Practical Management of the Side Effects of Psychotropic Drugs • Managing Side Effects of Psychotropic Drugs: A Clinical Handbook for Health Care Professionals

The number of psychotropic medications available to clinicians has grown considerably over the years. No solid evidence exists that any one drug works better than another in its class, and thus the choice of medication is governed largely by the side effects profile. Familiarity with side effects also guides the choice of alternative medications when patients cannot tolerate the initial drug or when one attempts to augment an incomplete therapeutic response. In other words, understanding side effects is indispensable for the competent practice of psychopharmacology.

Two monographs published in 1999 and 1998 have set out to assist clinicians in managing psychotropics' side effects. Richard Balon, M.D., professor of psychiatry at Wayne State University School of Medicine, has edited a monograph entitled Practical Management of the Side Effects of Psychotropic Drugs. Dr. L. Kola Oyewumi, a Canadian-trained psychiatrist, and Renee de Wit, a British-trained pharmacologist, have written Managing Side Effects of Psychotropic Drugs: A Clinical Handbook for Health Care Professionals. Although the books have similar aims, they vary considerably in approach and clinical usefulness.

Dr. Balon's monograph is organized by major classes of medication. It includes sections on antipsychotics, antidepressants, psychostimulants, mood stabilizers, drugs used in the treatment of alcoholism and drug abuse, and the like. Each chapter consists of a brief history, indications for use, a general discussion and a detailed consideration of the nature, etiology, and clinical management of the main side effects of the drugs in that class.

A good many tables enable the reader to rapidly judge the relative frequency and severity of side effects of a particular drug, drug-drug interactions, and rates of drug discontinuation—a handy measure of drug tolerability. Most chapters include a summary of the main points for easy reference. Guidelines for treating various psychiatric conditions both in general and in special populations are provided. These features enable a clinician to select the most appropriate medicine, taking into account the personality of the patient, preexisting pathology, and medication side effects.

Most chapters recommend starting low and going slow on dosages, being alert to potential risk factors, handling emerging problems promptly, ensuring compliance by educating patients, and avoiding polypharmacy as much as possible. Monotherapy goes counter to the current practice of combining two or more drugs of the same or differing classes in order to achieve a full response, such as using several antidepressants, with or without other augmenters, for treatment-resistant depression (1). Discussing the effects of selective serotonin reuptake inhibitors (SSRIs) on sexual functioning, the authors suggest switching to another antidepressant known to cause fewer sexual side effects or using specific antidotes, but they do not consider adding another antidepressant, such as mirtazapine, nefazodone, or bupropion, to the SSRI to minimize sexual side effects. When it comes to the management of addictive behaviors or bipolar disorder, the authors appropriately recommend polypharmacy. Management of the side effects of beta blockers, sedative-hypnotics, and cognitive enhancers is discussed in a separate chapter.

As is to be expected with texts of psychopharmacology, some of the newer drugs, such as citalopram, are not mentioned, and the side effects of anticonvulsants recently employed as mood stabilizers are only briefly discussed.

Despite these shortcomings, I recommend Dr. Balon's Practical Management of the Side Effects of Psychotropic Drugs to practicing psychiatrists and other mental health clinicians as a good general introduction and a useful reference.

In Managing Side Effects of Psychotropic Drugs, Dr. Oyewumi and Ms. de Wit concentrate on individual side effects of medications. The book is intended as a "reference manual for all health care professionals." They hope that their monograph will be useful even for drugs yet to be discovered, as they focus on side effects independently of the medications that cause them. In addition, they believe that the psychological consequences of adverse drug events apply to all preparations. This belief points to the weakness of the book—the tendency to underrate treatment strategies that are specific for management of side effects of a particular drug.

The book opens with a brief overview of psychotropic drugs, a definition of side effects in terms of physical and behavioral manifestations, and a conclusion that adverse effects are best understood as resulting from complex interactions between the drug, the prescriber, the patient, and the environment. The main body of the book consists of an alphabetical list of side effects. Each is described by name, prevalence, occurrence, presentation, putative mechanism of action, predisposing factors, and commonly associated drugs.

A chapter devoted to the evaluation of side effects is followed by one on managing them and, finally, by discussions of administrative issues and of the psychological and psychodynamic impact of side effects. In the management section, the authors attempt to redress the global generalizations of the recommendations by extensive discussion of specific topics such as neuromuscular side effects of neuroleptics, tardive dyskinesia, prophylaxis with anticholinergic drugs, risk factors, and miscellaneous syndromes.

This book is not handy for busy clinicians. It is laborious to use as a reference, yet it is not the kind of book that one reads through. One has to search the index separately for each side effect and for its management. For example, to discover if olanzapine can cause weight gain, one turns to the chapter on side effects, looks under "Gastro-Intestinal," finds weight gain, peruses the list of associated drugs, and discovers that olanzapine is on the list. Next one must turn to the chapter on management, which includes a general discussion of weight gain with no specific reference to olanzapine.

True, there are no proven ways to control the weight gain stimulated by olanzapine. However, the authors omit some helpful strategies: dose reduction, addition of an H₂ blocker, or the use of topiramate to curb appetite. Finally, one could switch to an alternative antipsychotic with a lower propensity for weight gain, such as loxapine, molindone, or risperidone.

Pages 117 and 118 give tables of side effects of some classical and atypical antipsychotics; however, they do not include molindone or quetiapine. The tables equate weight gain on risperidone with that on olanzapine, contrary to other sources (2).

Thus the book has some useful information, but the occasional inaccuracies and the cumbersome format detract from its value.

Dr. Backus is a psychiatrist at the Scripps Clinic Medical Group in La Jolla, California, and clinical associate professor of psychiatry at the University of California, San Diego.