changes;

weakness, lack of coordination;

numbness or tingly feeling;

feeling dizzy, drowsy, or tired;

nightmares;

blurred vision, headache;

low fever;

mild skin rash;

breast swelling (in men or women); or

decreased sex drive, impotence, or difficulty having an orgasm.

Side effects other than those listed here may also occur. Talk to your doctor about any side effect that seems unusual or that is especially bothersome.

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What other drugs will affect Asendin?

Before taking amoxapine, tell your doctor if you have used an "SSRI" antidepressant in the past 5 weeks, such as citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac, Sarafem), fluvoxamine (Luvox), paroxetine (Paxil), or sertraline (Zoloft).

Before taking amoxapine, tell your doctor if you are currently using any of the following drugs:

cimetidine (Tagamet); or

heart rhythm medications such as flecainide (Tambocor), propafenone (Rhythmol), or quinidine (Cardioquin, Quinidex, Quinaglute).

If you are using any of these drugs, you may not be able to use amoxapine, or you may need dosage adjustments or special tests during treatment.

There are many other medicines that can interact with amoxapine. Tell your doctor about all the prescription and over-the-counter medications you use. This includes vitamins, minerals, herbal products, and drugs prescribed by other doctors. Do not start using a new medication without telling your doctor. Keep a list with you of all the medicines you use and show this list to any doctor or other healthcare provider who treats you.

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Where can I get more information?

Your pharmacist has information about amoxapine written for health professionals that you may read

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What does my medication look like?

Amoxapine is available with a prescription generically and under the brand name Asendin. Other brand or generic formulations may also be available. Ask your pharmacist any questions you have about this medication, especially if it is new to you.

Asendin 25 mg--heptagon-shaped, white, scored tablets

Asendin 50 mg--heptagon-shaped, orange, scored tablets

Asendin 100 mg--heptagon-shaped, blue, scored tablets

Asendin 150 mg--heptagon-shaped, peach, scored tablets

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Anafranil (CLOMIPRAMINE)

Anafranil

Generic Name: clomipramine (kloe MI pra meen)
Brand Names: Anafranil

What is Anafranil?
What is the most important information I should know about Anafranil?
What should I discuss with my healthcare provider before taking Anafranil?
How should I take Anafranil?
What happens if I miss a dose?
What happens if I overdose?
What should I avoid while taking Anafranil?
Anafranil side effects
What other drugs will affect Anafranil?
Where can I get more information?
What does my medication look like?

What is Anafranil?

Clomipramine is a tricyclic antidepressant. It affects chemicals in the brain that may become unbalanced.

Clomipramine is used to treat symptoms of obsessive-compulsive disorder (OCD) such as recurrent thoughts or feelings and repetitive actions.

Clomipramine may also be used for purposes other than those listed in this medication guide.

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What is the most important information I should know about Anafranil?

Do not use this medication if you have recently had a heart attack, or if you have used an MAO inhibitor such as isocarboxazid (Marplan), phenelzine (Nardil), rasagiline (Azilect), selegiline (Eldepryl, Emsam), or tranylcypromine (Parnate) within the past 14 days. Do not use clomipramine if you are allergic to it or to similar drugs such as amitriptyline (Elavil, Etrafon), amoxapine (Ascendin), desipramine (Norpramin), doxepin (Sinequan), imipramine (Janimine, Tofranil), nortriptyline (Pamelor), protriptyline (Vivactil), or trimipramine (Surmontil).
You may have thoughts about suicide when you first start taking an antidepressant, especially if you are younger than 24 years old. Your doctor will need to check you at regular visits for at least the first 12 weeks of treatment.

Call your doctor at once if you have any new or worsening symptoms such as: mood or behavior changes, anxiety, panic attacks, trouble sleeping, or if you feel impulsive, irritable, agitated, hostile, aggressive, restless, hyperactive (mentally or physically), more depressed, or have thoughts about suicide or hurting yourself.

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What should I discuss with my healthcare provider before taking Anafranil?

Do not use this medication if you are allergic to clomipramine or to similar drugs such as amitriptyline (Elavil, Etrafon), amoxapine (Ascendin), desipramine (Norpramin), doxepin (Sinequan), imipramine (Janimine, Tofranil), nortriptyline (Pamelor), protriptyline (Vivactil), or trimipramine (Surmontil). Do not use clomipramine if you have recently had a heart attack, or if you have used an MAO inhibitor such as isocarboxazid (Marplan), phenelzine (Nardil), rasagiline (Azilect), selegiline (Eldepryl, Emsam), or tranylcypromine (Parnate) within the past 14 days. Serious, life-threatening side effects can occur if you take clomipramine before the MAO inhibitor has cleared from your body.
Before taking clomipramine, tell your doctor if you are allergic to any drugs, or if you have:

heart disease or a history of heart attack, stroke, or seizures;

bipolar disorder (manic-depression), schizophrenia or other mental illness;

kidney or liver disease;
overactive thyroid or adrenal gland tumor (pheochromocytoma);

glaucoma; or

problems with urination.

If you have any of these conditions, you may not be able to use clomipramine, or you may need a dosage adjustment or special tests during treatment.

You may have thoughts about suicide when you first start taking an antidepressant, especially if you are younger than 24 years old. Tell your doctor if you have worsening symptoms of depression or suicidal thoughts during the first several weeks of treatment, or whenever your dose is changed.

Your family or other caregivers should also be alert to changes in your mood or symptoms. Your doctor will need to check you at regular visits for at least the first 12 weeks of treatment.

FDA pregnancy category C. This medication may be harmful to an unborn baby. Tell your doctor if you are pregnant or plan to become pregnant during treatment. Clomipramine can pass into breast milk and may harm a nursing baby. Do not use this medication without telling your doctor if you are breast-feeding a baby. Do not give clomipramine to anyone younger than 18 years old without the advice of a doctor.

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How should I take Anafranil?

Take this medication exactly as it was prescribed for you. Do not take the medication in larger amounts, or take it for longer than recommended by your doctor. Your doctor may occasionally change your dose to make sure you get the best results from this medication. Follow the directions on your prescription label.

Take clomipramine with food to reduce stomach upset.
If you need to have any type of surgery, tell the surgeon ahead of time that you are taking clomipramine. You may need to stop using the medicine for a short time.

Do not stop using clomipramine without first talking to your doctor. You may need to use less and less before you stop the medication completely. It may take up to 4 weeks of using this medicine before your symptoms improve. For best results, keep using the medication as directed. Talk with your doctor if your symptoms do not improve after 4 weeks of treatment. Store clomipramine at room temperature away from moisture and heat.

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What happens if I miss a dose?

Take the missed dose as soon as you remember. If it is almost time for your next dose, skip the missed dose and take the medicine at the next regularly scheduled time. Do not take extra medicine to make up the missed dose.

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What happens if I overdose?

Seek emergency medical attention if you think you have used too much of this medicine. An overdose of clomipramine can be fatal. Symptoms may include fast or uneven heart rate, extreme drowsiness, confusion, agitation, vomiting, blurred vision, sweating, muscle stiffness, increased or decreased urination, swelling, shortness of breath, blue lips or fingernails, feeling light-headed, fainting, seizure (convulsions), or coma.

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What should I avoid while taking Anafranil?

Avoid drinking alcohol. It can cause dangerous side effects when taken together with clomipramine.
Avoid using other medicines that make you sleepy (such as cold medicine, pain medication, muscle relaxers, medicine for seizures, or other antidepressants). They can add to sleepiness caused by clomipramine.

Grapefruit and grapefruit juice may interact with clomipramine. Discuss the use of grapefruit products with your doctor before increasing or decreasing the amount of grapefruit products in your diet.

Clomipramine can cause side effects that may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be awake and alert. Avoid exposure to sunlight or artificial UV rays (sunlamps or tanning beds). Clomipramine can make your skin more sensitive to sunlight and sunburn may result. Use a sunscreen (minimum SPF 15) and wear protective clothing if you must be out in the sun.

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Anafranil side effects

Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat.
Call your doctor at once if you have any new or worsening symptoms such as: mood or behavior changes, anxiety, panic attacks, trouble sleeping, or if you feel impulsive, irritable, agitated, hostile, aggressive, restless, hyperactive (mentally or physically), more depressed, or have thoughts about suicide or hurting yourself.

Call your doctor at once if you have any of these serious side effects:
chest pain or heavy feeling, pain spreading to the arm or shoulder, nausea, sweating, general ill feeling;

sudden numbness or weakness, especially on one side of the body;

sudden headache, confusion, problems with vision, speech, or balance;

feeling light-headed, fainting;

fever, confusion, muscle stiffness, sweating, fast or uneven heartbeats;

pale skin, easy bruising or bleeding, unusual weakness; or

urinating more than usual.

Less serious side effects may be more likely to occur, such as:

nausea, vomiting, stomach pain, loss of appetite, constipation or diarrhea;

dry mouth, unpleasant taste;

increased appetite, weight changes;

feeling anxious, restless, dizzy, drowsy, or tired;

blurred vision, trouble concentrating;

sleep problems (insomnia), nightmares;

blurred vision;

increased sweating; or

decreased sex drive, impotence, or difficulty having an orgasm.

Side effects other than those listed here may also occur. Talk to your doctor about any side effect that seems unusual or that is especially bothersome.

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What other drugs will affect Anafranil?

Before taking clomipramine, tell your doctor if you have used an "SSRI" antidepressant in the past 5 weeks, such as citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac, Sarafem), fluvoxamine (Luvox), paroxetine (Paxil), or sertraline (Zoloft).

Before taking clomipramine, tell your doctor if you are currently using any of the following drugs:

cimetidine (Tagamet);

guanethidine (Ismelin);

methylphenidate (Concerta, Ritalin, Daytrana);

phenytoin (Dilantin);

warfarin (Coumadin);

heart or blood pressure medication such as clonidine (Catapres) or digoxin (Lanoxin);

heart rhythm medications such as flecainide (Tambocor), propafenone (Rhythmol), or quinidine (Cardioquin, Quinidex, Quinaglute); or

anti-psychotic medications such as chlorpromazine (Thorazine), haloperidol (Haldol), thioridazine (Mellaril), clozapine (Clozaril), olanzapine (Zyprexa, Zydis), quetiapine (Seroquel), risperidone (Risperdal), or ziprasidone (Geodon).

If you are using any of these drugs, you may not be able to use clomipramine, or you may need dosage adjustments or special tests during treatment.

There are many other medicines that can interact with clomipramine. Tell your doctor about all the prescription and over-the-counter medications you use. This includes vitamins, minerals, herbal products, and drugs prescribed by other doctors. Do not start using a new medication without telling your doctor. Keep a list with you of all the medicines you use and show this list to any doctor or other healthcare provider who treats you.

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Where can I get more information?

Your pharmacist has information about amoxapine written for health professionals that you may read

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What does my medication look like?

Clomipramine is available with a prescription under the brand name Anafranil. Other brand or generic forms may also be available. Ask your pharmacist any questions you have about this medication, especially if it is new to you.

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Adapin (DOXEPIN)

Generic Name: doxepin (DOX e pin)
Brand Names: Adapin, Sinequan

What is Adapin?
What is the most important information I should know about Adapin?
What should I discuss with my healthcare provider before taking Adapin?
How should I take Adapin?
What happens if I miss a dose?
What happens if I overdose?
What should I avoid while taking Adapin?
Adapin side effects
What other drugs will affect Adapin?
Where can I get more information?
What does my medication look like?

What is Adapin?

Doxepin is in a group of drugs called tricyclic antidepressants. Doxepin affects chemicals in the brain that may become unbalanced.

Doxepin is used to treat symptoms of depression and/or anxiety associated with alcoholism, psychiatric conditions, or manic-depressive conditions.

Doxepin may also be used for purposes other than those listed in this medication guide.

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What is the most important information I should know about Adapin?

Do not use this medication if you are allergic to doxepin, or if you have glaucoma or problems with urination. Do not use doxepin if you have used an MAO inhibitor such as isocarboxazid (Marplan), phenelzine (Nardil), rasagiline (Azilect), selegiline (Eldepryl, Emsam), or tranylcypromine (Parnate) within the past 14 days.
You may have thoughts about suicide when you first start taking an antidepressant, especially if you are younger than 24 years old. Your doctor will need to check you at regular visits for at least the first 12 weeks of treatment.

Call your doctor at once if you have any new or worsening symptoms such as: mood or behavior changes, anxiety, panic attacks, trouble sleeping, or if you feel impulsive, irritable, agitated, hostile, aggressive, restless, hyperactive (mentally or physically), more depressed, or have thoughts about suicide or hurting yourself.

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What should I discuss with my healthcare provider before taking Adapin?

Do not use this medication if you are allergic to doxepin, or if you have glaucoma or problems with urination. Do not use doxepin if you have used an MAO inhibitor such as isocarboxazid (Marplan), phenelzine (Nardil), rasagiline (Azilect), selegiline (Eldepryl, Emsam), or tranylcypromine (Parnate) within the past 14 days. Serious, life-threatening side effects can occur if you take doxepin before the MAO inhibitor has cleared from your body.
Before taking doxepin, tell your doctor if you are allergic to any drugs, or if you have:

bipolar disorder (manic-depression); or

diabetes (doxepin may raise or lower blood sugar).

If you have any of these conditions, you may not be able to use doxepin, or you may need a dosage adjustment or special tests during treatment.

You may have thoughts about suicide when you first start taking an antidepressant, especially if you are younger than 24 years old. Tell your doctor if you have worsening symptoms of depression or suicidal thoughts during the first several weeks of treatment, or whenever your dose is changed.

Your family or other caregivers should also be alert to changes in your mood or symptoms. Your doctor will need to check you at regular visits for at least the first 12 weeks of treatment.

This medication may be harmful to an unborn baby. Tell your doctor if you are pregnant or plan to become pregnant during treatment. It is not known whether doxepin passes into breast milk or if it could harm a nursing baby. Do not use this medication without telling your doctor if you are breast-feeding a baby. Do not give doxepin to anyone younger than 18 years old without the advice of a doctor.

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How should I take Adapin?

Take this medication exactly as it was prescribed for you. Do not take the medication in larger amounts, or take it for longer than recommended by your doctor. Your doctor may occasionally change your dose to make sure you get the best results from this medication. Follow the directions on your prescription label.

Measure doxepin oral concentrate (liquid) with the special dose-measuring dropper provided. Do not use a regular table spoon. If you do not have a dose-measuring dropper, ask your pharmacist for one.

Empty the measured dose from the medicine dropper into a small glass (4 ounces) of water, milk, orange juice, tomato juice, prune juice, or pineapple juice. Do not use a carbonated soft drink to mix doxepin oral concentrate. Stir the mixture and drink all of it right away. Do not save it for later use.

It may take a few weeks of using this medicine before your symptoms improve. For best results, keep using the medication as directed. Talk with your doctor if your symptoms do not improve during treatment. Store doxepin at room temperature away from moisture and heat.

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What happens if I miss a dose?

Take the missed dose as soon as you remember. If it is almost time for your next dose, skip the missed dose and take the medicine at the next regularly scheduled time. Do not take extra medicine to make up the missed dose.

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What happens if I overdose?

Seek emergency medical attention if you think you have used too much of this medicine. An overdose of doxepin can be fatal.
Symptoms of a doxepin overdose may include uneven heartbeats, extreme drowsiness, agitation, vomiting, blurred vision, confusion, hallucinations, feeling hot or cold, muscle stiffness, feeling light-headed, fainting, seizure (convulsions), or coma.

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What should I avoid while taking Adapin?

Avoid drinking alcohol. It can cause dangerous side effects when taken together with doxepin.
Avoid using other medicines that make you sleepy (such as cold medicine, pain medication, muscle relaxers, medicine for seizures, or other medication for depression or anxiety). They can add to sleepiness caused by doxepin.

Grapefruit and grapefruit juice may interact with doxepin. Discuss the use of grapefruit products with your doctor before increasing or decreasing the amount of grapefruit products in your diet.

Doxepin can cause side effects that may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be awake and alert.

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Adapin side effects

Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat.
Call your doctor at once if you have any new or worsening symptoms such as: mood or behavior changes, anxiety, panic attacks, trouble sleeping, or if you feel impulsive, irritable, agitated, hostile, aggressive, restless, hyperactive (mentally or physically), more depressed, or have thoughts about suicide or hurting yourself.

Call your doctor at once if you have any of these serious side effects:
fast, pounding, or uneven heart rate;

confusion, hallucinations, or seizure (convulsions);

easy bruising or bleeding, unusual weakness;

feeling light-headed, fainting;

restless muscle movements in your eyes, tongue, jaw, or neck;

tremors or uncontrollable shaking;

urinating less than usual or not at all; or

extreme thirst with headache, nausea, vomiting, and weakness.

Less serious side effects may be more likely to occur, such as:

nausea, vomiting, constipation, loss of appetite;

dry mouth;

weight changes;

weakness, lack of coordination;

numbness or tingly feeling;

feeling dizzy, drowsy, or tired;

sleep problems (insomnia), nightmares;

blurred vision, headache, ringing in your ears;

increased sweating;

breast swelling (in men or women); or

decreased sex drive, impotence, or difficulty having an orgasm.

Side effects other than those listed here may also occur. Talk to your doctor about any side effect that seems unusual or that is especially bothersome.

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What other drugs will affect Adapin?

Before taking doxepin, tell your doctor if you have used an "SSRI" antidepressant in the past 5 weeks, such as citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac, Sarafem), fluvoxamine (Luvox), paroxetine (Paxil), or sertraline (Zoloft).

Before taking doxepin, tell your doctor if you are currently using any of the following drugs:

cimetidine (Tagamet) or;

heart rhythm medications such as flecainide (Tambocor), propafenone (Rhythmol), or quinidine (Cardioquin, Quinidex, Quinaglute).

If you are using any of these drugs, you may not be able to use doxepin, or you may need dosage adjustments or special tests during treatment.

There are many other medicines that can interact with doxepin. Tell your doctor about all the prescription and over-the-counter medications you use. This includes vitamins, minerals, herbal products, and drugs prescribed by other doctors. Do not start using a new medication without telling your doctor. Keep a list with you of all the medicines you use and show this list to any doctor or other healthcare provider who treats you.

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Where can I get more information?

Your pharmacist has information about amoxapine written for health professionals that you may read

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What does my medication look like?

Doxepin is available with a prescription under the brand name Sinequan. Other brand or generic formulations may also be available. Ask your pharmacist any questions you have about this medication, especially if it is new to you.

Sinequan 10 mg--red/pink capsule

Sinequan 25 mg--blue/pink capsule

Sinequan 50 mg--pink/white capsule

Sinequan 75 mg--white/white capsule

Sinequan 100 mg--blue/white capsule

Sinequan 150 mg--blue/blue capsule

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Endep (AMITRIPTYLINE)

Generic Name: amitriptyline (a mee TRIP ti leen)
Brand Names: Elavil, Endep, Vanatrip

What is Elavil?
What is the most important information I should know about Elavil?
What should I discuss with my healthcare provider before taking Elavil?
How should I take Elavil?
What happens if I miss a dose?
What happens if I overdose?
What should I avoid while taking Elavil?
Elavil side effects
What other drugs will affect Elavil?
Where can I get more information?
What does my medication look like?

What is Endep?

Amitriptyline is in a group of drugs called tricyclic antidepressants. Amitriptyline affects chemicals in the brain that may become unbalanced.

Amitriptyline is used to treat symptoms of depression.

Amitriptyline may also be used for purposes other than those listed in this medication guide.

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What is the most important information I should know about Endep?

Do not use this medication if you are allergic to amitriptyline, or if you have recently had a heart attack. Do not use amitriptyline if you have taken cisapride (Propulsid) or used an MAO inhibitor such as isocarboxazid (Marplan), phenelzine (Nardil), rasagiline (Azilect), selegiline (Eldepryl, Emsam), or tranylcypromine (Parnate) within the past 14 days.
You may have thoughts about suicide when you first start taking an antidepressant, especially if you are younger than 24 years old. Your doctor will need to check you at regular visits for at least the first 12 weeks of treatment.

Call your doctor at once if you have any new or worsening symptoms such as: mood or behavior changes, anxiety, panic attacks, trouble sleeping, or if you feel impulsive, irritable, agitated, hostile, aggressive, restless, hyperactive (mentally or physically), more depressed, or have thoughts about suicide or hurting yourself.

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What should I discuss with my healthcare provider before taking Endep?

Do not use this medication if you are allergic to amitriptyline, or if you have recently had a heart attack. Do not use amitriptyline if you have taken cisapride (Propulsid) or used an MAO inhibitor such as isocarboxazid (Marplan), phenelzine (Nardil), rasagiline (Azilect), selegiline (Eldepryl, Emsam), or tranylcypromine (Parnate) within the past 14 days. Serious, life-threatening side effects can occur if you take amitriptyline before the MAO inhibitor has cleared from your body.
Before taking amitriptyline, tell your doctor if you are allergic to any drugs, or if you have:

heart disease;

a history of heart attack, stroke, or seizures;

bipolar disorder (manic-depression);

schizophrenia or other mental illness;

diabetes (amitriptyline may raise or lower blood sugar);

overactive thyroid;

glaucoma; or

problems with urination.

If you have any of these conditions, you may not be able to use amitriptyline, or you may need a dosage adjustment or special tests during treatment.

You may have thoughts about suicide when you first start taking an antidepressant, especially if you are younger than 24 years old. Tell your doctor if you have worsening symptoms of depression or suicidal thoughts during the first several weeks of treatment, or whenever your dose is changed.

Your family or other caregivers should also be alert to changes in your mood or symptoms. Your doctor will need to check you at regular visits for at least the first 12 weeks of treatment.

FDA pregnancy category C. This medication may be harmful to an unborn baby. Tell your doctor if you are pregnant or plan to become pregnant during treatment. Amitriptyline can pass into breast milk and may harm a nursing baby. Do not use this medication without telling your doctor if you are breast-feeding a baby. Do not give this medication to anyone under 18 years old without the advice of a doctor.

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How should I take Endep?

Take this medication exactly as it was prescribed for you. Do not take the medication in larger amounts, or take it for longer than recommended by your doctor. Follow the directions on your prescription label.

If you need to have any type of surgery, tell the surgeon ahead of time that you are taking amitriptyline. You may need to stop using the medicine for a short time.

Do not stop using amitriptyline without first talking to your doctor. You may need to use less and less before you stop the medication completely. Stopping this medication suddenly could cause you to have unpleasant side effects. It may take up to 4 weeks of using this medicine before your symptoms improve. For best results, keep using the medication as directed. Talk with your doctor if your symptoms do not improve after 4 weeks of treatment. Store amitriptyline at room temperature away from moisture and heat.

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What happens if I miss a dose?

Take the missed dose as soon as you remember. If it is almost time for your next dose, skip the missed dose and take the medicine at the next regularly scheduled time. Do not take extra medicine to make up the missed dose.

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What happens if I overdose?

Seek emergency medical attention if you think you have used too much of this medicine. An overdose of amitriptyline can be fatal.
Symptoms of an amitriptyline overdose may include uneven heartbeats, extreme drowsiness, confusion, agitation, vomiting, blurred vision, feeling hot or cold, sweating, muscle stiffness, feeling light-headed, fainting, seizure (convulsions), or coma.

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What should I avoid while taking Endep?

Avoid drinking alcohol. It can cause dangerous side effects when taken together with amitriptyline.
Avoid using other medicines that make you sleepy (such as cold medicine, pain medication, muscle relaxers, medicine for seizures, or other antidepressants).

Grapefruit and grapefruit juice may interact with amitriptyline. Discuss the use of grapefruit products with your doctor before increasing or decreasing the amount of grapefruit products in your diet.

Amitriptyline can cause side effects that may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be awake and alert. Avoid exposure to sunlight or artificial UV rays (sunlamps or tanning beds). Amitriptyline can make your skin more sensitive to sunlight and sunburn may result. Use a sunscreen (minimum SPF 15) and wear protective clothing if you must be out in the sun.

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Endep side effects

Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat.
Call your doctor at once if you have any new or worsening symptoms such as: mood or behavior changes, anxiety, panic attacks, trouble sleeping, or if you feel impulsive, irritable, agitated, hostile, aggressive, restless, hyperactive (mentally or physically), more depressed, or have thoughts about suicide or hurting yourself.

Call your doctor at once if you have any of these serious side effects:
fast, pounding, or uneven heart rate, chest pain or heavy feeling, pain spreading to the arm or shoulder, nausea, sweating, general ill feeling;

sudden numbness or weakness, especially on one side of the body;

sudden headache, confusion, problems with vision, speech, or balance;

hallucinations, or seizures (convulsions), feeling light-headed, fainting;

restless muscle movements in your eyes, tongue, jaw, or neck, uncontrollable shaking or tremor;

skin rash, severe tingling, numbness, pain, muscle weakness;

easy bruising or bleeding;

extreme thirst with headache, nausea, vomiting, and weakness; or

urinating less than usual or not at all.

Less serious side effects may be more likely to occur, such as:

nausea, vomiting, constipation, diarrhea, loss of appetite;

dry mouth, unpleasant taste;

feeling dizzy, drowsy, or tired;

trouble concentrating;

nightmares;

blurred vision, headache, ringing in your ears;

breast swelling (in men or women); or

decreased sex drive, impotence, or difficulty having an orgasm.

Side effects other than those listed here may also occur. Talk to your doctor about any side effect that seems unusual or that is especially bothersome.

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What other drugs will affect Endep?

Before taking amitriptyline, tell your doctor if you have used an "SSRI" antidepressant in the past 5 weeks, such as citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac, Sarafem), fluvoxamine (Luvox), paroxetine (Paxil), or sertraline (Zoloft).

Before taking amitriptyline, tell your doctor if you are currently using any of the following drugs:

cimetidine (Tagamet);

guanethidine (Ismelin);

disulfiram (Antabuse); or

heart rhythm medications such as flecainide (Tambocor), propafenone (Rhythmol), or quinidine (Cardioquin, Quinidex, Quinaglute).

If you are using any of these drugs, you may not be able to use amitriptyline, or you may need dosage adjustments or special tests during treatment.

There are many other medicines that can interact with amitriptyline. Tell your doctor about all the prescription and over-the-counter medications you use. This includes vitamins, minerals, herbal products, and drugs prescribed by other doctors. Do not start using a new medication without telling your doctor. Keep a list with you of all the medicines you use and show this list to any doctor or other healthcare provider who treats you.

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The Linden Method - Stop General Anxiety and Panic Attack Fast!

Where can I get more information?

Your pharmacist has information about amoxapine written for health professionals that you may read

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What does my medication look like?

Amitriptyline is available with a prescription generically and under the brand names Elavil and Endep. Other brand or generic formulations may also be available. Ask your pharmacist any questions you have about this medication, especially if it is new to you.

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Norpramin (DESIPRAMINE)

Generic Name: desipramine (des IP ra meen)
Brand Names: Norpramin

What is Norpramin?
What is the most important information I should know about Norpramin?
What should I discuss with my healthcare provider before taking Norpramin?
How should I take Norpramin?
What happens if I miss a dose?
What happens if I overdose?
What should I avoid while taking Norpramin?
Norpramin side effects
What other drugs will affect Norpramin?
Where can I get more information?
What does my medication look like?

What is Norpramin?

Desipramine is a tricyclic antidepressant. Desipramine affects chemicals in the brain that may become unbalanced.

Desipramine is used to treat symptoms of depression.

Desipramine may also be used for purposes other than those listed in this medication guide.

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What is the most important information I should know about Norpramin?

Do not use this medication if you have recently had a heart attack, or if you have used an MAO inhibitor such as isocarboxazid (Marplan), phenelzine (Nardil), rasagiline (Azilect), selegiline (Eldepryl, Emsam), or tranylcypromine (Parnate) within the past 14 days.
You may have thoughts about suicide when you first start taking an antidepressant, especially if you are younger than 24 years old. Your doctor will need to check you at regular visits for at least the first 12 weeks of treatment.

Call your doctor at once if you have any new or worsening symptoms such as: mood or behavior changes, anxiety, panic attacks, trouble sleeping, or if you feel impulsive, irritable, agitated, hostile, aggressive, restless, hyperactive (mentally or physically), more depressed, or have thoughts about suicide or hurting yourself.

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What should I discuss with my healthcare provider before taking Norpramin?

Do not use this medication if you are allergic to desipramine, or if you have recently had a heart attack. Do not use desipramine if you have used an MAO inhibitor such as isocarboxazid (Marplan), phenelzine (Nardil), rasagiline (Azilect), selegiline (Eldepryl, Emsam), or tranylcypromine (Parnate) within the past 14 days. Serious, life-threatening side effects can occur if you take desipramine before the MAO inhibitor has cleared from your body.
Before taking desipramine, tell your doctor if you are allergic to any drugs, or if you have:

heart disease, or a history of heart attack, stroke, or seizures;

bipolar disorder (manic-depression);

schizophrenia or other mental illness;

liver disease;

overactive thyroid;

diabetes (desipramine may raise or lower blood sugar);

glaucoma; or

problems with urination.

If you have any of these conditions, you may not be able to use desipramine, or you may need a dosage adjustment or special tests during treatment.

You may have thoughts about suicide when you first start taking an antidepressant, especially if you are younger than 24 years old. Tell your doctor if you have worsening symptoms of depression or suicidal thoughts during the first several weeks of treatment, or whenever your dose is changed.

Your family or other caregivers should also be alert to changes in your mood or symptoms. Your doctor will need to check you at regular visits for at least the first 12 weeks of treatment.

This medication may be harmful to an unborn baby. Tell your doctor if you are pregnant or plan to become pregnant during treatment. It is not known whether desipramine passes into breast milk or if it could harm a nursing baby. Do not use this medication without telling your doctor if you are breast-feeding a baby.
Older adults may be more likely to have side effects from this medication.

Do not give desipramine to anyone under 18 years old without the advice of a doctor.

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How should I take Norpramin?

Take this medication exactly as it was prescribed for you. Do not take the medication in larger amounts, or take it for longer than recommended by your doctor. Your doctor may occasionally change your dose to make sure you get the best results from this medication. Follow the directions on your prescription label.

If you need to have any type of surgery, tell the surgeon ahead of time that you are taking desipramine. You may need to stop using the medicine for a short time.

Do not stop using desipramine without first talking to your doctor. You may need to use less and less before you stop the medication completely. Stopping this medication suddenly could cause you to have unpleasant side effects. It may take a few weeks of using this medicine before your symptoms improve. For best results, keep using the medication as directed. Talk with your doctor if your symptoms do not improve during treatment. Store desipramine at room temperature away from moisture and heat.

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What happens if I miss a dose?

Take the missed dose as soon as you remember. If it is almost time for your next dose, skip the missed dose and take the medicine at the next regularly scheduled time. Do not take extra medicine to make up the missed dose.

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BACK TO INDEX

What happens if I overdose?

Seek emergency medical attention if you think you have used too much of this medicine. An overdose of desipramine can be fatal. Symptoms may include uneven heartbeats, extreme drowsiness, vomiting, blurred vision, confusion, hallucinations, muscle stiffness, feeling hot or cold, seizure (convulsions), or coma.

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What should I avoid while taking Norpramin?

Avoid drinking alcohol. It can cause dangerous side effects when taken together with desipramine.
Avoid using other medicines that make you sleepy (such as cold medicine, pain medication, muscle relaxers, medicine for seizures, or other antidepressants). They can add to sleepiness caused by desipramine.

Grapefruit and grapefruit juice may interact with desipramine. Discuss the use of grapefruit products with your doctor before increasing or decreasing the amount of grapefruit products in your diet.

Desipramine can cause side effects that may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be awake and alert. Avoid exposure to sunlight or artificial UV rays (sunlamps or tanning beds). Desipramine can make your skin more sensitive to sunlight and sunburn may result. Use a sunscreen (minimum SPF 15) and wear protective clothing if you must be out in the sun.

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Norpramin side effects

Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat.
Call your doctor at once if you have any new or worsening symptoms such as: mood or behavior changes, anxiety, panic attacks, trouble sleeping, or if you feel impulsive, irritable, agitated, hostile, aggressive, restless, hyperactive (mentally or physically), more depressed, or have thoughts about suicide or hurting yourself.

Call your doctor at once if you have any of these serious side effects:
fast, pounding, or uneven heart rate;

chest pain or heavy feeling, pain spreading to the arm or shoulder, nausea, sweating, general ill feeling;

sudden numbness or weakness, especially on one side of the body;

sudden headache, confusion, problems with vision, speech, or balance;

confusion, hallucinations, or seizure (convulsions);

easy bruising or bleeding, unusual weakness;

feeling light-headed, fainting;

tremors, restless muscle movements in your eyes, tongue, jaw, or neck;

fever with confusion, muscle stiffness, sweating, and fast or uneven heartbeats;

urinating more or less than usual;

extreme thirst with headache, nausea, vomiting, and weakness;

skin rash, bruising, severe tingling, numbness, pain, and muscle weakness; or

nausea, stomach pain, low fever, loss of appetite, dark urine, clay-colored stools, jaundice (yellowing of the skin or eyes).

Less serious side effects may be more likely to occur, such as:

vomiting, constipation;

dry mouth, unpleasant taste;

weakness, lack of coordination;

feeling anxious, restless, dizzy, or drowsy;

sleep problems (insomnia), nightmares;

blurred vision, trouble concentrating, headache, ringing in your ears;

breast swelling (in men or women); or

decreased sex drive, impotence, or difficulty having an orgasm.

Side effects other than those listed here may also occur. Talk to your doctor about any side effect that seems unusual or that is especially bothersome.

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What other drugs will affect Norpramin?

Before taking desipramine, tell your doctor if you have used an "SSRI" antidepressant in the past 5 weeks, such as citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac, Sarafem), fluvoxamine (Luvox), paroxetine (Paxil), or sertraline (Zoloft).

Before taking desipramine, tell your doctor if you are currently using any of the following drugs:

cimetidine (Tagamet);

guanethidine (Ismelin); or

heart rhythm medications such as flecainide (Tambocor), propafenone (Rhythmol), or quinidine (Cardioquin, Quinidex, Quinaglute).

If you are using any of these drugs, you may not be able to use desipramine, or you may need dosage adjustments or special tests during treatment.

There are many other medicines that can interact with desipramine. Tell your doctor about all the prescription and over-the-counter medications you use. This includes vitamins, minerals, herbal products, and drugs prescribed by other doctors. Do not start using a new medication without telling your doctor. Keep a list with you of all the medicines you use and show this list to any doctor or other healthcare provider who treats you.

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BACK TO INDEX

Where can I get more information?

Your pharmacist has information about amoxapine written for health professionals that you may read

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What does my medication look like?

Desipramine is available with a prescription generically and under the brand name Norpramin. Other brand or generic formulations may also be available. Ask your pharmacist any questions you have about this medication, especially if it is new to you.

Norpramin 10 mg--round, blue, coated tablets

Norpramin 25 mg--round, yellow, coated tablets

Norpramin 50 mg--round, green, coated tablets

Norpramin 75 mg--round, orange, coated tablets

Norpramin 100 mg--round, peach, coated tablets

Norpramin 150 mg--round, white, coated tablets

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Sinequan (DOXEPIN)

Generic Name: doxepin (DOX e pin)
Brand Names: Adapin, Sinequan

What is Sinequan?
What is the most important information I should know about Sinequan?
What should I discuss with my healthcare provider before taking Sinequan?
How should I take Sinequan?
What happens if I miss a dose?
What happens if I overdose?
What should I avoid while taking Sinequan?
Sinequan side effects
What other drugs will affect Sinequan?
Where can I get more information?
What does my medication look like?

What is Sinequan?

Doxepin is in a group of drugs called tricyclic antidepressants. Doxepin affects chemicals in the brain that may become unbalanced.

Doxepin is used to treat symptoms of depression and/or anxiety associated with alcoholism, psychiatric conditions, or manic-depressive conditions.

Doxepin may also be used for purposes other than those listed in this medication guide.

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What is the most important information I should know about Sinequan?

Do not use this medication if you are allergic to doxepin, or if you have glaucoma or problems with urination. Do not use doxepin if you have used an MAO inhibitor such as isocarboxazid (Marplan), phenelzine (Nardil), rasagiline (Azilect), selegiline (Eldepryl, Emsam), or tranylcypromine (Parnate) within the past 14 days.
You may have thoughts about suicide when you first start taking an antidepressant, especially if you are younger than 24 years old. Your doctor will need to check you at regular visits for at least the first 12 weeks of treatment.

Call your doctor at once if you have any new or worsening symptoms such as: mood or behavior changes, anxiety, panic attacks, trouble sleeping, or if you feel impulsive, irritable, agitated, hostile, aggressive, restless, hyperactive (mentally or physically), more depressed, or have thoughts about suicide or hurting yourself.

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What should I discuss with my healthcare provider before taking Sinequan?

Do not use this medication if you are allergic to doxepin, or if you have glaucoma or problems with urination. Do not use doxepin if you have used an MAO inhibitor such as isocarboxazid (Marplan), phenelzine (Nardil), rasagiline (Azilect), selegiline (Eldepryl, Emsam), or tranylcypromine (Parnate) within the past 14 days. Serious, life-threatening side effects can occur if you take doxepin before the MAO inhibitor has cleared from your body.
Before taking doxepin, tell your doctor if you are allergic to any drugs, or if you have:

bipolar disorder (manic-depression); or

diabetes (doxepin may raise or lower blood sugar).

If you have any of these conditions, you may not be able to use doxepin, or you may need a dosage adjustment or special tests during treatment.

You may have thoughts about suicide when you first start taking an antidepressant, especially if you are younger than 24 years old. Tell your doctor if you have worsening symptoms of depression or suicidal thoughts during the first several weeks of treatment, or whenever your dose is changed.

Your family or other caregivers should also be alert to changes in your mood or symptoms. Your doctor will need to check you at regular visits for at least the first 12 weeks of treatment.

This medication may be harmful to an unborn baby. Tell your doctor if you are pregnant or plan to become pregnant during treatment. It is not known whether doxepin passes into breast milk or if it could harm a nursing baby. Do not use this medication without telling your doctor if you are breast-feeding a baby. Do not give doxepin to anyone younger than 18 years old without the advice of a doctor.

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BACK TO INDEX

How should I take Sinequan?

Take this medication exactly as it was prescribed for you. Do not take the medication in larger amounts, or take it for longer than recommended by your doctor. Your doctor may occasionally change your dose to make sure you get the best results from this medication. Follow the directions on your prescription label.

Measure doxepin oral concentrate (liquid) with the special dose-measuring dropper provided. Do not use a regular table spoon. If you do not have a dose-measuring dropper, ask your pharmacist for one.

Empty the measured dose from the medicine dropper into a small glass (4 ounces) of water, milk, orange juice, tomato juice, prune juice, or pineapple juice. Do not use a carbonated soft drink to mix doxepin oral concentrate. Stir the mixture and drink all of it right away. Do not save it for later use.

It may take a few weeks of using this medicine before your symptoms improve. For best results, keep using the medication as directed. Talk with your doctor if your symptoms do not improve during treatment. Store doxepin at room temperature away from moisture and heat.

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What happens if I miss a dose?

Take the missed dose as soon as you remember. If it is almost time for your next dose, skip the missed dose and take the medicine at the next regularly scheduled time. Do not take extra medicine to make up the missed dose.

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BACK TO INDEX

What happens if I overdose?

Seek emergency medical attention if you think you have used too much of this medicine. An overdose of doxepin can be fatal.
Symptoms of a doxepin overdose may include uneven heartbeats, extreme drowsiness, agitation, vomiting, blurred vision, confusion, hallucinations, feeling hot or cold, muscle stiffness, feeling light-headed, fainting, seizure (convulsions), or coma.

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BACK TO INDEX

What should I avoid while taking Sinequan?

Avoid drinking alcohol. It can cause dangerous side effects when taken together with doxepin.
Avoid using other medicines that make you sleepy (such as cold medicine, pain medication, muscle relaxers, medicine for seizures, or other medication for depression or anxiety). They can add to sleepiness caused by doxepin.

Grapefruit and grapefruit juice may interact with doxepin. Discuss the use of grapefruit products with your doctor before increasing or decreasing the amount of grapefruit products in your diet.

Doxepin can cause side effects that may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be awake and alert.

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BACK TO INDEX

Sinequan side effects

Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat.
Call your doctor at once if you have any new or worsening symptoms such as: mood or behavior changes, anxiety, panic attacks, trouble sleeping, or if you feel impulsive, irritable, agitated, hostile, aggressive, restless, hyperactive (mentally or physically), more depressed, or have thoughts about suicide or hurting yourself.

Call your doctor at once if you have any of these serious side effects:
fast, pounding, or uneven heart rate;

confusion, hallucinations, or seizure (convulsions);

easy bruising or bleeding, unusual weakness;

feeling light-headed, fainting;

restless muscle movements in your eyes, tongue, jaw, or neck;

tremors or uncontrollable shaking;

urinating less than usual or not at all; or

extreme thirst with headache, nausea, vomiting, and weakness.

Less serious side effects may be more likely to occur, such as:

nausea, vomiting, constipation, loss of appetite;

dry mouth;

weight changes;

weakness, lack of coordination;

numbness or tingly feeling;

feeling dizzy, drowsy, or tired;

sleep problems (insomnia), nightmares;

blurred vision, headache, ringing in your ears;

increased sweating;

breast swelling (in men or women); or

decreased sex drive, impotence, or difficulty having an orgasm.

Side effects other than those listed here may also occur. Talk to your doctor about any side effect that seems unusual or that is especially bothersome.

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BACK TO INDEX

What other drugs will affect Sinequan?

Before taking doxepin, tell your doctor if you have used an "SSRI" antidepressant in the past 5 weeks, such as citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac, Sarafem), fluvoxamine (Luvox), paroxetine (Paxil), or sertraline (Zoloft).

Before taking doxepin, tell your doctor if you are currently using any of the following drugs:

cimetidine (Tagamet) or;

heart rhythm medications such as flecainide (Tambocor), propafenone (Rhythmol), or quinidine (Cardioquin, Quinidex, Quinaglute).

If you are using any of these drugs, you may not be able to use doxepin, or you may need dosage adjustments or special tests during treatment.

There are many other medicines that can interact with doxepin. Tell your doctor about all the prescription and over-the-counter medications you use. This includes vitamins, minerals, herbal products, and drugs prescribed by other doctors. Do not start using a new medication without telling your doctor. Keep a list with you of all the medicines you use and show this list to any doctor or other healthcare provider who treats you.

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BACK TO INDEX

Where can I get more information?

Your pharmacist has information about amoxapine written for health professionals that you may read

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BACK TO INDEX

What does my medication look like?

Doxepin is available with a prescription under the brand name Sinequan. Other brand or generic formulations may also be available. Ask your pharmacist any questions you have about this medication, especially if it is new to you.

Sinequan 10 mg--red/pink capsule

Sinequan 25 mg--blue/pink capsule

Sinequan 50 mg--pink/white capsule

Sinequan 75 mg--white/white capsule

Sinequan 100 mg--blue/white capsule

Sinequan 150 mg--blue/blue capsule

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Aventyl HCl (NORTRIPTYLINE)

Generic Name: nortriptyline (nor TRIP ti leen)
Brand Names: Aventyl HCl, Pamelor

What is Aventyl HCl?
What is the most important information I should know about Aventyl HCl?
What should I discuss with my healthcare provider before taking Aventyl HCl?
How should I take Aventyl HCl?
What happens if I miss a dose?
What happens if I overdose?
What should I avoid while taking Aventyl HCl?
Aventyl HCl side effects
What other drugs will affect Aventyl HCl?
Where can I get more information?
What does my medication look like?

What is Aventyl HCl?

Nortriptyline is in a group of drugs called tricyclic antidepressants. Nortriptyline affects chemicals in the brain that may become unbalanced.

Nortriptyline is used to treat symptoms of depression.

Nortriptyline may also be used for purposes other than those listed in this medication guide.

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BACK TO INDEX

What is the most important information I should know about Aventyl HCl?

Do not use nortriptyline if you have recently had a heart attack, or if you have used an MAO inhibitor such as isocarboxazid (Marplan), phenelzine (Nardil), rasagiline (Azilect), selegiline (Eldepryl, Emsam), or tranylcypromine (Parnate) within the past 14 days.
You may have thoughts about suicide when you first start taking an antidepressant, especially if you are younger than 24 years old. Your doctor will need to check you at regular visits for at least the first 12 weeks of treatment.

Call your doctor at once if you have any new or worsening symptoms such as: mood or behavior changes, anxiety, panic attacks, trouble sleeping, or if you feel impulsive, irritable, agitated, hostile, aggressive, restless, hyperactive (mentally or physically), more depressed, or have thoughts about suicide or hurting yourself.

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BACK TO INDEX

What should I discuss with my healthcare provider before taking Aventyl HCl?

Do not use this medication if you are allergic to nortriptyline, or if you have recently had a heart attack. Do not use nortriptyline if you have used an MAO inhibitor such as isocarboxazid (Marplan), phenelzine (Nardil), rasagiline (Azilect), selegiline (Eldepryl, Emsam), or tranylcypromine (Parnate) within the past 14 days. Serious, life-threatening side effects can occur if you take nortriptyline before the MAO inhibitor has cleared from your body.
Before taking nortriptyline, tell your doctor if you are allergic to any drugs, or if you have:

heart disease;

a history of heart attack, stroke, or seizures;

bipolar disorder (manic-depression);

schizophrenia or other mental illness;

diabetes (nortriptyline may raise or lower blood sugar);

overactive thyroid;

glaucoma; or

problems with urination.

If you have any of these conditions, you may not be able to use nortriptyline, or you may need a dosage adjustment or special tests during treatment.

You may have thoughts about suicide when you first start taking an antidepressant, especially if you are younger than 24 years old. Tell your doctor if you have worsening symptoms of depression or suicidal thoughts during the first several weeks of treatment, or whenever your dose is changed.

Your family or other caregivers should also be alert to changes in your mood or symptoms. Your doctor will need to check you at regular visits for at least the first 12 weeks of treatment.

This medication may be harmful to an unborn baby. Tell your doctor if you are pregnant or plan to become pregnant during treatment. It is not known whether nortriptyline passes into breast milk or if it could harm a nursing baby. Do not use this medication without telling your doctor if you are breast-feeding a baby.
Older adults may be more likely to have side effects from this medication.

Do not give this medication to anyone under 18 years old without the advice of a doctor.

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BACK TO INDEX

How should I take Aventyl HCl?

Take this medication exactly as it was prescribed for you. Do not take the medication in larger amounts, or take it for longer than recommended by your doctor. Your doctor may occasionally change your dose to make sure you get the best results from this medication. Follow the directions on your prescription label.

If you need to have any type of surgery, tell the surgeon ahead of time that you are taking nortriptyline. You may need to stop using the medicine for a short time.

Do not stop using nortriptyline without first talking to your doctor. You may need to use less and less before you stop the medication completely. Stopping this medication suddenly could cause you to have unpleasant side effects. It may take a few weeks of using this medicine before your symptoms improve. For best results, keep using the medication as directed. Talk with your doctor if your symptoms do not improve during treatment with nortriptyline. Store nortriptyline at room temperature away from moisture and heat.

BACK TO TOP

BACK TO INDEX

What happens if I miss a dose?

Take the missed dose as soon as you remember. If it is almost time for your next dose, skip the missed dose and take the medicine at the next regularly scheduled time. Do not take extra medicine to make up the missed dose.

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BACK TO INDEX

What happens if I overdose?

Seek emergency medical attention if you think you have used too much of this medicine. An overdose of nortriptyline can be fatal.
Symptoms of a nortriptyline overdose may include extreme drowsiness, confusion, agitation, hallucinations, blurred vision, vomiting, muscle stiffness, feeling hot or cold, fainting, seizure (convulsions), or coma.

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BACK TO INDEX

What should I avoid while taking Aventyl HCl?

Avoid drinking alcohol. It can cause dangerous side effects when taken together with nortriptyline.
Avoid using other medicines that make you sleepy (such as cold medicine, pain medication, muscle relaxers, medicine for seizures, or other antidepressants). They can add to sleepiness caused by nortriptyline.

Grapefruit and grapefruit juice may interact with nortriptyline. Discuss the use of grapefruit products with your doctor before increasing or decreasing the amount of grapefruit products in your diet.

Nortriptyline can cause side effects that may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be awake and alert. Avoid exposure to sunlight or artificial UV rays (sunlamps or tanning beds). Nortriptyline can make your skin more sensitive to sunlight and sunburn may result. Use a sunscreen (minimum SPF 15) and wear protective clothing if you must be out in the sun.

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BACK TO INDEX

Aventyl HCl side effects

Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat.
Call your doctor at once if you have any new or worsening symptoms such as: mood or behavior changes, anxiety, panic attacks, trouble sleeping, or if you feel impulsive, irritable, agitated, hostile, aggressive, restless, hyperactive (mentally or physically), more depressed, or have thoughts about suicide or hurting yourself.

Call your doctor at once if you have any of these serious side effects:
fast, pounding, or uneven heart rate;

chest pain or heavy feeling, pain spreading to the arm or shoulder, nausea, sweating, general ill feeling;

sudden numbness or weakness, especially on one side of the body;

sudden headache, confusion, problems with vision, speech, or balance;

confusion, hallucinations, or seizure (convulsions);

easy bruising or bleeding, unusual weakness;

restless muscle movements in your eyes, tongue, jaw, or neck;

tremors;

extreme thirst with headache, nausea, vomiting, and weakness;

feeling light-headed or fainting; or

urinating less than usual or not at all.

Less serious side effects may be more likely to occur, such as:

nausea, vomiting, stomach pain, loss of appetite;

constipation or diarrhea;

weight changes;

dry mouth, unpleasant taste;

weakness, lack of coordination;

numbness or tingly feeling;

blurred vision, headache, ringing in your ears;

mild skin rash;

breast swelling (in men or women); or

increased sweating.

Side effects other than those listed here may also occur. Talk to your doctor about any side effect that seems unusual or that is especially bothersome.

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BACK TO INDEX

What other drugs will affect Aventyl HCl?

Before taking nortriptyline, tell your doctor if you have used an "SSRI" antidepressant in the past 5 weeks, such as citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac, Sarafem), fluvoxamine (Luvox), paroxetine (Paxil), or sertraline (Zoloft).

Before taking nortriptyline, tell your doctor if you are currently using any of the following drugs:

cimetidine (Tagamet);

guanethidine (Ismelin);

reserpine; or

heart rhythm medications such as flecainide (Tambocor), propafenone (Rhythmol), or quinidine (Cardioquin, Quinidex, Quinaglute).

If you are using any of these drugs, you may not be able to use nortriptyline, or you may need dosage adjustments or special tests during treatment.

There are many other medicines that can interact with nortriptyline. Tell your doctor about all the prescription and over-the-counter medications you use. This includes vitamins, minerals, herbal products, and drugs prescribed by other doctors. Do not start using a new medication without telling your doctor. Keep a list with you of all the medicines you use and show this list to any doctor or other healthcare provider who treats you.

BACK TO TOP

BACK TO INDEX

Where can I get more information?

Your pharmacist has information about amoxapine written for health professionals that you may read

BACK TO TOP

BACK TO INDEX

What does my medication look like?

Nortriptyline is available with a prescription under the brand name Pamelor. Other brand or generic formulations may also be available. Ask your pharmacist any questions you have about this medication, especially if it is new to you.

Pamelor 10 mg--orange/white capsules

Pamelor 25 mg--orange/white capsules

Pamelor 50 mg--white/white capsules

Pamelor 75 mg--orange/orange capsules

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Pamelor (NORTRIPTYLINE)

Generic Name: nortriptyline (nor TRIP ti leen)
Brand Names: Aventyl HCl, Pamelor

What is Pamelor?
What is the most important information I should know about Pamelor?
What should I discuss with my healthcare provider before taking Pamelor?
How should I take Pamelor?
What happens if I miss a dose?
What happens if I overdose?
What should I avoid while taking Pamelor?
Pamelor side effects
What other drugs will affect Pamelor?
Where can I get more information?
What does my medication look like?

What is Pamelor?

Nortriptyline is in a group of drugs called tricyclic antidepressants. Nortriptyline affects chemicals in the brain that may become unbalanced.

Nortriptyline is used to treat symptoms of depression.

Nortriptyline may also be used for purposes other than those listed in this medication guide.

BACK TO TOP

BACK TO INDEX

What is the most important information I should know about Pamelor?

Do not use nortriptyline if you have recently had a heart attack, or if you have used an MAO inhibitor such as isocarboxazid (Marplan), phenelzine (Nardil), rasagiline (Azilect), selegiline (Eldepryl, Emsam), or tranylcypromine (Parnate) within the past 14 days.
You may have thoughts about suicide when you first start taking an antidepressant, especially if you are younger than 24 years old. Your doctor will need to check you at regular visits for at least the first 12 weeks of treatment.

Call your doctor at once if you have any new or worsening symptoms such as: mood or behavior changes, anxiety, panic attacks, trouble sleeping, or if you feel impulsive, irritable, agitated, hostile, aggressive, restless, hyperactive (mentally or physically), more depressed, or have thoughts about suicide or hurting yourself.

BACK TO TOP

BACK TO INDEX

What should I discuss with my healthcare provider before taking Pamelor?

Do not use this medication if you are allergic to nortriptyline, or if you have recently had a heart attack. Do not use nortriptyline if you have used an MAO inhibitor such as isocarboxazid (Marplan), phenelzine (Nardil), rasagiline (Azilect), selegiline (Eldepryl, Emsam), or tranylcypromine (Parnate) within the past 14 days. Serious, life-threatening side effects can occur if you take nortriptyline before the MAO inhibitor has cleared from your body.
Before taking nortriptyline, tell your doctor if you are allergic to any drugs, or if you have:

heart disease;

a history of heart attack, stroke, or seizures;

bipolar disorder (manic-depression);

schizophrenia or other mental illness;

diabetes (nortriptyline may raise or lower blood sugar);

overactive thyroid;

glaucoma; or

problems with urination.

If you have any of these conditions, you may not be able to use nortriptyline, or you may need a dosage adjustment or special tests during treatment.

You may have thoughts about suicide when you first start taking an antidepressant, especially if you are younger than 24 years old. Tell your doctor if you have worsening symptoms of depression or suicidal thoughts during the first several weeks of treatment, or whenever your dose is changed.

Your family or other caregivers should also be alert to changes in your mood or symptoms. Your doctor will need to check you at regular visits for at least the first 12 weeks of treatment.

This medication may be harmful to an unborn baby. Tell your doctor if you are pregnant or plan to become pregnant during treatment. It is not known whether nortriptyline passes into breast milk or if it could harm a nursing baby. Do not use this medication without telling your doctor if you are breast-feeding a baby.
Older adults may be more likely to have side effects from this medication.

Do not give this medication to anyone under 18 years old without the advice of a doctor.

BACK TO TOP

BACK TO INDEX

How should I take Pamelor?

Take this medication exactly as it was prescribed for you. Do not take the medication in larger amounts, or take it for longer than recommended by your doctor. Your doctor may occasionally change your dose to make sure you get the best results from this medication. Follow the directions on your prescription label.

If you need to have any type of surgery, tell the surgeon ahead of time that you are taking nortriptyline. You may need to stop using the medicine for a short time.

Do not stop using nortriptyline without first talking to your doctor. You may need to use less and less before you stop the medication completely. Stopping this medication suddenly could cause you to have unpleasant side effects. It may take a few weeks of using this medicine before your symptoms improve. For best results, keep using the medication as directed. Talk with your doctor if your symptoms do not improve during treatment with nortriptyline. Store nortriptyline at room temperature away from moisture and heat.

BACK TO TOP

BACK TO INDEX

What happens if I miss a dose?

Take the missed dose as soon as you remember. If it is almost time for your next dose, skip the missed dose and take the medicine at the next regularly scheduled time. Do not take extra medicine to make up the missed dose.

BACK TO TOP

BACK TO INDEX

What happens if I overdose?

Seek emergency medical attention if you think you have used too much of this medicine. An overdose of nortriptyline can be fatal.
Symptoms of a nortriptyline overdose may include extreme drowsiness, confusion, agitation, hallucinations, blurred vision, vomiting, muscle stiffness, feeling hot or cold, fainting, seizure (convulsions), or coma.

BACK TO TOP

BACK TO INDEX

What should I avoid while taking Pamelor?

Avoid drinking alcohol. It can cause dangerous side effects when taken together with nortriptyline.
Avoid using other medicines that make you sleepy (such as cold medicine, pain medication, muscle relaxers, medicine for seizures, or other antidepressants). They can add to sleepiness caused by nortriptyline.

Grapefruit and grapefruit juice may interact with nortriptyline. Discuss the use of grapefruit products with your doctor before increasing or decreasing the amount of grapefruit products in your diet.

Nortriptyline can cause side effects that may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be awake and alert. Avoid exposure to sunlight or artificial UV rays (sunlamps or tanning beds). Nortriptyline can make your skin more sensitive to sunlight and sunburn may result. Use a sunscreen (minimum SPF 15) and wear protective clothing if you must be out in the sun.

BACK TO TOP

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Pamelor side effects

Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat.
Call your doctor at once if you have any new or worsening symptoms such as: mood or behavior changes, anxiety, panic attacks, trouble sleeping, or if you feel impulsive, irritable, agitated, hostile, aggressive, restless, hyperactive (mentally or physically), more depressed, or have thoughts about suicide or hurting yourself.

Call your doctor at once if you have any of these serious side effects:
fast, pounding, or uneven heart rate;

chest pain or heavy feeling, pain spreading to the arm or shoulder, nausea, sweating, general ill feeling;

sudden numbness or weakness, especially on one side of the body;

sudden headache, confusion, problems with vision, speech, or balance;

confusion, hallucinations, or seizure (convulsions);

easy bruising or bleeding, unusual weakness;

restless muscle movements in your eyes, tongue, jaw, or neck;

tremors;

extreme thirst with headache, nausea, vomiting, and weakness;

feeling light-headed or fainting; or

urinating less than usual or not at all.

Less serious side effects may be more likely to occur, such as:

nausea, vomiting, stomach pain, loss of appetite;

constipation or diarrhea;

weight changes;

dry mouth, unpleasant taste;

weakness, lack of coordination;

numbness or tingly feeling;

blurred vision, headache, ringing in your ears;

mild skin rash;

breast swelling (in men or women); or

increased sweating.

Side effects other than those listed here may also occur. Talk to your doctor about any side effect that seems unusual or that is especially bothersome.

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What other drugs will affect Pamelor?

Before taking nortriptyline, tell your doctor if you have used an "SSRI" antidepressant in the past 5 weeks, such as citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac, Sarafem), fluvoxamine (Luvox), paroxetine (Paxil), or sertraline (Zoloft).

Before taking nortriptyline, tell your doctor if you are currently using any of the following drugs:

cimetidine (Tagamet);

guanethidine (Ismelin);

reserpine; or

heart rhythm medications such as flecainide (Tambocor), propafenone (Rhythmol), or quinidine (Cardioquin, Quinidex, Quinaglute).

If you are using any of these drugs, you may not be able to use nortriptyline, or you may need dosage adjustments or special tests during treatment.

There are many other medicines that can interact with nortriptyline. Tell your doctor about all the prescription and over-the-counter medications you use. This includes vitamins, minerals, herbal products, and drugs prescribed by other doctors. Do not start using a new medication without telling your doctor. Keep a list with you of all the medicines you use and show this list to any doctor or other healthcare provider who treats you.

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Where can I get more information?

Your pharmacist has information about amoxapine written for health professionals that you may read

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What does my medication look like?

Nortriptyline is available with a prescription under the brand name Pamelor. Other brand or generic formulations may also be available. Ask your pharmacist any questions you have about this medication, especially if it is new to you.

Pamelor 10 mg--orange/white capsules

Pamelor 25 mg--orange/white capsules

Pamelor 50 mg--white/white capsules

Pamelor 75 mg--orange/orange capsules

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Tofranil (IMIPRAMINE)

Generic Name: imipramine (im IP ra meen)
Brand Names: Tofranil, Tofranil-PM

What is Tofranil?
What is the most important information I should know about Tofranil?
What should I discuss with my healthcare provider before taking Tofranil?
How should I take Tofranil?
What happens if I miss a dose?
What happens if I overdose?
What should I avoid while taking Tofranil?
Tofranil side effects
What other drugs will affect Tofranil?
Where can I get more information?
What does my medication look like?

What is Tofranil?

Imipramine is in a group of drugs called tricyclic antidepressants. Imipramine affects chemicals in the brain that may become unbalanced.

Imipramine is used to treat symptoms of depression.

Imipramine may also be used for purposes other than those listed in this medication guide.

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What is the most important information I should know about Tofranil?

Do not use imipramine if you have recently had a heart attack, or if you have used an MAO inhibitor such as isocarboxazid (Marplan), phenelzine (Nardil), rasagiline (Azilect), selegiline (Eldepryl, Emsam), or tranylcypromine (Parnate) within the past 14 days.
You may have thoughts about suicide when you first start taking an antidepressant, especially if you are younger than 24 years old. Your doctor will need to check you at regular visits for at least the first 12 weeks of treatment.

Call your doctor at once if you have any new or worsening symptoms such as: mood or behavior changes, anxiety, panic attacks, trouble sleeping, or if you feel impulsive, irritable, agitated, hostile, aggressive, restless, hyperactive (mentally or physically), more depressed, or have thoughts about suicide or hurting yourself.

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What should I discuss with my healthcare provider before taking Tofranil?

Do not use this medication if you are allergic to imipramine, or if you have recently had a heart attack. Do not use imipramine if you have used an MAO inhibitor such as isocarboxazid (Marplan), phenelzine (Nardil), rasagiline (Azilect), selegiline (Eldepryl, Emsam), or tranylcypromine (Parnate) within the past 14 days. Serious, life-threatening side effects can occur if you take imipramine before the MAO inhibitor has cleared from your body.
Before taking imipramine, tell your doctor if you are allergic to any drugs, or if you have:

heart disease;

a history of heart attack, stroke, or seizures;

bipolar disorder (manic-depression);

kidney or liver disease;
overactive thyroid;

diabetes (imipramine may raise or lower blood sugar);

adrenal gland tumor (pheochromocytoma);

glaucoma; or

problems with urination.

If you have any of these conditions, you may not be able to use imipramine, or you may need a dosage adjustment or special tests during treatment.

You may have thoughts about suicide when you first start taking an antidepressant, especially if you are younger than 24 years old. Tell your doctor if you have worsening symptoms of depression or suicidal thoughts during the first several weeks of treatment, or whenever your dose is changed.

Your family or other caregivers should also be alert to changes in your mood or symptoms. Your doctor will need to check you at regular visits for at least the first 12 weeks of treatment.

This medication may be harmful to an unborn baby. Tell your doctor if you are pregnant or plan to become pregnant during treatment. Imipramine can pass into breast milk and may harm a nursing baby. Do not use this medication without telling your doctor if you are breast-feeding a baby. Do not give this medication to anyone younger than 18 years old without the advice of a doctor.

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How should I take Tofranil?

Take this medication exactly as it was prescribed for you. Do not take the medication in larger amounts, or take it for longer than recommended by your doctor. Your doctor may occasionally change your dose to make sure you get the best results from this medication. Follow the directions on your prescription label.

If you need to have any type of surgery, tell the surgeon ahead of time that you are taking imipramine. You may need to stop using the medicine for a short time.

Do not stop using imipramine without first talking to your doctor. You may need to use less and less before you stop the medication completely. Stopping this medication suddenly could cause you to have unpleasant side effects. It may take up to 3 weeks of using this medicine before your symptoms improve. For best results, keep using the medication as directed. Talk with your doctor if your symptoms do not improve after 3 weeks of treatment. Store imipramine at room temperature away from moisture and heat.

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What happens if I miss a dose?

Take the missed dose as soon as you remember. If it is almost time for your next dose, skip the missed dose and take the medicine at the next regularly scheduled time. Do not take extra medicine to make up the missed dose.

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What happens if I overdose?

Seek emergency medical attention if you think you have used too much of this medicine. An overdose of imipramine can be fatal.
Symptoms of an imipramine overdose may include uneven heartbeats, extreme drowsiness, agitation, vomiting, blurred vision, sweating, muscle stiffness, swelling, shortness of breath, blue lips or fingernails, feeling light-headed, fainting, seizure (convulsions), or coma.

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What should I avoid while taking Tofranil?

Avoid drinking alcohol. It can cause dangerous side effects when taken together with imipramine.
Avoid using other medicines that make you sleepy (such as cold medicine, pain medication, muscle relaxers, medicine for seizures, or other antidepressants). They can add to sleepiness caused by imipramine.

Grapefruit and grapefruit juice may interact with imipramine. Discuss the use of grapefruit products with your doctor before increasing or decreasing the amount of grapefruit products in your diet.

Imipramine can cause side effects that may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be awake and alert. Avoid exposure to sunlight or artificial UV rays (sunlamps or tanning beds). Imipramine can make your skin more sensitive to sunlight and sunburn may result. Use a sunscreen (minimum SPF 15) and wear protective clothing if you must be out in the sun.

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Tofranil side effects

Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat.
Call your doctor at once if you have any new or worsening symptoms such as: mood or behavior changes, anxiety, panic attacks, trouble sleeping, or if you feel impulsive, irritable, agitated, hostile, aggressive, restless, hyperactive (mentally or physically), more depressed, or have thoughts about suicide or hurting yourself.

Call your doctor at once if you have any of these serious side effects:
fast, pounding, or uneven heart rate;

chest pain or heavy feeling, pain spreading to the arm or shoulder, nausea, sweating, general ill feeling;

sudden numbness or weakness, especially on one side of the body;

sudden headache, confusion, problems with vision, speech, or balance;

feeling short of breath, even with mild exertion;

swelling, rapid weight gain;

confusion, hallucinations, or seizure (convulsions);

easy bruising or bleeding, unusual weakness;

restless muscle movements in your eyes, tongue, jaw, or neck;

urinating more or less than usual;

extreme thirst with headache, nausea, vomiting, and weakness;

skin rash, bruising, severe tingling, numbness, pain, or muscle weakness.

Less serious side effects may be more likely to occur, such as:

nausea, vomiting, stomach pain, loss of appetite;

constipation or diarrhea;

dry mouth, unpleasant taste;

weight changes;

weakness, lack of coordination;

feeling dizzy, drowsy, or tired;

nightmares;

blurred vision, headache, ringing in your ears;

breast swelling (in men or women); or

decreased sex drive, impotence, or difficulty having an orgasm.

Side effects other than those listed here may also occur. Talk to your doctor about any side effect that seems unusual or that is especially bothersome.

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What other drugs will affect Tofranil?

Before taking imipramine, tell your doctor if you have used an "SSRI" antidepressant in the past 5 weeks, such as citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac, Sarafem), fluvoxamine (Luvox), paroxetine (Paxil), or sertraline (Zoloft).

Before taking imipramine, tell your doctor if you are currently using any of the following drugs:

cimetidine (Tagamet);

clonidine (Catapres);

guanethidine (Ismelin);

methylphenidate (Concerta, Ritalin, Daytrana); or

heart rhythm medications such as flecainide (Tambocor), propafenone (Rhythmol), or quinidine (Cardioquin, Quinidex, Quinaglute).

If you are using any of these drugs, you may not be able to use imipramine, or you may need dosage adjustments or special tests during treatment.

There are many other medicines that can interact with imipramine. Tell your doctor about all the prescription and over-the-counter medications you use. This includes vitamins, minerals, herbal products, and drugs prescribed by other doctors. Do not start using a new medication without telling your doctor. Keep a list with you of all the medicines you use and show this list to any doctor or other healthcare provider who treats you.

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Where can I get more information?

Your pharmacist has information about amoxapine written for health professionals that you may read

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What does my medication look like?
Imipramine is available with a prescription generically and under the brand name Tofranil. Other brand or generic formulations may also be available. Ask your pharmacist any questions you have about this medication, especially if it is new to you.

Tofranil 10 mg--triangular, coral, sugar-coated tablets

Tofranil 25 mg--round, coral, sugar-coated tablets

Tofranil 50 mg--round, coral, sugar-coated tablets

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Vivactil (PROTRIPTYLINE)

Generic Name: protriptyline (proe TRIP ti leen)
Brand Names: Vivactil

What is Vivactil?
What is the most important information I should know about Vivactil?
What should I discuss with my healthcare provider before taking Vivactil?
How should I take Vivactil?
What happens if I miss a dose?
What happens if I overdose?
What should I avoid while taking Vivactil?
Vivactil side effects
What other drugs will affect Vivactil?
Where can I get more information?
What does my medication look like?

What is Vivactil?

Protriptyline is in a group of drugs called tricyclic antidepressants. Protriptyline affects chemicals in the brain that may become unbalanced.

Protriptyline is used to treat symptoms of depression.

Protriptyline may also be used for purposes other than those listed in this medication guide.

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What is the most important information I should know about Vivactil?

Do not use protriptyline if you have recently had a heart attack, or if you have taken cisapride (Propulsid) or used an MAO inhibitor such as isocarboxazid (Marplan), phenelzine (Nardil), rasagiline (Azilect), selegiline (Eldepryl, Emsam), or tranylcypromine (Parnate) within the past 14 days.
You may have thoughts about suicide when you first start taking an antidepressant, especially if you are younger than 24 years old. Your doctor will need to check you at regular visits for at least the first 12 weeks of treatment.

Call your doctor at once if you have any new or worsening symptoms such as: mood or behavior changes, anxiety, panic attacks, trouble sleeping, or if you feel impulsive, irritable, agitated, hostile, aggressive, restless, hyperactive (mentally or physically), more depressed, or have thoughts about suicide or hurting yourself.

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What should I discuss with my healthcare provider before taking Vivactil?

Do not use this medication if you are allergic to protriptyline, or if you have recently had a heart attack. Do not use protriptyline if you have taken cisapride (Propulsid) or used an MAO inhibitor such as isocarboxazid (Marplan), phenelzine (Nardil), rasagiline (Azilect), selegiline (Eldepryl, Emsam), or tranylcypromine (Parnate) within the past 14 days. Serious, life-threatening side effects can occur if you take protriptyline before the MAO inhibitor has cleared from your body.
Before taking protriptyline, tell your doctor if you are allergic to any drugs, or if you have:

heart disease;

a history of heart attack, stroke, or seizures;

bipolar disorder (manic-depression);

schizophrenia or other mental illness;

diabetes (protriptyline may raise or lower blood sugar);

glaucoma; or

problems with urination.

If you have any of these conditions, you may not be able to use protriptyline, or you may need a dosage adjustment or special tests during treatment.

You may have thoughts about suicide when you first start taking an antidepressant, especially if you are younger than 24 years old. Tell your doctor if you have worsening symptoms of depression or suicidal thoughts during the first several weeks of treatment, or whenever your dose is changed.

Your family or other caregivers should also be alert to changes in your mood or symptoms. Your doctor will need to check you at regular visits for at least the first 12 weeks of treatment.

This medication may be harmful to an unborn baby. Tell your doctor if you are pregnant or plan to become pregnant during treatment. It is not known whether protriptyline passes into breast milk or if it could harm a nursing baby. Do not use this medication without telling your doctor if you are breast-feeding a baby. Do not give this medication to anyone under 18 years old without the advice of a doctor.

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How should I take Vivactil?

TTake this medication exactly as it was prescribed for you. Do not take the medication in larger amounts, or take it for longer than recommended by your doctor. Your doctor may occasionally change your dose to make sure you get the best results from this medication. Follow the directions on your prescription label.

If you need to have any type of surgery, tell the surgeon ahead of time that you are taking protriptyline. You may need to stop using the medicine for a short time.

Do not stop using protriptyline without first talking to your doctor. You may need to use less and less before you stop the medication completely. Stopping this medication suddenly could cause you to have unpleasant side effects. It may take a few weeks of using this medicine before your symptoms improve. For best results, keep using the medication as directed. Talk with your doctor if your symptoms do not improve during treatment with protriptyline. Store protriptyline at room temperature away from moisture and heat.

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What happens if I miss a dose?

Take the missed dose as soon as you remember. If it is almost time for your next dose, skip the missed dose and take the medicine at the next regularly scheduled time. Do not take extra medicine to make up the missed dose.

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What happens if I overdose?

Seek emergency medical attention if you think you have used too much of this medicine. An overdose of protriptyline can be fatal.
Symptoms of a protriptyline overdose may include extreme drowsiness, confusion, agitation, hallucinations, blurred vision, muscle stiffness, feeling hot or cold, seizure (convulsions), or coma.

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What should I avoid while taking Vivactil?

Avoid drinking alcohol. It can cause dangerous side effects when taken together with protriptyline.
Avoid using other medicines that make you sleepy (such as cold medicine, pain medication, muscle relaxers, medicine for seizures, or other antidepressants). They can add to sleepiness caused by protriptyline.

Grapefruit and grapefruit juice may interact with protriptyline. Discuss the use of grapefruit products with your doctor before increasing or decreasing the amount of grapefruit products in your diet.

Protriptyline can cause side effects that may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be awake and alert. Avoid exposure to sunlight or artificial UV rays (sunlamps or tanning beds). Protriptyline can make your skin more sensitive to sunlight and sunburn may result. Use a sunscreen (minimum SPF 15) and wear protective clothing if you must be out in the sun.

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Vivactil side effects

Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat.
Call your doctor at once if you have any new or worsening symptoms such as: mood or behavior changes, anxiety, panic attacks, trouble sleeping, or if you feel impulsive, irritable, agitated, hostile, aggressive, restless, hyperactive (mentally or physically), more depressed, or have thoughts about suicide or hurting yourself.

Call your doctor at once if you have any of these serious side effects:
fast, pounding, or uneven heart rate;

chest pain or heavy feeling, pain spreading to the arm or shoulder, nausea, sweating, general ill feeling;

sudden numbness or weakness, especially on one side of the body;

sudden headache, confusion, problems with vision, speech, or balance;

confusion, hallucinations, or seizure (convulsions);

easy bruising or bleeding, unusual weakness;

restless muscle movements in your eyes, tongue, jaw, or neck;

urinating less than usual or not at all;

extreme thirst with headache, nausea, vomiting, and weakness; or

feeling light-headed or fainting.

Less serious side effects may be more likely to occur, such as:

nausea, vomiting, stomach pain, loss of appetite;

constipation or diarrhea;

dry mouth, unpleasant taste;

weakness, lack of coordination;

feeling anxious, restless, dizzy, drowsy, or tired;

sleep problems (insomnia), nightmares;

blurred vision, headache, ringing in your ears;

breast swelling (in men or women); or

decreased sex drive, impotence, or difficulty having an orgasm.

Side effects other than those listed here may also occur. Talk to your doctor about any side effect that seems unusual or that is especially bothersome.

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What other drugs will affect Vivactil?

Before taking protriptyline, tell your doctor if you have used an "SSRI" antidepressant in the past 5 weeks, such as citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac, Sarafem), fluvoxamine (Luvox), paroxetine (Paxil), or sertraline (Zoloft).

Before taking protriptyline, tell your doctor if you are currently using any of the following drugs:

cimetidine (Tagamet);

guanethidine (Ismelin);

tramadol (Ultram);

heart rhythm medications such as flecainide (Tambocor), propafenone (Rhythmol), or quinidine (Cardioquin, Quinidex, Quinaglute); or

anti-psychotic medications such as chlorpromazine (Thorazine), haloperidol (Haldol), thioridazine (Mellaril), clozapine (Clozaril), olanzapine (Zyprexa, Zydis), quetiapine (Seroquel), risperidone (Risperdal), ziprasidone (Geodon), and others.

If you are using any of these drugs, you may not be able to use protriptyline, or you may need dosage adjustments or special tests during treatment.

There are many other medicines that can interact with protriptyline. Tell your doctor about all the prescription and over-the-counter medications you use. This includes vitamins, minerals, herbal products, and drugs prescribed by other doctors. Do not start using a new medication without telling your doctor. Keep a list with you of all the medicines you use and show this list to any doctor or other healthcare provider who treats you.

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Where can I get more information?

Your pharmacist has information about amoxapine written for health professionals that you may read

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What does my medication look like?

Protriptyline is available with a prescription under the brand name Vivactil. Other brand or generic formulations may also be available. Ask your pharmacist any questions you have about this medication especially if it is new to you.

Vivactil 5 mg--oval, orange, film-coated tablets

Vivactil 10 mg--oval, yellow, film-coated tablets

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Emsam (SELEGILINE)

Generic Name: selegiline (transdermal) (se LE ji leen)
Brand Names: Emsam

What is Emsam?
What is the most important information I should know about Emsam?
What should I discuss with my healthcare provider before taking Emsam?
How should I take Emsam?
What happens if I miss a dose?
What happens if I overdose?
What should I avoid while taking Emsam?
Emsam side effects
What other drugs will affect Emsam?
Where can I get more information?
What does my medication look like?

What is Emsam?

Emsam prevents the breakdown of chemicals in the brain that are often imbalanced in people with depression.

Emsam is used to treat major depressive disorder.

Emsam may also be used for purposes other than those listed in this medication guide.

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What is the most important information I should know about Emsam?

There are many other medicines that can cause serious medical problems if you take them while using Emsam. Tell your doctor about all other prescription and over-the-counter medications you use, including vitamins, minerals, and herbal products.

While using Emsam, do not drink alcohol or eat foods that are high in tyramine, listed in the "What should I avoid while using Emsam?" section of this leaflet. Eating tyramine while you are using Emsam can raise your blood pressure to dangerous levels and cause life-threatening symptoms.
You may have thoughts about suicide when you first start using an antidepressant, especially if you are younger than 24 years old. Your doctor will need to check you at regular visits for at least the first 12 weeks of treatment.

Call your doctor at once if you have any new or worsening symptoms such as: mood or behavior changes, anxiety, panic attacks, trouble sleeping, or if you feel impulsive, irritable, agitated, hostile, aggressive, restless, hyperactive (mentally or physically), more depressed, or have thoughts about suicide or hurting yourself.

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What should I discuss with my doctor before taking Emsam

Do not use Emsam if you are allergic to selegiline, if you have an adrenal gland tumor (also called pheochromocytoma), or if you plan to have any type of surgery. Do not use Emsam if you have taken any of the following drugs within the past 14 days:
carbamazepine (Tegretol) or oxcarbazepine (Trileptal);

cyclobenzaprine (Flexeril);

dextromethorphan (cough medicine);

meperidine (Demerol), methadone (Dolophine, Methadose), propoxyphene (Darvon, Darvocet), or tramadol (Ultram, Ultracet);

mirtazapine (Remeron);

diet pills or cold medicines that contain dextromethorphan, ephedrine, pseudoephedrine, or phenylephrine;

St. John's wort;

antidepressants such as amitriptyline (Elavil), amoxapine (Ascendin), bupropion (Wellbutrin, Zyban), citalopram (Celexa), clomipramine (Anafranil), desipramine (Norpramin), doxepin (Sinequan), duloxetine (Cymbalta), escitalopram (Lexapro), fluoxetine (Prozac), fluvoxamine (Luvox), imipramine (Tofranil), nortriptyline (Pamelor), paroxetine (Paxil), protriptyline (Vivactil), sertraline (Zoloft), venlafaxine (Effexor), or trimipramine (Surmontil); or

other MAO inhibitors such as isocarboxazid (Marplan), tranylcypromine (Parnate), phenelzine (Nardil), rasagiline (Azilect), or oral selegiline (Eldepryl).

After you stop using Emsam, you must wait at least 14 days before taking any of the medications listed above.

Tell your doctor if you are allergic to any drugs, or if you have:

heart disease, high or low blood pressure;

seizures or epilepsy; or

a personal or family history of bipolar disorder (manic depression) or suicide attempt.

You may have thoughts about suicide when you first start using an antidepressant, especially if you are younger than 24 years old. Tell your doctor if you have worsening symptoms of depression or suicidal thoughts during the first several weeks of treatment, or whenever your dose is changed.

Your family or other caregivers should also be alert to changes in your mood or symptoms. Your doctor will need to check you at regular visits for at least the first 12 weeks of treatment.

FDA pregnancy category C. This medication may be harmful to an unborn baby. Tell your doctor if you are pregnant or plan to become pregnant during treatment. It is not known whether selegiline passes into breast milk or if it could harm a nursing baby. Do not use this medication without telling your doctor if you are breast-feeding a baby.

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How should I take Emsam?

Use this medication exactly as directed on the label, or as it has been prescribed by your doctor. Do not use more of the skin patches or use them for longer than recommended. Follow the directions on your prescription label.

While you are using Emsam and for 14 days after you stop, you must not eat foods listed in the "What should I avoid while using Emsam?" section of this leaflet. Eating these foods while you are using Emsam can raise your blood pressure to dangerous levels.
Foods that you MAY eat include:

fresh meat, poultry, or fish (including lunch meat, hot dogs, breakfast sausage, and cooked sliced ham);

any vegetables except broad bean pods (fava beans);

processed cheese, mozzarella, ricotta, cottage cheese;

pizza made with cheeses low in tyramine;

soy milk, yogurt; or

Brewer's or baker's yeast.

This medication comes with patient instructions for safe and effective use. Follow these directions carefully. Ask your doctor or pharmacist if you have any questions.

Before applying a skin patch, wash the skin with soap and water and dry completely. The patch can be worn on a dry, smooth, and hairless area of your back, upper arm, chest, or thigh. Do not apply the patch to a skin wound or irritated skin, or wear it under tight clothing.

Remove the patch after 24 hours, taking care not to touch the sticky side with your fingers. Fold the patch in half so that it sticks together. Throw the used patch away where children and pets cannot reach it.

Wash your hands with soap and water after applying a patch, and after removing one.
Use only one patch at a time. While you are wearing the patch, do not expose it to sunlight or other sources of heat such as a heating pad, electric blanket, hot tub, or sauna.

Do not stop using Emsam suddenly or you may have harmful side effects. It may take several weeks of using Emsam before your symptoms improve. For best results, keep using the medication as directed. Store the skin patches at room temperature away from heat and moisture. Keep each patch in the foil pouch until you are ready to apply one.

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What happens if I miss a dose?

Apply a skin patch as soon as you remember. If it is almost time to apply your next patch, skip the missed dose and apply a patch at your next regularly scheduled time. Do not use extra patches to make up the missed dose.

If a patch becomes loose, press it back in place. If a patch falls off, apply a new one and go back to your regular schedule for patch changes.

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What happens if I overdose?

Seek emergency medical attention if you think you have used too much of this medicine. Symptoms of a Emsam overdose may include severe headache, hallucinations, vision problems, sweating, cool or clammy skin, fast or uneven heart rate, feeling lightheaded, fainting, or seizure.

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What should I avoid while taking Emsam?

You must NOT eat foods that are high in tyramine, including:
air dried meats, aged or fermented meats, sausage or salami (including cacciatore and mortadella), pickled herring, and any spoiled or improperly stored beef, poultry, fish, or liver;

beer from a tap, beer that has not been pasteurized;

aged cheeses, including blue, boursault, brick, brie, camembert, cheddar, emmenthaler, gruyere, parmesan, romano, roquefort, stilton, and swiss;

over-the-counter supplements or cough and cold medicines that contain tyramine;

sauerkraut, soy beans, soy sauce, tofu, miso soup, bean curd, fava beans; or

yeast extracts (such as Marmite).

Eating tyramine while you are using Emsam can raise your blood pressure to dangerous levels which could cause life-threatening side effects. You should become very familiar with the list of foods to avoid while you are using Emsam.

Avoid drinking alcohol while you are using Emsam. Emsam can cause side effects that may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be awake and alert.

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Emsam side effects

Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat.
Call your doctor at once if you have any new or worsening symptoms such as: mood or behavior changes, anxiety, panic attacks, trouble sleeping, or if you feel impulsive, irritable, agitated, hostile, aggressive, restless, hyperactive (mentally or physically), more depressed, or have thoughts about suicide or hurting yourself.

Stop using Emsam and call your doctor at once if you have any of these serious side effects:
sudden and severe headache, confusion, blurred vision, problems with speech or balance, nausea, vomiting, chest pain, seizure (convulsions), and sudden numbness or weakness (especially on one side of the body);

feeling light-headed, fainting;

twitching muscle movements; or

painful or difficult urination.

Continue using Emsam and talk with your doctor if you have any of these less serious side effects:

constipation, gas, loss of appetite;

swelling, numbness or tingling, easy bruising, muscle pain;

dry mouth, sore throat, cough;

redness or itching where the patch is worn; or

impotence, loss of interest in sex, or trouble having an orgasm.

Side effects other than those listed here may also occur. Talk to your doctor about any side effect that seems unusual or that is especially bothersome.

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What other drugs will affect Emsam?

There are many other medicines that can cause serious medical problems if you take them while using Emsam. Do not use Emsam before telling your doctor about all other prescription and over-the-counter medications you use. This includes vitamins, minerals, herbal products, and drugs prescribed by other doctors. Keep a list with you of all the medicines you use and show this list to any doctor, dentist, or other healthcare provider who treats you.

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Where can I get more information?

Your pharmacist has information about Emsam written for health professionals that you may read.

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What does my medication look like?

Selegiline transdermal is available with a prescription under the brand name Emsam. Other brand or generic formulations may also be available. Ask your pharmacist any questions you have about this medication, especially if it is new to you.

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Ludiomil

Generic Name: maprotiline (ma PROE ti leen)
Brand Names: Ludiomil

What is Ludiomil?
What is the most important information I should know about Ludiomil?
What should I discuss with my healthcare provider before taking Ludiomil?
How should I take Ludiomil?
What happens if I miss a dose?
What happens if I overdose?
What should I avoid while taking Ludiomil?
Ludiomil side effects
What other drugs will affect Ludiomil?
Where can I get more information?

What is Ludiomil?

TMaprotiline is an antidepressant. Maprotiline affects chemicals in the brain that may become unbalanced and cause depression.

Maprotiline is used to treat major depressive disorder, depressive neurosis, and manic-depression illness.

Maprotiline may also be used for purposes other than those listed in this medication guide.

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What is the most important information I should know about Ludiomil?

You may have thoughts about suicide when you first start taking an antidepressant, especially if you are younger than 24 years old. Your doctor will need to check you at regular visits for at least the first 12 weeks of treatment.

Call your doctor at once if you have any new or worsening symptoms such as: mood or behavior changes, anxiety, panic attacks, trouble sleeping, or if you feel impulsive, irritable, agitated, hostile, aggressive, restless, hyperactive (mentally or physically), more depressed, or have thoughts about suicide or hurting yourself. Do not use maprotiline if you have a seizure disorder, or if you have used an MAO inhibitor within the past 14 days. Serious, life-threatening side effects can occur if you take maprotiline before the MAO inhibitor has cleared from your body.
Before taking maprotiline, tell your doctor if you have liver or kidney disease, seizures, heart disease, a thyroid disorder, if you receive electroshock therapy, or if you have a history of heart attack, stroke, drug abuse, or suicidal thoughts.

It may take up to 3 weeks of using this medicine before your symptoms improve. For best results, keep using the medication as directed. Talk with your doctor if your symptoms do not improve after 3 weeks of treatment. Avoid drinking alcohol. It can increase some of the side effects of maprotiline. Maprotiline can cause side effects that may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be awake and alert.

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What should I discuss with my doctor before taking Ludiomil?

You should not take this medication if you are allergic to maprotiline, or if you have a seizure disorder.
You may have thoughts about suicide while taking an antidepressant, especially if you are younger than 24 years old. Tell your doctor if you have worsening depression or suicidal thoughts during the first several weeks of treatment, or whenever your dose is changed.

Your family or other caregivers should also be alert to changes in your mood or symptoms. Your doctor will need to check you at regular visits for at least the first 12 weeks of treatment.

Do not use maprotiline if you have used an MAO inhibitor such as isocarboxazid (Marplan), phenelzine (Nardil), rasagiline (Azilect), selegiline (Eldepryl, Emsam), or tranylcypromine (Parnate) within the past 14 days. Serious, life-threatening side effects can occur if you take maprotiline before the MAO inhibitor has cleared from your body.
Before taking maprotiline, tell your doctor if you are allergic to any drugs, or if you have:

liver or kidney disease;
if you are receiving electroshock therapy;

seizures or epilepsy;

a thyroid disorder;

heart disease, heart rhythm disorder;

a history of heart attack or stroke; or

a history of drug abuse or suicidal thoughts.

If you have any of these conditions, you may not be able to use maprotiline, or you may need a dosage adjustment or special tests during treatment.

FDA pregnancy category B. This medication is not expected to be harmful to an unborn baby. Tell your doctor if you are pregnant or plan to become pregnant during treatment. Maprotiline can pass into breast milk and may harm a nursing baby. Do not use this medication without telling your doctor if you are breast-feeding a baby.
Older adults may be more sensitive to the side effects of this medication.

The orally disintegrating tablet form may contain phenylalanine. Talk to your doctor before using this form of maprotiline if you have phenylketonuria (PKU).

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How should I take Ludiomil?

Take this medication exactly as prescribed by your doctor. Do not take it in larger amounts or for longer than recommended. Follow the directions on your prescription label.

Take the regular tablet form of maprotiline with water.
To take maprotiline orally disintegrating tablets (Remeron SolTab):

Keep the tablet in its blister pack until you are ready to take the medicine. Open the package and peel back the foil from the tablet blister. Do not push a tablet through the foil or you may break the tablet.

Using dry hands, remove the tablet and place it in your mouth. It will begin to dissolve right away.

Do not swallow the tablet whole. Allow it to dissolve in your mouth without chewing.

Swallow several times as the tablet dissolves. No water is needed.

Maprotiline is usually taken once a day at bedtime. Follow your doctor's instructions.

It may take up to 3 weeks of using this medicine before your symptoms improve. For best results, keep using the medication as directed. Talk with your doctor if your symptoms do not improve after 3 weeks of treatment. Store maprotiline at room temperature, away from moisture and heat.

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What happens if I miss a dose?

Take the missed dose as soon as you remember. If it is almost time for your next dose, wait until then to take the medicine and skip the missed dose. Do not take extra medicine to make up the missed dose.

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What happens if I overdose?

Seek emergency medical attention if you think you have used too much of this medicine.
Overdose symptoms may include extreme drowsiness, fast heart rate, confusion, vomiting, blue lips or fingernails, and seizure (convulsions).

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What should I avoid while taking Ludiomil?

Cold or allergy medicine, narcotic pain medicine, sleeping pills, muscle relaxers, and medicine for seizures, depression or anxiety can add to sleepiness caused by maprotiline. Tell your doctor if you need to use any of these other medicines while you are taking maprotiline. Avoid drinking alcohol. It can increase some of the side effects of maprotiline. Maprotiline can cause side effects that may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be awake and alert.

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Ludiomil side effects

Get emergency medical help if you have any of these signs of an allergic reaction: skin rash or hives; difficulty breathing; swelling of your face, lips, tongue, or throat.
Call your doctor at once if you have any new or worsening symptoms such as: mood or behavior changes, anxiety, panic attacks, trouble sleeping, or if you feel impulsive, irritable, agitated, hostile, aggressive, restless, hyperactive (mentally or physically), more depressed, or have thoughts about suicide or hurting yourself.

Call your doctor at once if you have any of these serious side effects:

seizure (convulsions);

fast or pounding heart rate;

confusion, hallucinations;

unusual thoughts or behavior; or

feeling like you might pass out.

Less serious side effects include:

drowsiness, dizziness;

loss of balance or coordination;

numbness or tingling;

blurred vision;

ringing in your ears;

nausea, stomach pain;

constipation;

dry mouth; or

thirst.

This is not a complete list of side effects and others may occur. Tell your doctor about any unusual or bothersome side effect.

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What other drugs will affect Ludiomil?

The following drugs can interact with maprotiline. Tell your doctor if you are using any of these:

guanethidine (Ismelin);

medicines to treat psychiatric disorders, such as chlorpromazine (Thorazine), mesoridazine (Serentil), or thioridazine (Mellaril);

a sedative such as Valium;

cimetidine (Tagamet); or

phenytoin (Dilantin).

This list is not complete and there may be other drugs that can interact with maprotiline. Tell your doctor about all your prescription and over-the-counter medications, vitamins, minerals, herbal products, and drugs prescribed by other doctors. Do not start a new medication without telling your doctor.

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Where can I get more information?

Your pharmacist has information about Emsam written for health professionals that you may read.

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Marplan (ISOCARBOXAZID)

Generic Name: isocarboxazid (eye so kar BOX a zid)
Brand Names: Marplan

What is Marplan?
What is the most important information I should know about Marplan?
What should I discuss with my healthcare provider before taking Marplan?
How should I take Marplan?
What happens if I miss a dose?
What happens if I overdose?
What should I avoid while taking Marplan?
Marplan side effects
What other drugs will affect Marplan?
Where can I get more information?
What does my medication look like?

What is Marplan (isocarboxazid)?

Isocarboxazid is a monoamine oxidase inhibitor (MAOI) that works by increasing the levels of certain chemicals in the brain.

Isocarboxazid is used to treat symptoms of depression that may include anxiety, panic, or phobias. This medication is usually given after other antidepressants have been tried without successful treatment of symptoms.

Isocarboxazid may also be used for purposes other than those listed in this medication guide.

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What is the most important information I should know about Marplan (isocarboxazid)?

There are many other medicines that can cause serious or life-threatening medical problems if you take them together with isocarboxazid. Do not take isocarboxazid before telling your doctor about all other prescription and over-the-counter medications you use, including vitamins, minerals, and herbal products. Keep a list with you of all the medicines you use and show this list to any doctor, dentist, or other healthcare provider who treats you.

You may have thoughts about suicide when you first start taking an antidepressant, especially if you are younger than 24 years old. Your doctor will need to check you at regular visits for at least the first 12 weeks of treatment.

Call your doctor at once if you have any new or worsening symptoms such as: mood or behavior changes, anxiety, panic attacks, trouble sleeping, or if you feel impulsive, irritable, agitated, hostile, aggressive, restless, hyperactive (mentally or physically), more depressed, or have thoughts about suicide or hurting yourself. While you are taking isocarboxazid, you must not drink alcohol or eat foods that are high in tyramine, listed in the "What should I avoid while taking isocarboxazid?" section of this leaflet. Eating tyramine while you are taking isocarboxazid can raise your blood pressure to dangerous levels, causing symptoms that include sudden and severe headache, rapid heartbeat, stiffness in your neck, nausea, vomiting, cold sweat, vision problems, and sensitivity to light. Stop taking isocarboxazid and call your doctor at once if you have any of these symptoms.
You should become very familiar with the list of foods and medicines you must avoid while you are taking isocarboxazid.

Isocarboxazid can cause side effects that may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be awake and alert.

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What should I discuss with my doctor before taking Marplan (isocarboxazid)?

Do not use this medication if you have used another MAOI such as phenelzine (Nardil), rasagiline (Azilect), selegiline (Eldepryl, Emsam), or tranylcypromine (Parnate) within the past 14 days. Serious, life-threatening side effects can occur if you take isocarboxazid before another MAOI has cleared from your body. Do not take this medication if you are allergic to isocarboxazid, or if you have:
pheochromocytoma (tumor of the adrenal gland);

a history of stroke or blood clots;

liver disease;

kidney disease;

heart disease;

high blood pressure; or

a history of severe or frequent headaches.

There are many other medicines that can cause serious or life-threatening medical problems if you take them together with isocarboxazid. The following drugs should not be used while you are taking isocarboxazid:

diet pills, caffeine, stimulants, ADHD medication, asthma medication, over-the-counter cough and cold or allergy medicines;

blood pressure medication;

diuretics (water pills);

bupropion (Wellbutrin, Zyban);

buspirone (BuSpar); or

carbamazepine (Carbatrol, Tegretol);

furazolidone (Furoxone);

meperidine (Demerol, Mepergan);

pargyline (Eutonyl);

procarbazine (Matulane);

alcohol or medicines that make you sleepy (such as cold medicine, pain medication, muscle relaxers, and medicine for seizures, depression or anxiety).

antidepressants such as amitriptyline (Elavil, Etrafon), amoxapine (Ascendin), clomipramine (Anafranil), desipramine (Norpramin), doxepin (Adepin, Sinequan), imipramine (Janimine, Tofranil), nortriptyline (Pamelor), protriptyline (Vivactil), or trimipramine (Surmontil); or

antidepressants such as citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac, Sarafem), fluvoxamine (Luvox), paroxetine (Paxil), or sertraline (Zoloft).

Before taking isocarboxazid, tell your doctor if you have:

high blood pressure, heart disease;

diabetes;

liver or kidney disease;

a thyroid disorder;

schizophrenia;

epilepsy or other seizure disorder;

if you have taken another antidepressant within the past 5 weeks; or

if you are also taking tryptophan (also called L-tryptophan), guanethidine (Ismelin), levodopa (Larodopa, Parcopa, Sinemet), or methyldopa (Aldomet).

If you have any of these conditions, you may not be able to use isocarboxazid, or you may need a dosage adjustment or special tests during treatment.

You may have thoughts about suicide when you first start taking an antidepressant, especially if you are younger than 24 years old. Tell your doctor if you have worsening symptoms of depression or suicidal thoughts during the first several weeks of treatment, or whenever your dose is changed.

Your family or other caregivers should also be alert to changes in your mood or symptoms. Your doctor will need to check you at regular visits for at least the first 12 weeks of treatment.

FDA pregnancy category C. This medication may be harmful to an unborn baby. Tell your doctor if you are pregnant or plan to become pregnant during treatment. It is not known whether isocarboxazid passes into breast milk or if it could harm a nursing baby. Do not use this medication without telling your doctor if you are breast-feeding a baby. Do not give isocarboxazid to anyone younger than 16 years old without the advice of a doctor.

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How should I take Marplan (isocarboxazid)?

Take this medication exactly as it was prescribed for you. Do not take the medication in larger amounts, or take it for longer than recommended by your doctor. Follow the directions on your prescription label. Your doctor may occasionally change your dose to make sure you get the best results from this medication.

Take each dose with a full glass of water.
To be sure this medication is not causing harmful effects, your blood pressure will need to be tested on a regular basis. Do not miss any scheduled visits to your doctor.

Take this medication for the entire length of time prescribed by your doctor. It may take up to 6 weeks or longer before you notice improvement in your symptoms. Store isocarboxazid at room temperature away from moisture and heat.

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What happens if I miss a dose?

Take the missed dose as soon as you remember. If it is almost time for your next dose, skip the missed dose and take the medicine at the next regularly scheduled time. Do not take extra medicine to make up the missed dose.

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What happens if I overdose?

Seek emergency medical attention if you think you have used too much of this medicine. Symptoms of an isocarboxazid overdose may include shallow breathing, fast heart rate, sweating, fever, slow reflexes, feeling light-headed, fainting, or seizure (convulsions).

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What should I avoid while taking Marplan (isocarboxazid)?

While you are taking isocarboxazid you must not eat foods that are high in tyramine, including:
cheese (especially strong or aged cheeses);

sour cream;

beer (including non-alcoholic beer), sherry, Chianti wine, liquers;

dry sausage (such as hard salami, pepperoni, anchovies, caviar, liver, pickled herring;

canned figs, raisins, bananas;

avocados;

chocolate or caffeine;

soy sauce;

sauerkraut;

fava beans;

yeast extracts;

yogurt;

meat extracts;

meat prepared with tenderizer; or

over-the-counter supplements or cough and cold medicines that contain dextromethorphan or tyramine.

You should become very familiar with the list of foods and medicines you must avoid while you are taking isocarboxazid. Eating tyramine while you are taking isocarboxazid can raise your blood pressure to dangerous levels which could cause life-threatening side effects.

Isocarboxazid can cause side effects that may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be awake and alert.

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Marplan (isocarboxazid) side effects

Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat.
Call your doctor at once if you have any new or worsening symptoms such as: mood or behavior changes, anxiety, panic attacks, trouble sleeping, or if you feel impulsive, irritable, agitated, hostile, aggressive, restless, hyperactive (mentally or physically), more depressed, or have thoughts about suicide or hurting yourself.

Stop using isocarboxazid and call your doctor at once if you have any of these serious side effects:
sudden and severe headache, rapid heartbeat, stiffness in your neck, nausea, vomiting, cold sweat, sweating, vision problems, sensitivity to light;

chest pain, fast or slow heart rate;

swelling, rapid weight gain;

jaundice (yellowing of the skin or eyes); or

feeling light-headed, fainting.

Continue taking this medication and talk to your doctor if you have any of these less serious side effects:

dizziness, headache;

tremors or shaking;

constipation,nausea; or

dry mouth.

Side effects other than those listed here may also occur. Talk to your doctor about any side effect that seems unusual or that is especially bothersome.

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What other drugs will affect Marplan (isocarboxazid)?

There are many other medicines that can cause serious or life-threatening medical problems if you take them together with isocarboxazid. Do not take isocarboxazid before telling your doctor about all other prescription and over-the-counter medications you use. This includes vitamins, minerals, herbal products, and drugs prescribed by other doctors. Do not start using a new medication without telling your doctor. Keep a list with you of all the medicines you use and show this list to any doctor, dentist, or other healthcare provider who treats you.

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Where can I get more information?

Your pharmacist has more information about isocarboxazid written for health professionals that you may read.

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What does my medication look like?

Isocarboxazid is available with a prescription under the brand name Marplan. Other brand or generic formulations may also be available. Ask your pharmacist any questions you have about this medication, especially if it is new to you.

Marplan 10 mg--peach colored tablets

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Nardil (PHENELZINE)

Generic Name: phenelzine (FEN el zeen)
Brand Names: Nardil

What is Nardil?
What is the most important information I should know about Nardil?
What should I discuss with my healthcare provider before taking Nardil?
How should I take Nardil?
What happens if I miss a dose?
What happens if I overdose?
What should I avoid while taking Nardil?
Nardil side effects
What other drugs will affect Nardil?
Where can I get more information?

What is Nardil?

Phenelzine is a monoamine oxidase inhibitor (MAOI) that works by increasing the levels of certain chemicals in the brain.

Phenelzine is used to treat symptoms of depression that may include feelings of sadness, fear, anxiety, or worry about physical health (hypochondria). This medication is usually given after other anti-depressants have been tried without successful treatment of symptoms. Phenelzine is not for treating severe depression or bipolar disorder (manic depression).

Phenelzine may also be used for purposes other than those listed in this medication guide.

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What is the most important information I should know about Nardil?

There are many other medicines that can cause serious or life-threatening medical problems if you take them together with phenelzine. Do not take phenelzine before telling your doctor about all other prescription and over-the-counter medications you use, including vitamins, minerals, and herbal products. Keep a list with you of all the medicines you use and show this list to any doctor, dentist, or other healthcare provider who treats you.

You may have thoughts about suicide when you first start taking an antidepressant, especially if you are younger than 24 years old. Your doctor will need to check you at regular visits for at least the first 12 weeks of treatment.

Call your doctor at once if you have any new or worsening symptoms such as: mood or behavior changes, anxiety, panic attacks, trouble sleeping, or if you feel impulsive, irritable, agitated, hostile, aggressive, restless, hyperactive (mentally or physically), more depressed, or have thoughts about suicide or hurting yourself. While you are taking phenelzine, you must not drink alcohol or eat foods that are high in tyramine, listed in the "What should I avoid while taking phenelzine?" section of this leaflet. Eating tyramine while you are taking phenelzine can raise your blood pressure to dangerous levels, causing symptoms that include sudden and severe headache, rapid heartbeat, stiffness in your neck, nausea, vomiting, cold sweat, vision problems, and sensitivity to light. Stop taking phenelzine and call your doctor at once if you have any of these symptoms.
You should become very familiar with the list of foods and medicines you must avoid while you are taking phenelzine.

Phenelzine can cause side effects that may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be awake and alert.

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What should I discuss with my doctor before taking Nardil

Do not use this medication if you have used another MAOI such as isocarboxazid (Marplan), rasagiline (Azilect), selegiline (Eldepryl, Emsam), or tranylcypromine (Parnate) within the past 14 days. Serious, life-threatening side effects can occur if you take phenelzine before another MAOI has cleared from your body. Do not take this medication if you are allergic to phenelzine, or if you have:
pheochromocytoma (tumor of the adrenal gland);

congestive heart failure;

a history of liver problems; or

if you need any type of surgery with anesthesia.

There are many other medicines that can cause serious or life-threatening medical problems if you take them together with phenelzine. The following drugs should not be used while you are taking phenelzine:

diet pills, caffeine, stimulants, ADHD medication, asthma medication, over-the-counter cough and cold or allergy medicines;

tryptophan (also called L-tryptophan);

levodopa (Larodopa, Parcopa, Sinemet), methyldopa (Aldomet);

meperidine (Demerol, Mepergan);

furazolidone (Furoxone);

procarbazine (Matulane);

buspirone (BuSpar);

bupropion (Wellbutrin, Zyban);

dexfenfluramine (Redux);

guanethidine (Ismelin);

alcohol or medicines that make you sleepy (such as cold medicine, pain medication, muscle relaxers, and medicine for seizures, depression or anxiety); or

antidepressants such as citalopram (Celexa), duloxetine (Cymbalta), escitalopram (Lexapro), fluoxetine (Prozac, Sarafem), fluvoxamine (Luvox), paroxetine (Paxil), sertraline (Zoloft), or venlafaxine (Effexor).

Before taking phenelzine, tell your doctor if you have:

high blood pressure, heart disease;

diabetes;

schizophrenia;

epilepsy or other seizure disorder; or

if you have taken another antidepressant within the past 5 weeks.

You may have thoughts about suicide while taking an antidepressant, especially if you are younger than 24 years old. Tell your doctor if you have worsening depression or suicidal thoughts during the first several weeks of treatment, or whenever your dose is changed.

Your family or other caregivers should also be alert to changes in your mood or symptoms. Your doctor will need to check you at regular visits for at least the first 12 weeks of treatment.

FDA pregnancy category C. This medication may be harmful to an unborn baby. Tell your doctor if you are pregnant or plan to become pregnant during treatment. It is not known whether phenelzine passes into breast milk or if it could harm a nursing baby. Do not use this medication without telling your doctor if you are breast-feeding a baby.

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How should I take Nardil?

Take this medication exactly as it was prescribed for you. Do not take the medication in larger amounts, or take it for longer than recommended by your doctor. Follow the instructions on your prescription label.

Your doctor may occasionally change your dose to make sure you get the best results from this medication.

Take each dose with a full glass of water.
To be sure this medication is not causing harmful effects, your blood pressure will need to be tested on a regular basis. Do not miss any scheduled visits to your doctor.

It may take several weeks of using this medicine before your symptoms improve. For best results, keep using the medication as directed. Talk with your doctor if your symptoms do not improve after 4 weeks of treatment. Store phenelzine at room temperature away from moisture and heat.

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What happens if I miss a dose?

Take the missed dose as soon as you remember. However, if it is almost time for your next regularly scheduled dose, skip the missed dose and take only the next one as directed. Do not take a double dose of this medication.

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What happens if I overdose?

Seek emergency medical attention if you think you have used too much of this medicine. Overdose symptoms may include feeling drowsy or dizzy, severe headache, neck pain or stiffness, hallucinations, shallow breathing, fast and uneven heart rate, cold sweats, feeling like you might pass out, or seizure (convulsions).

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What should I avoid while taking Nardil?

While you are taking phenelzine you must not eat foods that are high in tyramine, including:
aged or smoked meats, fermented meats, dry sausage (including salami, pepperoni, Lebanon bologna), liver, pickled herring;

any spoiled or improperly stored meats, fish, or dairy products;

beer and wine (including non-alcoholic beer or wine);

cheese (other than cottage cheese or cream cheese);

sauerkraut;

over-the-counter supplements or cough and cold medicines that contain dextromethorphan or tyramine;

large amounts of chocolate or caffeine;

yogurt;

fava beans;

meat extracts; or

yeast extracts (including Brewer's yeast).

You should become very familiar with the list of foods and medicines you must avoid while you are taking phenelzine. Eating tyramine while you are taking phenelzine can raise your blood pressure to dangerous levels which could cause life-threatening side effects.

Phenelzine can cause side effects that may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be awake and alert.

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Nardil side effects

Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat.
Call your doctor at once if you have any new or worsening symptoms such as: mood or behavior changes, anxiety, panic attacks, trouble sleeping, or if you feel impulsive, irritable, agitated, hostile, aggressive, restless, hyperactive (mentally or physically), more depressed, or have thoughts about suicide or hurting yourself.

Stop using phenelzine and call your doctor at once if you have any of these serious side effects:
sudden and severe headache, rapid heartbeat, stiffness in your neck, nausea, vomiting, cold sweat, sweating, vision problems, sensitivity to light;

chest pain, fast or slow heart rate;

swelling, rapid weight gain;

agitation, unusual thoughts or behavior; or

feeling light-headed, fainting.

Less serious side effects may include:

dizziness;

feeling weak or drowsy;

sleep problems (insomnia);

constipation, upset stomach;

dry mouth, decreased urination; or

impotence, difficulty having an orgasm.

This is not a complete list of side effects and others may occur. Tell your doctor about any unusual or bothersome side effect.

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What other drugs will affect Nardil?

There are many other medicines that can cause serious or life-threatening medical problems if you take them together with phenelzine. Do not take phenelzine before telling your doctor about all other prescription and over-the-counter medications you use. This includes vitamins, minerals, herbal products, and drugs prescribed by other doctors. Do not start using a new medication without telling your doctor. Keep a list with you of all the medicines you use and show this list to any doctor, dentist, or other healthcare provider who treats you.

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Where can I get more information?

Your pharmacist has more information about isocarboxazid written for health professionals that you may read.

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Parnate (TRANYLCYPROMINE)

Generic Name: tranylcypromine (tran il SIP ro meen)
Brand Names: Parnate

What is Parnate?
What is the most important information I should know about Parnate?
What should I discuss with my healthcare provider before taking Parnate?
How should I take Parnate?
What happens if I miss a dose?
What happens if I overdose?
What should I avoid while taking Parnate?
Parnate side effects
What other drugs will affect Parnate?
Where can I get more information?
What does my medication look like?

What is Parnate?

Tranylcypromine is a monoamine oxidase inhibitor (MAOI) that works by increasing the levels of certain chemicals in the brain.

Tranylcypromine is used to treat major depressive episode in adults. This medication is usually given after other anti-depressants have been tried without successful treatment of symptoms. Tranylcypromine will not treat bipolar disorder (manic depression).

Tranylcypromine may also be used for purposes other than those listed in this medication guide.

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What is the most important information I should know about Parnate?

There are many other medicines that can cause serious medical problems if you take them together with tranylcypromine. Do not take tranylcypromine before telling your doctor about all other prescription and over-the-counter medications you use, including vitamins, minerals, and herbal products. Keep a list with you of all the medicines you use and show this list to any doctor, dentist, or other healthcare provider who treats you.

You may have thoughts about suicide when you first start taking an antidepressant, especially if you are younger than 24 years old. Your doctor will need to check you at regular visits for at least the first 12 weeks of treatment.

Call your doctor at once if you have any new or worsening symptoms such as: mood or behavior changes, anxiety, panic attacks, trouble sleeping, or if you feel impulsive, irritable, agitated, hostile, aggressive, restless, hyperactive (mentally or physically), more depressed, or have thoughts about suicide or hurting yourself. While you are taking tranylcypromine, you must not drink alcohol or eat foods that are high in tyramine, listed in the "What should I avoid while taking tranylcypromine?" section of this leaflet. Eating tyramine while you are taking tranylcypromine can raise your blood pressure to dangerous levels, causing life-threatening symptoms such as sudden and severe headache, confusion, blurred vision, problems with speech or balance, nausea, vomiting, chest pain, seizure (convulsions), and sudden numbness or weakness (especially on one side of the body). Call your doctor at once if you have any of these symptoms.
You should become very familiar with the list of foods you must avoid while you are taking tranylcypromine.

Tranylcypromine can cause side effects that may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be awake and alert.

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What should I discuss with my doctor before taking Parnate

Do not use this medication if you have used another MAOI such as isocarboxazid (Marplan), phenelzine (Nardil), rasagiline (Azilect), or selegiline (Eldepryl, Emsam) within the past 14 days. Serious, life-threatening side effects can occur if you take tranylcypromine before another MAOI has cleared from your body. If you are switching to tranylcypromine from another MAOI, your doctor may start you at a low dose.
There are many other medicines that can cause serious medical problems if you take them together with tranylcypromine. The following drugs should not be used while you are taking tranylcypromine:

antidepressants such as amitriptyline (Elavil, Etrafon), amoxapine (Ascendin), clomipramine (Anafranil), desipramine (Norpramin), imipramine (Janimine, Tofranil), nortriptyline (Pamelor), protriptyline (Vivactil), or trimipramine (Surmontil);

antidepressants such as citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac, Sarafem), fluvoxamine (Luvox), paroxetine (Paxil), or sertraline (Zoloft);

blood pressure medicine such as guanethidine (Ismelin), methyldopa (Aldomet), and reserpine;

diet pills, stimulants, ADHD medications, over-the-counter cough and cold or allergy medicines;

doxepin (Adapin, Sinequan);

carbamazepine (Carbatrol, Tegretol);

cyclobenzaprine (Flexeril);

maprotiline (Ludiomil);

procarbazine (Matulane);

bupropion (Wellbutrin, Zyban);

dexfenfluramine (Redux);

buspirone (BuSpar);

tryptophan (also called L-tryptophan);

levodopa (Larodopa, Parcopa, Sinemet); or

meperidine (Demerol, Mepergan).

Before using this medication, tell your doctor if you are allergic to any drugs, or if you have:

heart disease, high blood pressure, circulation problems, or a history of stroke;

a history of headaches (migraine, cluster, or other types);

diabetes; or

a seizure disorder such as epilepsy.

If you have any of these conditions, you may not be able to use tranylcypromine, or you may need a dosage adjustment or special tests during treatment.

You may have thoughts about suicide when you first start taking an antidepressant, especially if you are younger than 24 years old. Tell your doctor if you have worsening symptoms of depression or suicidal thoughts during the first several weeks of treatment, or whenever your dose is changed.

Your family or other caregivers should also be alert to changes in your mood or symptoms. Your doctor will need to check you at regular visits for at least the first 12 weeks of treatment.

This medication may be habit-forming. You may have withdrawal symptoms such as anxiety, confusion, headache, weakness, depression, or hallucinations) when you stop using tranylcypromine after using it over a long period of time. Do not stop using this medication suddenly without first talking to your doctor. You may need to use less and less before you stop the medication completely. FDA pregnancy category C. This medication may be harmful to an unborn baby. Tell your doctor if you are pregnant or plan to become pregnant during treatment. Tranylcypromine can pass into breast milk and may harm a nursing baby. Do not use this medication without telling your doctor if you are breast-feeding a baby.
Older adults may be more likely to have side effects from tranylcypromine.

Do not give tranylcypromine to anyone younger than 18 years old without the advice of a doctor.

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How should I take Parnate?

Take this medication exactly as it was prescribed for you. Do not take the medication in larger amounts, or take it for longer than recommended by your doctor. Follow the instructions on your prescription label.

Your doctor may occasionally change your dose to make sure you get the best results from this medication.

Take each dose with a full glass of water.
You may need to stop using the medicine for a short time if you need to have any type of surgery, or if you will have an x-ray, CT scan, or MRI of your spinal cord. Tell any doctor who treats you that you are taking tranylcypromine.

To be sure this medication is not causing harmful effects, your blood pressure will need to be tested on a regular basis. Do not miss any scheduled visits to your doctor.

Take this medication for the entire length of time prescribed by your doctor. It may take 4 weeks or longer before you notice improvement in your symptoms. Store tranylcypromine at room temperature away from moisture and heat.

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What happens if I miss a dose?

Take the missed dose as soon as you remember. If it is almost time for your next dose, skip the missed dose and take the medicine at the next regularly scheduled time. Do not take extra medicine to make up the missed dose.

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What happens if I overdose?

Seek emergency medical attention if you think you have used too much of this medicine. Symptoms of a tranylcypromine overdose may include feeling restless or anxious, sleep problems (insomnia), agitation, confusion, weakness, severe headache, neck pain or stiffness, fast or pounding heart beats, chest pain, cold sweats, feeling light-headed, or fainting.

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What should I avoid while taking Parnate?

While you are taking tranylcypromine, you must not eat foods that are high in tyramine, including:
avocados, bananas, figs, raisins, and sauerkraut;

beef or chicken liver, fish, meats prepared with tenderizer, bologna, pepperoni, salami, summer sausage, game meat, meat extracts, caviar, dried fish, herring, and shrimp paste;

beer (alcoholic and nonalcoholic), red wine (especially Chianti), sherry, vermouth, and other distilled spirits;

caffeine (including coffee, tea, cola); and

cheeses, including American, blue, boursault, brick, brie, camembert, cheddar, emmenthaler, gruyere, mozzarella, parmesan, romano, roquefort, stilton, and swiss;

chocolate;

ginseng;

sour cream and yogurt;

soy sauce, miso soup, bean curd, fava beans; or

yeast extracts.

Eating tyramine while you are taking tranylcypromine can raise your blood pressure to dangerous levels, causing life-threatening side effects.

Avoid drinking alcohol or using other medicines that make you sleepy (such as cold medicine, pain medication, muscle relaxers, and medicine for seizures, depression or anxiety). They can worsen the low blood pressure caused by tranylcypromine. Tranylcypromine can cause side effects that may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be awake and alert.

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Parnate side effects

Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat.
Call your doctor at once if you have any new or worsening symptoms such as: mood or behavior changes, anxiety, panic attacks, trouble sleeping, or if you feel impulsive, irritable, agitated, hostile, aggressive, restless, hyperactive (mentally or physically), more depressed, or have thoughts about suicide or hurting yourself.

Stop using tranylcypromine and call your doctor at once if you have any of these serious side effects:
frequent headaches, vision problems, sensitivity to light;

fast or pounding heart beats, tight feeling in your chest or throat;

swelling of your ankles or feet;

pale skin, easy bruising or bleeding, unusual weakness;

nausea, vomiting, dizziness, sweating, stiffness in your neck;

confusion, lack of coordination, feeling light-headed, fainting; or

tremors, muscle twitches you cannot control.

Continue taking this medication and talk to your doctor if you have any of these less serious side effects:

feeling restless, weak, or drowsy;

nausea, diarrhea or constipation, loss of appetite, stomach pain;

chills, numbness or tingly feeling;

dry mouth, decreased urination;

blurred vision, ringing in your ears; or

impotence, difficulty having an orgasm.

Side effects other than those listed here may also occur. Talk to your doctor about any side effect that seems unusual or that is especially bothersome.

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What other drugs will affect Parnate?

There are many other medicines that can cause serious medical problems if you take them together with tranylcypromine. Do not take tranylcypromine before telling your doctor about all other prescription and over-the-counter medications you use. This includes vitamins, minerals, herbal products, and drugs prescribed by other doctors. Do not start using a new medication without telling your doctor. Keep a list with you of all the medicines you use and show this list to any doctor, dentist, or other healthcare provider who treats you.

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Where can I get more information?

Your pharmacist has information about Emsam written for health professionals that you may read.

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What does my medication look like?

Tranylcypromine is available with a prescription under the brand name Parnate. Other brand or generic formulations may also be available. Ask your pharmacist any questions you have about this medication, especially if it is new to you.

Parnate 10 mg--round, red tablets

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Pexeva (PAROXETINE)

Generic Name: paroxetine (pa ROX a teen)
Brand Names: Paxil, Paxil CR, Pexeva

What is Pexeva?
What is the most important information I should know about Pexeva?
What should I discuss with my healthcare provider before taking Pexeva?
How should I take Pexeva?
What happens if I miss a dose?
What happens if I overdose?
What should I avoid while taking Pexeva?
Pexeva side effects
What other drugs will affect Pexeva?
Where can I get more information?
What does my medication look like?

What is Pexeva?

Paroxetine is an antidepressant in a group of drugs called selective serotonin reuptake inhibitors (SSRIs). Paroxetine affects chemicals in the brain that may become unbalanced.

Paroxetine is used to treat depression, obsessive-compulsive disorder, anxiety disorders, post-traumatic stress disorder (PTSD), and premenstrual dysphoric disorder (PMDD).

Paroxetine may also be used for purposes other than those listed in this medication guide.

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What is the most important information I should know about Pexeva?

You may have an increased risk of suicidal thoughts or behavior at the start of treatment with an antidepressant medication, especially if you are a child or young adult. Talk with your doctor about this risk. While you are taking paroxetine you will need to be monitored for worsening symptoms of depression and/or suicidal thoughts during the first weeks of treatment, or whenever your dose is changed. In addition to you watching for changes in your own symptoms, your family or other caregivers should be alert to changes in your mood or symptoms. Your doctor will need to check you at regular visits for at least the first 12 weeks of treatment.

Contact your doctor promptly if you have any of the following side effects, especially if they are new symptoms or if they get worse: mood changes, anxiety, panic attacks, trouble sleeping, irritability, agitation, aggressiveness, severe restlessness, mania (mental and/or physical hyperactivity), thoughts of suicide or hurting yourself. Paroxetine may cause heart defects or serious, life-threatening lung problems in newborn babies whose mothers take the medication during pregnancy. However, you may have a relapse of depression if you stop taking your antidepressant during pregnancy. If you are planning a pregnancy, or if you become pregnant while taking paroxetine, do not stop taking the medication without first talking to your doctor. Do not take paroxetine together with pimozide (Orap), thioridazine (Mellaril), or a monoamine oxidase inhibitor (MAOI) such as isocarboxazid (Marplan), phenelzine (Nardil), rasagiline (Azilect), selegiline (Eldepryl, Emsam), or tranylcypromine (Parnate).

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What should I discuss with my doctor before taking Pexeva?

You may have an increased risk of suicidal thoughts or behavior at the start of treatment with an antidepressant medication, especially if you are a child or young adult. Talk with your doctor about this risk. While you are taking paroxetine you will need to be monitored for worsening symptoms of depression and/or suicidal thoughts during the first weeks of treatment, or whenever your dose is changed. In addition to you watching for changes in your own symptoms, your family or other caregivers should be alert to changes in your mood or symptoms. Your doctor will need to check you at regular visits for at least the first 12 weeks.

Do not use paroxetine if you are using pimozide (Orap), thioridazine (Mellaril), or an MAO inhibitor such as isocarboxazid (Marplan), tranylcypromine (Parnate), phenelzine (Nardil), rasagiline (Azilect), or selegiline (Eldepryl, Emsam). Serious and sometimes fatal reactions can occur when these medicines are taken with paroxetine. You must wait at least 14 days after stopping an MAO inhibitor before you can take paroxetine. After you stop taking paroxetine, you must wait at least 14 days before you start taking an MAOI.
Before taking paroxetine, tell your doctor if you are allergic to any drugs, or if you have:

liver or kidney disease;

seizures or epilepsy;

bipolar disorder (manic depression), or a history of drug abuse or suicidal thoughts.

If you have any of these conditions, you may not be able to use paroxetine, or you may need a dosage adjustment or special tests.

FDA pregnancy category D. Paroxetine may cause heart defects or serious, life-threatening lung problems in newborn babies whose mothers take the medication during pregnancy. However, you may have a relapse of depression if you stop taking your antidepressant during pregnancy. If you are planning a pregnancy, or if you become pregnant while taking paroxetine, do not stop taking the medication without first talking to your doctor. Paroxetine can pass into breast milk and may harm a nursing baby. Do not use this medication without telling your doctor if you are breast-feeding a baby.

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How should I take Pexeva?

Take this medication exactly as it was prescribed for you. Do not take the medication in larger amounts, or take it for longer than recommended by your doctor. Your doctor may occasionally change your dose to make sure you get the best results from the medication.

Try to take the medicine at the same time each day. Follow the directions on your prescription label.

Do not crush, chew, or break a controlled-release tablet. Swallow the pill whole. It is specially made to release medicine slowly in the body. Breaking the pill would cause too much of the drug to be released at one time. Shake the liquid form of paroxetine well just before you measure a dose. To be sure you get the correct dose, measure the liquid with a marked measuring spoon or medicine cup, not with a regular table spoon. If you do not have a dose-measuring device, ask your pharmacist for one. It may take up to 4 weeks of using this medicine before your symptoms improve. For best results, keep using the medication as directed. Talk with your doctor if your symptoms do not improve after 4 weeks of treatment.
You may have withdrawal symptoms (such as agitation, dizziness, numbness or tingling, ringing in your ears, confusion, or behavior changes) after you stop taking paroxetine. Do not stop taking this medication suddenly without first talking to your doctor.

Store paroxetine at room temperature away from moisture and heat.

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What happens if I miss a dose?

Take the missed dose as soon as you remember. However, if it is almost time for the next regularly scheduled dose, skip the missed dose and take the next one as directed. Do not take extra medicine to make up the missed dose.

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What happens if I overdose?

Seek emergency medical attention if you think you have taken too much of this medication. Symptoms of a paroxetine overdose may include nausea, vomiting, tremor, sweating, decreased urination, blurred vision, rapid heartbeat, confusion, aggression, seizures, and coma.

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What should I avoid while taking Pexeva?

Avoid drinking alcohol, which can increase some of the side effects of paroxetine.
Avoid using other medicines that make you sleepy (such as cold medicine, pain medication, muscle relaxers, medicine for seizures, other medication for depression or anxiety). They can add to sleepiness caused by paroxetine.

Paroxetine can cause side effects that may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be awake and alert.

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Pexeva side effects

Get emergency medical help if you have any of these signs of an allergic reaction: skin rash or hives; difficulty breathing; swelling of your face, lips, tongue, or throat. Contact your doctor promptly if you have any of the following side effects, especially if they are new symptoms or if they get worse: mood changes, anxiety, panic attacks, trouble sleeping, irritability, agitation, aggressiveness, severe restlessness, mania (mental and/or physical hyperactivity), thoughts of suicide or hurting yourself.
Call your doctor at once if you have any of these serious side effects:

seizure (convulsions);

tremors, shivering, muscle stiffness or twitching;

problems with balance or coordination; or

agitation, confusion, sweating, fast heartbeat.

Other less serious side effects are more likely to occur, such as:

feeling nervous, restless, or unable to sit still;

drowsiness, dizziness, weakness;

sleep problems (insomnia);

nausea, constipation, loss of appetite;

weight changes;

decreased sex drive, impotence, or difficulty having an orgasm; or

dry mouth, yawning, or ringing in your ears.

Side effects other than those listed here may also occur. Talk to your doctor about any side effect that seems unusual or that is especially bothersome.

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What other drugs will affect Pexeva?

Talk to your doctor before taking any medicine for pain, arthritis, fever, or swelling. This includes aspirin, ibuprofen (Advil, Motrin), naproxen (Aleve, Naprosyn), diclofenac (Voltaren), indomethacin, piroxicam (Feldene), nabumetone (Relafen), etodolac (Lodine), and others. Taking any of these drugs with paroxetine may cause you to bruise or bleed easily.

Before taking paroxetine, tell your doctor if you are using any of the following medicines:

atomoxetine (Strattera), cimetidine (Tagamet), fosamprenavir (Lexiva), lithium (Lithobid, Eskalith), risperidone (Risperdal), ritonavir (Norvir), St. John's wort, tramadol (Ultram), or tryptophan (also called L-tryptophan);

heart rhythm medication such as flecainide (Tambocor) or propafenone (Rhythmol);

a blood thinner such as warfarin (Coumadin);

any other antidepressants such as amitriptyline (Elavil), citalopram (Celexa), escitalopram (Lexapro), fluoxetine (Prozac, Sarafem), fluvoxamine (Luvox), imipramine (Tofranil), nortriptyline (Pamelor), or sertraline (Zoloft);

a phenothiazine such as prochlorperazine (Compazine), chlorpromazine (Thorazine), fluphenazine (Prolixin), mesoridazine (Serentil), and others; or
almotriptan (Axert), frovatriptan (Frova), sumatriptan (Imitrex), naratriptan (Amerge), rizatriptan (Maxalt), or zolmitriptan (Zomig).

If you are using any of these drugs, you may not be able to use paroxetine, or you may need dosage adjustments or special tests during treatment.

There may be other drugs not listed that can affect paroxetine. Tell your doctor about all the prescription and over-the-counter medications you use. This includes vitamins, minerals, herbal products, and drugs prescribed by other doctors. Do not start using a new medication without telling your doctor.

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Where can I get more information?

Your pharmacist has additional information about paroxetine written for health professionals that you may read.

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What does my medication look like?

Paroxetine is available with a prescription under the brand names Paxil, Paxil CR and Pexeva. Other brand or generic formulations may also be available. Ask your pharmacist any questions you have about this medication, especially if it is new to you.

Paxil 10 mg--oval, yellow, film-coated scored tablets

Paxil 20 mg--oval, pink, film-coated scored tablets

Paxil 30 mg--oval, blue, film-coated scored tablets

Paxil 40 mg--oval, green, film-coated scored tablets

Paxil CR 12.5 mg--round yellow, film-coated tablets

Paxil CR 25 mg--round, pink, film-coated tablets

Paxil CR 37.5 mg-round, blue, film-coated tablets

Paxil 10 mg/5 mL-orange-colored, orange-flavored oral suspension

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BuSpar Oral (BUSPIRONE)

Generic Name: buspirone (byoo SPYE rone)

What is BuSpar Oral?
What is the most important information I should know about BuSpar Oral?
What should I discuss with my healthcare provider before taking BuSpar Oral?
How should I take BuSpar Oral?
What happens if I miss a dose?
What happens if I overdose?
What should I avoid while taking BuSpar Oral?
BuSpar Oral side effects
What other drugs will affect BuSpar Oral?
Where can I get more information?
What does my medication look like?

What is BuSpar Oral?

BuSpar is an anti-anxiety medicine that affects chemicals in your brain that may become unbalanced and cause anxiety.

BuSpar is used to treat symptoms of anxiety, such as fear, tension, irritability, dizziness, pounding heartbeat, and other physical symptoms.

BuSpar may also be used for purposes not listed in this medication guide.

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What is the most important information I should know about BuSpar Oral?

Do not this medication if you are allergic to BuSpar, or if you have used an MAO inhibitor such as isocarboxazid (Marplan), phenelzine (Nardil), rasagiline (Azilect), selegiline (Eldepryl, Emsam), or tranylcypromine (Parnate) within the past 14 days. Serious, life-threatening side effects can occur if you take BuSpar before the MAO inhibitor has cleared from your body. BuSpar can cause side effects that may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be awake and alert. Avoid drinking alcohol. It may increase some of the side effects caused by BuSpar.
Grapefruit and grapefruit juice may interact with BuSpar and lead to potentially dangerous effects. Discuss the use of grapefruit products with your doctor. Do not increase or decrease the amount of grapefruit products in your diet without first talking to your doctor.

BuSpar is usually taken for only a short time. Do not take this medication for longer than 4 weeks without your doctors advice.

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What should I discuss with my healthcare provider before taking BuSpar Oral?

Do not this medication if you are allergic to BuSpar, or if you have used an MAO inhibitor such as isocarboxazid (Marplan), phenelzine (Nardil), rasagiline (Azilect), selegiline (Eldepryl, Emsam), or tranylcypromine (Parnate) within the past 14 days. Serious, life-threatening side effects can occur if you take BuSpar before the MAO inhibitor has cleared from your body.
Before taking BuSpar, tell your doctor if you are allergic to any drugs, or if you have:

kidney disease; or
liver disease.
If you have any of these conditions, you may not be able to use BuSpar, or you may need a dosage adjustment or special tests during treatment.

FDA pregnancy category B. This medication is not expected to be harmful to an unborn baby. Tell your doctor if you are pregnant or plan to become pregnant during treatment. It is not known whether BuSpar passes into breast milk or if it could harm a nursing baby. Do not use this medication without telling your doctor if you are breast-feeding a baby. Do not give this medication to a child younger than 18 years old.

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How should I take BuSpar Oral?

Take this medication exactly as it was prescribed for you. Do not take the medication in larger amounts, or take it for longer than recommended by your doctor. Follow the directions on your prescription label.

BuSpar is usually taken for only a short time. Do not take this medication for longer than 4 weeks without your doctors advice.

You may take BuSpar with or without food but take it the same way each time.

Some tablet forms of buspirone (Buspar Dividose) may need to be broken before you take the medicine. These tablets have special scored marks on them to make breaking the tablet easy. Do not use the tablet if it has not broken correctly and the piece is too big or too small. Follow your doctors instructions about how much of the tablet to take.
If you have been switched to BuSpar from another anxiety medication, you may need to slowly decrease your dose of the other medication rather than stopping suddenly. Some anxiety medications can cause withdrawal symptoms when you stop taking them suddenly after long-term use.

Store BuSpar at room temperature away from moisture and heat.

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What happens if I miss a dose?

Take the missed dose as soon as you remember. If it is almost time for your next dose, skip the missed dose and take the medicine at your next regularly scheduled time. Do not take extra medicine to make up the missed dose.

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What happens if I overdose?

Seek emergency medical attention if you think you have used too much of this medicine.
Overdose symptoms may include nausea, vomiting, dizziness, drowsiness, blurred vision, and stomach pain.

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What should I avoid while taking BuSpar Oral?

BuSpar can cause side effects that may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be awake and alert. Avoid drinking alcohol. It may increase some of the side effects caused by BuSpar.
Cold or allergy medicine, narcotic pain medicine, sleeping pills, muscle relaxers, and medicine for seizures, or depression can add to sleepiness caused by BuSpar. Tell your doctor if you regularly use any of these other medicines.

Grapefruit and grapefruit juice may interact with BuSpar and lead to potentially dangerous effects. Discuss the use of grapefruit products with your doctor. Do not increase or decrease the amount of grapefruit products in your diet without first talking to your doctor.

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BuSpar Oral side effects

Get emergency medical help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat. Call your doctor at once if you have any of these serious side effects:
feeling light-headed, fainting;

fast or uneven heart rate;

depressed mood, unusual thoughts or behavior; or

lack of balance or coordination.

Less serious side effects may be more likely to occur, such as:

drowsiness, dizziness, blurred vision;

feeling restless;

nausea, upset stomach;

sleep problems (insomnia); or

trouble concentrating.

This is not a complete list of side effects and others may occur. Tell your doctor about any unusual or bothersome side effect.

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What other drugs will affect BuSpar Oral?

Before taking BuSpar, tell your doctor if you are using any of the following drugs:

medicines to treat psychiatric disorders, such as chlorpromazine (Thorazine), haloperidol (Haldol), mesoridazine (Serentil), pimozide (Orap), or thioridazine (Mellaril);

dexamethasone (Decadron, Hexadrol);

erythromycin (E-Mycin, E.E.S., Ery-Tab, Erythrocin);

itraconazole (Sporanox), ketoconazole (Nizoral);

ritonavir (Norvir);

rifampin (Rifadin, Rimactane, Rifater);

antibiotics such as capreomycin (Capastat), rifampin (Rifadin, Rimactane, Rifater), vancomycin (Vancocin, Vancoled);

a calcium channel blocker such as diltiazem (Tiazac, Cartia, Cardizem) or verapamil (Calan, Covera, Isoptin, Verelan); or

seizure medication such as carbamazepine (Carbatrol, Tegretol), phenytoin (Dilantin), phenobarbital (Luminal, Solfoton).

If you are using any of these drugs, you may not be able to use BuSpar, or you may need dosage adjustments or special tests during treatment.

This list is not complete and there may be other drugs that can interact with BuSpar. Tell your doctor about all your prescription and over-the-counter medications, vitamins, minerals, herbal products, and drugs prescribed by other doctors. Do not start using a new medication without telling your doctor.

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Where can I get more information?

Your pharmacist can provide more information about BuSpar.

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What does my medication look like?

Buspirone is available with a prescription under the brand name BuSpar. Other brand or generic forms may also be available. Ask your pharmacist any questions you have about this medication, especially if it is new to you.

BuSpar 5 mg white, rounded rectangular, scored tablet

BuSpar 10 mg white, rounded rectangular, scored tablet

BuSpar 15 mg two joined, rounded rectangles, forming a white, scored tablet.

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Cymbalta (DULOXETINE)

Generic Name: duloxetine (du LOX e teen)
Brand Names: Cymbalta

What is Cymbalta?
What is the most important information I should know about Cymbalta?
What should I discuss with my healthcare provider before taking Cymbalta?
How should I take Cymbalta?
What happens if I miss a dose?
What happens if I overdose?
What should I avoid while taking Cymbalta?
Cymbalta side effects
What other drugs will affect Cymbalta?
Where can I get more information?
What does my medication look like?

What is Cymbalta?

Cymbalta is an antidepressant in a group of drugs called selective serotonin and norepinephrine reuptake inhibitors (SSNRIs).
Cymbalta affects chemicals in the brain that may become unbalanced and cause depression.
Cymbalta is used to treat major depressive disorder and general anxiety disorder. It is also used to treat pain caused by nerve damage in people with diabetes (diabetic neuropathy).
Cymbalta may also be used for other purposes not listed in this medication guide.

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What is the most important information I should know about Cymbalta?

Do not take Cymbalta together with thioridazine (Mellaril), or a monoamine oxidase inhibitor (MAOI) such as isocarboxazid
(Marplan), phenelzine (Nardil), rasagiline (Azilect), selegiline (Eldepryl, Emsam), or tranylcypromine (Parnate). You must wait at least 14 days after stopping an MAOI before you can take Cymbalta. After you stop taking Cymbalta, you must wait at least 5 days before you start taking an MAOI.
You may have thoughts about suicide when you first start taking an antidepressant, especially if you are younger than 24 years old. Your doctor will need to check you at regular visits for at least the first 12 weeks of treatment.
Call your doctor at once if you have any new or worsening symptoms such as: mood or behavior changes, anxiety, panic attacks, trouble sleeping, or if you feel impulsive, irritable, agitated, hostile, aggressive, restless, hyperactive (mentally or physically), more depressed, or have thoughts about suicide or hurting yourself. Avoid drinking alcohol while taking Cymbalta. Alcohol may increase the risk of damage to your liver. Cold or allergy medicine, narcotic pain medicine, sleeping pills, muscle relaxers, and medicine for seizures, depression or anxiety can add to sleepiness caused by Cymbalta. Tell your doctor if you regularly use any of these other medicines. Cymbalta can cause side effects that may impair your thinking or
reactions. Be careful if you drive or do anything that requires you to be awake and alert.

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What should I discuss with my healthcare provider before taking Cymbalta?

Do not use Cymbalta together with thioridazine (Mellaril), or an MAO inhibitor such as isocarboxazid (Marplan), tranylcypromine (Parnate), phenelzine (Nardil), rasagiline (Azilect), or selegiline (Eldepryl, Emsam). Serious and sometimes fatal reactions can occur when these medicines are taken with Cymbalta. You must wait at least 14 days after stopping an MAO
inhibitor before you can take Cymbalta. After you stop taking Cymbalta, you must wait at least 5 days before you start taking an MAOI. Do not use this medication if you are allergic to duloxetine, or if you have untreated or uncontrolled glaucoma.
Before taking Cymbalta, tell your doctor if you are allergic to any drugs, or if you have:
liver or kidney disease; seizures or epilepsy; bipolar disorder (manic depression); or
a history of drug abuse or suicidal thoughts.
If you have any of these conditions, you may need a dose adjustment or special tests to safely take Cymbalta.
You may have thoughts about suicide when you first start taking an antidepressant, especially if you are younger than 24 years old. Tell your doctor if you have worsening symptoms of depression or suicidal thoughts during the first several weeks of treatment, or whenever your dose is changed.
Your family or other caregivers should also be alert to changes in your mood or symptoms. Your doctor will need to check you at regular visits for at least the first 12 weeks of treatment.
FDA pregnancy category C. Cymbalta may be harmful to an unborn baby, and may cause problems in a newborn baby if the mother takes the medication late in pregnancy (during the third trimester). Tell your doctor if you are pregnant or plan to become pregnant during treatment. Cymbalta can pass into breast milk and may harm a nursing baby. Do not use this medication without telling your doctor if you are breast-feeding a baby.
Older adults may be more sensitive to the side effects of this medication.
Do not give Cymbalta to anyone younger than 18 years old without the advice of a doctor.

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How should I take Cymbalta?

Take this medication exactly as it was prescribed for you. Do not take the medication in larger amounts, or take it for longer than recommended by your doctor. Your doctor may occasionally change your dose to make sure you get the best results from the medication.
Try to take the medicine at the same time each day. Follow the directions on your prescription label.
Do not crush, chew, break, or open a delayed-release capsule. Swallow the pill whole. It is specially made to release medicine slowly in the body. Breaking or opening the pill would cause too much of the drug to be released at one time. It may take 4 weeks or longer for your symptoms to improve. For best results, keep using the medication as directed. Do not stop
using Cymbalta without first talking to your doctor. You may have unpleasant side effects if you stop taking this medication suddenly. Store Cymbalta at room temperature away from moisture and heat.

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What happens if I miss a dose?

Take the missed dose as soon as you remember. However, if it is almost time for the next regularly scheduled dose, skip the missed dose and take the next one as directed. Do not take extra medicine to make up the missed dose.

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What happens if I overdose?

Seek emergency medical attention if you think you have taken too much of this medication. Overdose symptoms may include nausea, vomiting, diarrhea, agitation, confusion, hallucinations, fast heart rate, feeling light-headed, or fainting.

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What should I avoid while taking Cymbalta?

Avoid drinking alcohol while taking Cymbalta. Alcohol may increase the risk of damage to your liver. Cold or allergy medicine, narcotic pain medicine, sleeping pills, muscle relaxers, and medicine for seizures, depression or anxiety can add to sleepiness caused by Cymbalta. Tell your doctor if you regularly use any of these other medicines. Cymbalta can cause side
effects that may impair your thinking or reactions. Be careful if you drive or do anything that requires you to be awake and alert.

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Cymbalta side effects

Get emergency medical help if you have any of these signs of an allergic reaction: skin rash or hives; difficulty breathing; swelling of your face, lips, tongue, or throat.
Call your doctor at once if you have any new or worsening symptoms such as: mood or behavior changes, anxiety, panic attacks, trouble sleeping, or if you feel impulsive, irritable, agitated, hostile, aggressive, restless, hyperactive (mentally or physically), more depressed, or have thoughts about suicide or hurting yourself.
Call your doctor at once if you have any of these serious side effects:nausea, stomach pain, low fever, loss of appetite, dark urine, clay-colored stools, jaundice (yellowing of the skin or eyes);restlessness, overactive reflexes, hallucinations, loss of coordination, fainting, coma; or
nausea, vomiting, diarrhea, fever, and fast heartbeat.
Less serious side effects may include:
constipation;
drowsiness, dizziness, headache;
sleep problems (insomnia);
weight changes;
feeling anxious or nervous, increased sweating;
sore throat; or decreased sex drive, impotence, or difficulty having an orgasm.
This is not a complete list of side effects and others may occur. Tell your doctor about any unusual or bothersome side effect.

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What other drugs will affect Cymbalta?

Before taking Cymbalta, tell your doctor if you are using any of the following medicines:

cimetidine (Tagamet);

linezolid (Zyvox);

lithium (Lithobid, Eskalith);

St. John's wort;

tramadol (Ultram);

tryptophan (sometimes called L-tryptophan);

almotriptan (Axert), frovatriptan (Frova), sumatriptan (Imitrex), naratriptan (Amerge), rizatriptan (Maxalt), or zolmitriptan

(Zomig); or any other antidepressants such as amitriptyline (Elavil), amoxapine (Ascendin), clomipramine (Anafranil), desipramine

(Norpramin), escitalopram (Lexapro), fluoxetine (Prozac, Sarafem), fluvoxamine (Luvox), imipramine (Janimine, Tofranil),

nortriptyline (Pamelor), paroxetine (Paxil), protriptyline (Vivactil), sertraline (Zoloft), trimipramine (Surmontil), or venlafaxine (Effexor).

This list is not complete and there may be other drugs that can interact with Cymbalta. Tell your doctor about all the prescription and over-the-counter medications you use. This includes vitamins, minerals, herbal products, and drugs prescribed by other doctors. Do not start using a new medication without telling your doctor.

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Where can I get more information?

Your pharmacist can provide more information about Cymbalta.

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What does my medication look like?

Duloxetine is available with a prescription generically and under the brand name Cymbalta. Other brand or generic formulations may also be available. Ask your pharmacist any questions you have about this medication, especially if it is new to you.

Cymbalta 20 mg - green capsules

Cymbalta 30 mg -m white/blue capsules

Cymbalta 60 mg - green/blue capsules

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Making Sense of Antidepressants


What should I know before taking these drugs?
What are the causes of depression?
What other treatments are there?
How do antidepressants work?
What sorts of side effects can occur?
How long do they take to start working?
When shouldn't I take antidepressants?
How long should I stay on antidepressants?
Are antidepressants addictive?
How easy is it to come off them?
The different types of antidepressants
Tricyclic and related antidepressants
Tricyclics
Tricyclic-related antidepressants
Noradrenergic and Specific Serotonergic Antidepressant (NaSSA)
Monoamine-oxidase Inhibitors (MAOIs)
Reversible MAOI (RIMA)
Serotonin Specific Re-uptake Inhibitors (SSRIs)
SSRI-related antidepressants
Noradrenaline Re-uptake Inhibitor (NARI)
Combination or compound drugs
Other drugs for treating depression
References
Useful organisations

What should I know before taking these drugs?

Informed consent
The law says that you have the right to make an informed decision about which treatment to have, and whether or not to accept the treatment a doctor suggests. To consent, properly, you need to have enough information to understand the nature, likely effects and risks of the treatment, including its chance of success, and any alternatives to it. Generally, you can only receive treatment that you have specifically agreed to. Once you have given your consent, it isn't final and you can always change your mind. This consent to treatment is fundamental, and treatment given without it can amount to assault and negligence. To find out more about when treatment can be given without consent, see (Mind rights guide 3: consent to medical treatment.)

Patient information leaflets
If you are prescribed medication as an outpatient, or from your GP, you should find with it an information sheet called a patient information leaflet (PIL), in accordance with a European Union directive. As an inpatient, you may have to ask for it, specifically.

The EU directive sets out what information should be included in the leaflet, and in what order. The order in which the information is given has recently changed, to make it more user-friendly. Many PILs will still follow the old pattern until they are revised, but the information they include should be the same:

both the trade and general (generic) names
the strength of the medicine and the form it takes; for example, each tablet contains 5mg of drug X
who it is intended for; for example, adults, children, babies
the type of medicine it is; for example, a tricyclic antidepressant
what it is licensed to treat; for example, depression
things you need to know before taking it, such as conditions which mean you should either not take it at all, or you should take it with caution
the instructions for taking it: whether by mouth or other route; at what time of day; when to take it in relation to meals (if necessary)
a list of possible side effects, with an indication of how likely they are to occur
the expiry date of the drugs and how to store them
a full list of all the ingredients, including the extra contents that hold it together as a tablet or capsule, such as maize starch, gelatin, cellulose, and colourings. This information is important because some people may be allergic to one or other of the ingredients, such as lactose or gluten or a colouring.
The final item on the leaflet tells you that it contains only the most important information you need to know about the medicine, and that if you need to know more, you should ask your doctor or your pharmacist.

There is a lot of information to include in the PIL, so it's often printed in very small type, on a piece of paper that is folded many times, which may get thrown away with the packaging, by mistake. If you do not receive this information with your medicine, you should ask for it from the person who makes up your prescription.

Some of the information is quite hard to understand, and the Commission on Human Medicines (formerly the Committee on Safety of Medicines) has been looking at ways of making it easier. They have produced a leaflet Taking medicines  some questions and answers about side effects which you can find on their website or request by telephone. There is more information on medicines and their use, in the form of Medicines Guides, available from the Medicines Information Project website. See below for details of these organisations.)

You should also consider talking to your pharmacist. Pharmacists are drug specialists, and may be more knowledgeable about your drugs than the doctor who prescribes them. They may be more aware of possible side effects, and also possible interactions with other drugs (this is when a drug changes the effect of other drugs you are taking, makes them less effective, or causes additional side effects). Pharmacists are usually very willing to discuss drugs with patients, and some high-street chemists have space set aside where you can talk privately.

From January 2006 a new scheme is being put in place called the Medicines Use Review. People who regularly take more than one prescription medicine, or take medicines for a longterm illness, are encouraged to go to pharmacists who are operating the scheme, for a full discussion of their medicines and any problems they may have with them. The Medicines and Healthcare products Regulatory Agency (MHRA), who are responsible for overseeing the licensing of medicines, have produced a guide to the scheme (see their website under Useful websites below).

Many people would like to have the information about their proposed treatment before they are given the prescription for it, and not after they have got it from the pharmacist and taken it home. The following are issues you might like to discuss with your doctor when she or he gives you a prescription for a drug:

What is the name of the drug, and what is it for?
How often do I have to take it?
How long will I have to take it for?
If I am taking any other drugs, will it be all right to take them together?
Will I still be able to drive?
What are the most likely side effects, and what should I do if I get them?
Do I have to take it at any particular time of day? For example, if it is likely to make me sleepy, can I take it at night rather than in the morning? If it is likely to make me feel sick, can I take it with or after food?
When I want to stop taking it, am I likely to have any problems with withdrawal?
You may well think of other questions you wish to ask.

If you have troublesome side effects, or withdrawal symptoms when you stop taking your medication, you can report them yourself to the MHRA on their website or their hotline (see Useful organisations below). You no longer need to go through a health professional to do this, although you can if you wish. You can also see a full list of side effects reported on the same website.

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What are the causes of depression

There are a number of theories about the causes of depression; social, psychological and physical factors all play their part. Very often, doctors tell people with depression that they are suffering from a chemical imbalance; but this is a fairly meaningless phrase, as there is no real evidence for it. The only evidence is that medication which is designed to change the chemistry in particular ways does often lift the depression, but the interplay of chemicals in the brain is extremely sophisticated and complicated, and still very inadequately understood. Talking of chemical imbalance not only implies a better understanding than we have, but also ignores what may have caused the supposed imbalance in the first place.

Many people know exactly why they are depressed, and can talk about the life events that preceded it. But they may need some medication to help them to cope while they recover and adjust. Medication alone rarely provides a complete solution.

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What other treatments are there?

Drugs and electroconvulsive therapy (ECT) are often the only form of help offered to people diagnosed with depression. The most common treatment, by far, is antidepressant drugs. But antidepressants alone can't relieve life problems or prevent natural human emotional reactions.

In December 2004, the National Institute for Health and Clinical Excellence (NICE) published guidelines on the treatment of depression. These suggest that antidepressants should not be used as a first treatment for mild to moderate depression, and that other treatments should be offered, including talking treatments and exercise regimes, which may be as effective as drug treatment. It also suggests watchful waiting  recognition of the fact that depression sometimes just goes away without any medical intervention, and that active treatment may be unnecessary. The guidelines suggest that when an antidepressant is prescribed, it should be an SSRI, because their side effects are better tolerated than those of the alternative antidepressants.

A herbal remedy, St John's wort (Hypericum perforatum) has been found helpful for mild to moderate depression. It's worth remembering, however, that many standard medicines are based on plant extracts, and just because something is a herb, it doesn't mean that it's necessarily safer than other medicines, or free from side effects. Do not take St John's wort with other antidepressants, as there is evidence of adverse interactions.

Psychiatric research indicates that:

Antidepressants can be effective for 70 per cent of people who have them prescribed. However, the value of these findings is weakened by the fact that in 40 per cent of people, a dummy drug (placebo) is just as effective. In other words, the psychological impact of just being given something that's meant to help you appears to be beneficial. Moreover, the advantage of antidepressants over placebo may be exaggerated by the research methods used.
Recent reviews of groups of research studies suggest that SSRIs are no more effective than a dummy drug.
In milder depressions, short-term psychotherapy (a talking treatment) is as effective as drugs (see Understanding talking treatments).
The evidence that antidepressants are more effective in severe depression is weak.
One study comparing standard GP care, drug treatment from a psychiatrist, cognitive behaviour therapy (a particular type of talking treatment) and social work counselling found that specialist referral, particularly for cognitive behaviour therapy, produced the best results.
A high proportion of people with depression recover spontaneously without treatment.
The use of antidepressants has not affected rates of depression or suicide If your depression is related to housing, financial or other social problems, practical resolutions to these difficulties might be the most appropriate way of shifting your depression.

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How do antidepressants work?

Nerve cells, or neurons, communicate with one another by means of chemicals called neurotransmitters, which are released by one neuron and interact with receptors on another neuron. Their action is terminated by being taken back up into the neuron that released them (re-uptake). Depression is thought to be associated with low levels of certain neurotransmitters, particularly noradrenaline (also known as norepinephrine) and serotonin (also called 5-hydroxytryptamine or 5-HT). Most antidepressant drugs are therefore designed either to prolong the effects of the neurotransmitters by blocking their re-uptake into the neuron that released them, or to increase the amount that is accumulated in that neuron and so available for release.

Most types of neurotransmitters have actions at several different sites in the brain, and in other parts of the body, as well. This means that drugs that interfere with their actions will have side effects caused by the effect of the same type of neurotransmitters in other areas. As we learn more about the specific actions of different neurotransmitters, we can classify their receptors into different subtypes, depending on what response they trigger; for example, noradrenaline receptors are classified as alpha and beta receptors. Many people are familiar with the term 'beta blockers'  these drugs block beta receptors and therefore reduce the effect of noradrenaline at these sites. In designing new antidepressants, the aim is usually to target the drug only on brain receptors thought to be directly involved with depression, to avoid changing the action of the neurotransmitter at other sites.

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What sorts of side effects can occur?

A significant number of people who are prescribed these drugs stop taking them because of unpleasant and worrying side effects. If you are already depressed, struggling with some of the drugs' adverse effects can make you feel even more distressed, especially as the worst of these effects tends to occur at the beginning of treatment, before the drugs have started to lift the depression.

You may not experience any of the adverse effects listed in this booklet, or the ones that affect you may be no more than a minor inconvenience, which you consider an acceptable price to pay for the benefits the drugs give you. However, if they do cause troublesome or unpleasant side effects, don't hesitate to tell your doctor, if necessary by letter. You are the best judge as to whether or not the drugs are working for you.

Many antidepressants are very dangerous if more than the prescribed dose is taken. They should be prescribed in small amounts only, taken with great care and stored out of reach of children. It's very important not to increase the dose above that prescribed. Doctors should keep in close contact with you, especially at the beginning of your treatment. You should be able to visit your doctor to discuss any adverse effects you experience.

There is a warning from the Committee on Safety of Medicines about low blood sodium levels (hyponatraemia) associated with all antidepressants. This mainly affects elderly people. Signs are drowsiness, confusion or convulsions.

Antidepressants may affect driving and other skilled tasks.

Drugs that cause a dry mouth may cause tooth decay as a secondary effect. Saliva is important in protecting against tooth decay, and there have been several reports of people developing dental problems, especially after long-term use of tricyclic and related antidepressants.

There is a possibility that taking antidepressants may make people feel suicidal when they had not felt this way before they started the medication. Suicidal feelings have mainly be associated with SSRI antidepressants, with many published anecdotes, but there is a suggestion that the same thing may occur with other types of antidepressants too. It is possible that when someone is very depressed they cannot summon up the motivation or energy for suicide, and in the early stages of treatment this changes, so that they then do have the energy to act, before the depression has really started to lift. This has usually been the explanation for suicide in the early stages of treatment. However, the suggestion that the drugs themselves cause suicidal thoughts and urges is increasingly being taken seriously, and this issue is discussed below in relation to SSRI antidepressants in particular.

If someone is so depressed that they sometimes feel suicidal, it might be advisable for a relative or close friend to help them to look after their tablets so the right dose is taken at the right time.

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How long do they take to start working?

Most antidepressants take two to four weeks to take effect, although this may not be the case for some of the newest drugs. Some doctors have attempted to speed up the response to antidepressants by combining them with pindolol (a beta blocker). So far, the results of these trials have been mixed. For some people, the combination produced a faster and more effective response; for others pindolol made no difference. However, it has been suggested that for people who have not found an antidepressant helpful, this approach might be worth trying, perhaps before resorting to lithium or electroconvulsive therapy. Most common adverse effects of pindolol are low blood pressure, headache, nausea, diarrhoea and increased irritability.

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When shouldn't I take antidepressants?

Pregnant and nursing mothers

Although few drugs have been proved to cause birth defects, great caution is necessary with drugs during pregnancy. A balance has to be struck between the needs of the mother-to-be and the possible risk to the unborn child, particularly in the first three months of pregnancy.

Tricyclic antidepressants, SSRIs and SNRIs given in late pregnancy have been associated with withdrawal symptoms in newborn babies. Tricyclics are associated with rapid heartbeat, irritability, muscle spasms, restlessness, sleeplessness, fever and fits. SSRIs and SNRIs have been associated with jitteriness, poor muscle tone, weak cry, respiratory distress, low blood sugar and fits. Recently published research suggests that taking SSRIs in pregnancy may be associated with an increase in the likelihood of birth defects, especially heart problems and high blood pressure in the lungs in the newborn infant.

After the birth, a nursing mother is likely to pass any drugs she is taking to her baby through her breast milk. Newer drugs carry a higher risk than drugs that have been in use longer, as less is known about them. Doxepin (Sinequan), in particular, should be avoided in breastfeeding.

When a woman who is pregnant or who is breastfeeding is suffering from depression, every alternative to drugs should be explored. With help and support, drugs may be unnecessary.

Children and antidepressants

Antidepressant drugs are not licensed for the treatment of depression in children under 16. The NICE guidelines on depression in children and young people, published in September 2005, recommend that antidepressants should only be given to children in combination with psychological therapies, unless these are refused.

The only antidepressant that should be used initially is fluoxetine (Prozac), because this is the only one whose benefits outweigh its possible harms in children. Fluoxetine should be prescribed by a child psychiatrist. If fluoxetine cannot be used, citalopram or sertraline may be tried. Paroxetine, venlafaxine, St Johns wort and tricyclic antidepressants should not be used.

Antidepressants are not tested in children and when used they should be started cautiously at a dose appropriate to the childs size. Because of reported cases of suicidal thoughts, suicide, self-harm and violence  especially by young people taking these drugs  children should be carefully monitored, especially in the initial stages of treatment.

The following tricyclics are licensed for the treatment of bedwetting: amitriptyline, imipramine and nortriptyline.

Drug interactions

If you are prescribed antidepressants, it's important to inform your doctor about any drugs you are taking, as antidepressants can interact with a number of different types of drug, and some combinations can be dangerous. Where combinations of psychiatric drugs are known to interact, these have been listed further in this booklet. Sometimes, a number of interacting psychiatric drugs are prescribed together, which can add to the adverse effects of the individual drugs.

Alcohol

People taking antidepressants should be careful about drinking alcohol. Alcohol is a depressant and may be a significant contributor to the depression in the first place: some people are made very depressed by particular alcoholic drinks, but may be unaware of the causal link. Alcohol interacts with most antidepressants, increasing sedation and affecting the ability to perform skilled tasks even further. It can make older people more prone to falls and confusion. It's therefore wise to ask your doctor or pharmacist whether it's safe to drink alcohol with the drug you are taking.

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How long should I stay on antidepressants?

Studies show that staying on antidepressants for six months after they have become effective can help prevent further episodes of depression. Some studies suggest that most people aren't being given sufficient antidepressants for long enough. The BNF recommends that people should be maintained at the effective dose for at least four to six months after the depression has lifted. If treatment stops too soon, the depression is likely to come back.

In recurrent depression, maintenance therapy with an effective dose may need to continue for several years (information about 'maintenance' doses is included under the individual drugs). Because of possible problems with withdrawal (see below), it is important not to suddenly reduce the dose or stop altogether. If possible you should discuss with your doctor or other professional how long to remain on your antidepressants and how to go about stopping them.

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Are antidepressants addictive?

Drug companies and some doctors have often said that antidepressants are not addictive, because if drugs are addictive, people develop a craving for them if they stop taking them suddenly, find the need to increase the dose to maintain the same effect, and use the drug to get high. They have alleged that none of these things happen with antidepressants.

However, after taking them for some time, some people do become 'tolerant' to antidepressants and report needing to take higher doses to achieve the same effect.

Although antidepressants don't usually produce the sort of 'buzz' that results in cravings, some of them are used as street drugs, indicating that they do have the potential to have this effect. People can get slightly high from the stimulant effect of the monoamine oxidase inhibitor (MAOI) antidepressant tranylcypromine. A few people take larger doses than prescribed in order to keep getting the mild high. This is dangerous because tranylcypromine (see below) can be very poisonous when people take more than the prescribed dose; also, because there is a greater risk of adverse interactions with other drugs or substances in food (see below). There is a risk of dependency with all MAOIs. (This means that people are likely to experience side effects upon withdrawal.)

A tolerance to one of the tricyclic antidepressants, amoxapine, has been reported, possibly caused by a mild stimulant or 'high' effect (see below). Taking amoxapine may therefore carry a particular risk of physical dependency. It's also important to be aware that any drug can become a psychological habit.

The difficulties many people have coming off tricyclics and, especially, SSRIs have been well publicised in recent years. When withdrawal symptoms are severe, they may prevent people from going out and leading a normal life, and are particularly dangerous with activities like driving.

In a very useful summary of the whole issue of addiction to or dependence on antidepressant drugs, the American psychiatrist, Joseph Glenmullen, has written, Not all patients who develop withdrawal symptoms become addicted, or dependent. Addiction occurs when patients suffer such intolerable or incapacitating withdrawal symptoms that they are forced to restart the drugs, put the dose back up, or taper them off more slowly. Patients are then dependent on antidepressants for as long as it takes to wean off the drugs. Dependence and addiction are the same things: dependence being the technical medical term used by doctors and addiction the plain English term used by patients. He defines withdrawal as the process of stopping or tapering off antidepressants and the characteristic symptoms that can develop as a result.

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How easy is it to come off them?

Withdrawal reactions can occur with all major types of antidepressant. Problems are more likely to occur after abrupt withdrawal and longer courses of treatment. Reactions usually start suddenly within a few days of stopping the antidepressant, or of reducing its dose. Individuals vary in their susceptibility to withdrawal problems, and while some people may stop taking their drugs with no problems, others experience extremely unpleasant withdrawal symptoms and have to reduce the dose very slowly over a long period. The difficulties are also related to the half-life of the drug: this is an estimate of how long it takes for a drug to be eliminated from the body. The drugs with the shortest half-lives cause the greatest problems with withdrawal. (See Useful websites for more information.)

Withdrawal problems vary, depending on the type of antidepressant. Common symptoms include gastric problems (nausea, vomiting, abdominal pain or diarrhoea), loss of appetite, sleep disturbance (insomnia, vivid dreams or nightmares), general discomfort (sweating, lethargy or headaches), and mood changes (low mood, hypomania  'high' moods, panic, anxiety or irritability) and extreme restlessness. With SSRIs, the commonest symptoms appear to be dizziness, lightheadedness, numbness, tingling and sensations that resemble having electric shocks.

The BNF (British National Formulary) recommends that if antidepressants have been prescribed continuously for eight weeks, or more, they should not be stopped abruptly, but should be reduced gradually over four weeks. For many people four weeks will not be long enough and withdrawal will have to be more gradual over a much longer period. Some reports suggest that tapering off the dose may not be necessary when switching between SSRIs. If discontinuation reactions are severe, the antidepressant may need to be restarted and the dose tapered off more gradually. Some drugs are available in liquid form and this means that the dose can be tapered very gradually by repeated dilution.

A listing of possible withdrawal symptoms that you may experience can be found under the relevant group of antidepressants or the individual drug, if appropriate. This information may help you to distinguish a brief and temporary withdrawal period from what may otherwise be mistaken for a re-emergence of the earlier depression or distress.

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The different types of antidepressants

All information about drug doses mentioned in this thread is taken from recommendations in The British National Formulary (BNF) and in The Associated British Pharmaceutical Industry Data Sheet Compendium. Sometimes, higher maximum doses can be given in hospital under close supervision. It is very dangerous to exceed the prescribed dose. The trade names of the drugs are in brackets after the general name.

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Tricyclic and related antidepressants

This group of antidepressants is given for depression with no obvious cause, or where depression is associated with physiological changes such as loss of appetite and sleep disturbance. Tricyclics are so named because of their chemical structure, and have been in use since the 1960s. They prolong the action of both the neurotransmitters noradrenaline and serotonin. Related drugs (such as, maprotiline, mianserin and trazodone) have a similar chemical structure and action to the tricyclics. Differences between the two types mainly relate to the adverse effects. The tricyclic drugs have a broader chemical action and also affect another transmitter system, causing side effects to the heart and circulatory system. These are called 'anticholinergic' or 'antimuscarinic' effects: drowsiness, dry mouth, blurred vision, constipation, rapid heartbeat, difficulty passing water and sweating.

Cautions

This group can cause drowsiness and so may affect the ability to perform skilled tasks such as driving or operating machinery. Some drugs in this group are more sedating than others, and some have fewer effects than others on the heart and circulatory system.

Older people find the adverse effects of tricyclics a particular problem, as low blood pressure can lead to dizziness and falls, so gradual introduction is very important. This group of antidepressants should not be given to people who have had a recent heart attack, have heart block, manic episodes or severe liver disease. They should be used with caution in people with diabetes, heart, liver or thyroid disease, the eye disease glaucoma, and for anyone already experiencing problems passing water. Special difficulties arise when antidepressants are used in the treatment of psychosis. If given to people with epilepsy, this group of antidepressants can make people more likely to have fits, and they should not be used in conjunction with ECT or with anaesthetics. It is very dangerous to exceed the prescribed dose.

Drug interactions

If this group of antidepressants is taken with some antipsychotics, such as chlorpromazine (Largactil) the adverse effects can become much worse. If they are taken with minor tranquillisers or sleeping pills, such as diazepam (Valium), the sedative effect increases. This group of drugs should not be taken for at least two weeks after stopping MAOI antidepressants (see below). There is also evidence of significant adverse interaction between tricyclics and SSRIs (see below for more details). If you are taking any other drugs you should discuss this with your doctor.

Withdrawal

Don't suddenly stop your tablets for no good reason. Do taper the dose down gradually. Following these guidelines will help minimise any withdrawal symptoms. People withdrawing may experience the following more common symptoms: a flu-like pattern, which can include nausea, vomiting, abdominal pain, loss of appetite, diarrhoea, generally feeling unwell, chills, weakness, tiredness, sweating, and headache. Jitteriness, anxiety, agitation and panicky feelings may occur.

Sleep disturbance may be a problem - difficulty getting to sleep, followed by very vivid dreams early in the night, which can be frightening. People may experience general restlessness. There are a few reports of people developing disturbed and extremely excitable (manic) behaviour. On rare occasions, if the drug is stopped abruptly, panic attacks may occur. (See, in particular, amitriptyline and imipramine below.)

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Tricyclics

Amitriptyline hydrochloride (Elavil, and also in the compounds Triptafen and Triptafen-M)
Form: tablets or liquid

Adult dose: 50-75mg daily initially, in divided doses or as a single dose at bedtime; increased gradually as needed to a maximum dose of 150mg. Older people and adolescents: 30-75mg. Children: may be used to treat bedwetting for a maximum of three months. Side effects: (commonest first), dry mouth, sedation, drowsiness, blurred vision, constipation, nausea, difficulty passing water. Heart and circulatory system effects: changes in heart rhythm, rapid heartbeat, low blood pressure on standing, fainting (particularly at high doses and in elderly people). Sweating, tremor, rashes and allergic reactions, disturbed behaviour (particularly in children), manic episodes, confusion particularly in older people), reduced sexual arousal and interference with sexual function, blood sugar changes and weight changes (usually gain). Hormone-related effects: enlargement of testicles, breast development and secretion of milk. Fits, movement disorders, fever, blood disorders, low blood sodium levels, abnormal liver function. Withdrawal: an estimated 80 per cent of people may experience withdrawal symptoms. Children may find these symptoms particularly distressing.

Amoxapine (Ascendis)

Amoxapine has some neuroleptic effects (like an antipsychotic), and is thought to block the neurotransmitter dopamine. Reviewers tend to regard its potentially adverse effects as outweighing its benefits. Claims that it acts more quickly than other antidepressants have been queried. Form: tablets Adult dose: 100-150mg daily up to a maximum 300mg daily in divided doses or as a single dose at bedtime. Usually 150-250mg daily. Older people: 25mg twice daily initially, increased after five to seven days to a maximum 50mg three times daily. Side effects: similar to those caused by amitriptyline, although less sedating, but includes a possible risk of developing tardive dyskinesia, a movement disorder that may be irreversible (see Mind's booklet Making sense of antipyschotics [major tranquillisers]). Interference with menstruation, breast enlargement and secretion of breast milk in women have been reported. Rarely: fits (which may be difficult to control) especially when using doses higher than those recommended. Caution: one study suggests that people may show tolerance to the therapeutic effects of this drug after an initial response. Withdrawal: abrupt withdrawal after long-term treatment can lead to gastric troubles, excessive sweating and increased anxiety.

Clomipramine (Anafranil)

Clomipramine is also given for obsessional states, when the doses given may be higher than for depression. Form: tablets or capsules Adult dose: 10mg daily initially, increasing gradually as necessary to 30-150mg maximum daily. Usual maintenance dose 30-50mg daily. Older people: 10mg daily initially, increased to 30-50mg daily. Side effects: similar to amitriptyline, but claimed to be less sedating. Drug interactions: see 'drug interactions with MAOIs below.

Dosulepin/dothiepin (Prothiaden, Prepadine, Dothapax)

Form: tablets or capsules. Adult dose: 75mg daily initially, increased as necessary up to a maximum 150mg daily. Older people: 50-75mg. Side effects: similar to amitriptyline.

Doxepin (Sinequan)

Form: capsules Adult dose: 75mg daily initially, in three divided doses, increased as necessary up to a maximum of 300mg daily in three divided doses (up to 100mg at one dose). Older people: 10-50mg daily initially. 30-50mg daily may be enough. Side effects: similar to those caused by amitriptyline. Caution: avoid while breastfeeding.

Imipramine (Tofranil)

Form: tablets Adult dose: 75mg daily initially, in divided doses, increased gradually as necessary up to a maximum 150-200mg (up to 300mg in hospital patients). Up to 150mg may be given as a single dose at bedtime. Older people: 10mg daily initially, increased gradually to 30-50mg daily. Children: May be given to children over six years old for bedwetting. Side effects: similar to amitriptyline, but less sedating. Withdrawal: studies show that 21 to 55 per cent of people experience gastric and other bodily discomforts.

Lofepramine (Gamanil, Lomont)

Form: tablets or liquid Adult dose: 140-210mg daily in divided doses. Older people : older people may respond to lower doses. Side effects: like amitriptyline, but less sedating. Reports of liver disorders. Caution: to be avoided in people with liver or severe kidney disorders.

Nortriptyline (Allegron; also in the compound Motival)

Form: tablets Adult dose: low dose initially, increasing gradually as necessary up to 75-100mg daily in divided doses or as a single dose. (Blood to be monitored if dose is any higher). Maximum dose 150mg in hospital patients. Older people and adolescents: 30-50mg initially in divided doses. Children: may be used for bedwetting for a maximum of three months. Side effects: similar to those caused by amitriptyline, but less sedating.

Trimipramine (Surmontil)

Form: tablets or capsules Adult dose: 50-75mg daily initially, as a single dose two hours before bedtime, or as 25mg at midday and 50mg in the evening, increasing as necessary up to a maximum dose of 300mg daily for four to six weeks. Older people: 10-25mg three times daily initially, half the adult maintenance dose may suffice. Side effects: similar to those caused by amitriptyline, but may be more sedating.

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Tricyclic-related antidepressants

Maprotiline hydrochloride (Ludiomil)

Form: tablets Adult dose: 25-75mg daily initially, in three divided doses or a single dose at bedtime. Increased gradually as necessary to a maximum dose of 150mg daily. Older people: 30mg daily initially. Half the usual adult dose should suffice. Side effects: similar to amitriptyline, but said to be fewer antimuscarinic effects. Skin rashes are common and there is increased risk of fits at higher doses. Careful supervision from a doctor is advised.

Mianserin hydrochloride

Form: tablets Adult dose: 30-40mg daily initially, in divided doses or as a single dose at bedtime. Increased gradually as necessary. Usual dose range 30-90mg. Older people: 30mg daily initially. Side effects: similar to amitriptyline, but said to be fewer and milder antimuscarinic effects and effects on the heart and circulatory system. Other unwanted effects may include jaundice, arthritis, pain in the joints and a flu-like syndrome. Caution: in rare cases may cause serious blood disorders, especially in older people. Blood tests every four weeks recommended during the first three months of treatment. See your doctor if a fever, sore throat, sore mouth or other infection develops.

Trazodone hydrochloride (Molipaxin)

Form: tablets, capsules or liquid. Adult dose: 150mg daily in divided doses after food or as a single dose at bedtime, increased as necessary up to 300mg daily. Hospital patients up to a maximum of 600mg daily in divided doses. Older people: 100mg daily. Side effects: similar to amitriptyline, but claimed to be fewer antimuscarinic effects and effects on the heart and circulatory system; may be more sedating. Caution : a rare but distressing and serious adverse effect in males is persistent erection, when the drug should immediately be stopped and medical advice sought.

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Noradrenergic and Specific Serotonergic Antidepressant (NaSSA)

Mirtazapine (Zispin)

Mirtazapine was first licensed for use in the UK in 1997. It is similar to the tricyclics, in that it affects both the noradrenaline and the serotonin systems, but it is more selective, stimulating only one type of serotonin receptor. It should have fewer side effects than the older drugs.

Form: tablets or liquid Adults and older people: 15mg daily initially, increasing according to response up to 45mg daily as a single dose at bedtime or in two divided doses. Side effects: (most common) increased appetite and weight gain, sedation. Less common: raised liver enzymes, jaundice (see caution). Rarely : oedema (fluid retention causing puffiness), low blood pressure on standing, skin rash, tremor, muscle spasms, reversible blood disorders. Caution: avoid in pregnancy and breastfeeding. Should be avoided or used with caution in people who have epilepsy, liver or kidney disease, low blood pressure, a history of urinary retention, angle-closure glaucoma, diabetes mellitus, psychotic illnesses, and a history of manic depression (bipolar disorder). Patients should report any fever, sore throat, mouth ulcers or other signs of infection during treatment, and blood tests should be carried out. If patients become jaundiced, treatment should not continue. Withdrawal: avoid abrupt withdrawal.

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Monoamine oxidase inhibitors (MAOIs)

MAOIs work on the same neurotransmitters as the tricyclics, but act by blocking the enzymes that break them down. Blocking the enzymes enables the transmitters to accumulate so that more of them are released. Because of their side effects, fewer MAOIs tend to be prescribed and, usually, when other antidepressants (tricyclics or SSRIs) have failed. It may take three to five weeks for MAOIs to work.

Avoiding certain food and drink
Most MAOIs currently available can affect the way that certain foods are digested and can cause them to become poisonous. You should be very careful about what you eat and drink (you will be given a treatment card with advice on what to avoid). Steer clear of anything that is not fresh, which has been fermented, pickled, cured, hung, dried and matured. This is because when food is exposed to the air, a substance called tyramine, which causes this dangerous interaction with MAOIs, rises to high levels. Excluded foods include: matured cheeses; game; protein extracts such as Marmite, Bovril or Oxo; alcohol (especially red wine); non-alcoholic beer and lager, overripe fruits; broad bean pods and banana skins. If you do eat or drink any of these and they disagree with you, you should immediately inform your doctor. It may result in a dangerous rise in blood pressure and severe headache. Fortunately, serious incidents and deaths are rare.

When MAOIs are not suitable
MAOIs should usually be avoided by people who are prone to agitation or who have liver, kidney or heart disease, epilepsy, diabetes, and blood disorders. They should not be given to children, and only with great caution, if at all, to older people. Tranylcypromine is the most hazardous, because of its stimulant effect.

Drug interactions with MAOIs
It may be dangerous to take MAOIs at the same time as certain other prescribed or over-the-counter medicines, whether these are tablets, capsules, nose drops, inhalations or suppositories. Cough mixtures and cold treatments should be avoided. Always check with your GP first. Do not use with the following psychiatric drugs:

Tricyclic and other antidepressants. It is essential to have a gap after stopping these before starting MAOIs. Leave at least one week after SSRIs; five weeks after fluoxetine (Prozac); two weeks after paroxetine (Seroxat) and sertraline (Lustral). Always wait at least 14 days after finishing a course of MAOIs before starting a different antidepressant. It is particularly dangerous to combine clomipramine (Anafranil) and tranylcypromine.
Buspirone (Buspar) given for anxiety.
Carbamazepine (Tegretol) given for manic depression or epilepsy.
Barbiturates because their effects may be heightened.
Certain antipsychotic drugs (major tranquillisers) prescribed for severe mental distress such as hallucinations and delusions because their effects may be heightened.
Withdrawing from MAOIs
This is a similar experience to coming off tricyclics. It is important to taper the dose down gradually. Do continue with food and drink restrictions for two weeks after stopping completely. Avoid abrupt withdrawal, unless there's good reason, because fits may occur. There have been rare reports of abrupt withdrawal resulting in hallucinations or delusions. People may have difficulty coming off tranylcypromine because of its stimulant effect.

Phenelzine (Nardil)
Form: tablets
Adult dose: 15mg three times daily, increased if necessary to four times daily after two weeks. Then reduce to lowest possible maintenance dose; 15mg on alternate days may be enough. Hospital patients may be given a maximum of 30mg three times daily. Side effects: (commonest first) low blood pressure on standing and dizziness. Drowsiness, insomnia, headache, weakness and tiredness, dry mouth, constipation and other gastric disturbances, oedema (puffiness), muscle spasms and jerks, raised liver enzymes, agitation and tremors, nervousness, feelings of excitement, disturbances of heart rhythm, blurred vision, wobbling eye movement, difficulty in passing water, sweating, fits, rashes, blood disorders, interference with sexual function, weight gain with appetite changes. Psychotic episodes with mania, confusion and hallucinations may occur in some vulnerable people. Rare reports of jaundice and of liver poisoning.

Isocarboxazid
Form: tablets
Adult dose: 30mg daily initially, in single or divided doses, increased after four weeks if necessary to a maximum of 60mg daily for up to six weeks under close supervision only. Then reduced to usual maintenance dose 10-20mg daily (but 40mg daily may be necessary). Side effects: similar to phenelzine.

Tranylcypromine
Form: tablets
Adult dose: 10mg twice daily initially (not later than 3pm), increasing the second dose to 20mg after one week, if necessary. Doses above 30mg daily under close supervision only. Usual maintenance dose 10mg daily. Side effects: see phenelzine. Also, insomnia (if given in the evening). Hypertensive crisis (high blood pressure) with a throbbing headache requiring that treatment ends is more likely than with other MAOIs. Liver damage occurs less frequently than with phenelzine. Withdrawal: because tranylcypromine has a stimulant effect, people may have difficulty coming off it.

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Reversible MAOI (RIMA)


Moclobemide (Manerix)
Moclobemide, used for major depression, derives from the MAOI group, but differs from others because it is 'reversible'. This means that there is much less risk of a tyramine crisis arising (see above, although the BNF warns against eating large amounts of food high in tyramine (large amounts of mature cheese, yeast extracts or fermented soya products). The tablets should be taken after meals.
Form: tablets
Adult dose: 300mg daily initially, in divided doses after food, adjusted according to response; usual range 150-600mg daily.Side effects: sleep disturbance, dizziness, nausea, headache (listed on the datasheet as transient), restlessness, and agitation. Confusional states have been noticed, which have disappeared rapidly when the drug was stopped. Rarely: raised liver enzymes. Drug interactions: may be less likely than with older MAOIs, but patients should check with their doctors before taking it with any other medications (including those bought over the counter). Moclobemide should not be given with another antidepressant. Because its effect is short, no treatment-free period is necessary after stopping it. However, leave at least a week's gap before starting moclobemide after taking tricyclics, SSRIs, or related antidepressants. (After paroxetine and sertraline, leave at least two weeks, and after fluoxetine at least five weeks.) After taking an older MAOI, leave a week. Caution: these should not be given to people who are agitated or excited or to people who swing between depression and mania. They should not be given to people with overactive thyroid, severe liver impairment or anyone acutely confused or with phaeochromocytoma. Do not use during pregnancy or breastfeeding. Withdrawal: see above.

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Serotonin Specific Reuptake Inhibitors (SSRIs)

SSRIs are a type of antidepressant marketed in the UK since 1989. They block the re-uptake of serotonin into the nerve cell that released it, thereby prolonging its action. This group of drugs, and especially fluoxetine (Prozac) has received enormous media interest in the UK and USA, resulting in its image as a 'lifestyle' drug. Several books have been written about it in this vein. However, the reality is that these drugs are antidepressants, available on prescription, and possibly no more effective than the tricyclics in treating depression. They have at least as many possible side effects listed in the BNF as the others, though they may be better tolerated than the older drugs.

SSRIs and children and teenagers under 18
See above for information on NICE guidance on treating depression in this age group.

None of these drugs has ever been licensed for anyone under the age of 18, but they have been widely prescribed for this age group. In December 2003, the MHRA issued guidance stating that no SSRIs should be given to this age group except fluoxetine (Prozac), which should only be given on the advice of a child psychiatrist. Only if a child can't tolerate fluoxetine can another SSRI be used; again, on the advice of a child psychiatrist. Research evidence suggests paroxetine, sertraline and citalopram are not effective in this age group and are more prone to cause side effects, including suicidal feelings, in young people than in adults. (Escitalopram and fluvoxamine have not been studied in this age group.) This guidance also applies to venlafaxine (see below).

Side effects of SSRIs
The most common side effects include gastric disturbance, such as nausea, headaches, restlessness, anxiety, sleep problems, and internal bleeding. It may also cause a variety of sexual difficulties. The most commonly reported in men are reduced sexual desire, prolonged erection, failed erection, delayed ejaculation and lack of orgasm. In women, the effects are more varied and may include spontaneous orgasm, delayed or lack of orgasm (associated with the drug fluoxetine) or increased libido (with fluvoxamine). Such problems may be treatable by lowering the dose, changing to an alternative drug or stopping the drug for a while. (Because of these side effects, these drugs are sometimes used to treat sexual difficulties, such as premature ejaculation). Some people may experience hypomania on these drugs, either while taking them or during withdrawal, and this may be misinterpreted by doctors who are not aware of the link with the drug, so that you end up with a diagnosis of bipolar disorder and receiving further medication. For more details about side effects, refer to the list of individual drugs.

In addition to the side effects, the BNF also lists effects that have been reported in association with SSRIs, but where a causal link has not been proved. These include blood disorders, stroke, raised levels of the hormone prolactin (leading to breast tenderness and possibly milk production), pancreatitis (a disorder of the pancreas), suicidal thoughts, vaginal bleeding on withdrawal, violent behaviour, and hair loss.

Although a causal link with these effects is said not to have been proved, suicidal and violent feelings have been experienced not only by people who were being treated for depression but also by people prescribed these drugs for conditions such as chronic fatigue syndrome or back pain, who were not depressed before taking the drugs.

It has been suggested that suicidal and violent thoughts associated with SSRIs may be preceded by akathisia  a feeling of mental restlessness and agitation that causes great unease, and is more commonly associated with antipsychotic medication. Anyone who experiences such a sensation while taking an SSRI should discuss this with their doctor promptly, and be aware of the feelings that may be associated with it. Suicidal or violent thoughts or actions are also associated, in some reports, with changes in dose (either increases or decreases), and it is important to be aware of this.

Dangerous drug interactions
There are risks if SSRIs are taken with other antidepressants including MAOIs (or within two weeks of stopping MAOIs). It's essential to have at least a one-week gap after stopping SSRIs before starting MAOIs (with fluoxetine, at least five weeks and for paroxetine and sertraline at least two weeks).

There is evidence of significant adverse interaction between SSRIs and tricyclic antidepressants. All currently available SSRIs (except, perhaps, citalopram) may raise the blood levels of tricyclics, and therefore increase the risk of serious side effects. Such interactions may occur when drugs are changed from an SSRI to a tricyclic, and this should therefore be done with caution, starting with a low dose of tricyclic and increasing gradually.

If SSRIs are given with other antidepressants including MAOIs, tryptophan and lithium, there is a risk of serotonin syndrome developing. This is serious and potentially fatal. The symptoms are: hyperthermia (high temperature), tremor and convulsions (fits), agitation and muscle spasms.

There are possible hazards if SSRIs and antipsychotic drugs are prescribed together; in particular: fluoxetine with haloperidol; and fluvoxamine with clozapine. Some SSRIs may increase levels of carbamazepine with risk of carbamazepine levels rising to toxic levels. Check with your doctor or pharmacist for further information if you are prescribed drugs together, or closely following one another, in case of possible interactions.

Withdrawal from SSRIs
All SSRIs should be withdrawn slowly if possible. The following withdrawal effects are reported: dizziness, numbness, pins and needles, anxiety, disturbed sleep (and vivid dreams), agitation, tremor, nausea, sweating, confusion, depersonalisation, and a feeling of electric shocks or head zaps.

The Committee on Safety of Medicines have received more yellow-card reports of withdrawal symptoms for paroxetine (Seroxat) than for any other SSRI. This drug has a short half-life which makes it more difficult to come off. The other drugs in this group with relatively short half-lives are citalopram and sertraline. Fluoxetine (Prozac) has a long half-life, which means it takes a long time for the body to clear the drug completely, and so withdrawal is more gradual than for related drugs. This means that withdrawal from Prozac is usually easier, but also that when problems do occur, they come later in the withdrawal process.

Citalopram (Cipramil)
This drug has been available in the UK since 1995. The active ingredient is escitalopram, which was introduced as a new drug in 2002.
Form: tablets or liquid
Adult dose: 20mg daily as a single dose in the morning or evening, increased if necessary. 40mg tablets available for people with severe depression. For panic disorder: 10mg daily initially, increased to 20mg after one week; usual dose 20-30mg daily. Maximum dose should be 60mg daily. Older people: maximum of 40mg daily. Side effects: (most common) nausea, sweating, tremor, drowsiness and dry mouth (see fluoxetine, below). Cautions: see fluoxetine, and general information above. Drug interactions: may have fewer interactions with other drugs than other SSRIs.

Escitalopram (Cipralex)
This was licensed as a new drug in 2002, although it is the active ingredient of citalopram, and so is almost identical.
Form: tablets
Adult dose: for depression, 10mg daily, increased as necessary to a maximum of 20mg daily. For panic attacks, the starting dose is 5mg, which may be increased to 10mg after one week. Again, the maximum daily dose is 20mg. Older people: doses should be halved. Side effects: (most common) nausea, diarrhoea or constipation, decreased appetite; loss of libido (women), ejaculation problems and impotence; insomnia, dizziness (see fluoxetine, below). Cautions: see fluoxetine. Drug interactions: see citalopram.

Fluoxetine (Oxactin, Prozac)
The patent for Prozac has now expired. This means that the drug (fluoxetine) can now be made by other drug companies, and may be marketed under its generic name of fluoxetine, and may also be given other trade names. These versions will not look the same as Prozac, and the inactive ingredients may be different, but the active ingredient (fluoxetine) will be exactly the same.
Form: capsules or liquid
Adult dose: 20mg daily for depression should be enough. 60mg daily if given for the eating problem bulimia nervosa. For obsessive-compulsive disorder: 20mg daily initially; if there is no response after several weeks, the dose may be increased but may result in more side effects. Maximum dose 60mg daily. Side effects: (most common) gastric problems, including nausea, vomiting, indigestion, abdominal pain, diarrhoea, constipation, loss of appetite with weight loss and possible changes in blood sugar. Less common: allergic reactions, including rashes (when the BNF recommends treatment should be stopped), breathing difficulties, dry mouth, nervousness, anxiety, headache, insomnia, palpitations, tremor, confusion, dizziness, low blood pressure, hypomania or mania, fits, drowsiness, weakness, fever, sexual problems (see above), sweating, movement disorders, a pattern of symptoms that resembles neuroleptic malignant syndrome (high temperature, rigidity, jerking muscles, extreme agitation that can progress to delirium and coma), low blood sodium levels. Abnormal liver function tests have been reported. Caution: fluoxetine should be given with caution to people with heart disease, those having ECT, or with a history of mania or liver or kidney disease, or to anyone with epilepsy (when it should be discontinued if fits develop). Avoid it during pregnancy or while breastfeeding. Fluoxetine may impair ability to drive or operate machinery. Drug interactions: MAOIs should not be given until at least five weeks after stopping fluoxetine.

Fluvoxamine (Faverin)
Form: tablets
Adult dose: 100mg daily up to a maximum of 300mg daily (over 100mg daily should be given in divided doses). Fluvoxamine can also be given for obsessive-compulsive disorder, but if there is no improvement within 10 weeks, it should be reviewed.
Side effects and cautions: see fluoxetine, and other general information above. Fluvoxamine may slow the heart rate. In rare cases it may increase liver enzymes (the BNF then recommends drug should be stopped). Production of breast milk is reported.
Drug interactions: see fluoxetine, and general information above. It also interacts with the asthma drugs theophylline and aminophylline. Consult your doctor or pharmacist if this applies. Withdrawal: avoid abrupt withdrawal.

Paroxetine (Seroxat)
Form: tablets or liquid
Adult dose: 20mg daily, increasing, if necessary, by 10mg stages to a maximum of 50mg daily. Normally taken in the morning. For obsessive-compulsive disorder (OCD): 20mg each morning, initially increasing by 10mg stages weekly to a usual dose of 40mg and a maximum dose of 60mg. For panic disorde r: as for OCD, but maximum of 50mg.
Older people: 20mg daily up to a maximum of 40mg.
Side effects and cautions:see fluoxetine and also above regarding the MHRA guidance that this drug should not be used in children and young people under 18. May worsen the symptoms of panic disorders initially. The Committee on the Safety of Medicines has received more reports of neuromuscular reactions (involuntary movements of mouth and face) than for other SSRIs. A 1993 Drug Safety Research Unit report revealed a higher rate of male sexual dysfunction than with other SSRIs. Drug interactions : see general information above. MAOIs should not be used within two weeks of stopping paroxetine.

Sertraline (Lustral)
Form: tablets
Adult dose: 50mg daily initially, increased if necessary in 50mg stages over several weeks to a maximum dose of 200mg daily, then reduced to usual maintenance dose of 50mg daily. Doses of 150mg or more should not be used for more than eight weeks. Side effects and cautions: see general information and fluoxetine above. Drug interactions : see above. After stopping sertraline, MAOIs should not be taken within seven days.

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SSRI-related antidepressants (Serotonin and noradrenaline reuptake inhibitors  SNRIs)

These drugs slow the re-uptake of both noradrenaline and serotonin and thus prolong their action. Venlafaxine was the first SNRI antidepressant (serotonin-noradrenaline re-uptake inhibitor), which has a more selective action than the tricyclics.

These drugs should not be taken at the same time as other antidepressants, including St Johns wort.

Venlafaxine (Efexor and Efexor XL)
At doses of up to 150mg, venlafaxine acts in the same way as the SSRIs, and is therefore often included in that group. At higher doses it also inhibits noradrenaline.
Form: tablets or capsules.
Adult dose: 75mg daily initially, in two divided doses, increased if necessary after several weeks to 150mg daily in two divided doses. For severe depression (and those in hospital) 150mg daily initially in two divided doses, increased if necessary in steps of up to 75mg every two to three days to a maximum of 375mg daily, then gradually reduced. Efexor XL is a modified release form, available as 75mg and 150mg, enabling the daily dose to be taken all at once. Manufacturers suggest new users start on 75mg once daily, increasing after two weeks to 150mg if necessary. Maximum dose 225mg daily. Best taken at the same time each day. Side effects: nausea, headaches, insomnia, sleepiness, dry mouth, dizziness, constipation, weakness, sweating, and nervousness. Fits may occur (discontinue) and, occasionally, low blood pressure. (Nausea may occur less with the modified release form of drug.) Other reported effects include: loss of appetite, indigestion, abdominal pain, anxiety, visual disturbances, dilatation of blood vessels, vomiting, tremor, abnormal dreams, tingling sensations, chills, high blood pressure, palpitations, weight changes, agitation, muscle tension, rash, low blood sodium levels. There have also been reports of reversible increase in liver enzymes and alterations in blood cholesterol. If a rash develops contact your doctor. There has been a fairly high number of reports of sexual side effects, including lack of orgasm, ejaculation problems, impotence and spontaneous erection without sexual desire (priapism). Driving and other skilled tasks may be affected. Caution: should be used with caution in people who have had a heart attack or have unstable heart disease (blood pressure should be monitored if taking more than 200mg daily), in people with a history of epilepsy, liver or kidney disease and in those who have abused drugs. It should not be given to those with severe kidney or liver disease, or in pregnancy or while breastfeeding. Withdrawal: this drug has a very short half-life so withdrawal is often difficult and should be done slowly. Withdrawal symptoms include: dizziness, vertigo, nausea, light-headedness, fatigue, headache, insomnia, agitation, abdominal cramps, chills, and shock-like sensations. It should be no more difficult to come off the modified release than the standard form.

Duloxetine (Cymbalta)
Duloxetine was licenced for the treatment of major depression in the UK in December 2004. It is also used for treating other conditions, including stress incontinence. When used for stress incontinence, it has a different trade name, which is Yentreve. You should not take two different formulations of duloxetine at the same time.
Form: capsules.
Adult dose: the recommended starting and maintenance dose is 60mg/day. Higher doses can be given, but there is no evidence that they will be more effective in patients who do not respond to the starting dose. Older people: there is only limited information on the use of duloxetine in older people, who should therefore be treated with caution. It is not recommended for people over the age of 75. Side effects: nausea, dry mouth, constipation; decreased appetite and weight loss; insomnia; excessive sleepiness; fatigue; loss of libido and lack of orgasm; problems with erection and ejaculation; dizziness; tremor; blurred vision; hot flushes; diarrhoea and vomiting; increased sweating; urinary hesitancy. It may cause dilated pupils. Suicidal thoughts and behaviour, during treatment or soon after withdrawal. Low blood sodium, especially in older people. Caution: should not be given to people with impaired liver function, nor those with severe kidney disease. It should be used with caution in people with a history of mania or bipolar disorder or fits; with increased pressure in the eyes, or glaucoma; with high blood pressure or heart disease  blood pressure should be monitored in these cases; taking anticoagulant drugs such as warfarin. Drug interactions: its use with other psychiatric drugs has not been evaluated, so it should be used with caution with other substances which affect the brain, including alcohol and sedative drugs such as benzodiazepines (minor tranquillisers), morphine-related drugs, antipsychotics, phenobarbital, and antihistamine sleeping pills. Withdrawal: common withdrawal symptoms, especially if it is stopped abruptly, include dizziness, nausea, insomnia, headache, and anxiety. The mean half-life of duloxetine is longer than venlafaxine and paroxetine, but shorter than fluoxetine (Prozac).

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Noradrenaline Reuptake Inhibitor (NARI)

Reboxetine (Edronax)
Reboxetine, was first licensed in the UK in 1997 and is supposed to act more quickly than other antidepressants, although the evidence for this is weak. It may have fewer antimuscarinic effects. It's suggested that it may suit those who have not responded to, or who can't tolerate, SSRIs or tricyclic antidepressants.
Form: tablets
Adult dose: 4mg twice daily increased if necessary after three to four weeks to 10mg daily in divided doses, to a maximum of 12mg daily. Side effects: insomnia, sweating, dizziness, low blood pressure on standing, vertigo, tingling in the skin, impotence, difficulty with urination (mainly men), dry mouth, constipation, rapid heart beat, reduced blood potassium, especially in the older people. Drug interactions: reboxetine should not be started until two weeks after stopping an MAOI antidepressant, and an MAOI should not be started until at least one week after stopping reboxetine. Manufacturers advise against its use with heart drugs, antipsychotics, tricyclic antidepressants, cyclosporin, and some antifungal drugs and antibiotics. It's very important your doctor knows about all of the medications you are taking (including over-the-counter remedies). Its use with other antidepressants has not been evaluated. Caution: not recommended for elderly people. Reboxetine should be avoided or used with caution in people with severe kidney disease, liver disease, bipolar disorder, a history of epilepsy, urinary retention and glaucoma. It should be avoided in pregnancy and while breastfeeding.

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Combination or compound drugs

It's possible for doctors to prescribe tablets that combine the actions of two groups of drugs, for example antidepressants and antipsychotics, or antidepressants and minor tranquillisers. However, the BNF does not recommend this, mainly because the doses of the component parts can't be adjusted to individual needs. It may be preferable to prescribe the two kinds of drugs separately.

Caution with compound drugs

Combined drugs of this kind can cause the side effects of each component part to become worse and more frequent. The side effects of antipsychotics may include: trembling hands, dry mouth and stiffening muscles as well as other side effects that may be serious enough to require treatment with other drugs. When taken over a period of years, antipsychotics may cause tardive dyskinesia, a condition in which the person develops uncontrollable movements of the face, body and limbs, which may be permanent and for which there is, as yet, no proven treatment. It is extremely unlikely that any of these problems will arise with the low doses found in Motival and Triptafen, but it's nonetheless a risk that can be avoided (see also Making sense of antipsychotics (major tranquillisers ). People who have been taking a combination drug for more than a few months should ask their doctor to take a fresh look at their needs. The following drugs combine antidepressants with a major tranquilliser in these proportions:

Motival: 10mg nortriptyline; 500 micrograms fluphenazine hydrochloride. Triptafen: 25mg amitriptyline hydrochloride; 2mg perphenazine. Triptafen-M: 10mg amitriptyline hydrochloride; 2mg perphenazine.

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Other drugs for treating depression

Carbamazepine (Tegretol)
Carbamazepine is sometimes used for manic depression (bipolar disorder) when lithium has not been effective. (See Further reading for more information.)
 

Flupentixol/flupenthixol (Fluanxol)
This is a low-dose preparation of an antipsychotic, which is used in higher doses to treat severe mental distress such as schizophrenia. It should be used for short-term treatment only. As this drug tends to take effect quickly, if there is no improvement within one week, manufacturers advise that treatment be stopped. (See above for risks of antipsychotics.)
Form: tablets
Adult dose: 1mg initially in the morning, increasing after one week to 2mg if necessary. Maximum dose 3mg daily in divided doses, not later than 4pm.
Older people: 0.5mg initially, increasing to 1mg if necessary. Maximum: 2mg daily in divided doses, not later than 4pm. Side effects: restlessness, insomnia, and overactive and excitable behaviour. Rarely: dizziness, tremor, visual disturbances, headache, raised blood prolactin levels (a hormone involved in producing breast milk), movement disorders. If movement disorders occur, the drug should be stopped. Drug interactions: unwanted effects may be increased if given with other antidepressants. Taken with sleeping pills or anti-anxiety drugs, sedation will increase. Avoid alcohol as this also provokes drowsiness. Caution: skilled tasks such as driving can be affected. Should be avoided in excitable, overactive or manic people and used with caution in people with Parkinson's disease, liver, kidney or heart disease or dementia. Withdrawal: should be stopped gradually.

Lithium (Camcolit, Liskonum, Priadel)
Mainly used for bipolar disorder, but may also be given as a preventive therapy where there are repeated episodes of severe depression. (See Making sense of lithium for more information.)

Tryptophan/L-tryptophan (Optimax)
Tryptophan was re-introduced for 'exceptional cases' of treatment-resistant depression in 1994. It can only be prescribed by hospital specialists for people 'who have had severe and disabling depression continuously for more than two years'. Both patient and prescribing doctor must be registered with the manufacturer.

Tryptophan is an amino acid present in the normal diet in small quantities. Used as an antidepressant since the 1970s, the then Committee on Safety of Medicines then withdrew it from general use in 1990 because it was associated with a serious illness eosinophilia-myalgia syndrome (EMS). This is a blood disorder bringing severe muscle pain, joint pain, fever, swelling and skin rash, which may involve the lungs and central nervous system. The company warns that EMS is 'a multi-system disorder, which is usually reversible, but rarely fatal'. It states that various investigations have not as yet precisely identified the cause, which may have been associated with a contaminated batch of the drug. It recommends blood monitoring (for eosinophil, a particular white blood cell) and monitoring for any muscular symptoms. Safety questionnaires are issued to the prescriber every three months to begin with, and thereafter six-monthly. The Committee on Safety of Medicines reviews the information.
Adult dose: 1g three times daily to a maximum of 6g daily. Older people: a lower dose may be appropriate, especially for those with kidney or liver disease. Side effects: drowsiness, nausea, headache, light-headedness, eosinophilia-myalgia syndrome (see above). Drug interactions: the BNF warns that prescribing Optimax with other antidepressants may be hazardous. They specify MAOIs and SSRIs; yet also indicate it should only be used as an adjunct to other antidepressant medication. Caution: drug manufacturers point out that it is only available under the limited circumstances previously mentioned, and from hospital specialists. It should not be given to people who have had EMS following tryptophan use. Manufacturers advise against using it in pregnancy or while breastfeeding.

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References

British National Formulary 50 (September 2005)
Coming off antidepressants , J. Glenmullen (Robinson, 2006)
'Effectiveness of antidepressants: meta-analysis of dose-effect relationships in randomised clinical trials', P. Bollini, S. Pampallona, G. Tibaldi, B. Kupelnick, C. Munizza (British Journal of Psychiatry 1999) 174, 297-303
Efficacy of antidepressants in adults, J. Moncrieff and I. Kirsch (British Medical Journal, 331, 16 July, 155-157).
'Emergence of antidepressant-induced suicidality', D. Healy, (Primary Care Psychiatry 2000, 6, 23-28)
Is maternal use of selective serotonon reuptake inhibitors in the third trimester of pregnancy harmful to neonates?, G. Koren et al, (Canadian Medical Association Journal, 172 (11) 1457-1459)
'MHRA press releases on paroxetine and venlafaxine' (Openmind, Issue 76 August/September 1995)
'Selective serotonin reuptake inhibitors and tricyclic antidepressants in combination, interactions and therapeutic uses', D. Taylor (British Journal of Psychiatry 1995 167, 575-580)
'Size does matter: a study of antidepressant prescribing in a general hospital', A. J. Carson, P. Shah (Psychiatric Bulletin 2000, 24, 23-25)
'Spiral of violence blamed on Prozac', A. Browne (The Observer, March 12, 2000)
SSRIs and gastrointestinal bleeding, C Paton and I N Ferrier, (British Medical Journal, 331, 529-530.)
Suicidality in adults being treated with antidepressant medications, (FDA Public Health Advisory, US Food and Drug Administration, 30 June 2005) (
www.fda.gov/cder/drug/advisory/SSRI200507.htm)
'The fluoxetine and suicide controversy - a review of the evidence', D. Healy (Prozac Survivors website).

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Useful organisations

British Association for Behavioural and Cognitive
Psychotherapies (BABCP)

The Globe Centre, PO Box 9, Accrington BB5 0XB
tel. 01254 875 277 fax: 01254 239 114
email: babcp@babcp.com
web: http://www.babcp.com
Can provide details of accredited therapists

British Association for Counselling and Psychotherapy (BACP)
BACP House 35-37, Albert Street, Rugby CV21 2SG
tel. 0870 443 5252
web: http://www.bacp.co.uk
See website or send A5 SAE for details of local practitioners

Carers UK
20-25 Glasshouse Yard, London EC1A 4JT
carers line: 0808 808 7777 tel. 020 7490 8818
email: info@ukcarers.org
web: http://www.carersonline.org.uk
Information and advice on all aspects of caring

MDF The Bipolar Organisation
Castle Works, 21 St Georges Road, London SE1 6ES
tel. 08456 340 540 fax: 020 7793 2639
email: mdf@mdf.org.uk
web: http://www.mdf.org.uk
Works to enable people affected by manic depression to take control of their lives

Medicines and Healthcare products Regulatory Agency (MHRA) (and Commission on Human Medicines)
Information Centre, 10-2 Market Towers, 1 Nine Elms Lane, London, SW8 5NQ, tel. 020 7284 2000
email: info@mhra.gsi.giv.uk
web: http://www.mhra.gov.uk
See their website for documents on taking medicines

Psychiatric Drug helpline
helpline: 020 7919 2999
Run by pharmacists

UK Council for Psychotherapy (UKCP)
2nd Floor, Edward House, 2 Wakley Street, London EC1V 7LT
tel. 020 7014 9955
email: info@psychotherapy.org.uk
web: http://www.psychotherapy.org.uk
Maintains a voluntary register of qualified psychotherapists

Yellow card reporting:
hotline: 0808 100 3352 (business hours)
web: http://www.yellowcard.gov.uk
Also has a translation service for those whose first language is not English

Useful websites


http://www.citawithdrawal.org.uk
Council for Information on Tranquillisers and Antidepressants (CITA)

http://medguides.medicines.org.uk/
Medicines Information Project

http://www.medicines.org.uk
For detailed information on on drugs, including the half-lives of individual drugs

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Making sense of antipsychotics


What should I know before taking these drugs?
What are antipsychotic drugs?
How does a doctor decide when to prescribe them?
How do the drugs work?
What dosage should I be on?
What are the side effects?
What is neuroleptic malignant syndrome (NMS)?
What is tardive dyskinesia (TD)?
What is tardive psychosis?
Which type of antipsychotic should I be on?
Why do people take more than one?
What happens if I am taking other drugs?
What is rapid tranquillisation?
How easy is it to come off these drugs?
Is there an alternative?
The different types of antipsychotics
Atypical antipsychotics
Antipsychotics through depot injection
Anti-Parkinson's drugs
References
Useful organisations


What should I know before taking these drugs?


Informed consent
The law says that you have the right to make an informed decision about which treatment to have, and whether or not to accept the treatment a doctor suggests. To consent, properly, you need to have enough information to understand the nature, likely effects and risks of the treatment, including its chance of success, and any alternatives to it. Generally, you can only receive treatment that you have specifically agreed to. Once you have given your consent, it isnt final and you can always change your mind. This consent to treatment is fundamental, and treatment given without it can amount to assault and negligence. To find out more about when treatment can be given without consent, see Mind rights guide 3: consent to medical treatment.

Patient information leaflets
If you are prescribed medication as an outpatient, or from your GP, you should find with it an information sheet called a patient information leaflet (PIL), in accordance with a European Union directive. As an inpatient, you may have to ask for it, specifically. The EU directive sets out what information should be included in the leaflet, and in what order. The order in which the information is given has recently changed, to make it more user-friendly. Many PILs will still follow the old pattern until they are revised, but the information they include should be the same:

both the trade and general (generic) names
the strength of the medicine and the form it takes; for example, each tablet contains 5mg of drug X
who it is intended for; for example, adults, children, babies
the type of medicine it is; for example, an antipsychotic
what it is licensed to treat; for example, schizophrenia
things you need to know before taking it, such as conditions which mean you should either not take it at all, or you should take it with caution
the instructions for taking it: whether by mouth or other route; at what time of day; when to take it in relation to meals (if necessary)
a list of possible side effects, with an indication of how likely they are to occur
the expiry date of the drugs and how to store them
a full list of all the ingredients, including the extra contents that hold it together as a tablet or capsule, such as maize starch, gelatin, cellulose, and colourings. This information is important because some people may be allergic to one or other of the ingredients, such as lactose or gluten or a colouring. Gelatin is unacceptable to some people because it is an animal product.
The final item on the leaflet tells you that it contains only the most important information you need to know about the medicine, and that if you need to know more, you should ask your doctor or your pharmacist.

There is a lot of information to include in the PIL, so its often printed in very small type, on a piece of paper that is folded many times, which may get thrown away with the packaging, by mistake. If you do not receive this information with your medicine, you should ask for it from the person who makes up your prescription.

Some of the information is quite hard to understand, and the Commission on Human Medicines (formerly the Committee on Safety of Medicines) has been looking at ways of making it easier. They have produced a leaflet Taking medicines  some questions and answers about side effects which you can find on their website or request by telephone, or may be available in your local pharmacy. There is more information on medicines and their use, in the form of Medicines Guides, available from the Medicines Information Project website. (See Useful organisations.)

You should also consider talking to your pharmacist. Pharmacists are drug specialists, and may be more knowledgeable about your drugs than the doctor who prescribes them. They may be more aware of possible side effects, and also possible interactions with other drugs (this is when a drug changes the effect of other drugs you are taking, makes them less effective, or causes additional side effects). Pharmacists are usually very willing to discuss drugs with patients, and some high-street chemists have space set aside where you can talk privately.

Since January 2006 a new scheme has been in place called the Medicines Use Review. People who regularly take more than one prescription medicine, or take medicines for a long-term illness, are encouraged to go to pharmacists who are operating the scheme, for a full discussion of their medicines and any problems they may have with them. The Medicines and Healthcare products Regulatory Agency (MHRA), who are responsible for overseeing the licensing of medicines, have produced a guide to the scheme (see their website under Useful websites).

Many people would like to have the information about their proposed treatment before they are given the prescription for it, and not after they have got it from the pharmacist and taken it home. The following are issues you might like to discuss with your doctor when she or he gives you a prescription for a drug:

What is the name of the drug, and what is it for?
How often do I have to take it?
How long will I have to take it for?
If I am taking any other drugs, will it be all right to take them together?
Will I still be able to drive?
What are the most likely side effects, and what should I do if I get them?
Do I have to take it at any particular time of day? For example, if it is likely to make me sleepy, can I take it at night rather than in the morning? If it is likely to make me feel sick, can I take it with or after food?
When I want to stop taking it, am I likely to have any problems with withdrawal?
You may well think of other questions you wish to ask.

If you have troublesome side effects, or withdrawal symptoms when you stop taking your medication, you can report them yourself to the MHRA on their website or their hotline (see Useful organisations), or on a form which you can get from your pharmacy. You no longer need to go through a health professional to do this, although you can if you wish. You can also see a full list of side effects reported on the same website.

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What are antipsychotic drugs?

Antipsychotic drugs have been in use since the 1950s. They are sometimes prescribed for anxiety, in very low doses, and occasionally for treating physical problems, such as persistent hiccups, problems with balance, and nausea. Often, they are used for dementia. However, they are generally used to help people who are experiencing psychosis, either as a one-off episode or as part of an ongoing illness. Psychosis is a broad term, which covers schizophrenia and manic behaviour, but people may also experience brief episodes during severe depression or a physical illness, or sometimes because of taking street drugs.

Psychosis and antipyschotics
People who are psychotic perceive things and interpret events differently from those around them. This may include hearing things, such as voices, seeing something other people dont see (a hallucination) or thinking things that are not based on reality (a delusion). A person may believe, for example, that he or she is under the control of an outside force. (For more information, see Understanding psychotic experiences, How to recognise the early signs of mental distress, Understanding bipolar disorder [manic depression] and Understanding schizophrenia.)

Antipsychotics are often effective in controlling the symptoms of psychosis, and enable many people to return to normal life. They may lessen delusions, hallucinations, incoherent speech and thinking, and reduce confusion. The drugs can control anxiety and serious agitation, make the person feel less threatened, and also reduce violent, disruptive and manic behaviour. However, not everybody finds antipsychotics helpful, and they can't cure the problem. They can also have very serious side effects, which cause major concern to users.

Antipsychotic drugs are standard, routine treatment for people who are experiencing psychosis, and doctors believe that drug treatment should be started as soon as possible. But recent research has raised important questions about whether people might not do better without using these drugs.

Some research suggests that someone with schizophrenia, who remains on antipsychotics for a number of years, may be less likely to relapse than someone who is not taking them. But a paper published in the Journal of Medical Hypotheses in 2004 suggests that resorting to antipsychotics straight away, as a matter of routine, may worsen long-term outcomes, and that a considerable percentage of those treated would do better if they were not given drugs. This paper suggests that people experiencing their first episode of psychosis should not be treated with drugs, and that every person who is taking antipsychotics should be given the opportunity to withdraw from them, gradually. It suggests that this would dramatically improve recovery rates and reduce the numbers of people who become ill in the long term.

Other background information on antipsychotics
There are two main types of antipsychotics: the older antipsychotics and the newer atypical antipsychotics.

The older antipsychotics divide, generally, into two chemical groups:

Low-potency drugs, such as chlorpromazine (Largactil), which are taken in relatively large doses, tend to be very sedating and cause more antimuscarinic side effects.
High-potency drugs, such as haloperidol (Dozic, Serenace and Haldol), which require lower doses and tend to cause more neuromuscular side effects.
The newer atypical antipsychotics, such as risperidone, dont produce the most disturbing neuromuscular side effects that characterise the older drugs. However they do cause serious metabolic side effects associated with gross weight gain, for which the term metabolic syndrome is increasingly being used. For a listing of antipsychotics licensed in the UK, see below.

Antipsychotics are also known as major tranquillisers or neuroleptics. Calling them major tranquillisers is misleading, because these drugs don't make people feel tranquil.
Although they can cause drowsiness through their sedative action, they may also cause intense restlessness. Neuroleptic is a better term as it means taking control of the nerves, and refers to the effects these drugs have on thought, behaviour and physical movement.

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How does a doctor decide when to prescribe them?

Your doctor has to weigh up the advantages and disadvantages of treatment. The benefits to you, your family and friends have to be balanced against the disadvantage of unpleasant side effects. Doctors also have to ask themselves what might happen if the drugs were not prescribed. A person with psychotic symptoms may show dangerous behaviour, or such disturbed ideas, that they put their own or other people's lives in danger. This may also place great strain on carers and the people they live with. Some people who experience psychosis cope better with it than others. If you have had frequent psychotic episodes, you may have developed your own coping strategies, which could mean you need to rely less on medication than other people.

People respond differently to medication, and doctors have to decide on each case, individually. When a drug is prescribed, your doctor should take into account any medical conditions you are suffering from. It may mean that a particular drug is not suitable for you, or only in low doses.

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How do the drugs work?

No one knows precisely how they work. Most of them have a sedative action, and most of them block the effects of dopamine, a chemical neurotransmitter that carries signals between brain cells. This interrupts the flow of messages, which may be too frequent in psychotic states. One specialist at the University of Newcastle has suggested that they work by causing Parkinsonism i.e. producing the psychological symptoms of this disease such as emotional blunting and demotivation, as well as the physical symptoms, which are already well recognised as side effects.

The new atypical drugs work on other brain chemicals as well as dopamine, and have a rather different range of side effects. Clozapine, in particular, may be successful in suppressing psychosis in some people who have not responded to older drugs.

How quickly do they act?
This depends partly on how you take them, whether orally or by injection. When they are injected into a muscle, the sedative effect is rapid and reaches a peak within an hour. If you take them by mouth, in tablet or in syrup form, the sedative effect usually takes a few hours longer. However, the psychotic symptoms, such as voices, may take days or weeks to suppress. Nobody knows why.

Depot injections
Some drugs are available in an oil-based, slow-release form given by deep injection, known as a 'depot', into a muscle. Depot injections do not have a fast action, and are given every two to six weeks.

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What dosage should I be on?

The average dose has tended to rise over the years. This is despite the facts that the most effective dose may be quite low; that increasing the dose will probably not make it more effective; and that it may make the side effects worse. Since the advent of the atypical drugs this trend has reversed, and indeed research has suggested that atypical drugs have no advantages over the older drugs, if the older ones are used at the lowest effective dose.

Doses should be kept as low as possible. High doses can have a zombie-like effect, giving you a mask-like expression and strange movements. It can make it very difficult for you to move normally, to get up and get going in the morning, and to take part in normal activities and social events. Moderate to high doses increase the risk of tardive dyskinesia, which is a serious problem causing involuntary movements. Research suggests that low, maintenance doses are as effective in preventing relapse as higher doses. Older people need smaller doses of drugs, and their health is at risk if they are given too high a dose.

You have a right to know what dosage you have been prescribed, and these vary widely. For example, chlorpromazine (Largactil) can be prescribed in tablet form to physically healthy adults in doses ranging from 75mg up to 1g (1000mg) daily. The aim should be to find the dose that lets you lead as normal a life as possible. If the medication is not working, it's important for doctors to reconsider the treatment rather than automatically putting up the dose.

The National Institute for Clinical Excellence (NICE) current guidelines on the treatment of schizophrenia suggest that doctors prescribe antipsychotics at the lowest effective dose, introducing the drugs gradually. They suggest that people should not be given a high starting dose.

Maximum dosage
Among other information, the British National Formulary (BNF) gives maximum doses for some, but not all, of the antipsychotics. A list of drugs appears below, and provides this information, whenever possible. Generally, the drugs arent licensed for use above these dosages, but hospital doctors do exceed them, at their discretion. They may also prescribe medication to be given as necessary (p.r.n.), which can mean in addition to your regular dose. As a result, your total dose could be above the BNF maximum, although your psychiatrist has a duty to review the total dosage, daily.

If you are taking more than one antipsychotic drug, you can work out the dose of each (including p.r.n. prescribing) as a percentage of the maximum recommended in the BNF. Add the percentages together to see if you are taking more than 100 per cent in total. You can also ask your doctor or a pharmacist to help you work this out. The Prescribing Observatory for Mental Health (see Useful organisations) has created a ready reckoner chart for wards to help with this calculation. If you think you are taking too much medication, you can ask your doctor to review it.

If you are worried about your diagnosis and treatment, and unsure about the advice you have been given, you could ask either your GP or psychiatrist to refer you for a second opinion.

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What are the side effects?

People's sensitivity and response to drugs varies enormously. One person may be able to tolerate standard doses with no significant side effects, while someone else may find the same dose has intolerable results.

Neuromuscular effects
Antipsychotics, as a group, have a large number of side effects in common. Because they interfere with dopamine, which is important in controlling movement, many of the side effects are to do with the neuromuscular system. These neuromuscular effects include: Parkinsonism, loss of movement, restlessness and muscle spasms.

Parkinsonism
Some side effects resemble Parkinsons disease, which is caused by the loss of dopamine:

Muscles become stiff and weak, so that your face may lose its animation, and you find fine movement difficult.
You may develop a slow tremor (shaking), especially in your hands.
Your fingers may move as if you were rolling a pill.
When walking, you may lean forward, take small steps, and find it difficult to start and stop.
Your mouth may hang open and produce excessive saliva.
Loss of movement (akinesia)
You may find it difficult to move, and your muscles may feel very weak. This may be mistaken for a symptom of depression.

Restlessness (akathisia)
You may feel intensely restless and unable to sit still. This is more than just a physical restlessness and can make you feel emotionally tense and uneasy, as well. The compulsion to move may be overwhelming. You may rock from foot to foot, shuffle your legs, cross or swing your legs repeatedly, or continuously pace up and down. Nursing staff sometimes misread this as a sign of agitation or anxiety, and may wish to treat it by increasing your dose of antipsychotics. If you are very troubled by akathisia, your doctor may be able to prescribe something to reduce it.

Muscle spasms/dystonia (dysphonia and oculogyric crisis)
These are acute muscle contractions that are uncontrolled and may be painful. They particularly affect young men. Sometimes the problem affects the muscles of the larynx (voice box), which makes it difficult to speak normally (dysphonia). It can be socially disabling, but is treatable.

Another form of muscle spasm affects the muscles that control eye movements. Called oculogyric crisis, it makes the eyes turn suddenly, so that you cant control where you look. This is very unpleasant and can make it dangerous crossing the road, or pouring hot water, for instance. Its also very disconcerting for people around you.

Such neuromuscular symptoms can be reduced with the sorts of drugs that are prescribed to treat Parkinsons disease (see below for more information on these drugs). These symptoms die down while you are asleep, so if you take the antipsychotics as a single daily dose in the evening, you could avoid the worst of them (as well as avoiding daytime sedation). You may want to discuss this with your doctor to find out whether it would be an option for you.

Sexual side effects
Many antipsychotic drugs cause levels of the hormone prolactin to rise, which is related to some very common sexual side effects for both women and men, who may feel embarrassed to talk about them:

Breast development and the production of breast milk can affect men as well as women.
A drop in sexual desire can make men and women less easily aroused, and cause impotence and sterility in men. Some drugs can interfere with erection and affect ejaculation.
Priapism, a persistent erection of the penis without sexual arousal, sometimes results. This is rare, but if it occurs you should treat it as an emergency and seek medical advice, because it may cause serious harm to the penis.
Spontaneous ejaculation is sometimes a problem.
Loss of periods, vaginal dryness, unwanted hair and acne may occur in women.
Osteoporosis (loss of bone density) as a consequence of hormone changes is a serious risk for men and women, and increases the risk of fractures.
Some of the atypical antipsychotics have less effect on prolactin and produce fewer of these problems. Note: women who change from an older antipsychotic to an atypical should bear in mind that this may cause prolactin levels to drop back down.  This may cause their periods to return and they may need to think about contraception.

Antimuscarinic or anticholinergic effects
The drugs affect acetylcholine (another chemical messenger) and this may cause drowsiness, dry mouth, blurred vision, dizziness, constipation, feeling sick, difficulty passing water and rapid heartbeat. Constipation may be severe, and should be taken seriously. Low blood pressure can be a problem, especially in older and frail people, and it may contribute to falls; hot baths increase the risk.

Heart rhythm
Several antipsychotics have been implicated in sudden deaths. Although these have been investigated, with no clear conclusion, sudden deaths have been linked to high doses of antipsychotics (above the BNF maximum) and to polypharmacy, when people are on several different antipsychotics at the same time. Many of these drugs affect the heart rhythm. The Royal College of Psychiatrists' guidelines suggest that people on high doses of antipsychotics should be given an ECG before treatment starts and every one to three months, while the dose remains high. Whatever your dose, if you have unexplained blackouts, you should have your heart rhythm monitored. Be cautious with grapefruit and grapefruit juice, because it's thought this might increase the impact on heart rhythm.

Sedation
Sleepiness is a common side effect with antipsychotics, but some, such as chlorpromazine, are more sedating than others.

Eye problems
Various antipsychotics may be responsible for different eye disorders. These include blurred vision and difficulty reading, a build up of granular deposits in the cornea and lens (which doesn't usually affect sight), degeneration of the retina (the light-sensitive part of the eye) that restricts vision and may be serious, an oculogyric crisis (see above), and glaucoma (increased pressure inside the eye). Any antipsychotic can cause narrow-angle glaucoma, which is a medical emergency. You should not take the low-potency antipsychotics if you have had glaucoma.

Weight gain
Weight gain is a very common side effect with a number of antipsychotics, including some of the atypical drugs, and causes a lot of distress. It is linked to increased appetite and decreased activity, but is mainly caused by changes in metabolism - the way your body uses food and converts it to energy or stores it as fat. This means that dieting may be of limited use. You may put on a lot of weight, and this may increase your risk of developing diabetes, and other physical health problems.

Metabolic syndrome, including diabetes
Some side effects, associated especially, but not exclusively, with atypical antipsychotics, are linked, and have begun to be referred to as 'metabolic syndrome'. This group of symptoms: weight gain and obesity; high blood sugar; high blood pressure, and high cholesterol, puts people at risk of heart disease, stroke and diabetes. The risk is increased by dietary factors, such as drinking sugary carbonated drinks and eating a lot of fatty, sugary foods. Everyone, especially those with a family history of diabetes, should have their blood glucose monitored while they are taking these drugs. You should also tell your doctor if you have a family history of cardiovascular disease such as high blood pressure or heart attack. Metabolic syndrome is thought to cause a two- to three-fold increase in the risk of death from cardiovascular disease.

Agranulocytosis
A number of blood disorders are linked to antipsychotics. The most serious is agranulocytosis, a serious blood disorder, which involves the loss of one type of white blood cell. It reduces resistance to infection and has led to deaths in the past. It's very rare with the older antipsychotics, and is a particular risk of clozapine.

Other physical effects
Some people develop blood clots in the veins (thromboembolism), linked to low-potency drugs as well as clozapine.

Liver disorders and jaundice are sometimes linked to using these drugs.

There are various skin problems that may occur. If you get a rash, you should go to the doctor straight away. Any allergic rashes usually occur within the first two months of starting treatment and disappear when the drug is stopped. Some types of skin may develop a blue-grey discoloration. Your skin may become more sensitive to sunlight, especially at high doses, so you should protect your skin from the sun.

You may have problems with regulating body temperature. It may be too high or too low, both of which may make you feel a little unwell.

Another problem that might occur is difficulty urinating.

Emotional effects
Antipsychotics can sometimes make people more excited, agitated and aggressive. They can also cause emotional changes, such as depression. Others may have an antidepressant effect, although the available information about this is contradictory. Some drugs cause an emotional unease, making people restless, giving them bizarre dreams and disturbing their sleep. They can make people feel out of touch with reality or strange in familiar surroundings (depersonalised and derealised). It may also cause them to become more withdrawn, socially.

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What is neuroleptic malignant syndrome (NMS)?

This neurological complication is thought to occur in about one per cent of hospital patients taking antipsychotic drugs. It can be very dangerous if it's not detected and treated, but the symptoms can be mistaken for an infection.

The symptoms are: sweating or fever, with a high temperature; tremor, rigidity or loss of movement; difficulty speaking and swallowing; changes in consciousness, from lethargy and confusion to stupor or coma; rapid heartbeat, very rapid breathing and changes in blood pressure. Blood tests show abnormal results. NMS develops rapidly over 24 to 72 hours, and rigidity and a high temperature are usually the first symptoms to appear.

The condition mostly affects people under forty, and is twice as common in men. It can occur if you are taking standard doses of antipsychotics, and if you have been taking the drugs for many years. The main trigger seems to be a change of dose within the last 4 to 11 days. High-potency antipsychotics may produce greater risk, but it can happen with all of these drugs, including the atypical group.

Treatment varies and can include reducing the fever, giving drugs to relax the muscles, and drugs to counter the chemical imbalance that is thought to cause NMS. Electroconvulsive therapy has also been used effectively.

The symptoms may last for days, or even weeks, after stopping the drugs. Although the criteria for making the diagnosis are not clear, it seems that only about one per cent of people on antipsychotics are likely to get NMS. Out of these, 11 per cent may be fatal. Many people who have had NMS once go on to get it again, so you should only take antipsychotics afterwards if they are absolutely essential, and then only the low-potency drugs at the lowest doses.

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What is tardive dyskinesia (TD)?

TD is a disorder of the central nervous system, which causes abnormal, uncontrollable, disfiguring, and embarrassing movements. These usually start in the face and mouth, as involuntary tongue movements and slight grimacing. The problem can spread to the rest of the body, with writhing movements in the limbs, muscle spasms, tremors and tics.

Most psychiatrists agree that TD is caused by antipsychotics, mainly affecting people who have been taking moderate to high doses for long periods of time, and who have had quite severe Parkinson's symptoms. It's rare in someone who has been taking antipsychotics for less than six months, if the doses have been small. It seems that people are more likely to get TD if they get bad Parkinson's effects. Women, children and older people may be more vulnerable, and possibly those with a mood disorder such as manic depression (bipolar disorder).

The problem may not be discovered until after you stop taking the antipsychotics, because they mask the symptoms of TD. Unfortunately, stopping and starting the drugs may make TD more persistent, once it has developed.

Some people remain on the drugs as a way of dealing with the symptoms, although this may result in further damage. Sometimes when drugs are withdrawn, withdrawal dyskinesias may occur, but this is not necessarily the same as TD.

There's disagreement about how common TD is, and about the number of people who are permanently affected. Estimates of the risks of developing TD, after long-term use, range from 5 to 56 per cent, but 20 per cent is a widely accepted estimate for those treated for four years, or longer. The risk is higher for people on depot preparations. There is believed to be much less risk of TD with the atypical drugs.

Treatment
If you stop taking the drugs, TD may disappear of its own accord. The symptoms improve, spontaneously, in about half of patients, although this may take up to five years after stopping the drugs. However, for a lot of people, TD is permanent. Although it's incurable, some possible treatments may help, if it's identified early.

Some people can't stop taking the drugs, because of the risk of relapse. This risk must be weighed in the balance against the risk of TD. If you have been taking one of the old antipsychotics, you might be able to switch to an atypical, such as clozapine, risperidone, olanzapine or quetiapine, which may help TD.

There is evidence that clonazepam (a benzodiazepine used in epilepsy) may be useful, and that Vitamin E and also Vitamin B6 are helpful in some cases. If you are taking anti-Parkinson drugs, it may be a good idea to stop. TD doesn't necessarily develop or get progressively worse in all cases, and using the lowest possible dose of antipsychotic minimises the risk. (See Mind's factsheet, Tardive dyskinesia, for more information.)

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What is tardive psychosis?

Sometimes, psychotic symptoms develop during or after using antipsychotics for long periods of time. Dopamine receptors may become super-sensitive after long-term drug use, or new receptors may develop to replace those that are being blocked by the drugs, which means that higher doses are needed to maintain the antipsychotic effects. Some people who withdraw from these drugs find that their psychotic symptoms have become worse. This is another reason for using no more of the drug than is absolutely necessary.

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Which type of antipsychotic should I be on?

Antipsychotic drugs treat the 'positive' symptoms of schizophrenia, which include delusions and hearing voices. The 'negative' symptoms include feeling apathetic, not looking after yourself, and being unable to concentrate. Older antipsychotics usually have no effect on the negative symptoms, and some of the side effects may even make them worse. Atypical antipsychotics usually help with both types of symptoms.
You should be given a choice about which type of antipsychotic to take, but if you are unable to make a choice, then you should be given an atypical. NICE recommends that atypical antipsychotics should be used:

as a first-line treatment, if you are newly diagnosed with schizophrenia. The initial dosage should be at the lower end of the standard range
if you have an acute episode of schizophrenia, and you are not able to discuss the choice of drug with the doctor
if you have had unacceptable side effects on older drugs
if you have had a relapse, and your symptoms did not respond well to the older drugs.
If you are already on an older antipsychotic, and your symptoms are responding well, without causing you unacceptable side effects, there's no need to change to an atypical antipsychotic. If neither older nor atypical antipsychotics are controlling your symptoms, after an adequate trial period of six to eight weeks, you should try clozapine.

When shouldn't people take them?
 
 

Anyone with the following should use these drugs with caution:

liver or kidney disease
cardiovascular (heart and circulation) disease  or a family history of
family history of diabetes (see above)
Parkinsons disease
epilepsy
depression
myasthenia gravis (a disease affecting nerves and muscles)
an enlarged prostate
a history of glaucoma, an eye disease (see above)
lung disease with breathing problems
some blood disorders.
Antipsychotics should not be given to people with phaeochromocytoma (a type of tumour causing very high blood pressure) or anyone in a state of impaired consciousness, such as a coma.

Older people
Doctors should also prescribe them with caution to older people. This is because they may be prone to drops in blood pressure when standing up, leading to falls, and also to both high and low body temperature.

Expectant and new mothers
As a general rule, you should avoid taking any drugs during pregnancy and while breastfeeding, unless the benefits to you are likely to outweigh the risk to the baby. If possible, avoid all drugs at least during the first three months. Prochlorperazine (Stemetil), in particular, is associated with malformations in the developing baby during this period. There have also been reports of temporary muscle disorders in newborn babies, if antipsychotics are used in the last three months of pregnancy. Because long-acting drugs take time to clear from the body, it's important to take your final dose six to eight weeks before the baby's expected delivery date.

The manufacturers advise women not to take the atypical drugs when breastfeeding. It's best to avoid antipsychotics altogether, if possible. Ask your doctor and your pharmacist about the safety of any drug you are advised to take. It's very important to discuss any concerns with your doctor and other professionals responsible for your health during pregnancy and delivery.

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Why do people take more than one?

Your doctor may want to prescribe more than one antipsychotic at a time, if the drug you are currently taking doesn't seem to be working well enough. This is known as polypharmacy. This could mean that a doctor prescribes an oral drug as well as a depot, or a conventional drug as well as an atypical antipsychotic. However, in most cases, doctors should avoid combining conventional with atypical antipsychotics. The atypicals have fewer side effects than the standard antipsychotics, but this benefit is undermined if you are taking both at the same time. There are some cases, though, when doctors may legitimately augment clozapine with sulpiride, for example.

The BNF does not recommend polypharmacy, because even though the individual drugs may be within the recommended dose range, patients may end up having a high total dose. Research has shown that adding a second drug doesn't usually improve the outcome very much, but does increase the side effects, can diminish your quality of life, and may even be life-threatening. The NICE guidelines also say that it's best to use a single drug. They say that two or more antipsychotics should not be given at the same time, except for short periods when you are switching from one to another.

If you are detained in hospital under the Mental Health Act 1983 (current Act at time of print), you are far more likely to be taking more than one antipsychotic, or to be on a high dose, than someone who is a voluntary patient.

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What happens if I am taking other drugs?

If you are taking any other drugs (whether these are on prescription, or bought over the counter from a pharmacist or alternative health practitioner) discuss with your doctor any possible interactions, which could increase adverse effects or be dangerous. The following information only relates to combinations of psychiatric drugs.

Combining antipsychotics with other dugs that have antimuscarinic properties is likely to increase the antimuscarinic effects (see above). This applies particularly in the case of tricyclic antidepressants and antipsychotics such as chlorpromazine (Largactil) or other low-potency antipsychotics. The anti-Parkinson's drugs are also antimuscarinics, and combining with these can induce delirium, which may be hard to detect in psychosis.

If you are taking tricyclic antidepressants and antipsychotics, it can affect your heart rhythm. If you take the antidepressant trazodone with drugs such as chlorpromazine (Largactil), it can lower your blood pressure. Taking lithium (Camcolit, Liskonum, Priadel and Litarex), together with the older antipsychotics, increases the chances of Parkinson's effects, muscle spasms and neuromuscular restlessness, as well as possibly being toxic. The antipsychotics should be started at a lower dose than usual.

Carbamazepine makes the body process some drugs faster, which will lower the level of the drug in your blood.

If you are taking anti-epileptic drugs, the antipsychotics increase your chance of having a fit.

Taking drugs for anxiety, or to help you sleep, increases the sedative action of the antipsychotics. Drinking alcohol does the same. You should ask your doctor whether it's safe to drink when you are on these drugs.

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What is rapid tranquillisation?

In an emergency situation, if you are endangering yourself or others, doctors may decide you need something to calm you down as quickly as possible. This means you may be given drugs by injection. Clopixol Acuphase is one of the older drugs used. Of the atypical antipsychotics, olanzapine exists in an injectable form for this purpose. The Royal College of Psychiatrists suggests that doctors can avoid using high doses of these drugs by combining moderate doses of an antipsychotic with a benzodiazepine tranquilliser. The NICE guidelines recommend lorazepam (a benzodiazepine) with haloperidol or olanzapine. If using haloperidol, you need an anti-Parkinson's drug to minimise the side effects.

The guidelines also say that rapid tranquillisation may be traumatic, and afterwards you should be given the opportunity to discuss it with hospital staff, and to write your own record of the experience if you wish, to be kept in your hospital notes.

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How easy is it to come off these drugs?

Doctors may suggest that once youre on these drugs, you need to stay on them for some time. The substantial majority of people tend to remain on them. However, if you have been taking antipsychotics for some time, and have been well, you may want to stop and see if you really need them, or if you can cope successfully in other ways, without medication.

To increase your chances of success, you need plenty of support, and this should ideally include your doctor. Unfortunately, a lot of people find that their doctors are not very helpful when it comes to withdrawing. Some psychiatrists believe that people with a diagnosis of schizophrenia, who remain on antipsychotics for a number of years, have fewer relapses than those who are not on antipsychotics. But there are other factors that influence relapses, besides taking medication. Giving families and carers supportive services is helpful and reduces the risk of relapse.

The best time to try is when you are not currently under stress from other life problems, such as housing, finance, a job or your family, for example. It may be a good idea to postpone withdrawal until you are more relaxed, and can pay attention to how you are feeling. The BNF (British National Formulary  see References) says: Withdrawal of antipsychotic drugs after longtermtherapy should always be gradual and closely monitored,to avoid the risk of acute withdrawal symptoms or rapid relapse. For information about withdrawal from antipsychotics, see Minds booklet Making sense of coming off psychiatric drugs.

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Is there an alternative?

Most doctors feel that antipsychotic drugs are essential, and that you will need to take them in order to be able to benefit from any other sorts of treatment, such as cognitive behaviour therapy, that may be available. If you have had episodes in the past and know what is helpful to you and what is not, you may disagree and prefer to use alternatives to drugs.

Crisis centres
Crisis centres are alternatives to hospital, planned as places of asylum and refuge. Staff can support people through their experience, together with others who have been through a similar crisis themselves. Such services are still too rare in this country. (See Mind's factsheet, Crisis services.)

Talking treatments
You may find it helpful to talk to a counsellor or a psychotherapist about your experiences, to try and make sense of them, or to relate them to events in your life. More and more GPs are employing counsellors in their practices. If not, your GP or your psychiatrist may be able to refer you to a psychotherapist or counsellor. (See Useful organisations and Further reading for more information.)

Cognitive behaviour therapy (CBT) is a talking treatment that can provide practical strategies for coping with psychotic experiences and the disruption to everyday life that this may bring. It's based on the idea that people can change negative thought patterns that feed psychotic or paranoid feelings and so bring about a state of wellbeing. You may be offered CBT as part of your care plan. If not, you could ask your care coordinator or your GP for a referral to see a clinical psychologist, or you could contact a professional body. (See Useful organisations and Further reading for more information.)

Looking after yourself
There is increasing evidence to suggest that eating healthily and getting plenty of physical activity can be as beneficial for the mind as it is for the body. Massage, yoga and other methods of increasing relaxation and decreasing stress are also likely to be very helpful. (See Further Reading for more information.)

Arts therapies
Therapies using art, music, drama, dance or creative writing may be very powerful aids to recovery, helping you to make sense of your symptoms and work your way through them. If you have difficulty putting your feelings into words, they are a means of expressing yourself. These therapies are available in some psychiatric units and community mental health facilities, and it's worth asking local information providers what is happening in your area. (See Mind's factsheet, Arts therapies.)

Complementary therapies
Complementary and alternative therapies such as herbalism and homeopathy may be very helpful when you are recovering from an episode of distress. They can be a useful tool for promoting relaxation and inducing a state of wellbeing. Complementary therapists emphasise the connections between mind and body and are not concerned with merely treating symptoms. (See Useful organisations for more information.)

Self-help groups
Many people experiencing emotional distress find it helpful to share their feelings with others going through similar difficulties. There are self-help organisations for people suffering from various forms of mental distress, including those who hear voices. (See Useful organisations for more information.)

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The different types of antipsychotics

Side effects common to all the drugs listed in this sectionare covered earlier. It is essential that youread those pages as well as the section on the particulardrug you are taking, in order to get full informationabout possible harmful effects.

Older antipsychotics
All these drugs are listed under their general names, with the manufacturers' names in brackets afterwards. They are all high-potency drugs, unless otherwise indicated. The drug chlorpromazine is the standard by which all the others are measured.

Dosages of antipsychotics can vary considerably and details are not given here, except when the BNF specifies a maximum daily dose. Maximum doses are based on what is dangerous, rather than what is most effective. The most effective dose may be considerably lower than the maximum safe dose, in some cases. Where a drug is not recommended for children, this is shown by the symbol * next to the drug name.

Benperidol (Anquil, Benquil) *
Licensed for the control of deviant antisocial sexual behaviour. Similar to haloperidol. Dose: maximum 1.5mg per day. Form: tablets

Chlorpromazine (Largactil)
A low-potency drug, and the one with which all the others are compared. Chlorpromazine is irritant to the skin: tablets should not be crushed, and solutions should be handled with care.
Side effects: one of the most sedating of the older antipsychotics and causes antimuscarinic effects, in particular. Can make skin very sensitive to sunlight. It may cause low blood pressure (especially in people who are old and frail), blurred vision and weight gain. Around 20 to 30 per cent of long-term users have a build up of granular deposits in the cornea and lens. This is partly dose-related. It does not usually affect sight. Avoid it if you have glaucoma. It sometimes causes emotional unease, but may have an antidepressant effect. It has been linked with blood clots (thromboembolism). Chlorpromazine can cause liver toxicity (poisoning) and regular tests of liver function are sometimes advised before starting, and during the first six months of treatment. Jaundice may occur in the first two months. It should disappear in the month after stopping.
Dose: maximum not specified, but 1g (1000mg) per day is the highest dose mentioned in the BNF. This drug may be given to children for childhood schizophrenia and autism, and for intractable hiccups. The maximum dose for a child aged one to five is 40mg per day, and for a child aged six to 12 years, 75mg per day. Form: tablets, oral solution, intramuscular injection, suppositories.

Flupentixol (Depixol, Fluanxol, Flupenthixol) *
Side effects: less sedating than chlorpromazine, but with more neuromuscular (Parkinson's) effects. It may have an antidepressant effect.
Dose: maximum 18mg per day. (See also flupentixol decanoate) Form: tablets.

Fluphenazine (Moditen) *
Side effects: less sedating and fewer antimuscarinic effects than chlorpromazine, but more neuromuscular reactions, especially muscle spasms and restlessness. It may cause depression. Dose: anything over 20mg per day to be used only with special caution. Form: tablets.

Haloperidol (Dozic, Haldol, Serenace)
Side effects: less sedating and fewer antimuscarinic effects than chlorpromazine, but more neuromuscular effects, especially muscle spasms and restlessness. Rare side effects include altered liver function, gastrointestinal disturbance and weight loss.
Caution: fluoxetine increases levels of this drug in the blood, and carbamazepine lowers them. There are increased risks if haloperidol is taken with lithium.
Dose: no maximum dose is specified in the BNF, but the highest dose mentioned is 30mg per day. This drug may be given to children to treat schizophrenia or dangerously violent or impulsive behaviour, at a maximum dose of 10mg per day. Form: tablets, oral liquid, injection. (See also haloperidol decanoate, below.)

Levomepromazine/methotrimeprazine (Nozinan)
Low potency. Side effects: more sedating than chlorpromazine, and with a risk of lowered blood pressure, particularly in people over 50. Dose: highest mentioned in BNF is 1g (1000mg) per day. No clear advice about children. Form: tablets, injection.

Pericyazine (Neulactil)
Side effects: more sedating than chlorpromazine, and lowered blood pressure when treatment starts. Dose: usual maximum 300mg per day. May be given to children for severe mental or behavioural disorders only, at a maximum dose of 10mg per day. Form: tablets, oral syrup.

Perphenazine (Fentazin) *
Side effects: less sedating than chlorpromazine, but more neuromuscular reactions, especially muscle spasms, particularly at high doses. It may cause blurred vision.
Dose: maximum 24mg per day. Form: tablets.

Pimozide (Orap) *
Side effects: less sedating than chlorpromazine. It may cause depression.
Caution: serious disturbances in heart rhythm reported, especially when doses are high dose. The Commission on Human Medicines recommends ECG before treatment starts and periodically thereafter on doses over 16mg daily. If other antipsychotic drugs are taken at the same time, there may be a greater risk of toxic effects on the heart. Avoid taking it with tricyclic antidepressants, and other drugs which affect the heart. Dose: up to 20 mg. Form: tablets.

Prochlorperazine (Stemetil) *
Side effects: less sedating than chlorpromazine, but more neuromuscular reactions, particularly muscle spasms. Form: tablets, syrup, injection.

Promazine *
Low potency. Side effects: Similar to chlorpromazine and one of the most sedating of the older antipsychotics. Form: tablets, oral solution.

Sulpiride (Dolmatil, Sulpitil, Sulpor) *
Low potency. Side effects: less sedating than chlorpromazine and a different chemical group. Not associated with jaundice or skin reactions. Dose: maximum 2.4g per day (2400mg per day). Form: tablets, oral solution.

Trifluoperazine (Stelazine)
Side effects: less sedating, less likely to lower body temperature or blood pressure, and causes fewer antimuscarinic effects than chlorpromazine. Produces neuromuscular reactions, and restlessness, especially when the dose is over 6mg daily. It may cause spontaneous ejaculation. May be given to children. Form: tablets, spansules (a sustained release capsule), syrup, oral solution.

Zuclopenthixol (Clopixol Acuphase) *
Side effects: Similar to chlorpromazine. This drug is given by injection, has a rapid sedative action shortly after injection and an antipsychotic action persisting for two to three days, and is for up to two weeks treatment only. Spontaneous ejaculation may occur. Dose: maximum 400mg per course and four injections.

Zuclopenthixol dihydrochloride (Clopixol) *
Side effects: Similar to chlorpromazine. Dose: maximum 150mg per day. Form: tablets (see also zuclopentixol decanoate).

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Atypical antipsychotics

The atypical antipsychotics were mostly first licensed in the 1990s, having been developed with the aim of reducing the neuromuscular side effects associated with the older drugs. Some of them also have fewer of the side effects associated with raised prolactin levels (see 'Sexual side effects' above). All of these drugs are licensed for the treatment of schizophrenia, and some of them are also licensed for mania.

Caution
They should be used with caution in people with cardiovascular (heart and circulation) disease, those with a history of epilepsy, or Parkinson's disease. They may affect your ability to perform skilled tasks, including driving, and may increase the effects of alcohol.

In March 2004, the Committee on Safety of Medicines (now the Commission on Human Medicines) issued new advice that the two atypical antipsychotics, risperidone and olanzapine, should not be used to treat behavioural problems in older patients with dementia. This is because there is evidence that these drugs significantly increase the risk of stroke in these patients. These drugs should also be used with caution in all older patients at risk of stroke.

Side effects
The most significant side effects are weight gain and associated metabolic effects, which may be very serious. Peoples physical health should be carefully monitored whatever type of antipsychotic they are taking, but with atypicals it is especially important to check weight, blood pressure, blood glucose and cholesterol. Research suggests that monitoring of these side effects is not taken sufficiently seriously by many health professionals. However, The Prescribing Observatory for Mental Health (part of the Royal College of Psychiatrists, which works with a number of NHS Trusts to improve practice with regard to mental health prescribing) has produced a card for users entitled Looking after your physical health, to encourage people who are taking antipsychotics to have regular health checks and keep their own record (see Useful organisations for details).

Other important side effects include: extreme sleepiness (somnolence), dizziness, mild and short-lived neuromuscular symptoms, low blood pressure on standing upright, which may be associated with fainting or rapid heart beat in some people. Occasionally, tardive dyskinesia may occur after long-term use; rarely, neuroleptic malignant syndrome. Other side effects are listed under the individual drugs.

Amisulpride (Solian) *
This is given for both positive and negative symptoms of schizophrenia.
Caution: it should be used with caution in people with kidney problems and in older people. It should not be used in pregnancy or while breastfeeding.
Side effects: insomnia, anxiety, agitation, raised prolactin levels causing milk production, loss of menstrual periods, breast development, breast pain and sexual problems. Occasionally: slow heartbeat and fits; changes in heart rhythm may occur. Dose: maximum 1.2g per day (1200mg per day). Form: tablets, oral solution.

Aripiprazole (Abilify)
This drug does not cause as much weight gain as some of the other atypical antipsychotic drugs. Caution:the usual cautions apply regarding people with liver or kidney disease. It should also be used with caution in people with a history of fits. It should not be used during pregnancy or while breastfeeding. Aripiprazole may take days or weeks to have its full antipsychotic effect. The tablets contain lactose. Interactions: Aripiprazole interacts with carbamazepine in such a way that the dose of aripiprazole should be doubled if they are given together. Side effects: light-headedness, trouble sleeping, akathisia, sleepiness, tremor, blurred vision, feeling and being sick, indigestion, constipation, headache, lack of energy. Less common: fast heart beat, low blood pressure on standing. Rare: neuroleptic malignant syndrome, tardive dyskinesia and fits may also occur. Neuromuscular symptoms occur less commonly with aripiprazole than with haloperidol. Aripiprazole is similar to olanzapine in this respect. Dose: the recommended starting dose is 15mg per day; the effective dose range is 15-30mg per day. Maximum dose: 30mg. It has not been studied either in children under 18 or in people aged 65 or older. If it is used in older people, a lower dose should be given. Form: tablets, dissolving tablets, oral solution.

Clozapine (Clozaril, Denzapine, Zaponex) *
Clozapine is licensed for treatment of schizophrenia when other antipsychotics are unsuitable. Because of the severity of the possible side effects, the prescribing psychiatrist, the patient and the supplying pharmacist must all be registered with the Clozaril or Denzapine Patient Monitoring Service, or the Zaponex Treatment Access System (depending which brand they are using). This takes several days. Caution: Blood: Clozapine carries a three per cent risk of causing agranulocytosis (see above), and this is why you must have regular blood tests, every week for the first 18 weeks of treatment, and fortnightly thereafter. Blood counts must be satisfactory before the drug is started. If blood problems are detected, the drug must be stopped. The problem is not dose-related, and the risk of developing it decreases after the first year. It is almost always reversible by stopping the drug. The greatest risk of developing serious blood disorders appears to be between the 6th and 18th weeks of treatment, and is more common in women. Any infections that develop should be reported to the doctor. It should not be used at the sametime as other drugs that cause agranulocytosis, including carbamazepine. Heart: Clozapine is also associated with myocarditis and cardiomyopathy (serious heart disorders), and the CHM has advised that a careful history should be taken before the drug is started, and heart function should be monitored especially in the first two months of treatment. There is a high risk of metabolic syndrome with clozapine (see above). Gut: Gastrointestinal obstruction has been reported; clozapine should be used cautiously with other drugs which cause constipation, and patients should be monitored for constipation. There is a higher risk of diabetes with clozapine and olanzapine than with other antipsychotics. Clozapine has also been linked with blood clots (thromboembolism). Interactions: SSRI antidepressants may increase its levels in the blood. It should not be combined with long-acting depot antipsychotics. Smoking may decrease its blood levels, while caffeine may increase them, so dosage should be monitored accordingly.

Side effects: sedation, drooling saliva, rapid heartbeat, blood pressure changes (high or low), dizziness, headache, and dry mouth. Some of these improve, although rapid heartbeat, drooling and sedation may persist. Less common side effects: fits occur occasionally (dose-related), constipation, nausea or vomiting, high body temperature, weight gain, drowsiness, fever and headache. Movement disorders and tardive dyskinesia are rare, but neuromuscular restlessness, sluggish movements and tremor can occur. Toxic delirium and sedation, requiring withdrawal in a small percentage of people. Withdrawal: rebound psychosis has been reported, and other antipsychotic drugs may not be effective afterwards. Clozapine should not be stopped abruptly. Dose: maximum 900mg per day. Form: tablets.

Olanzapine (Zyprexa)
This drug is licensed for schizophrenia, mania (in combination with mood stabilisers) and preventing recurrence in bipolar disorder. Caution: See above for cautions about the use of this drug in older people. It should be used with caution in pregnancy, in men with prostate problems, and in people with paralytic ileus, or liver or kidney problems, or those taking certain types of heart drugs. Anyone with closed-angle glaucoma (an eye disease) should not take it. It should not be used while breastfeeding. Carbamazepine lowers the level of this drug in the blood. Side effects: mild, short-lived antimuscarinic effects, drowsiness, increased appetite, peripheral oedema (puffy feet and hands), raised prolactin (but rarely high enough to cause symptoms), occasional blood problems, and sensitivity to sunlight. There is a higher risk of diabetes with olanzapine and clozapine than with other antipsychotics. Research suggests that it may cause an increase in blood fats, such as cholesterol, in older people. Dose: maximum daily dose, including the injectable version, is 20mg. Form: tablets, dissolving tablets (Velotab), injection (for rapid control of agitation or disturbed behaviour  this form should be discontinued and replaced with tablets or Velotab as soon as possible).

Paliperidone (Invega) *
This was licensed in June 2007 as a 'new' drug which is in fact an active metabolite of risperidone (see below). It therefore shares most of risperidone's characteristics. The main difference from risperidone and other antipsychotics is that paliperidone is produced in a 'prolonged-release' formulation which means that after the drug is taken it is released steadily over a 24-hour period, minimising peaks and troughs in the level of the drug in the blood. You must swallow the tablet whole with a drink, and must not chew it or divide it or crush it, because it is in a special shell designed to release the drug steadily through the day. The tablet shell is expelled from the body largely unchanged, and you should not worry if you see something that looks like a tablet when you have been to the toilet. You can take it either before food or with food, but you must be consistent  either always take it before food, or always take it with food.

Caution: Because of the structure of the tablet shell, it should not be given to people who have difficulty with swallowing. The 3mg tablet contains lactose; the higher dose tablets do not. Liver: the drug is not extensively metabolised by the liver and is excreted by the kidney largely unchanged, so it can be taken by people with mild or moderate liver disease. It should be used with caution in those with severe liver disease. Kidney: people with mild kidney disease should start on the lowest dose (3mg/day) which may be increased if it is well tolerated. People with moderate kidney disease should remain on 3mg/day, and those with severe kidney problems may be able to take 3 mg on alternate days. Older people: older people with normal kidney function can take a standard dose. Heart: It may cause changes in heart rhythm and should be used with caution in people with a family history of heart disease, stroke or related problems. It should be used with caution in people with a history of fits. Pregnancy and breastfeeding: It should not be used during pregnancy or while breast-feeding. Side effects: The commonest reported side effect is headache. The usual side effects of antipsychotics may occur, including Parkinsonism, and other neuromuscular effects; raised prolactin with sexual effects; affects on heart rhythm. As paliperidone is an active metabolite of risperidone, any of the side effects of risperidone may occur. Dose: range 3mg to 12mg. There is no need to start with a low dose and increase gradually when you start taking it. Form: prolonged release tablets. Withdrawal: There are no guidelines on withdrawal of paliperidone in relation to its gradual-release formulation. Its half-life is about 23 hours.

Quetiapine (Seroquel) *
Licensed for schizophrenia and for manic episodes, either alone or with mood stabilisers. Used especially in people with intolerable Parkinsons symptoms, or symptoms of raised prolactin levels caused by other drugs. Similar to clozapine, and causes fewer neuromuscular effects than the older antipsychotics. Not associated with serious blood disorders. Caution: it should be used with caution in pregnancy, in people with liver or kidney problems, in older people, and in people who are taking some types of heart drugs, or who have cerebrovascular disease. It should not be used while breastfeeding. Side effects: drowsiness, indigestion, mild loss of strength and energy, stuffy nose, fast heartbeat, anxiety, fever, muscle pain, rash. Rare effects: blood disorders, low thyroid hormone and possible changes in heart rhythm. Dose: maximum 750mg per day. Form: tablets.

Risperidone (Risperdal) *
Licensed for acute and chronic psychoses and mania. Thought to improve both positive and negative symptoms of schizophrenia. It has effects similar to chlorpromazine, but neuromuscular effects are usually less marked. Caution: see above for restrictions on its use in older people. It should be used with caution in people with liver or kidney disease, epilepsy or heart disease, as low blood pressure can occur. It may aggravate Parkinsons disease. It can impair alertness and can therefore interfere with the ability to drive and operate machinery. It should not be used while breast feeding. Caution is advised if other drugs with similar actions are given. Carbamazepine lowers its blood levels. Side effects: insomnia, agitation, anxiety, and headache, weight gain. Less common side effects: drowsiness, fatigue, dizziness, difficulty concentrating, constipation, indigestion, nausea, abdominal pain, blurred vision, problems with erection and ejaculation, nasal inflammation, and rash. Occasional side effects: low blood pressure, dizziness, nose bleeds and increased heart rate, particularly if high doses are given at the start of treatment. There are rare reports of neuroleptic malignant syndrome, water intoxication and fits. Dose: maximum 16mg per day. Form: tablets and dissolving tablets (Quicklet).

Sertindole (Serdolect)
Licensed for schizophrenia. Sertindole was suspended following reports of serious effects on heart rhythm and sudden death. It has now been reintroduced, on a named patient basis only, and restricted to people who are enrolled in clinical studies and those who are unable to take at least one other antipsychotic. You should be given heart function tests (ECG) before and during treatment with sertindole, and your blood pressure should be monitored during the initial stages of treatment. Low blood levels of potassium and magnesium should be corrected before you start treatment.
Side effects: effects on heart rhythm, low blood pressure on standing, fluid retention in hands and feet (peripheral oedema), dry mouth, stuffy nose, shortness of breath, tingling sensations, abnormal ejaculation (decreased volume). Rare side effects: fits and raised blood sugar. Dose: maximum 24mg per day in exceptional cases only; usual range 12-20mg per day. Form: tablets.

Zotepine (Zoleptil) *
Licensed for schizophrenia. Caution: It should not be given to people intoxicated with alcohol or other central nervous system depressants, or to people with gout or kidney stones. It should be used with caution in people with epilepsy, people at risk of heart problems and those with high blood pressure, prostate problems, urinary retention, narrow-angle glaucoma, and paralytic ileus. Because of its effects on the heart, people should have an ECG before starting treatment and with each dose increase. Blood levels of sodium and potassium should also be monitored. It should also be used with caution in combination with other antipsychotics, fluoxetine (Prozac) and diazepam (Valium), and with drugs that lower blood pressure. Zotepine should be avoided, if possible, in pregnancy and while breastfeeding. Side effects: weight gain, drowsiness, loss of strength and energy, dry mouth, akathisia and other neuromuscular effects (but less common than with the older antipsychotics). Chills, headache, pain, low blood pressure, rapid heart beat, constipation, indigestion, altered liver function, blood effects, depression, dizziness, insomnia and blurred vision were reported during trials. Less common side effects: flu-like symptoms, raised prolactin, sexual problems, appetite changes and convulsions. Sexual side effects should be less of a problem at lower doses. Isolated cases of neuroleptic malignant syndrome and tardive dyskinesia have been reported. Dose: maximum 300mg per day. Form: tablets.

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Antipsychotics through depot injection

Some antipsychotics can be given in a slow-release formulation by deep injection into a muscle. They may be given weekly, fortnightly, or every few weeks. Depot injections may cause more neuromuscular reactions than oral drugs. There can be pain at the site of the injection and, occasionally, swelling and small lumps. Many people remain on a high depot dose for many years, because their dose has not been changed since they were discharged from hospital after an acute episode of illness. You should have a continuous assessment of the risk of harm to you, versus the benefits, and to find out whether you could have a lower dose.

The depot versions of the older antipsychotics are based on nut oils, to which some people may be hypersensitive or allergic. Sometimes, these are referred to as 'vegetable oil' in the patient information leaflet, but they are either sesame or coconut oil. If you and your doctors are considering depot drugs, and you have a nut allergy, make sure they know this.

Flupentixol/flupenthixol decanoate (Depixol, Depixol Concentrate, Depixol Low Volume) *
Caution: contains coconut oil. Can cause over-excitement if given to people who are agitated or aggressive. Side effects: more neuromuscular reactions than chlorpromazine. Dose: maximum 400mg per week.

Fluphenazine decanoate (Modecate, Modecate Concentrate) *
Caution: should not be given to people who are severely depressed. Contains sesame oil. Side effects: any neuromuscular reactions usually appear a few hours after the dose is given and continue for about two days, but may be delayed.

Haloperidol decanoate (Haldol Decanoate) *
See haloperidol. Caution: contains sesame oil.

Pipothiazine palmitate (Piportil Depot) *
Similar to chlorpromazine. It may cause depression. Caution: contains sesame oil. Dose: maximum 200mg every four weeks.

Risperidone (Risperdal Consta)
Risperidone is the first atypical antipsychotic to be available as a depot injection. It is available for people who have been successfully treated with risperidone tablets and wish to receive their medication by fortnightly injection. It is licensed for the treatment of schizophrenia and other psychotic illnesses. Unlike other depot antipsychotics, Risperdal Consta does not contain nut oil. It is supplied as a powder and a solvent to be made up at the time of injection. Once reconstituted, it should normally be used immediately, but has a shelf-life of six hours.
Caution: see above for restrictions on its use in elderly people. People with no previous history of taking risperidone should take oral risperidone first, for a few days, to make sure they can take it safely. This drug should be used with caution in people who have liver or kidney disease, heart disease, Parkinson's disease, or epilepsy.
Dose: for people currently taking risperidone tablets of up to 4mg daily, initially 25mg every two weeks. For people currently taking oral risperidone of over 4mg daily, initially 37.5mg every two weeks. The dose should then be adjusted at intervals of at least four weeks, in steps of 12.5mg, to a maximum of 50mg (25mg for those over 65 years), every two weeks. Dosage adjustments will take at least three weeks to have an effect. During initiation, risperidone by mouth may be continued, if necessary, for a maximum of three weeks. Maximum dose: 50mg every two weeks. For older people (over 65 years), the maximum dose is 25mg every two weeks. (See above for information about elderly people with dementia.) Side effects: the side effects are very similar to those associated with oral risperidone. The most common side effects include weight gain, depression, fatigue and symptoms mimicking Parkinson's disease, such as slowed movement and tremor, disturbed sleep, constipation, and nausea. Uncommon side effects include weight loss, nervousness, loss of concentration, low blood pressure, fainting and visual problems.

Zuclopentixol decanoate (Clopixol, Clopixol Concentrate) *
Side effects: similar to chlorpromazine but less sedating. Caution: contains coconut oil. Dose: maximum 600mg per week.

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Anti-Parkinson's drugs

These drugs are given to lessen the neuromuscular effects of antipsychotics, which resemble the symptoms of Parkinson's disease. They are called antimuscarinics. The World Health Organisation has stated that anti-Parkinson's drugs should not be given routinely to people on antipsychotics, but only when Parkinsonism has actually developed. Anti-Parkinson's drugs should only be used when it is either not advisable to change the antipsychotic or reduce the dose, or where this has not worked. These drugs can cause confusion and memory problems and, occasionally, make the psychosis worse. Due to their stimulant effect, they have the potential for abuse and can occasionally be habit forming. When withdrawing, you should go gradually and not stop suddenly. The BNF says that no important differences exist between these drugs, but some people tolerate one better than another. Trihexyphenidyl hydrochloride is the standard to which the others are compared.

Benzatropine mesylate/benztropine mesylate (Cogentin)
A sedative rather than stimulant effect, otherwise similar to trihexyphenidyl hydrochloride. May cause depression and high temperature. Caution: Avoid in children under three years old. Dose: maximum 6mg per day. Form: injection.

Orphenadrine hydrochloride (Biorphen, Disipal)
Similar to trihexyphenidyl hydrochloride. Side effects: it can have a euphoric effect and may cause insomnia. Dose: maximum 400mg per day. Form: tablets, oral solution.

Procyclidine hydrochloride (Arpicolin, Kemadrin)
Similar to trihexyphenidyl hydrochloride. Causes sedation rather than stimulation; also gingivitis (inflammation of the gums). Dose: maximum 30mg per day (60mg per day in exceptional circumstances). Form: tablets, syrup, injection.

Trihexyphenidyl hydrochloride/benzhexol hydrochloride (Broflex) *
Side effects: dry mouth, gastrointestinal disturbances, dizziness, and blurred vision. Less common side effects: difficulty urinating, rapid heartbeat, hypersensitivity, nervousness and, with high doses, confusion, excitement and psychiatric disturbances. If this happens the drug should be withdrawn. This drug has a stimulant effect. Dose: maximum 20mg per day. Form: tablets, syrup.

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References

Antipsychotic drugs and heart muscle disorder in international pharmacovigilance D. M. Coulter, A. Bate, R. H. B. Meyboom, M. Lindquist, I. R. Edwards (British Medical Journal 2001, 322)
'Antipsychotic drugs  information and choice: a patient survey B. Olofinjana, D. Taylor (Psychiatric Bulletin 2005, 29, 369-371)
Antipsychotic prescribing  time to review practice D. Taylor (Psychiatric Bulletin 2002, 26, 401-402)
Antipsychotics and risk of venous thrombolysis F. Curtin, M. Blum (British Journal of Psychiatry 2002, 180, 85)
Brain dopamine and obesity G. Wang et al (The Lancet 2001, 357)
British National Formulary, 53 (British Medical Association and Royal Pharmaceutical Society of Great Britain March 2007)
The case against antipsychotic drugs: a 50-year record of doing more harm than good, R. Whitaker (Medical Hypotheses 2004, 62, 1, 5-13)
Chlorpromazine equivalents and percentage of British National Formulary maximum recommended dose in patients receiving high-dose antipsychotics G. Yorston, A. Pinney (Psychiatric Bulletin 2000, 24, 130-132)
Conventional antipsychotic drug use linked to venous thromboembolism G. L. Zornberg, H. Jick (The Lancet 2000, 356, 1219-1223)
Coprescribing of atypical and typical antipsychotics  prescribing sequence and documented outcome D. Taylor, S. Mir, S. Mace, E. Whiskey (Psychiatric Bulletin 2002, 26, 170-172)
Depot injections and nut allergy S. Reeves, R. Howard (British Journal of Psychiatry 2002, 180, 188)
Effects of antipsychotics on fat deposition and changes in leptin and insulin levels, Z. J. Zhang, Z. J. Yao, W. Liu, Q. Fang and G. P Reynolds (British Journal of Psychiatry 2004, 184, 58-62)
Effects of long-term prolactin-raising antipsychotic medication on bone mineral density in patients with schizophrenia A. M. Meaney, S. Smith, O. D. Howes, M. OBrien, R. M. Murray, V. OKeane (British Journal of Psychiatry 2004, 184, 503-508)
Electronic Medicines Compendium (web: www.emc.vhn.net)
Hyperprolactinaemia caused by antipsychotic drugs A. Wieck, P. Haddad (British Medical Journal 2002, 324, 250-252)
S. Smith (British Medical Journal 2002, 324, 1278)
Insight: Drug Information, News, Views and Comment, Issue 4 (SW London and St Georges Mental Health Trust 2000)
Monitoring weight and blood glucose in in-patients: how helpful is a protocol?, O. Runcie, M. Boilson, and R. Hamilton, (Psychiatric Bulletin, 2007, vol 31, pp 88-91)
Nose bleeds associated with use of risperidone D. W. J. Clark, M. Harrison-Woolrych (British Medical Journal 2004, 328)
Olanzapine may increase risk of hyperlipidemia in geriatric patients C. E. Koro et al (The Brown University Geriatric Psychopharmacology Update 2003, 7(2), 1, 4-5)
Olanzapine-associated diabetes mellitus E. A. Koller, P. Murali Doraiswamy (Pharmacotherapy 2000, 22(7), 841-852)
Physical complications of mental illness must be remembered S. Winning (British Medical Journal 2002, 324, 1278-1279)
Psychotropic drugs and sudden death S. A. Chong (British Journal of Psychiatry 2001, 178, 179-180)
Randomized Controlled Trial of the Effect on Quality of Life of Second- vs First-Generation Antipsychotic Drugs in Schizophrenia P.B. Jones et al, (Arch Gen Psychiatry. 2006, 63:1079-1087)
Schizophrenia: core interventions in the treatment and management of schizophrenia in primary and secondary care  Clinical Guideline 1 (NICE 2002)
Sexual dysfunction in patients taking conventional antipsychotic medication S. M. Smith, V. OKeane, R. Murray (British Journal of Psychiatry 2002, 181, 49-55)
The influence of patient variables on polypharmacy and combined high dose of antipsychotic drugs prescribed for inpatients P. Lelliott, C. Paton, M. Harrington, M. Konsolaki, T. Sensky, C. Okocha (Psychiatric Bulletin 2002, 26, 411-414)
The results of a multi-centre audit of the prescribing of antipsychotic drugs for inpatients in the UK M. Harrington, P. Lelliott, C. Paton, C. Okocha, R. Duffett, T. Sensky (Psychiatric Bulletin 2002, 26, 414-418)
Use of serotonin antagonists in the treatment of neuroleptic-induced akathisia I. Maidment (Psychiatric Bulletin 2000, 24)
Why are doctors still prescribing neuroleptics?, Charlton, B.C., (Medical Hypotheses, 2005, vol 6, pp 1005-1009)

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Useful organisations

British Association for Behavioural and Cognitive Psychotherapies (BABCP)
tel: 0161 797 4484 web: www.babcp.com
Directory of psychotherapists available online

British Confederation of Psychotherapists (BCP)
tel. 020 7267 3626 web: www.bcp.org.uk
Can provide a register of members

Depression Alliance
tel. 0845 123 2320 web: www.depressionalliance.org
Information, support and understanding depression

Food for the Brain
web: www.foodforthebrain.org
A non-profit educational charity promoting the link between nutrition and mental health

Hearing Voices Network
tel: 08451228641 helpline: 0845 122 8642
web: www.hearing-voices.org
National network and local groups for people who hear voices

The Institute for Complementary Medicine (ICM)
tel. 020 7237 5165 web: www.i-c-m.org.uk
Can send a list of practitioners

The Institute for Optimum Nutrition
web: www.ion.ac.uk
Aim to further the knowledge and practice of nutritional therapy

MDF The Bipolar Organisation
tel. 08456 340 540 web: www.mdf.org.uk
Works to enable affected people to take control of their lives

Prescribing Observatory for Mental Health
Tel: 020 7977 4999/6641
web: www.rcpsych.ac.uk/crtu/centreforqualityimprovement/prescribingobservatory.aspx
For Looking after your physical health cards, email: pomh-uk@cru.rcpsych.ac.uk

Rethink
tel: 0845 456 0455 advice line: 020 8974 6814
web: www.rethink.org
For everyone affected by severe mental illness

Useful websites

http://emc.medicines.org.uk
Access to patient information leaflets

http://medguides.medicines.org.uk/mip.aspx
Medicines Information Project

www.mhra.gov.uk
The Medicines and Healthcare products Regulatory Agency.
Also has information about the Commission on Human Medicines

www.yellowcard.gov.uk
For reporting side effects of any medicine

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Making sense of herbal remedies


Why do people choose herbal medicine?
How is it best to use herbs?
How should I take herbal remedies?
How do I shop for them?
Do herbs have side-effects?
Is it safe to treat myself or my family using herbs?
In what way can a herbalist help me?
What happens during a consultation?
How do I find a good herbalist?
What herbs are used for mental and emotional health?
Herbs that may be used for mental health
References
Useful organisations


Why do people choose herbal medicine?

People try herbal remedies for all sorts of reasons: because they hear from others that it has worked, because they feel it's natural and believe it's likely to have fewer side effects, or because they prefer its holistic approach. People also like the idea of having more control over their own treatment. Others turn to herbal remedies because conventional medicine has let them down, or because they want to relieve the side effects caused by the prescription medication they need to take.

The popularity of herbal medicines is clear now that herbs are much more widely available over the counter. Also on the increase is the number of qualified practitioners and those choosing plant medicines, in their many forms.

Herbal medicines can be used to treat health problems that are short-lived (acute) or firmly established (chronic), as part of a holistic approach to health. In other words, when looking at the person as a whole, and working out whether there are underlying medical, emotional or lifestyle factors that may be having some influence on the outbreak of symptoms.

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How is it best to use herbs?

It's important to recognise, first of all, that herbs don't have a specific and limited purpose, in the way that conventional medicines do. Each person should have their individual needs identified, so that herbs prescribed specially for him or her, at the time, can address these. For example, not only are there different types of depression, but they can also vary in intensity. A person may go through a depression that is altogether different from their experience of depression on a previous occasion. It may also involve a whole range of physical symptoms - lethargy, stomach problems (constipation and diarrhoea) and headaches, to name just a few - that are individual to that person.

A herbalist will take into consideration the whole picture of someones symptoms, and use an individually tailored combination of plants to address those symtoms and to restore health. Combining two or more herbs can enhance the individual effects of each one. This is known as synergism. Herbs for the nervous system fall into a number of categories. They can be used to strengthen a system, to relax or sedate a system, or to stimulate it.

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How should I take herbal remedies?

At home, the easiest way is to make a tea or 'infusion', by leaving the plant material in boiling water for 5-10 minutes, before straining and drinking it. Herbal remedies come in many other forms, however. They can be bought over the counter as:

fresh herbs (such as, garlic cloves or peppermint leaves)
capsules or tablets (powdered herbs)
extracts (a concentrated form that comes as liquid tinctures, solid pills or capsules)
tea
in foods
as essential oils (for external use)
as creams and ointments (for applying to the skin).
The potency and quality of all of these vary widely. The herbs need additives to make them into extracts, which come in a range of strengths. Tinctures are more readily absorbed and solid extracts (pills or capsules) are the most concentrated and perhaps the best value. Some products are (or contain) 'standardised extract'. This means that the manufacturer guarantees that the product contains a certain amount of a particular ingredient, so that you know how much (by weight) of that ingredient is in each day's dose. Different manufacturers produce remedies in different strengths and to different qualities. Prices will vary, and may not necessarily reflect the quality of the product.

Herbalists themselves prefer to use herbs in their natural state, or as close to it as possible, with nothing added and nothing taken away. They prefer this 'full spectrum' to standardised extracts because they feel that preparations with added or boosted components influence the effectiveness and safety of plants, for no good reason.

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How do I shop for them?

Remedies are now available in health food shops, chemists and supermarkets, and directly from herbalists. (Some can even be bought via mail order.) Supplements can be useful, but its always better to get an individual prescription rather than just guessing which herbs to use.

Herbal remedies aren't covered by a standard licensing procedure (although some do have product licences). They are either classed as food supplements, or come under section 12 of the Medicines Act, which makes them exempt from licensing. They don't have to undergo the same testing procedures as pharmaceutical drugs.

When buying herbs,
Choose remedies carefully - do a bit of research before you buy anything, and compare manufacturers as well as different forms of the herb. Don't choose on the basis of price alone.
Buy your herbs from a reputable supplier to ensure high quality.
Check the expiry date.
Choose single herbs, not combinations. (Remember that herbs act synergistically.)
Check the recommended dosage - different manufacturers have different recommendations.
Always read and follow the instructions on the label, carefully.
Dont overuse products. With all herbs, if you are self-prescribing, follow the instructions on the product, or the recommendations of a qualified herbalist. Start with the minimum dosage recommended.
Be aware of any side effects you experience. If you feel a herb does not suit you, stop taking it and seek advice from a qualified herbalist.
Many of the herbs available are user-friendly and have clear instructions. If you are self-prescribing but are unsure what to buy, contact a herbalist for advice.

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Do herbs have side-effects?

A herb, like any other chemical compound, may have side effects. Being 'natural' doesn't make something automatically safe. But, on the whole, the side effects seem to be much milder and more infrequent than for pharmaceutical drugs. Most of the herbs that may have side effects in high doses arent readily available to buy over the counter. Where problems have been reported, this seems to have been caused by very poor-quality products or by extreme misuse.

Sometimes, people do take the wrong remedy for the wrong reason - mistakenly believing, perhaps, that taking a higher dose will make it work better. Not only might they do themselves harm, they also miss out on the real benefits of the remedy. That's why it's vital to know what you're taking and why you're taking it.

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Is it safe to treat myself or my family using herbs?

Most people can safely treat themselves for problems that are normally fairly short-lived, but for any long-standing condition, or one that doesn't go away, you should consult a qualified herbalist, and make sure that another form of treatment isn't also necessary. With self-diagnosis, it's important to know if and when to consult a doctor.

If your child is under five or has a tendency to allergies, seek help from a qualified practitioner. Otherwise, using herbs for children is relatively straightforward, with chamomile perhaps being the mainstay of the first-aid cabinet. When giving children herbs, mix them in yogurt with a little honey or dilute fruit juice, to help them.

For safe and accurate treatment, follow these guidelines:

Don't overuse products. Use the minimum dosage for all herbs, if you are self-prescribing.
Be aware of any side effects you experience. If a herb doesnt suit you, stop using it.
The more severe the problem, the more cautious you should be about self-treatment, as a general rule.
Don't use herbal remedies if you are trying to have a baby, or if you are already pregnant or breastfeeding, without first consulting a qualified herbalist or your GP.
Never use herbs for babies or small children without seeking professional advice.
Don't take herbs alongside other prescribed drugs without consulting a qualified herbalist, because some herbs may strengthen the effects of drugs or make others less effective. With consultation, it may be possible to reduce your conventional medication.
Don't make the mistake of switching from your existing pharmaceutical drug to a herbal remedy without consultation. Herbs are medicines that work in complex and subtle ways and won't always have exactly the same effect.
If you have long-standing health problems, see a herbalist who can work with you in a holistic and effective way to treat the underlying causes and achieve the best outcome.
If you have a short-lived condition and the symptoms arent getting better within a few days, get professional advice.

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In what way can a herbalist help me?

Herbalists see people of all ages, who are trying to cope with short- or long-term problems. People often ask for help when they havent been able to find relief from long-standing problems, or when they are taking prescription drugs, which have unwelcome side effects. Often, herbal remedies can help reduce these. Medical herbalists also see many children with common and ongoing conditions, such as eczema, asthma and problems sleeping or with digestion.

Herbalists treat symptoms affecting many systems of the body. Frequently, people have a batch of symptoms that can all be addressed by a trained practitioner. The same person could have a problem with their kidneys (recurrent cystitis), digestive system (irritable bowel syndrome or diverticulitis), heart and circulation (high blood-pressure), gynaecological problems (period pains or menopausal problems), nervous system (insomnia or nerve pain) and joints (arthritis).

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What happens during a consultation?

Herbalists want to tackle the underlying causes of ill-health, as well as to relieve the symptoms that brought you to see them in the first place. So, a first consultation will take between an hour and an hour-and-a-half. It will cover, in detail, aspects of your medical, dietary, and emotional history and lifestyle, as well as getting a good account of your current state of health. He or she may do a physical examination, if that's necessary, and will usually check your blood pressure. This is especially useful if you havent been to see your GP for a long time. It's also important for a herbalist to decide whether you should see your doctor, or whether a different system of health-care could be helpful.

Herbalists don't dispense standard remedies for symptoms. Following a consultation, a herbalist may prescribe herbs for a period of two to three weeks. After this time, the prescription will be reviewed, depending on what the outcome has been.

Remedies can take time to work or may work quickly, depending on the symptom and health picture. A qualified herbalist will give you an indication of timescales in which to expect changes and improvements to your symptoms, and how this will be evaluated.

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How do I find a good herbalist?

To be confident about someone treating you, you should check whether they are qualified members of a recognised, professional body, and find out details of their training and experience. For instance, members of the National Institute of Medical Herbalists (established in 1864) have undergone a rigorous, four-year training, including subjects such as Western medical sciences, pharmacy, nutrition, the therapeutic actions of plants, and therapeutics. They have a strict code of ethics and full professional insurance. The letter MNIMH or FNIMH after the name indicate that someone is a member of the Institute.

Most herbalists have a sliding scale of fees, which they can apply according to whether you are working or on a reduced income. Unfortunately, not everyone can afford herbal medicine. Many GPs are open to the idea of herbal remedies (some are even practising herbalists themselves). Although they have general guidelines for referring patients to complementary practitioners, they don't have standard criteria for doing so. In some areas, herbalists work within GP practice settings, alongside other health professionals who may work with complementary or conventional medicine.

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What herbs are used for mental and emotional health?

Practitioners approaching mental or emotional problems frequently choose from a class of herbs that includes those known as the nervous trophorestoratives. In other words, these are herbs that feed and nourish a system. Herbs usually have a primary action, but may also have additional influences. It's therefore important to use herbs that synergise, or enhance each other's activities. Such herbs may include St John's wort, lemon balm, damiana, passionflower, hops, valerian and kava kava.

Herbalists need to take care that the herbs they use do not over-stimulate an individual. In the short-term, the herbalist may use additional prescriptions of regular doses of herbs throughout the day to regulate sleep or alleviate panic attacks, for instance. This will go on until the main prescription begins to make an impact. The time-scale will depend on the choice of treatment and individual needs.

Scientific research on the herbs St John's wort, kava kava and valerian has confirmed good results in treating, variously, depression, anxiety, insomnia, and memory problems. It has also provided much more information about side effects that might be associated with them.

There are other herbs traditionally used for emotional problems:

passionflower, reishi and hops, for anxiety and stress
sage, hyperzine and peony, for memory problems
chamomile, lemon balm and passionflower, for sleep.
Recently, theres been greater focus and interest in treating problems relating to sexual function. Here, herbs are seen as a safe option when compared to the medications frequently prescribed. Self-help is probably of limited value however, because problems of this kind can have so many origins. Its best to speak to a qualified practitioner about this, if possible.

St John's wort has been successful as a safe treatment for many people who have mild or moderate depression. But this has fuelled a mistaken idea that a particular herb can 'fix' a particular problem, and that all people need do is go and buy a bottle. This contradicts the core principles of herbal medicine, and creates false expectations. It's important to remember that what works for one person may not work for another, in just the same way that someone may try several conventional antidepressants before finding one that works.

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Herbs that may be used for mental health

Although there have been tests on many herbs, there is often no conclusive information about what side effects may occur and how likely they are. However, in comparison to the majority of pharmaceuticals, herbs are well tolerated. Its worth remembering that herbal remedies have been used safely for a very long time.

Damiana
A herb, Damiana Turnera diffusa. ( Plant family: Turneraceae.) Comes as a leaf, powder, capsule, tincture or fluid extract.
What's it for?
A tonic herb to strengthen the reproductive and nervous systems. For mild to moderate depression and anxiety associated with fatigue. Also for lack of sexual desire.
Possible side effects
No reported side effects.
Caution
Turnera can be very stimulating, so, if you are self-prescribing, use the minimum dosage.

Gingko biloba
Extract from a Chinese tree. (Plant family: Gingkoaceae.) Comes as tablets, liquid or tea.
What's it for?
Memory and other age-related mental effects. Can be helpful for depression, and when an antidepressant reduces interest in sex. Gingko has a powerful influence on the circulatory system, and research has been undertaken into how it affects Alzheimers disease and dementia.
Possible side effects
Rare. Stomach upset, headache, allergic skin reactions, or slight dizziness, on occasion.

Kava kava
A shrub, Piper methysticum, a member of the pepper family. (Plant family: Piperaceae.) Comes as pills, capsules, liquids, tea, tincture or spray. Currently unavailable in the UK.
What's it for?
Anxiety and stress. May also be helpful for sleep, pain and depression. Used for chronic irritation of the urinary tract and for some arthritis.
Possible side effects
Generally well tolerated. Exceptionally, people have experienced stomach discomfort, headache, tiredness and wobbliness.
Caution
Consult your doctor if you are already taking sedatives.

Lavender
A herb, Lavendula officinalis. (Plant family: Labiatae.) Available as a tea, essential oil and in some over-the-counter preparations.
Whats it for?
A safe herb, generally used to influence the nervous system, digestive system, circulation and skin. Aids sluggish digestion and sleep, and relieves tension headaches. Also used by herbalists to help people with mild to moderate depression, and to ease pain.
Possible side effects
No reported side effects.

Lemon balm
A herb, Melissa officinalis. (Plant family: Labiatae.) Available as a tea and essential oil.
Whats it for?
Anxiety, irritability, insomnia, headaches and period pains.
Possible side effects
No reported side effects.

Peppermint
Mentha piperita. (Plant family: Labiatae.) Comes as herb, powder, capsule, essential oil, tincture and fluid extract.
What's it for?
Commonly used by sufferers of irritable bowel syndrome. Useful for those who experience nausea due to emotional disruption, for digestive spasm and pain, mild diarrhoea, headaches and migraine.
Caution
Do not use medicinally in children under five. Do not use during pregnancy or when breastfeeding.

St John's wort
A herb, Hypericum perforatum. (Plant family: Guttiferae.) Comes as tablets, capsules, liquid, tea, tincture, ointment and oil.
What's it for?
Depression. Clinical trials confirm its benefits for treating mild depression. May also be helpful for anxiety, sleep problems and seasonal affective disorder (SAD). It can influence the nervous system, the body's defences (the immune system) and the glands, and can be used, internally and externally, for a wide range of symptoms. Herbalists may use St Johns wort to influence a number of health problems, including nerve damage, menopausal symptoms and viral infections.
Possible side effects
Mild nausea, headaches, sleepiness, dry mouth, constipation, itchiness, restlessness, dizziness, mania (in manic depression) and sunburn. Has been shown in scientific trials to have fewer side effects than older antidepressants.
Caution
Do not use it if you are taking medication (including the contraceptive pill) without seeking professional advice. May thin the blood. The Medicines Control Agency suggests it should not be used with drugs such as Warfarin, anticonvulsants and certain antidepressants. Increases the skin's sensitivity to sun.

Valerian
A common plant, Valeriana officinalis. (Plant family: Valerianaceae.) Comes in capsules, pills, liquid extracts, tinctures, infusions, and tea.
What's it for?
Anxiety and stress. It may be helpful for depression and for sleep problems. Herbalists may use valerian in combination with other herbs for pain management and to influence a whole range of health problems that may be exacerbated by disruption of the nervous system.
Possible side effects
Mild headaches, feeling sick, nervousness, palpitations, grogginess on waking. Long-term use at large doses may increase the range and severity of side effects.

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References

A combination of plant extracts in the treatment of outpatients with adjustment disorder with anxious mood M. Bourin, T. Bougerol, B. Guitton (Fundamental and clinical pharmacology 1997, 11)
The complete floral healer A. McIntyre (Gaia 1996)
Critical evaluation of the effects of valerian extract on sleep structure and sleep quality F. Donath, S. Quisipe et al. (Pharmacopsychiatry November 2000)
Double blind study of a valerian preparation O. Lindahl, L. Lindwall (Pharmacology biochemistry and behavior April 1998)
Effects of a fixed valerian-hop extract A. Fussel, A. Wolf, A Brattistrom, (European journal of medical research September 2000)
The effects of valerian, propanolol and their combination on activation, performance and mood in healthy volunteers under stress conditions R. Kohnen, W. D. Oswald (Pharmacopsychiatry 1988, 21)
Herbs for the mind J. R. T. Davidson, K. M. Connor (The Guilford Press 2000)
Herbal first aid A. Chevalier (Amberwood Publishing 1993)
Herbal remedies - a beginners: guide to making effective remedies in the kitchen C. Hedley, N. Shaw (Paragon 1997)
The new holistic herbal D. Hoffman (Element 1991)

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Useful organisations

The British Holistic Medical Association
59 Lansdowne Place, Hove, East Sussex BN3 1FL
tel./fax: 01273 725 951, email: bhma@bhma.org
web: http://www.bhma.org
Promotes a holistic approach to healthcare

Institute for Complementary Medicine
PO Box 194, London, SE16 7QZ
tel. 020 7237 5165, web: http://www.icmedicine.co.uk
Maintains a register of practitioners

The National Institute of Medical Herbalists (NIMH)
56 Longbrook Street, Exeter, Devon EX4 6AH
tel. 01392 426 022, fax: 01392 498 963
email: nimh@ukexeter.freeserve.co.uk web: http://www.nimh.org.uk
Send a 60p A5 SAE for a list of practitioners

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Drugs for attention deficit hyperactivity disorder (ADHD)

The diagnosis of ADHD is controversial, and so is the treatment. If you or your child have been diagnosed with attention deficit hyperactivity disorder (ADHD), you/they may have been offered a drug treatment. This factsheet is for people who wish to know more about the drugs that are sometimes used when ADHD is diagnosed.

Background to the drugs used for ADHD

Stimulant drugs (amphetamines) have been used to treat ADHD since 1937. Studies show that they decrease physical activity and increase alertness, and improve performance in learning tasks in all groups. Recently, non-stimulant drugs have also been developed for this condition.

There are three drugs which are licensed for the treatment of ADHD in the UK. All three are to be prescribed only under the supervision of a specialist experienced in managing ADHD. The National Institute for Health and Clinical Excellence (NICE) recommends that they should be used only in conjunction with social, behavioural and psychological treatments.

The way these drugs work in ADHD is not known, and the long-term effects of all of these drugs are not known.

Stimulant drugs

Methylphenidate and dexamfetamine are stimulant drugs in the class that includes amphetamines (amfetamines) and they act in a similar way to cocaine, increasing activity in the parts of the brain that control attention. The chemistry is different from cocaine in a way which makes these drugs less likely to become addictive. However, the British National Formulary recommends that amphetamines have a very limited field of usefulness, and their use should be discouraged as they may cause dependence and psychotic states. They are Schedule II controlled drugs  in the same category as barbiturates and methadone.

In February 2006, the drug safety and risk committee of the Food and Drug Administration (FDA) in America recommended that ADHD stimulant treatments should carry a 'black box' warning of the risk of sudden death, following a report listing 25 sudden deaths in both adults and children, between 1999 and 2003. Some of the patients had known heart disease, and the cautions for these drugs do include heart disease (see below).

Methylphenidate (trade names Ritalin, Concerta XL, Equasym, and Equasym XL)

This drug is licensed for the treatment of ADHD when behavioural measures alone are not enough. It comes in tablet and capsule form.

Ritalin tablets contain a 10mg dose.

Concerta XL tablets contain either 18mg or 38mg, in a modified release formulation, which means that the drug is active over a longer period than Ritalin. A total daily dose of 15mg of the normal release formulation (standard form) is considered equivalent to 18mg daily of the Concerta XL modified release formulation.

Equasym tablets contain doses of 5, 10 and 20mg.

Equasym XL capsules contain doses of 10, 20 and 30mg, in a modified release formulation.

When not to use methylphenidate
Methylphenidate should not be given to people with anxiety or agitation; tics or a family history of Tourette's syndrome; an overactive thyroid; severe angina (heart pain) or irregular heart beat; glaucoma (an eye disease); or while breast-feeding.

Cautions
Growth should be monitored if the drug is taken for a long time; blood pressure and blood cell counts should be checked. It should be used with caution in people with a history of drug or alcohol dependence; psychosis; epilepsy (discontinue if fits occur more frequently); and in pregnancy. Withdraw slowly.

Side effects of methylphenidate
Abdominal pain, feeling or being sick, dry mouth; fast heart rate, palpitations, irregular heart beat, changes in blood pressure; insomnia, nervousness, loss of appetite, headache, drowsiness, dizziness, movement disorders; painful joints; rashes, itching, hair loss; rarely, inflammation of blood vessels in the brain, angina (heart pain), hyperactivity, fits, psychosis, tics including Tourette's syndrome, neuroleptic malignant syndrome (a serious condition more commonly associated with antipsychotic drugs, involving high fever, tremor and rigidity and changes in consciousness), becoming dependent on the drug, growth retardation, reduced weight gain, blood disorders, muscle cramps, visual disturbances, peeling skin, erythema multiforme (raised red patches on the skin),

The modified release form may pass through the gut without being broken down, and is not appropriate for people with recurrent indigestion or people with a narrowed gut.

Dose
Normal release formulation for children over six years: initially 5mg once or twice/day, increased if necessary at weekly intervals by 5-10mg/day to a maximum dose of 60mg/day, in two or more doses.

Modified release formulation for children over the age of six years: initially 18mg/day in the morning, increased if necessary in weekly steps of 18mg to a maximum of 54mg/day.

For both forms, if there is no response after one month it should be stopped. It should also be stopped periodically to assess the child, and is usually stopped completely at puberty. It is not recommended for children under the age of six years.
 

Dexamfetamine (dexamphetamine) (trade name Dexedrine)

This drug can be used, under specialist supervision, to treat ADHD in children where other medication is not adequate to control the condition. It comes in tablet form. Each tablet contains 5mg.

When not to use dexamfetamine
It should not be given to people with moderate to severe high blood pressure or heart disease, excitability or agitation; an overactive thyroid; glaucoma (an eye disease); a history of drug or alcohol abuse; or during pregnancy or breast-feeding.

Cautions
This should be used with caution in people with slightly raised blood pressure, epilepsy (stop if fits occur); tics and Tourette's syndrome (stop if tics occur). Children's growth should be monitored as it may slow growth. It can be withdrawn for periods to allow growth to catch up, but it should not be stopped abruptly, as it may induce depression or renewed hyperactivity. It may increase behavioural disturbances and thought disorder in children with a diagnosis of psychosis.
 
Side effects of dexamfetamine
Sleeplessness, restlessness, irritability and excitability, nervousness, night terrors, euphoria, shaking, dizziness, headache, fits; becoming dependent on the drug; sometimes psychosis, loss of appetite, gastro-intestinal symptoms, slowed growth in children, dry mouth, sweating, fast heart beat, palpitations, raised blood pressure, visual disturbances; heart muscle problems with long-term use, movement disorders, tics and Tourette's syndrome.

Dose
Children over six years: 5-10mg/day, increased if necessary by 5mg/week to maximum dose 20mg/day. Older children have received a maximum of 40mg/day. NICE suggests it may be used for children over three years old, but there are no dosage guidelines in the British National Formulary for children under six.
 

Non-stimulant drugs

Atomoxetine (trade name Strattera)

Atomoxetine is not a stimulant, but its effects on the brain are similar to those of stimulant drugs, and it is less likely to be addictive or to become a drug of abuse.

This drug is licensed for the treatment of ADHD in children and adults. Treatment should be started by a specialist, but may be continued by a GP. It comes in capsule form. The smallest available dose is 10mg, and the largest 60mg.

When not to use atomoxetine
It should not be given to people with closed-angle glaucoma (an eye disease).

Cautions
Atomoxetine should be used with caution in people with diseases of the heart or blood vessels, including fast heart rate and low blood pressure on standing up. It may slow growth in children so this should be monitored. It should be used with caution during pregnancy and while breast-feeding, and in people with liver disease. Because a few people have developed liver disease while taking this drug, you should be told how to recognise symptoms, and see a doctor promptly in any case of stomach pain, unexplained nausea (feeling sick), feeling unwell, dark urine, or jaundice (yellow skin).

Side effects of atomoxetine
Commonest first: loss of appetite, dry mouth, feeling or being sick, abdominal pain, constipation, indigestion, wind, palpitations, fast heart rate, raised blood pressure, low blood pressure when you stand up, hot flushes, disturbed sleep, dizziness, headache, tiredness, lack of energy, depression, anxiety, irritability, shaking, stiffness, difficulty urinating, bed-wetting, inflammation of the prostate gland, sexual problems, menstrual disturbances, dilated pupils, conjunctivitis, inflammation of the skin, itching, rashes, sweating weight changes; less commonly, cold hands and feet; very rarely, liver problems and suicidal thoughts.

In September 2005, the Committee on Safety of Medicines in the UK published a warning about an increase in suicidal thoughts and behaviour in children aged 7-12 years taking Strattera. Up to 15,000 patients have been treated with the drug in the UK since it was first marketed in July 2004. There have been 169 yellow card reports of adverse reactions, of which 11 included suicidal thoughts or behaviour.

Dose
Adolescents weighing over 70kg and adults: 40mg/day for seven days, then increased according to response to usual maintenance dose of 80mg/day.
Maximum dose 100mg/day.

Children over six years and adolescents weighing up to 70kg: 500mcg/kg/day for seven days, increased according to response to usual maintenance dose 1.2mg/kg/day. Maximum dose: 1.8mg/kg/day.

For example, for a child weighing 30kg, the starting dose would be 500mcg (0.5mg) X 30 = 15mg/day; the usual maintenance dose would be 1.2 X 30 = 36mg/day; the maximum dose would be 1.8 X 30 = 54mg/day.
 
The total daily dose should be given either all at once in the morning, or in two doses, with the second given no later than early evening.
 

References

British National Formulary (BNF) 51, March 2006.
Electronic medicines compendium, http://emc.medicines.org.uk
NICE, 2006, Methylphenidate, atomoxetine and dexamfetamine for attention deficit hyperactivity disorder (ADHD) in children and adolescents. Technology appraisal 98.
'FDA panel proposes black box warning for ADHD stimulants', www.scripnews.com, No. 3131, 15 February 2006.
'Updated warnings on the attention deficit hyperactivity disorder drug Strattera  information for healthcare professionals', Medicines and Healthcare products Regulatory Agency, www.mhra.gov.uk, 16 February 2006.
Bailly, L. 2005, 'Stimulant medication for the treatment of attention-deficit hyperactivity disorder: evidence-b(i)ased practice?', Psychiatric Bulletin, vol 29, pp 284-287.
 

Useful organisations

ADDISS
tel: 020 8906 9068
web: www.addiss.co.uk
The national attention deficit hyperactivity disorder information and support service.
 

Psychiatric drugs helpline
tel: 020 7919 2999 (Mon to Fri 11am to 5pm)

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Making sense of sleeping pills and minor tranquillisers


What should I know before taking any drugs?
What sort of drugs are used for anxiety or sleeping problems?
The benzodiazepines
When and how should benzodiazepines be used?
What are the different types of benzodiazepines?
What are the possible side effects?
Drugs for anxiety only
What else can I do to tackle my anxiety?
Drugs for sleeping problems only
Chloral hydrate and related drugs
How can I improve my sleep without drugs?
References
Useful organisations


What should I know before taking any drugs?

Drug names
Drugs can have two types of names: their general (generic) name and the trade names given by the drug companies (starting with a capital letter). The same drug can have several different trade names. In this booklet, drugs are listed using their generic name, with the trade name/s after it in brackets.

Informed consent
The law says that you have the right to make an informed decision about which treatment to have, and whether or not to accept the treatment a doctor suggests. To consent, properly, you need to have enough information to understand the nature, likely effects and risks of the treatment, including its chance of success, and any alternatives to it. Generally, you can only receive treatment that you have specifically agreed to. Once you have given your consent, it isnt final and you can always change your mind. This consent to treatment is fundamental, and treatment given without it can amount to assault and negligence. However, there are times when treatment can be given without consent  see Mind rights guide 3: consent to medical treatment for more details.

Patient information leaflets
If you are prescribed medication as an outpatient, or from your GP, it should come with a patient information leaflet (PIL) in accordance with a European Union directive. As an inpatient, you may have to ask for it, specifically. If you do not receive this information with your medicine, or accidentally throw the PIL away (its usually a very small piece of paper), you should ask for it from the person who makes up your prescription.

The PIL contains information such as: the trade and general (generic) names of the drug; the strength of the medicine and the form it takes  for example, tablets; who should take it; what conditions the drug is licensed to treat; any cautions you should be aware of before taking it, such as conditions which mean you should take a reduced dose or not take it at all; how to take it and when; possible side effects; the expiry date of the drugs and how to store them.

It should also contain a full list of all the ingredients, including the extra contents that hold it together as a tablet or capsule, such as maize starch, gelatin, cellulose, and colourings. This information is important because some people may be allergic to one or other of the ingredients, such as lactose or gluten or a colouring. Gelatin is unacceptable to some people because it is an animal product.
 

Some of the information is quite hard to understand, and the Commission on Human Medicines (formerly the Committee on Safety of Medicines) has been looking at ways of making it easier. They have produced a leaflet Taking medicines  some questions and answers about side effects which you can find on their website or request by telephone, or may be available in your local pharmacy. There is more information on medicines and their use, in the form of Medicines Guides, available from the Medicines Information Project website (See Useful websites for details of both these organisations.)

The final item on the leaflet tells you that it contains only the most important information you need to know about the medicine, and that if you need to know more, you should ask your doctor or your pharmacist.

Getting more information from your doctor or pharmacist
Many people would like to have the information about their proposed treatment before they are given the prescription for it, and not after they have got it from the pharmacist and taken it home. The following are issues you might like to discuss with your doctor when she or he gives you a prescription for a drug:

What is the name of the drug, and what is it for?
How often do I have to take it?
How long will I have to take it for?
If I am taking any other drugs, will it be all right to take them together?
Will I still be able to drive?
What are the most likely side effects, and what should I do if I get them?
Do I have to take it at any particular time of day?
Is it likely to make me sleepy?
Should I take it with food?
When I want to stop taking it, am I likely to have any problems with withdrawal?
You may well think of other questions you wish to ask.
 

You should also consider talking to your pharmacist. Pharmacists are drug specialists, and may be more knowledgeable about your drugs than the doctor who prescribes them. They may be more aware of possible side effects, and also possible interactions with other drugs (this is when a drug changes the effect of other drugs you are taking; making them less effective, or causing additional side effects). Pharmacists are usually very willing to discuss drugs with patients, and some high-street chemists have space set aside where you can talk privately.
 

Since January 2006, a new scheme has been in place called the Medicines Use Review. People who regularly take more than one prescription medicine, or take medicines for a long-term illness, are encouraged to go to pharmacists who are operating the scheme, for a full discussion of their medicines and any problems they may have with them. The Medicines and Healthcare products Regulatory Agency (MHRA), who are responsible for overseeing the licensing of medicines, have produced a guide to the scheme, which is available on the Department of Health website. (See Useful websites.)
 

Side effects and withdrawal symptoms
If you have troublesome side effects, or withdrawal symptoms when you stop taking your medication, you can report them yourself to the MHRA under the Yellow Card scheme. You can do this on their website or by phoning them (see Useful organisations) or on a form which you can get from your pharmacy. You can also see a full list of side effects reported on the MHRA website. You can also report symptoms with the help of a health professional if you prefer.

Drug misuse and the law
Some of the drugs discussed in this booklet are controlled drugs. This means that the rules for storing them, and writing and dispensing prescriptions, are stricter than for other drugs. Of the drugs discussed in this booklet, the benzodiazepines, zolpidem, and meprobamate are classified as class C drugs. Barbiturates are classified as class B.

People who pass on any of the prescribed drugs mentioned above to relatives or friends may not realise it, but they are committing a criminal act and are liable to serious penalties in the form of imprisonment or fines.

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What sort of drugs are used for anxiety or sleeping problems?

This booklet covers the group of drugs called benzodiazepines which may be prescribed both for anxiety and sleeping problems. It also includes drugs that are prescribed solely for anxiety, or solely for sleeping problems. The drugs mentioned are sometimes referred to as sleeping pills, minor tranquillisers, sedatives or anxiety-busters; doctors may also call them anxiolytics or hypnotics.

None of these drugs should be used for long-term treatment, either for anxiety or for sleep.

All of the drugs mentioned have a sedative effect and carry a warning about driving and operating machinery, and its very important to take this seriously. Research has shown that users of benzodiazepines and zopiclone were more likely to have a road traffic accident. Research looking at a number of different studies of benzodiazepines suggests that the short increase in sleep time they offered was not worth the increased drowsiness and dizziness that followed, and the increased risk of road accidents and falls.

When should drugs be used for anxiety?
None of the drugs listed for anxiety are suitable for long-term use. Because there is a serious risk that dependency will develop, they should be used only for severe anxiety which is seriously affecting someones ability to live a normal life. They should not be taken for more than four weeks, and preferably should not be taken every day. In many cases, anxiety states are appropriately treated with antidepressants which may be taken continuously, for longer periods (see below).

When might sleeping pills be helpful?
Sleeping pills can be helpful for short-term sleeping problems when the cause of the problem is understood: often, short-term sleeping difficulties are related to an emotional problem such as bereavement, or to serious illness. Sleeping pills, whether benzodiazepines or other types, should not be used for more than three weeks, and preferably for no more than a week. Its also best not to take them every night.

Sleeping pills rarely help long-term sleep problems. Instead, doctors should investigate and treat the underlying problems. Sleeping pills may be used to try and break a bad sleep habit, but other techniques, such as cognitive behaviour therapy (CBT), have been found to be more effective for some people. In some instances, your doctor may be able to refer you to a specialist sleep laboratory, which can assess your insomnia and sleep patterns. (See Minds booklet, How to cope with sleep problems, for more information.)

Guidance by the National Institute for Health and Clinical Excellence (NICE), issued in 2004 (see Useful websites), reinforces the message that sleeping drugs should only be prescribed for severe insomnia and for short periods of time, and only after considering other forms of treatment, including CBT.

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The benzodiazepines

Benzodiazepines are minor tranquillisers, and therefore sedatives, and some of them are used to treat anxiety and sleeping problems. They are also widely used in alcohol withdrawal programmes. (They also have other uses, not covered in this booklet.)

Benzodiazepines increase the effect of a brain chemical called GABA (gamma amino butyric acid). GABA reduces brain activity in the areas of the brain, responsible for rational thought, memory, the emotions, and essential functions, such as breathing. Therefore benzodiazepines are very effective for treating anxiety, as well as acting as sedatives or sleeping pills. However, their widespread action is also responsible for other unwelcome effects. They may also cease to be effective after about four months, as the brain gets used to having higher levels of GABA.

When and how should benzodiazepines be used?

Because of the risk of people becoming dependent on these drugs, and finding it difficult to withdraw from them, benzodiazepines should be used only for the short-term treatment of severe anxiety or severe insomnia. They are not for long-term use.
 

According to the British National Formulary (BNF):

Benzodiazepines are indicated for the short-term relief (two to four weeks only) of anxiety that is severe, disabling or subjecting the individual to unacceptable distress, occurring alone or in association with insomnia or short-term psychosomatic, organic or psychotic illness.
The use of benzodiazepines to treat short-term mild anxiety is inappropriate and unsuitable.
Benzodiazepines should be used to treat insomnia only when it is severe, disabling, or extremely distressing.
In addition, a report by the Royal College of Psychiatrists suggests that the drugs should not be prescribed regularly for longer than one month and, ideally, should be taken only as required and with a gap every few days. Treatment should always be at the lowest possible dose, for the shortest possible time. The maximum treatment period includes the time for withdrawal.

The best way to use benzodiazepines, whether for acute anxiety or for severe sleeping problems, is as a one-off dose for one occasion, and not as continuous treatment; that way they are likely to be most effective, and you are very unlikely to become dependent on them.

Although benzodiazepines are effective in treating anxiety states, its clear that there are situations when their use is not justified. In bereavement, for example, tranquillisers may prevent people from grieving properly.

Children
None of these drugs is recommended for children, except in rare cases of acute anxiety or insomnia caused by fear or sleep-walking, when diazepam (Valium) may be used.

Older people
The doses should be reduced in older people.

Medical conditions
Use benzodiazepines with caution if you have any of the following conditions: respiratory disease (chest and lung problems); muscle weakness (especially a condition called myasthaenia gravis); a history of alcohol or drug abuse; marked personality disorder (a psychiatric diagnosis).

The dose should be reduced for those with liver or kidney problems or porphyria (a rare, inherited illness).

You should not take them at all if you have severe respiratory disease, sleep apnoea (breathing problems during sleep), or severe liver disease. They should not be used if you have a long-lasting psychosis or, on their own, if you are depressed.

During pregnancy and breastfeeding
Avoid benzodiazepines during pregnancy and while breastfeeding. Benzodiazepines used at the end of pregnancy cause drowsiness in the newborn baby, floppy muscles, breathing problems, hypothermia (low body temperature), and withdrawal symptoms that include abnormal sleeping patterns, high-pitched crying, tremor, vomiting and diarrhoea. Some research suggests that the use of benzodiazepines during pregnancy may be associated with long-term problems in children, such as dyslexia, dyspraxia (a movement disorder) and attention hyperactivity deficit disorder (ADHD). There may be physical problems, including cleft palate, urinary tract abnormalities, and heart and stomach abnormalities.

Breastfeeding your baby while taking benzodiazepines is not a good idea because the drug comes through the breast milk.

Using benzodiazepines with antipsychotics
Benzodiazepines are often used together with antipsychotic drugs to treat schizophrenia, or similar conditions. They may be prescribed, short-term, to help with over-excitement, agitation and severe psychotic disturbance, to aid rapid tranquillisation. Its better than giving a high dose of antipsychotic drugs, which have a risk of severe side effects.

Using benzodiazepines with other drugs
Benzodiazepines may interact with other drugs and change their effects, or make either drug less effective, or cause additional side effects; for example, taking tranquillisers with medication that already makes you sleepy will increase the sedative effect. If your doctor or psychiatrist suggests prescribing one of these drugs for you, you should make sure they know about any other medication you are taking, including over-the-counter (non-prescription) remedies and herbal remedies. Alcohol increases the sedative effect of these drugs.

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When and how should benzodiazepines be used?

Because of the risk of people becoming dependent on these drugs, and finding it difficult to withdraw from them, benzodiazepines should be used only for the short-term treatment of severe anxiety or severe insomnia. They are not for long-term use.
 

According to the British National Formulary (BNF):

Benzodiazepines are indicated for the short-term relief (two to four weeks only) of anxiety that is severe, disabling or subjecting the individual to unacceptable distress, occurring alone or in association with insomnia or short-term psychosomatic, organic or psychotic illness.
The use of benzodiazepines to treat short-term mild anxiety is inappropriate and unsuitable.
Benzodiazepines should be used to treat insomnia only when it is severe, disabling, or extremely distressing.
In addition, a report by the Royal College of Psychiatrists suggests that the drugs should not be prescribed regularly for longer than one month and, ideally, should be taken only as required and with a gap every few days. Treatment should always be at the lowest possible dose, for the shortest possible time. The maximum treatment period includes the time for withdrawal.

The best way to use benzodiazepines, whether for acute anxiety or for severe sleeping problems, is as a one-off dose for one occasion, and not as continuous treatment; that way they are likely to be most effective, and you are very unlikely to become dependent on them.

Although benzodiazepines are effective in treating anxiety states, its clear that there are situations when their use is not justified. In bereavement, for example, tranquillisers may prevent people from grieving properly.

Children
None of these drugs is recommended for children, except in rare cases of acute anxiety or insomnia caused by fear or sleep-walking, when diazepam (Valium) may be used.

Older people
The doses should be reduced in older people.

Medical conditions
Use benzodiazepines with caution if you have any of the following conditions: respiratory disease (chest and lung problems); muscle weakness (especially a condition called myasthaenia gravis); a history of alcohol or drug abuse; marked personality disorder (a psychiatric diagnosis).

The dose should be reduced for those with liver or kidney problems or porphyria (a rare, inherited illness).

You should not take them at all if you have severe respiratory disease, sleep apnoea (breathing problems during sleep), or severe liver disease. They should not be used if you have a long-lasting psychosis or, on their own, if you are depressed.

During pregnancy and breastfeeding
Avoid benzodiazepines during pregnancy and while breastfeeding. Benzodiazepines used at the end of pregnancy cause drowsiness in the newborn baby, floppy muscles, breathing problems, hypothermia (low body temperature), and withdrawal symptoms that include abnormal sleeping patterns, high-pitched crying, tremor, vomiting and diarrhoea. Some research suggests that the use of benzodiazepines during pregnancy may be associated with long-term problems in children, such as dyslexia, dyspraxia (a movement disorder) and attention hyperactivity deficit disorder (ADHD). There may be physical problems, including cleft palate, urinary tract abnormalities, and heart and stomach abnormalities.

Breastfeeding your baby while taking benzodiazepines is not a good idea because the drug comes through the breast milk.

Using benzodiazepines with antipsychotics
Benzodiazepines are often used together with antipsychotic drugs to treat schizophrenia, or similar conditions. They may be prescribed, short-term, to help with over-excitement, agitation and severe psychotic disturbance, to aid rapid tranquillisation. Its better than giving a high dose of antipsychotic drugs, which have a risk of severe side effects.

Using benzodiazepines with other drugs
Benzodiazepines may interact with other drugs and change their effects, or make either drug less effective, or cause additional side effects; for example, taking tranquillisers with medication that already makes you sleepy will increase the sedative effect. If your doctor or psychiatrist suggests prescribing one of these drugs for you, you should make sure they know about any other medication you are taking, including over-the-counter (non-prescription) remedies and herbal remedies. Alcohol increases the sedative effect of these drugs.

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What are the different types of benzodiazepines?

Short-acting and long-acting
The main difference between the different benzodiazepines is the length of time the drugs are active in the body. There are basically two types: short-acting drugs, which have a short half-life; and long-acting drugs, which have a long half-life. The half-life is the time it takes for the amount of the drug in the body to be reduced by half.

The shorter the half-life, the faster the drug will be eliminated from your system, and so the body has less time to adapt to the loss of the drug: because of this, there is a greater risk of withdrawal symptoms. The longer the half-life, the more slowly the drug will be eliminated from the body, and the more likely you are to experience a hangover effect after taking them.

The actual rate at which drugs are eliminated from the body will vary from individual to individual. Some people absorb and dispose of substances more quickly than others, and this process slows down as people get older. Drug levels therefore tend to build up in older people, who should be given lower doses of most drugs, as a rule.

Also, generally speaking, those that are short-acting are used as sleeping pills, and those that are long-acting are used for anxiety; but the different types are not clear-cut, and drugs prescribed for anxiety will help you sleep if taken at night (for example, diazepam [Valium]), while sleeping pills will calm you if taken during the day.

The different benzodiazepines
Below is a table providing information about the different benzodiazepines usually prescribed for anxiety and to aid sleep.

Its important to note that, usually, the dose should be halved in older people.

Benzodiazepines are usually only available on the NHS under their generic (general) name, with the exception of diazepam, which is also available under its trade name/s (given by the drug company). The trade names of the drugs are included, in brackets, after the generic name.
 

Benzodiazepines licensed in UK
 
Drug [and form]
 Dose range for anxiety or sleep
 Half-life
 
Benzodiazepines used for anxiety

Long-acting
 
Chlordiazepoxide (Librium, Tropium)

[capsules, tablets]
 10mg three times per day, increased, if necessary, to a maximum of 100mg per day
 530 hours (36200 hours*)
 
Diazepam (Valium, Rimapam, Tensium, Dialar, Diazemuls, Diazepam Rectubes, Stesolid, Valclair)

[tablets, oral liquid, injectable liquids, rectal tubes, suppositories]
 6mg per day, increased up to 30mg per day. For children (for night terrors and sleep-walking) the dose is 15mg. Available in tablet form in doses of 2mg, 5mg and 10mg. Doses vary, according to the condition
 20100 hours (36200 hours*)
 
Short-acting
 
Alprazolam (Xanax)

[tablets]
 Normal dose: 0.250.5mg three times per day, up to a maximum of 3mg per day
 612 hours
 
Lorazepam (Ativan) [tablets, liquid for injection]
 14mg per day. Maximum dose 4 mg/day for anxiety and 2 mg/day for insomnia
 1020 hours
 
Oxazepam
[tablets]
 1530mg, three to four times per day. Maximum dose 50mg
 415 hours
 
Benzodiazepines used as sleeping pills

Long-acting
 
Flurazepam (Dalmane)
[capsules]
 1530mg at bedtime
 (40250 hours*)
 
Nitrazepam (Mogadon, Remnos, Somnite) [tablets, oral liquid]
 510mg at bedtime
 1538 hours
 
Short-acting
 
Loprazolam (Dormonoct)

[tablets]
 1mg at bedtime, can increase to 1.5 or 2mg
 612 hours
 
Lormetazepam
[tablets]
 0.51.5mg at bedtime
 1012 hours
 
Temazepam

[tablets, oral liquid]
 1020mg at bedtime. Exceptionally, 3040mg
 822 hours
 
* This refers to the half-life of the active metabolite, the substance the drug turns into, in the body, which has the therapeutic effect.
 
 

Of the sleeping pills, nitrazepam and flurazepam are relatively long-acting and may give a hangover effect the next day. Loprazolam, lormetazepam, and temazepam are all short-acting and produce little or no hangover. However, they are more likely to produce withdrawal symptoms. Benzodiazepines that are normally used for anxiety, such as diazepam (Valium), may also be used as sleeping pills.

Note: flunitrazepam (Rohypnol) and clorazepate (Tranxene) have been taken of the market in the UK, although they may still be available through unregulated sources.

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What are the possible side effects?

All drugs have side effects, although some people are more vulnerable than others. The most common side effects of the benzodiazepines are drowsiness, light-headedness, confusion, unsteadiness (especially in older people, for whom it may lead to falls and fractures), memory problems and muscle weakness. In some people, they may increase hostility, aggression or anxiety, instead of doing the opposite.

Less common side effects are headaches, vertigo (dizziness), low blood pressure, changes in saliva production, digestive disturbances, sight problems (such as double vision), problems speaking clearly, tremor, changes in sexual desire, incontinence (loss of bladder control) and difficulty urinating. Blood disorders and jaundice have also been reported.

These drugs may impair judgement and slow down your reaction time, which affects your ability to drive and to operate machinery. The hangover effect of a night-time dose may affect your driving the following day. If they are taken with alcohol, the impact of the drink is increased.

If these drugs are taken for more than a short time, people may find it more difficult to concentrate, and begin to lose confidence in themselves and their abilities. They may feel dulled, slow, isolated, unreal and unable to respond emotionally to pleasure or pain. They may develop weight problems, and feel irritable and impatient. The drugs can also be addictive.

Dependence or addiction to benzodiazepines

Dependence is a combination of psychological and physical need for the drug. It ranges from mild psychological dependence, or nervousness about stopping a drug, to severe withdrawal symptoms if the drug is reduced or stopped.

You would probably need to take benzodiazepines regularly, for at least a fortnight, for dependence to develop; although taking sleeping pills for as little as three or four nights can be habit-forming. The longer you remain on the drugs, the greater the risk of physical dependence. You are also likely to become psychologically dependent; in other words, to feel very unsure about how you will manage without them. Its therefore important to reduce the drugs very gradually, in most cases.

People on benzodiazepines for more than a short period of time may become tolerant and experience withdrawal, even before reducing or coming off them, as the drugs lose their effectiveness. Strictly speaking, this means you need more and more of the drug to achieve the desired effect; but its rare for people on these drugs to increase their own dosage, unless they are already abusing alcohol or other drugs.

What are the withdrawal symptoms?

Its important to recognise that individual responses to drugs differ, and you may not experience all the symptoms listed below. Some of them resemble the original complaint, so doctors may be tempted to continue prescribing the drug.

Symptoms may include: increased anxiety and depression, insomnia, nightmares, restlessness and inability to concentrate, panic attacks and agoraphobia (fear of crowded places), cravings for the tablets, loss of interest in sex, loss of appetite and of body weight, muscle tension, tight chest, palpitations, sweating, trembling or shaking, dizziness, headaches, feeling sick, blurred vision, sore eyes, increased sensitivity to light, noise, touch and smell, tinnitus (ringing in the ears), sore tongue and metallic taste, face and neck pain, tingling in the hands and feet, abdominal cramps, unsteady legs.

Severe withdrawal symptoms can include: muscle twitching, burning sensations in the skin, severe depression, hallucinations, paranoia and delusions (baseless fears and beliefs), confusion, memory loss, fits, depersonalisation (feeling strange in familiar surroundings), derealisation (feeling out of touch with reality). (It has been suggested that symptoms of depersonalisation and derealisation are defence mechanisms, which reduce the bodys reactions to stress by slowing down the responses.)

If you withdraw from benzodiazepines abruptly, it may cause: confusion; psychosis (symptoms such as seeing or hearing things others don't); fits; rapid heartbeat; a condition resembling delirium tremens (caused by alcohol withdrawal), which can trigger a rapid heartbeat, sweating, high blood pressure, tremors, hallucinations and agitated behaviour.

Withdrawal symptoms may develop at any time up to three weeks after stopping a long-acting benzodiazepine, but may occur within a few hours of stopping a short-acting one. Short-acting benzodiazepines (which are most likely to be taken as sleeping pills) can be particularly difficult to come off if you have been taking them for a long time, and its recommended that people should switch to diazepam, which has the longest half-life, at an equivalent dose, at the start of their withdrawal.

How long symptoms last varies. Some may continue for weeks or months. Experiences and reactions will differ, but if you have been relying on benzodiazepines for many years, not only is it likely take a long time to withdraw from them completely, but you will need to re-learn normal coping skills for dealing with tension and stress. This can take some time, and would probably depend on what kind of support systems you have. For more information on drug withdrawal, see Minds booklet, Making sense of coming off psychiatric drugs. Also see above for details on how to report withdrawal symptoms.

Antidepressants
Many people become depressed after coming off tranquillisers, and you may be offered antidepressants. A recent Dutch study concluded that serotonin specific re-uptake inhibitor (SSRI) antidepressants were of limited use in treating depression in these circumstances. Because of this, and the fact that antidepressants also bring the risk of side effects and withdrawal problems, you need to consider this option carefully.

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Drugs for anxiety only

What other drugs can be used for anxiety?
 

Buspirone (Buspar)
This can be used to treat anxiety, but is for short-term use only. It does not help with the symptoms of benzodiazepine withdrawal.

Cautions: people with liver or kidney problems should use this with caution. Anyone who is pregnant, breastfeeding, who has epilepsy, or severe liver or kidney problems should not use it. It may affect your ability to drive or perform other skilled tasks and can also increase the effects of drinking alcohol.

Side effects: most common: feeling sick, dizziness, headache, nervousness, light-headedness, excitement. Less common: rapid heartbeat, palpitations, chest pain, sweating, dry mouth, drowsiness, fatigue, confusion, fits.

Dose: 1530mg per day (5mg three times per day, increased, as necessary, every two to three days); maximum 45mg per day. It is not suitable for children. Form: tablets
 

Beta-blockers
Beta-blockers, such as propranolol, are sometimes used to treat the physical symptoms of anxiety such as rapid heart beat, and may also be useful for relieving some of the symptoms of withdrawal, such as palpitations and tremor. These are not psychiatric drugs and dont produce psychological symptoms; however, they may produce their own adverse effects, such as sleep problems and nightmares. Theres no problem of dependence or withdrawal symptoms but, because of their effects on the heart and blood pressure, withdrawal should be done gradually, and through slowly reducing the dose.

Meprobamate
Meprobamate is licensed for short-term use in anxiety. The BNF says: Older drugs such as meprobamate and barbiturates are not recommended  they have more side-effects and interactions than benzodiazepines, and are much more dangerous in overdosage.

Cautions: it should be used with caution, in people who have respiratory disease, muscle weakness, epilepsy, a history of drug or alcohol abuse, marked personality disorder, liver or kidney disease, in older people, and in pregnancy. It should not be used for people with severe respiratory disease or porphyria, or while breastfeeding.

Its not suitable for children.

Side effects: similar to those of the benzodiazepines, but more common. Drowsiness, digestive disturbances, low blood pressure, pins and needles, weakness, headaches, excitement and visual disturbance. Rarely: blood disorders and rashes.

Dose: 400mg, three to four times per day. Older people should halve the dose. Form: tablets

Antidepressants
Some forms of anxiety, such as obsessive-compulsive disorder, panic disorder and some phobias, may be treated with SSRI antidepressants. These may be prescribed for much longer periods than other drugs, but unfortunately they have their own withdrawal problems, and should be withdrawn slowly in the same way as benzodiazepines (see above and also Making sense of coming off psychiatric drugs ). Another disadvantage of antidepressants is that their possible side effects include anxiety and sleep disturbances. SSRIs have been associated with suicide and violent episodes in some people. (See Making sense of antidepressants.)

Antipsychotics
Antipsychotics are sometimes used in low doses for severe anxiety, because of their sedative action, but long-term use should be avoided. (See Making sense of antipsychotics (major tranquillisers).)

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What else can I do to tackle my anxiety?

When faced with a threatening situation, the body automatically gears itself up to fight or to run away (the fight or flight reflex). The body reacts this way, even when the danger is not a physical threat. As the muscles tense, you need more oxygen, so breathing becomes faster and deeper, or comes in gasps. The heart beats faster to send the blood to where its needed and away from other organs. Digestion slows down and the mouth becomes dry. Sometimes, this can lead to a panic attack. People experiencing panic attacks may think they are having a heart attack, dying, or going mad. (See Minds booklets Understanding anxiety, and How to cope with panic attacks.)

Breathing techniques and relaxation
You can learn special breathing techniques to promote calmness or use muscle relaxation exercises to reduce levels of anxiety. You can also use your imagination, in a positive way, to create mental images and situations that give you a sense of wellbeing and to transport you to a place, that for you, symbolises peace and relaxation; for example, a meadow or a beach. You can find more details of these techniques in the Mind guide to relaxation.

Talking treatments
You can ask your GP about counselling or other therapies such as CBT, which can help you to deal with the problems underlying and surrounding your anxiety. The treatment works by providing an opportunity for you to talk in a way that assists you to understand yourself better. It can then help you to work out a more positive and constructive way of living. The organisations listed under Useful organisations can provide details of counsellors and other therapists. Some will operate a sliding scale of fees, which takes into account peoples financial situation. (See, also, Understanding talking treatments.)

Complementary and alternative therapies
Complementary and alternative therapies have proved to be particularly helpful when people are experiencing stress-related symptoms, anxiety and depression. They can help people relax and feel better. Therapists emphasise the connection between mind and body, and are not concerned with merely treating symptoms.

There are many different therapies, including homeopathy, herbal medicine, acupuncture, aromatherapy, reflexology, meditation, and various types of massage. (See the Mind guide to series of booklets.) Therapies using art, music, drama, dance or creative writing may also prove invaluable. (See Minds factsheet Arts therapies.)

Exercise
Exercise, such as walking and swimming, can be helpful. It helps you to develop better breathing techniques, and also encourages the body to produce endorphins. These are natural morphine-like chemicals, which help you cope with shock, pain and stress. (See the Mind guide to physical activity.)

Diet
Caffeine, alcohol and smoking can all contribute to panic attacks, and should be avoided. Healthy eating, on the other hand, can have the opposite effect. Some of the symptoms of withdrawal are similar to the effects of low blood sugar; therefore it can help to avoid foods with a high sugar content, which can cause wide fluctuations in blood sugar. Instead, eat more complex carbohydrates, such as wholemeal bread, pasta, fruit and vegetables.

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Drugs for sleeping problems only

The Z drugs: zolpidem, zopiclone and zaleplon

Zolpidem tartrate (Stilnoct), zopiclone (Zimovane) and zaleplon (Sonata) were introduced more recently than the benzodiazepines. They are a bit different from benzodiazepines and were designed to try and get over some of the problems associated with the older drugs; but they act in the same way. Problems of dependence and withdrawal are just as likely to occur with these hypnotic drugs, and guidelines for use of all of them say that they should be given at the lowest effective dose, for the shortest possible time, and they should be withdrawn gradually. They are short-acting and have little or no hangover effect.

NICE (National Institute for Health and Clinical Excellence) has made the following recommendations about the use of zaleplon, zolpidem and zopiclone to treat insomnia.

Doctors should consider using non-medicine treatments, and then, if they think that a hypnotic medicine is the appropriate way to treat severe insomnia that is interfering with normal daily life, they should prescribe one for only short periods of time and strictly according to the licence for the drug.
Because there is no firm evidence of differences in the effects of zaleplon, zolpidem, zopiclone and the shorter-acting benzodiazepines, NICE recommends that doctors should prescribe the cheapest drug, taking into account the daily dose required and the cost for each dose.
Treatment should only be changed from one of these hypnotics to another if side effects occur that are directly related to the medicine.
If treatment with one of these hypnotic medicines does not work, the doctor should not prescribe one of the others.
The British Sleep Society, a professional organisation for medical and scientific staff who deal with sleep disorders, consider that the Z drugs are preferable to benzodiazepines because they are more likely to be free of significant hangover effects the next day.

These drugs should not be given to people with sleep-related breathing problems (obstructive sleep apnoea), neuromuscular weakness, or during pregnancy or breast-feeding. The same cautions apply as for the benzodiazepines (see above).

Zolpidem (Stilnoct)
Side effects: diarrhoea, feeling or being sick, dizziness, headache, daytime drowsiness, weakness, memory problems, dependence, nightmares, restlessness at night, depression, reduced alertness, confusion, gait disturbances or unsteadiness, falls, double vision, upset stomach, changes in libido, skin rashes, and paradoxical excitement or hostility.

Dose: for a maximum of 4 weeks. 10mg at bedtime. Older people 5mg. Not suitable for children. Form: tablets.

Zopiclone (Zimovane)
Side effects: bitter or metallic after-taste, mild stomach upset (including feeling or being sick), dry mouth, dizziness, headache, drowsiness. More rarely: irritability, aggressiveness, confusion, depression, difficulty remembering new information, hallucinations, nightmares, skin rashes, light-headedness, and loss of coordination.

Dose: for a maximum of 4 weeks. 7.5mg at bedtime. Older people 3.75mg. Not suitable for children. Form: tablets.

Zaleplon (Sonata)
Zaleplon appears to have less hangover effect than other sleeping pills, but is also less effective in keeping people asleep. It may be helpful for people who have difficulty falling asleep, but will be less helpful for people who wake frequently. A study of zaleplon in older people showed that they got to sleep more quickly and stayed asleep for longer after zaleplon than after a placebo (dummy pill), and there seemed to be no significant hangover effects next day.

Side effects: loss of memory, tingling sensations, drowsiness, painful periods, loss of energy. Less commonly: feeling sick, loss of appetite, feeling weak, loss of coordination, confusion, loss of concentration, depression, feeling detached from things, dizziness, hallucinations, disturbances of smell, hearing, speech and vision, sensitivity to light, and paradoxical excitement or hostility (discontinue the drug if this occurs).

Dose: for a maximum of 2 weeks. 10mg at bedtime, or after going to bed if difficulty falling asleep. Older people 5mg. Not suitable for children. Form: tablets

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Chloral hydrate and related drugs

The drugs in this group are chloral hydrate (Welldorm), triclofos sodium and clomethiazole (formerly spelt chlormethiazole). These used to be given to children, but nowadays giving children sleeping drugs is not recommended. Nor is there any convincing evidence and that these drugs are particularly useful in older people and so they are not actually used very often as sleeping pills any more.

They should be used with caution for people who have a history of drug or alcohol abuse, and marked personality disorder. Contact with the skin should be avoided.

Chloral hydrate and triclofos sodium
Side effects: feeling or being sick, bloated stomach and wind, feeling unwell, unsteadiness, confusion, rashes, headache, light-headedness, ketonuria, excitement, nightmares, delirium (especially on sudden withdrawal), dependence on prolonged use. Triclofos causes fewer gastrointestinal disturbances than chloral hydrate.

Dose: depends on preparation used; liquid versions of chloral hydrate should be freshly mixed. Form: oral solution, tablets.

Clomethiazole (chlormethiazole, Heminevrin)
This should be prescribed only for older people (and only for the short term), and for very short-term use in younger people who are going through alcohol withdrawal. Regular use is undesirable and likely to cause dependence.

Cautions: it should not be used in alcoholic patients who continue to drink. It should be used with caution in people with heart or chest diseases (confusion may develop caused by insufficient oxygen), history of drugs abuse, personality disorders, liver or kidney disease. It is not suitable for children.

Side effects: nasal congestion and irritation, eye irritation, and headache. More rarely: excitement, confusion, dependence, stomach upsets, rashes, severe allergic reaction and alterations in liver function.

Dose: 1-2 capsules or 5-10ml syrup at bedtime. Form: capsules, sugar-free syrup.

Barbiturates
Barbiturates were used as sedatives before benzodiazepines became available. They are rarely prescribed now. The BNF (British National Formulary) says, the intermediate-acting barbiturates have a place only in the treatment of severe intractable insomnia in patients already taking barbiturates; they should be avoided in the elderly, and that the use of the long-acting barbiturate pentobarbital, as a sedative, is unjustified.

Antihistamines
Two antihistamines, diphenhydramine (Dreemon, Medinex, Nightcalm, Nytol) and promethazine (Phenergan, Sominex) are available over the counter without a prescription, to treat insomnia. Antihistamines are primarily used for treating allergic reactions and conditions such as hay fever. They can be used for short-term sleeping problems, because they cause drowsiness, which is their main side effect. Diphenhydramine is also available as Panadol Night and Medised for Children, combined with paracetamol, to treat temporary insomnia with night-time pain.

These drugs are long-acting and so often leave a hangover the following day. They may be slow to act, and their sedative effect may diminish after a few days.

Cautions: they should be used with caution for men with an enlarged prostate, people with problems urinating (urinary retention), glaucoma (an eye disease), liver disease, epilepsy and porphyria (a rare, inherited problem). They should not be used during pregnancy or while breastfeeding. If you are in any doubt about whether they are suitable for you, or if you are taking any other medication, including herbal remedies, you should discuss this with the pharmacist before you buy them.

Side effects: dizziness, restlessness, headaches, nightmares, tiredness and disorientation. Occasionally, and especially in older people: blurred vision, dry mouth, urinary retention, confusion, and excitement (also, especially in children). More rarely: loss of appetite, stomach discomfort, palpitations, low blood pressure, disturbances of heart rhythm, shaking, muscle spasms, tic-like movements, blood disorders, and sensitivity to sunlight.

Diphenhydramine
Dose: 50mg (2 tablets) 20 minutes before going to bed (Medised for Children: see patient information leaflet for age-appropriate dosage). Form: tablets, oral liquid.

Promethazine
Dose: 25mg at bedtime increased to 50mg if necessary. Not recommended for children under 2 years old; see patient information leaflet for age-appropriate dosage. Form: tablets, oral liquid.

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How can I improve my sleep without drugs?

There are some simple steps you can take to begin with:

Make sure your bed and mattress are comfortable.
Think about whether the level of light suits you.
Make sure that you are not going to be disturbed by noise. Some people may find ear-plugs helpful.
Go to bed only when you are feeling tired. If you dont sleep within about 20 minutes, get up and relax in another room for a while before going back to bed.
Dont read or watch television in bed. These activities will only encourage you to stay awake; but some people may find that a radio on quietly for a short time will take their mind off intrusive thoughts which are keeping them awake.
Avoid coffee, tea, and other caffeine-containing drinks in the evening. A herb tea such as valerian or camomile, or a hot, milky drink may help you to sleep.
Some foods are known to make you sleepy; including lettuce, pumpkin seeds, turkey, nuts, oats. Avoid sugary foods at night.
Dont eat a large meal too late in the day: eating gives you an energy boost, which may keep you awake.
Get enough exercise during the day; fit people sleep better.
Try to relax before you go to bed, so that you are not preoccupied with daytime concerns. Yoga and meditation could prove helpful; a bath is usually relaxing too.
Avoid alcohol. Although alcohol is sedating and may help you get to sleep initially, it interferes with sleep later on in the night. Because its a diuretic (increasing urine production) it may cause you to wake up to use the toilet or because you are thirsty. After long-term use, it disturbs sleep patterns and causes insomnia.
A herbal remedy such as valerian may help.
Some people are helped by lavender, or a hop pillow.
There are many possible causes for sleeping difficulties  including stress, ill health, old age or emotional difficulties  and there are various ways of tackling them. These include changes to lifestyle, holistic approaches, such as homeopathy or herbal remedies, or talking treatments, such as counselling or CBT.

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References

Association of road-traffic accidents with benzodiazepine use F. Barbone et al (The Lancet 352, 1331, October 24 1998)
Benzodiazepine Equivalence Table (June 2001) (www.benzo.org.uk/bzequiv.htm)
Benzodiazepines: how they work and how to withdraw (The Ashton Manual) C. H. Ashton (University of Newcastle 2001)
Benzodiazepines: risks, benefits or dependence: a re-evaluation (The Royal College of Psychiatrists Council Report CR59 January 1997)
Benzodiazepines: the still unfinished story Professor C. H. Ashtons speech to the Beat the Benzos Campaign Launch Conference, Croydon (November 2000)
British National Formulary 54 (British Medical Association and Royal Pharmaceutical Society of Great Britain 2007)
Chronic benzodiazepine use in general practice patients with depression: an evaluation of controlled treatment and taper-off: report on behalf of the Dutch Chronic Benzodiazepine Working Group F. G. Zitman, J. E. Couvée (British Journal of Psychiatry 2001, 178, 317-324)
Cut down on tranquilliser prescriptions, GPs warned, The Guardian, 11 February 2004.
Meta-analysis of benzodiazepine use in the treatment of insomnia A. M. Holbrook, R. Crowther, A. Lotter et al (Evidence-Based Mental Health 3, 81, August 2000)
New drug evaluation: zaleplon (NHS Northern and Yorkshire Regional Drug and Therapeutics Centre 2000)
New product evaluation: zaleplon (Sonata) (Trent Drug Information Services 2000)
Prescribing guidelines (5th ed) M. Dunitz (The Bethlem and Maudsley NHS Trust 1999)
Prescription cost analysis England 2006, The Information Centre, 2007.
Psychotropic drug directory S. Bazire (Quay Books 1999)
Short-term zaleplon use effective in older patients with chronic insomnia J. K. Walsh et al (Clinical Drug Investigations 20, 143-149, 2000)
Reasons for a diazepam (Valium) taper Professor C. H. Ashton (University of Newcastle April 2001) (web: htttp://members/dencity.com/ashtonpapers/diazepam.htm)
Review: benzodiazepines increase sleep duration but also lead to adverse effects in adults with insomnia T. Furukawa (Evidence-Based Mental Health 2000, 3, 81)
Zaleplon, zolpidem and zopiclone for the management of insomnia: technology appraisal, NICE, 2004.

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Useful organisations

Battle Against Tranquillisers
PO Box 658, Bristol BS99 1XP
tel. 0117 966 3629
web: www.bataid.org
Helps people who take benzodiazepine tranquillisers or sleeping pills to withdraw from them as comfortably as possible. Telephone helpline. Carers support

British Association for Behavioural and Cognitive Psychotherapies (BABCP)
tel. 01254 875 277
web: www.babcp.co.uk
Can provide details of accredited therapists. Full directory of psychotherapists available online

British Association for Counselling and Psychotherapy (BACP)
tel. 0870 443 5252 minicom: 0870 443 5162
web: www.bacp.co.uk
See website for details of local practitioners

The British Psychological Society
tel. 0116 254 9568
web: www.bps.org.uk
Publishes a directory of chartered psychologists across the UK

First Steps to Freedom
PO Box 476, Newquay TR7 1WQ
helpline: 0845 120 2916
web: www.first-steps.org
Charity helping those with anxiety disorders

The Institute for Complementary Medicine (ICM)
ICM Unit 25, Tavern Quay Business Centre, Sweden Gate, London SE16 7TX
tel. 020 7231 5855
web: www.i-c-m.org.uk

The Medicines and Healthcare products Regulatory Agency
tel. 020 7084 2000
web: www.mhra.gov.uk
See the Safety information section of their website, for reporting side effects and withdrawal problems to the MHRA, and see the Committees section for the Commission on Human Medicines.

National Institute of Medical Herbalists (NIMH)
Elm House, 54 Mary Arches Street, Exeter EX4 3BA
tel. 01392 426 022
web: www.nimh.org.uk

Rethink Severe Mental Illness (formerly NSF)
tel. 0845 456 0455 advice line: 020 8974 6814
web: www.rethink.org
For everyone affected by severe mental illness

Samaritans
Chris, P.O. Box 9090, Stirling, FK8 2SA
helpline: 08457 90 90 90 minicom: 08457 90 91 92
email: jo@samaritans.org
web: www.samaritans.org
24-hour help

Sleep Matters Insomnia Helpline
tel. 020 8994 9874

United Kingdom Council for Psychotherapy (UKCP)
tel. 020 7014 9955
web: www.psychotherapy.org.uk
Umbrella organisation for psychotherapy in UK. Has a directory of psychotherapists in local areas

Victims of Tranquillisers
Helpline: 01202 311 689
Help, support and information to those who have suffered medical and legal problems resulting from tranquillisers and other psychoactive drugs.

Useful websites

www.benzo.org.uk
Benzodiazepine addiction, withdrawal and recovery site

www.dh.gov.uk
Department of Health  see their publications section for Medicines use review

www.foodforthebrain.org
Charity promoting optimum nutrition for mental health

www.insomniacs.co.uk
Advice on insomnia

www.medicines.org.uk/mip.aspx
Medicines Information Project

www.nice.org.uk
For the latest suggested guidance on prescribing treatments and the use of drugs

www.sleeping.org.uk
The British Sleep Society

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General information about the use of medicines

Before using your medicine

Before you use any medicine, tell your health care professional:

If you have ever had an allergic or unusual reaction to any medicine, food, or other substance, such as yellow dye or sulfites.
If you are on a low-salt, low-sugar, or any other special diet. Most medicines contain more than their active ingredient, and many liquid medicines contain alcohol.
If you are pregnant or if you plan to become pregnant. Certain medicines may cause birth defects or other problems in the unborn child. For other medicines, safe use during pregnancy has not been established. The use of any medicine during pregnancy must be carefully considered and should be discussed with a health care professional.
If you are breast-feeding. Some medicines may pass into the breast milk and cause unwanted effects in the baby.
If you are now taking or have taken any medicines or dietary supplements in the recent past. Do not forget over-the-counter (nonprescription) medicines such as pain relievers, laxatives, antacids or dietary supplements.
If you use alcohol or tobacco. Using alcohol or tobacco while you are taking certain medicines could cause unwanted effects and should be discussed with a health care professional.
If you have any medical problems other than the one(s) for which your medicine was prescribed.
If you have difficulty remembering things or reading labels.

Storage of your medicine

It is important to store your medicines properly. Guidelines for proper storage include:

Keep out of the reach of children.
Keep medicines in their original containers.
Store away from heat and direct light.
Do not store capsules or tablets in the bathroom, near the kitchen sink, or in other damp places. Heat or moisture may cause the medicine to break down. Also, do not leave the cotton plug in a medicine container that has been opened, since it may draw moisture into the container.
Keep liquid medicines from freezing.
Do not store medicines in the refrigerator unless directed to do so.
Do not leave your medicines in an automobile for long periods of time.
Do not keep outdated medicine or medicine that is no longer needed. Be sure that any discarded medicine is out of the reach of children.

Proper use of your medicine

Take medicine only as directed, at the right time, and for the full length of your prescribed treatment. If you are using an over-the-counter (nonprescription) medicine, follow the directions on the label unless otherwise directed by your health care professional. If you feel that your medicine is not working for you, check with your health care professional.

Unless your pharmacist has packaged different medicines together in a "bubble-pack," different medicines should never be mixed in one container. It is best to keep your medicines tightly capped in their original containers when not in use. Do not remove the label since directions for use and other important information may appear on it.

To avoid mistakes, do not take medicine in the dark. Always read the label before taking, especially noting the expiration date and any directions for use.

For oral (by mouth) medicines:

In general, it is best to take oral medicines with a full glass of water. However, follow your health care professional's directions. Some medicines should be taken with food, while others should be taken on an empty stomach.
When taking most long-acting forms of a medicine, each dose should be swallowed whole. Do not break, crush, or chew before swallowing unless you have been specifically told that it is all right to do so.
If you are taking liquid medicines, you should use a specially marked measuring spoon or other device to measure each dose accurately. Ask your pharmacist about these devices. The average household teaspoon may not hold the right amount of medicine.
Oral medicine may come in a number of different dosage forms, such as tablets, capsules, and liquids. If you have trouble swallowing the dosage form prescribed for you, check with your health care professional. Another dosage form that you can swallow more easily may be available.
Child-resistant caps on medicine containers have decreased greatly the number of accidental poisonings that occur each year. Use of these caps is required by law. However, if you find it hard to open such caps, you may ask your pharmacist for a regular, easier-to-open cap. He or she can provide you with a regular cap if you request it. However, you must make this request each time you get a prescription filled.

For skin patches:

Apply the patch to a clean, dry skin area that has little or no hair and is free of scars, cuts, or irritation. Remove the previous patch before applying a new one.
Apply a new patch if the first one becomes loose or falls off.
Apply each patch to a different area of skin to prevent skin irritation or other problems.
Do not try to trim or cut the adhesive patch to adjust the dosage. Check with your health care professional if you think the medicine is not working as it should.

For inhalers:

Medicines that come in inhalers usually come with patient directions. Read the directions carefully before using the medicine. If you do not understand the directions, or if you are not sure how to use the inhaler, check with your health care professional.
Since different types of inhalers may be used in different ways, it is very important to follow carefully the directions given to you.

For ophthalmic (eye) drops:

To prevent contamination, do not let the tip of the eye drop applicator touch any surface (including the eye) and keep the container tightly closed.
The bottle may not be full; this is to provide proper drop control.
How to apply: First, wash your hands. Tilt your head back and, with the index finger, pull the lower eyelid away from the eye to form a pouch. Drop the medicine into the pouch and gently close your eyes. Do not blink. Keep your eyes closed for 1 to 2 minutes.
If your medicine is for glaucoma or inflammation of the eye: Follow the directions for application that are listed above. However, immediately after placing the drops in your eye, apply pressure to the inside corner of the eye with your middle finger. Continue to apply pressure for 1 to 2 minutes after the medicine has been placed in the eye. This will help prevent the medicine from being absorbed into the body and causing side effects.
After applying the eye drops, wash your hands to remove any medicine.

For ophthalmic (eye) ointments:

To prevent contamination of the eye ointment, do not let the tip of the applicator touch any surface (including the eye). After using, wipe the tip of the ointment tube with a clean tissue and keep the tube tightly closed.

How to apply:

First, wash your hands. Pull the lower eyelid away from the eye to form a pouch. Squeeze a thin strip of ointment into the pouch. A 1-cm (approximately 1/3-inch) strip of ointment is usually enough unless otherwise directed. Gently close your eyes and keep them closed for 1 to 2 minutes.
After applying the eye ointment, wash your hands to remove any medicine.

For nasal (nose) drops:

How to use: Blow your nose gently. Tilt your head back while standing or sitting up, or lie down on your back on a bed and hang your head over the side. Place the drops into each nostril and keep your head tilted back for a few minutes to allow the medicine to spread throughout the nose.
Rinse the dropper with hot water and dry with a clean tissue. Replace the cap right after use. To avoid the spread of infection, do not use the container for more than one person.

For nasal (nose) spray:

How to use: Blow your nose gently. With your head upright, spray the medicine into each nostril. Sniff briskly while squeezing the bottle quickly and firmly.
Rinse the tip of the spray bottle with hot water, taking care not to suck water into the bottle, and dry with a clean tissue. Replace the cap right after cleaning. To avoid the spread of infection, do not use the container for more than one person.

For otic (ear) drops:

To prevent contamination of the ear drops, do not touch the applicator tip to any surface (including the ear).
The bottle may not be full; this is to provide proper drop control.

How to apply:

Lie down or tilt the head so the ear needing treatment faces up. For adults, gently pull the earlobe up and back (pull down and back for children). Drop the medicine into the ear canal. Keep the ear facing up for about 5 minutes so the medicine can run to the bottom of the ear canal. (For young children and other patients who cannot stay still for 5 minutes, try to keep the ear facing up for at least 1 or 2 minutes.)
Do not rinse the dropper after use. Wipe the tip of the dropper with a clean tissue and keep the container tightly closed.

For rectal suppositories:

How to insert suppository: First, wash your hands. Remove the foil wrapper and moisten the suppository with water. Lie down on your side. Push the suppository well up into the rectum with your finger. If the suppository is too soft to insert, chill it in the refrigerator for 30 minutes or run cold water over it before removing the foil wrapper.
Wash your hands after you have inserted the suppository.

For rectal cream or ointment:

Clean and dry the rectal area. Apply a small amount of cream or ointment and rub it in gently.
If your health care professional wants you to insert the medicine into the rectum: First, attach the plastic applicator tip onto the opened tube. Insert the applicator tip into the rectum and gently squeeze the tube to deliver the cream. Remove the applicator tip from the tube and wash with hot, soapy water. Replace the cap of the tube after use.
Wash your hands after you have inserted the medicine.

For vaginal medicines:

How to insert the medicine: First, wash your hands. Use the special applicator. Follow any special directions that are provided by the manufacturer. If you are pregnant, however, check with your health care professional before using the applicator to insert the medicine.
Lie on your back, with your knees drawn up. Using the applicator, insert the medicine into the vagina as far as you can without using force or causing discomfort. Release the medicine by pushing on the plunger. Wait several minutes before getting up.
Wash the applicator and your hands with soap and warm water.
Precautions while using your medicine
Never give your medicine to anyone else. It has been prescribed for your personal medical problem or condition and may be harmful to another person.

Many medicines should not be taken with other medicines or with alcoholic beverages. Follow your health care professional's directions to help avoid problems.

Before having any kind of surgery (including dental surgery) or emergency treatment, tell the physician or dentist about any medicine you are taking.

If you think you have taken an overdose of any medicine or if a child has taken a medicine by accident: Call your poison control center or your health care professional at once. Keep those telephone numbers handy. Also, keep a bottle of Ipecac Syrup safely stored in your home in case you are told to cause vomiting. Read the directions on the label of Ipecac Syrup before using.

Side effects of your medicine

Along with its intended effects, a medicine may cause some unwanted effects. Some of these side effects may need medical attention, while others may not. It is important for you to know what side effects may occur and what you should do if you notice signs of them. Check with your health care professional about the possible side effects of the medicines you are taking, or if you notice any unusual reactions or side effects.

Other information

It is a good idea for you to learn both the generic and brand names of your medicine and even to write them down for future use.

Many prescriptions may not be refilled until your pharmacist checks with your health care professional. To save time, do not wait until you have run out of medicine before requesting a refill. This is especially important if you must take your medicine every day.

When traveling:

Carry your medicine with you rather than putting it in your checked luggage. Checked luggage may get lost or stored in very cold or very hot areas.
Make sure a source of medicine is available where you are traveling, or take a large enough supply to last during your visit. It is also a good idea to take a copy of your written prescription with you.
If you want more information about your medicines, ask your health care professional. Do not be embarrassed to ask questions about any medicine you are taking. To help you remember, it may be useful to write down any questions and bring them with you on your next visit to your health care professional.

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DISCLAIMER:The information in this database is intended to supplement, not substitute for, the expertise and judgment of healthcare professionals. The information is not intended to cover all possible uses, directions, precautions, drug interactions or adverse effects, nor should it be construed to indicate that use of a particular drug is safe, appropriate or effective for you or anyone else. A healthcare professional should be consulted before taking any drug, changing any diet or commencing or discontinuing any course of treatment. I have found this information from other sources on the Internet so I am not responsible for its content and advice.

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