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Medications

Medications for Depression
Traditionally, there are three categories of antidepressant medications: tricyclics, monoamine oxidase inhibitors (MAOIs) and selective serotonin reuptake inhibitors (SSRIs).

The latter (chiefly Prozac) are more recent medications that date to the 1980s. Since they are presumed to be more effective and produce fewer side effects, the belief has spread among the general population that depression is a common easily treatable psychosocial disorder. People tend to regard it as separate from other mental diseases, and are more willing to take medication even if they were once mistrustful or hostile towards drug treatments.

The presumed relative harmlessness of SSRIs has also led to these medications being used on pediatric patients.

However, it is often necessary to try several drugs before finding the most effective medication for the individual patient. Sometimes the dose levels have to be increased to be effective. Although some improvements may appear very quickly, even after a week, it generally takes at least three or four weeks before the full therapeutic effect can be observed.

This slow time-to-effect sometimes makes the patient think the treatment is not working, and ask for it to be replaced, especially if side effects aggravate the typical symptoms of depression such as feelings of fatigue, lack of energy and blunting.

Some of the typical side effects of tricyclic antidepressants may be:

gastrointestinal
- dry mouth, nausea, vomiting, constipation
visual
reduced visual acuity, scotoma
olfactory and auditory
- hallucinations or dysperceptions
neurological and otoneurological
- impaired concentration
- memory and thinking
- drowsiness/lethargy
- tremors
- loss of balance
- dizziness
sexual (loss of sex drive)
urinary (
- difficult urination
- pollakiuria
arthromuscular
- joint pain and the
- appearance or aggravation of rheumatism
- musculoskeletal pain

Symptoms that are characteristic of SSRI antidepressants include:

headache and orofacial pain

nausea

restlessness and sleep disorders

tremors and loss of balance

The onset of side effects such as these without any appreciable reduction in affective symptoms may worsen the depression and cause patients to stop taking the medication or to develop an even more negative view of their condition.

In other cases, if the medication is effective, patients are often tempted to stop taking it too soon.

Once an improvement has been noticed, the medication must be taken for at least 4-9 months, to prevent recurrences of the depression; in any case the decision to discontinue or modify treatment must be taken by the physician, not the patient.

Antidepressants of any kind can be discontinued only following a rational dose reduction schedule (called controlled “wash-out”).

In some cases such as bipolar disorder (manic-depressive disorder), medication (such as Lithium salts) may need to be maintained indefinitely.

When taking antidepressants, a number of activities and habits will be prohibited or restricted. These may include alcohol and certain medications that may reduce the effectiveness of the antidepressant, driving the car, and tasks that require precision and responsibility, due to the risk of synergic effects causing a decline in alertness and slower, less well controlled mental and physical reflexes and responses.

Medications for Chronic fatigue

Nonsteroidal antiinflammatory drugs
These drugs can be used to relieve pain in CFS patients. Some are available as over-the-counter medications.

Examples include:

naproxen (Aleve, Anaprox, Naprosen),
ibuprofen (Advil, Bayer Select, Motrin, Nuprin)
piroxicam (Feldene)
Prescription drugs include:
tramadol hydrochloride (Ultram)
celecoxib (Celebrex)
refecoxib (Vioxx)

These medications are generally safe when used as directed, but can cause a variety of adverse effects, including kidney damage, gastrointestinal bleeding, abdominal pain, nausea, and vomiting. Some patients may become dependent on certain of these agents.

Low-dose tricyclic antidepressants
Tricyclic agents may be prescribed for CFS patients to improve sleep and to relieve mild, generalized pain.

Examples include:

doxepin (Adapin, Sinequan),
amitriptyline (Elavil, Etrafon, Limbitrol, Triavil)
desipramine (Norpramin), and
nortriptyline (Pamelor).

Effective dosages are often much lower than those used to treat depression. Some adverse reactions include dry mouth, drowsiness, weight gain, and elevated heart rate.

Other antidepressants
Newer antidepressant have been used to treat depression in CFS patients, although non-depressed CFS patients receiving treatment with serotonin reuptake inhibitors have been found by some health care providers to benefit from this treatment as well or better than depressed patients.

Examples of antidepressants used to treat patients with CFS include serotonin reuptake inhibitors(SSRI), such as:

fluoxetine (Prozac),
sertraline (Zoloft), and
paroxetine (Paxil);
venlafaxine (Effexor);
trazodone (Desyrel); and
bupropion (Wellbutrin).

A number of adverse reactions, varying with the specific drug, may be experienced, but include agitation, sleep disturbances, and increased fatigue.

Anxiolytic agents
Anxiolytic agents may be used to treat symptoms of anxiety in CFS patients.

Examples include:

alprazolam (Xanax)
lorazepam (Ativan).
clonazepam (Klonopin)

It is another member of this family of drugs that is used to control exaggerated nervous systems problems such as vertigo, burning or exaggerated tenderness in the skin, and "nervous" limb movements, may also be useful.

However, they should not be used in the general treatment of CFS.

Common adverse reactions include sedation, amnesia, and symptoms accompanying acute withdrawal (insomnia, abdominal and muscle cramps, vomiting, sweating, tremors, and convulsions.

Stimulants
Fatigue by itself is not a good indication for symptomatic therapy. However, if the fatigue represents lethargy or daytime sleepiness, treatment may be indicated.

Anti-allergy therapy
Some CFS patients have histories of allergy, and these symptoms may flare periodically. Non-sedating antihistamines may be helpful for CFS patients with allergies.

Examples include:

desloratadine (Clarinex)
fexofenadine (Allegra)
ceterizine (Zyrtec)

However, anti-allergy therapy has no efficacy in the treatment of CFS itself. Some of the more common adverse reactions associated with use of these medications include drowsiness, fatigue, and headache.

Sedating antihistamines such as Benadryl can also be of benefit to patients at bedtime.

The tricyclic antidepressants mentioned above also have potent antihistamine effects.

Antihypotensive/antitachycardia therapy
Such medications may be useful in specific circumstances.

For example, fludrocortisone (Florinef) has been prescribed for CFS patients.

However, controlled studies have not found Florinef alone effective in the general treatment of CFS patients.

Beta blockers such as atenolol (Tenormin) have also been prescribed for patients with orthostatic hypotension. Midodrine (Proamatine), an agent that directly increases blood pressure, may be useful in selected patients identified by an abnormal tilt test.

Increased salt and water intake is also recommended for these patients but should be done only under supervision of a health care provider.

Adverse reactions include elevated blood pressure and fluid retention.

Corticosteroids
Controlled studies of corticosteroids have been conducted because some patients with CFS had a slight decrease in urinary cortisol levels.

Some benefits were noted in patients treated with low dose hydrocortisone but the effects disappeared after one month.

High dose replacement therapy had some benefit but was complicated by attendant adrenal suppression.

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Author: Riccardo Ciancaglini
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