8.3 Medication management

A Family Guide to Concurrent Disorders - Part III: Treatment

Outline - Chapter 8: Medication

While full remission and recovery are possible, the amount of symptom relief varies from person to person. There is still a great deal of trial and error involved in finding the best medication for each person. You and your relative should be involved in the decision-making process, and be given information about the benefits and risks, including side-effects, of medications.

Identifying and minimizing side-effects

Side-effects may increase or decrease over time, and can range from mild discomfort to problems that are severe enough to make it impossible to cope with day-to-day life. Your relative should feel comfortable discussing side-effects with family members as well as with his or her treatment team. People often stop taking medication because of unpleasant side-effects, without reporting them to anyone. It is dangerous to stop or change medication without consulting the treatment team.

The treatment team can suggest ways to minimize side-effects. Strategies include:

taking the medication in smaller doses spread out over the day
taking medication with appropriate food
taking an additional medication to treat specific side-effects
changing the medication.

It is sometimes surprising how much of a difference even a very small dosage adjustment can make in how someone responds to treatment or is affected by side-effects. While a higher dose may be needed to control an acute episode, a person can generally be kept on a lower dose. The dose may need to be changed over time.

There are also practical, non-pharmacological strategies that your relative can use to deal with side-effects. Some of these are listed in Table 8-1.

Table 8-1: Managing common side-effects

Anticholinergic effects
Side-effect	Management Strategies
Dry mouth	- chewing sugarless gum or sucking on sugarless or sour candy (both dry mouth and excess sugar can increase the risk of tooth decay) - ensuring good mouth hygiene, including frequent brushing, ﬂossing and use of mouthwashes - having regular dental checkups - using oral lubricants (e.g., MoiStir)
Dry eyes and/or blurred vision	- reading under a bright light while holding the reading material at a distance - getting a prescription for eye drops
Constipation	- increasing fluid intake (e.g., water, juice and other non-caffeinated, non-alcoholic beverages) - increasing regular physical activity and exercise - increasing dietary ﬁbre (e.g., bran, raw fruits and vegetables) - trying a bulk laxative (e.g., Metamucil, Prodiem) or stool softener (e.g., Surfak, Colace) - avoiding regular use of stronger or stimulant laxatives (e.g., sennosides [Senokot], bisacodyl [Dulcolax]).
Urinary retention	- using patience and running water while attempting to urinate if problem is mild - getting a prescription medication to help counteract this effect if problem is more severe

Central nervous system effects
Side-Effect	Management Strategies
Drowsiness	- taking most of the dose, or the full dose if possible, at bedtime - using caution when driving or operating machinery
Lack of muscle co-ordination or muscle weakness (ataxia)	- checking with a doctor since it may be due to too high a dose
Headache	- trying over-the-counter headache remedies such as acetaminophen (Tylenol), aspirin or ibuprofen (Advil)—but ﬁrst asking a doctor or pharmacist to check for possible drug interactions - getting a prescription for a different medication if, with time, headaches don’t go away. Increased energy (activation effect)

Increased Energy (Activation Effect)
Side-effect	Management Strategies
Extrapyramidal effects (tremor, restlessness, muscle stiffness and spasms, difficulty walking)	- adjusting the dose - getting a prescription for antiparkinsonian drugs (e.g., benztropine [Cogentin]—but this medication must be monitored, as excessive doses may cause other side-effects such as disorientation, confusion and delirium) - taking propranolol, a prescription medication used to treat tremor or restlessness - taking a benzodiazepine (e.g., lorazepam [Ativan]) to treat restlessness

Gastrointestinal Effects
Side-Effect	Management Strategies
Nausea	- taking medications with meals, having small snacks or drinking milk - not using antacids within two hours of taking the medication, as they may interfere with drug absorption
Diarrhea	- trying loperamide (Imodium) or attapulgite (Kaopectate) after checking with a doctor or pharmacist for any drug interactions - taking smaller doses throughout the day or—if the diarrhea is the result of taking lithium—using a slow-release preparation (sudden diarrhea may indicate lithium toxicity)

Cardiovascular effects
Side-Effect	Management Strategies
Dizziness, fainting	- getting up slowly from a lying or sitting position and dangling feet - wearing support hose and doing calf exercises to reduce blood pooling in the calves
Rapid heartbeat	- taking the drug in smaller, divided doses throughout the day - reporting this side-effect to a doctor—however, this is usually not a serious problem
High blood pressure	- speaking to a doctor about reducing the dose, changing medications or adding a high blood pressure medication

Other
Side-Effect	Management Strategies
Weight effects	- reducing carbohydrate and sugar intake and consulting a dietician, if possible - increasing physical activity and exercise
Sexual side-effects	- reporting these side-effects to a doctor, as all treatments for this side-effect involve prescription medications - trying a different drug, if these side-effects don't go away over time
Difficulty regulating extreme changes in temperature (altered thermo-regulation)	- spending only a short time in saunas or out in the sun on hot humid days due to increased risk of sunstroke - drinking plenty of fluids and staying in the shade as much as possible - wearing loose-fitting clothing and a wide-brimmed hat - avoiding overexposure on freezing days due to increased risk of hypothermia
Photosensitivity	- avoiding prolonged sun exposure - wearing loose-fitting clothing and a wide-brimmed hat - always using sunscreen with an SPF of 15 or higher
Excessive sweating	- using talcum powder and a stronger antiperspirant (e.g., Drysol) for greater comfort - reducing the dose - speaking to a doctor about adding another medication if a severe case

Questions for the doctor or pharmacist about medication:

What is the name of the medication, and what is it supposed to do?
How and when is it taken, and when should a person stop taking it?
What food, drinks or other medications should be avoided while taking the prescribed medication?
Should the medication be taken with food or on an empty stomach?
Is it safe to drink alcohol while on this medication?
What are the side-effects, and what should be done if they occur?
Where is information about this medication available?

(National Institute of Mental Health, 2002)

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Activity 8-1: Tracking side-effects

Working with the treatment team

Make sure you and your relative know the name and dose of each drug taken, and the problem for which each has been prescribed.

You can help by:

ranking symptoms of the illnesses on a scale of one to 10 and reporting any improvement
noting side-effects and discussing them with the treatment team
checking with a doctor and/or pharmacist for drug interactions before your relative takes any new medication (prescription or over-the-counter).

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A Family Guide to Concurrent Disorders

Preface

Part I: What are concurrent disorders?

1. Introduction to concurrent disorders

2. Substance use problems

3. Mental health problems

Part II: The impact on families

4. How concurrent disorders affect family life

5. Self-care

6. Stigma

Part III: Treatment