Section 5: Depression/Anxiety Caused by Drugs and Medications

Many drugs have a direct effect on the brain or on the organs that support the normal functioning of the brain. Often medications used to treat medical illnesses may induce mental illness as well. There is evidence of a link between depressive symptoms and certain types of frequently prescribed medications such as:

- Calcium channel blockers
- Digoxin (heart medicines)
- Antihyperlipidemic agents (cholesterol medicines)
- Angiotensin converting enzyme inhibitors
- Sedative hypnotics (sleepers and anti-anxiety medicines)
- Psychostimulants (Ritalin and other “speed” type medicines) (10)

Given the connection between hormones and mood, it is not surprising that medication induced changes in hormone levels will affect mood. Such hormones include:

- Corticosteroids – drugs related to the hormone cortisol that are prescribed for a variety of illnesses such as arthritis, neurological (nervous system) illnesses, cancer and allergic reactions (11)
- Anabolic Steroids – taken by athletes and body builders to improve performance and power, but which often lead to depression and irritability (11)
- Birth-control Pills – just as changes in hormone affect mood cyclically, the addition of these hormones via the pill can cause depression (11)

Depression is significant in the cycle of pain. Pain can make depression worse and depression worsens pain. (5) Neurotransmitters are involved in both pain and depression. Within this biochemical feedback system, the medications used to reduce pain also can lead to depression. Anti-inflammatory agents, muscle relaxants and opiates can all independently cause depressive symptoms.

Patients with seizure disorder have 4 to 5 times greater incidence of major depressive disorder and 4 times the incidence of suicide than normal controls. Some of this is due to the overall negative impact to their quality of life as well as a tendency to develop a symptom tolerance to their dysphoria, expecting it as part of their epileptic state. Some antiepileptic drugs may provoke depressive symptoms, including benzodiazepines, phenobarbital and others. (16)

Tranquilizers and sedatives are a group that directly causes depression as well as leading to addiction, if over used. This is the valium, ativan, xanax and sleeping pills group of medications. Often prescribed for anxiety, they may actually lead to depressive symptoms.

Other psychotropic medications prescribed in layered, often excessive amounts - or with medications for medical illnesses - can lead to depression as well as medical complications. The alert clinician must be aware of potential interactions at all levels of evaluating clients on prescription medication.

Recreational drugs have a role in depression as follows:

- Alcohol, a central nervous system depressant, can cause depression especially in excess.
- Stimulants such as cocaine and amphetamines when withdrawn can lead to depression
- Marijuana, also a CNS depressant, can cause apathy, poor functioning and depression when used in excess (11)

There are numerous other drugs that from time to time have psychological symptoms – although less frequently. The clinician should be alert to any depressive symptoms that coincide with starting the drug. Other drugs with the potential to produce psychological symptoms include:

- Medications prescribed to strengthen the heart such as digitoxin and digoxin, known as digitalis medications
- Prescription medications for high blood pressure and angina such as propranolol (Inderal) and other beta blocker drugs
- Antibiotics, such as ampicillin, sulfa drugs and the newer generation of antimicrobial agents
- Reserpine and other high blood pressure medications that are prescribed to control nerve impulses (8)


CASE PRESENTATION

Melanie is a 50 y.o. white single woman who was diagnosed with schizophrenia twenty years ago. She had been a productive employee at a large corporation and successfully raised her son as a single mother. Her psychosis began to interfere with her ability to function at work and she was forced to leave her job, to go on disability and to struggle for meaning in other ways.

She suffered from both visual and auditory hallucinations. This therapist watched as medications prescribed to help with her psychotic symptoms caused other symptoms from weight gain to dyskinesia. Her previously productive life suddenly had no meaning and felt hopeless and empty. She entered the throngs of mental health patients labeled by their disease and discounted by the systems that allegedly served them.

Several years ago Melanie became severely ill. She was unable to sleep for days at a time and when she finally did she would sleep for up to seventy-two hours. She had nausea, vomiting and diarrhea and her physical weakness compounded her emotional hopelessness and sense of futility. She went to numerous medical doctors, each who reportedly did a history of her disease and medications and suddenly discounted her physical symptoms as the product of her psychosis. When a prominent metropolitan hospital treated her as mentally ill rather than medically ill she became convinced that no one cared.

It is important to note that Melanie was being followed by a psychiatrist who had prescribed at least two antidepressants, two anti-psychotics, a continuation of her cholesterol, hypertension and thyroid medications, as well as others totaling twelve different medications.

This therapist suggested that many of her symptoms might be medication related and that it would be best to reduce dosages or discontinue them in order to evaluate the effects. Frustrated and without a plan she weaned herself off of all of her medications over a period of six months. She “rode out” the delusions and hallucinations knowing what they were and deciding to live with them temporarily as her physical body healed.

Today she is on one new anti-psychotic medication. The medications for cholesterol, blood pressure and thyroid are no longer necessary as symptoms cleared with the elimination of medications that were actually causing kidney and liver dysfunction pouring toxins into an already compromised physical/emotional system.

At the point that Melanie decided to discontinue her medication regimen, she was nearly at death being severely dehydrated and nutritionally depleted, hopeless, helpless perceiving no support. The lesson is an important one: the client knows what is happening in his/her body, so, listen. Medical doctors can make mistakes, challenge them as an advocate for your client.


Summary

It is critical for the clinician to be aware of the interaction of medications on the psychological and physical presentation of the client. Medications used for psychological symptoms affect the systems of the body directly with such visible signs as nausea and indirectly by hindering their ability to effectively remove toxins from the body. Treatments for medical illnesses can compromise the efficient firing of nerve cells critical in the maintenance of mood and other mental processes.

It is especially important where alcohol or other recreational drugs are involved. Treatment must begin with the addiction. The efficacy of anti-depressants is impacted by alcohol and marijuana use. The client would essentially be taking an anti-depressant to offset the effects of the depressant they are taking for recreational purposes.

Evaluating the complete list of medications the client is taking is an essential part of the assessment process. If there is doubt about drug effects on depression, drug-drug interactions on the mental/medical state of your client/patient or medical sequelae to medication use, consult your pharmacist or the internet for a plethora of information.





Summary Page

Depression/Anxiety Caused by Drugs and Medications

WHAT THEY ARE:

Medications for medical illnesses:

- Calcium channel blockers
- Digoxin (heart med)
- Antihyperlipidemic agents (cholesterol med)
- Angiotensin converting enzyme inhibitors
- Sedative hypnotics (sleepers and anti-anxiety meds)
- Psychostimulants (Ritalin and other “speed” type meds) (10)

Medications to change hormone levels:

- Corticosteroids
- Anabolic Steroids
- Birth-control pills

Pain medications:

- Anti-inflammatory agents
- Muscle relaxants
- Opiates

Seizure disorder medications:

- Benzodiazepines
- Phenobarbital

Recreational drugs:

- Alcohol
- Stimulants
- Marijuana

Others with occasional depressive symptoms:

- Heart strengthening medications
- Blood pressure and angina medications
- Antibiotics
- Reserpine and other high blood pressure medications

A variety of other medications for either mental or physical conditions

HOW THEY CAUSE SYMPTOMS:

Many drugs have a direct effect on the brain or on the organs that support the normal functioning of the brain. Medications used to treat medical illnesses may induce psychological symptoms just as psychotropic medications may cause problems with the physical systems of the body.

Because of the connection between hormones and mood, medications to induce changes in hormone levels will affect mood. Neurotransmitters are involved in both pain and depression. Within this biochemical feedback system, the medications used to reduce pain also can lead to depression.

Tranquilizers and sedatives are a group that directly causes depression as well as leading to addictions.

CRITICAL ASPECTS OF ASSESSMENT:

- Awareness of the link between medications of all kinds and their potentially widespread effects throughout the body
- Thorough history to include medications presently taking, those taken in the past and their effects to the client/patient
- Information on substance use, treatment and compliance
- Critical, empathic listening to clients' comments and complaints without judgments of somaticization, hypochondriasis or quick labeling


RISKS AND DANGERS IF LEFT UNTREATED:

Medications can effectively treat medical and mental disorders, but they can also cause harm or even kill. They can mask an underlying mental disorder that if left untreated will compromise the effectiveness of medical treatments, even to the point of increasing the risk of suicide. They can cause temporary or permanent damage to vital organs, leading to severe medical complications or death.

A wise health care professional knows the risks of medications and does not assume that medications are just the area of the medical practitioner prescribing. They are part of treating the whole individual and communicating as part of the total health care team.

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