Transcription
Are you overmedicated?
Hi, I'm Dr. Ysep W. During, a board-certified psychiatrist who specializes in psychiatric medications and their side effects. And today, we're going to discuss what overmedication is, what it looks like, why this happens, and what you can do about it.
So, overmedication can be defined in two ways. First, your medication dose could be too high for your body, and you're developing a drug effect that you don't like, or maybe even a side effect. When I say side effect, I mean an effect from the drug other than its intended effect. Second, you're taking multiple medications, and when combined together, they're creating a drug effect that you don't like.
So, what sort of drug effects could you experience? I like to think about this in two opposing categories: either effects that turn the volume up too much in the brain, or those that turn the volume down.
And so, when the drugs turn the volume down, what does that look like? Well, you could see blunting. This refers to the limited range of emotions you have access to. Often, this can be overshot, and you can feel very numb on these meds. Next, you could have sedation. Often, a drug that helps you sleep can give you a hangover feeling the next day, or work too well and have you sleeping for over 10 hours. You may also feel sleepy all day, and you may even need to nap frequently. You could also have low motivation or kind of apathy, where you feel no drive to be social or play sports if that's what you like to do. You may not feel any enjoyment from activities that you used to love. You could could experience derealization or depersonalization. Many drugs are pro-dissociative, so they'll cause you to experience feelings of disconnectedness from your body or the environment around you. You could have cognitive dulling or word-finding difficulty, where you may not be able to concentrate, have difficulty remembering things, or may even have trouble speaking and remembering what words you want to say. So, you've probably heard someone say, "I've felt like a zombie on this," and maybe now that all makes sense.
So, now let's talk about the other end of the spectrum and drug effects where the volume's turned up too high. In the most extreme effects, you could experience suicidal thoughts and behaviors, homicidal thoughts and behaviors, hallucinations, delusions, and paranoia. Often, the suicidal ideation is a very different flavor when compared to ones that people have had prior to being medicated. Typically, I've had patients describe a very aggressive attack on their mind that felt extremely foreign, like it wasn't even coming from their mind.
People can have things like mania and hypomania. And so, mania is the primary symptom of bipolar disorder, but it can also happen to someone without a bipolar history who is sensitive to certain medications. Mania is a period of abnormally elevated or agitated mood and energy that can be quite dangerous, as it's common to experience psychosis and delusions. There is a characteristic lack of insight, meaning the person does not know they are acting different, combined with extreme disinhibition, meaning the person may be acting extremely out of character without concern for their safety or the safety of others. Hypomania is a milder form of mania that lasts for a short period.
You could have disinhibition. This is a behavioral state seen in mania, but I've also seen this as a drug effect without the other symptoms of mania. This behavioral state can lead to riskier behaviors like gambling, promiscuity, or infidelity, and increased substance abuse. Next, insomnia. What will be called an activating effect of medication in the office can lead to pretty severe insomnia in some people. Commonly, I hear patients saying they felt so tired and out of it, but could not fall asleep. Anxiety and panic. You may feel more anxious, have more panic attacks, or experience a different type of anxiety than before you started the medication. You may also develop symptoms seen in obsessive-compulsive disorder, like thought looping or ritualistic compulsive behaviors. Akathisia. You may feel an uncomfortable urge to move along with a sense of internal restlessness and a lot of mental turmoil. Akathisia can be quite unbearable and has been described as feeling like you want to rip your skin off. It has been a catalyst to many people acting on suicidal thoughts after they start medications. Irritability or aggression. You can have quite a change in your temperament and without realizing, become very irritable. In extreme cases, this can lead to aggression that is quite out of character.
Have you noticed these drug effects are all symptoms of psychiatric disorders? Any medications that act on the brain have the power to create changes in your mental state that can mimic an organic psychiatric disorder.
So, how does this happen? What is crucial to understand here is how much variability exists amongst each person's reaction to the same medication at the same doses. You can give the same medicine at the same dose to four different people and get four different experiences. Here are a few contributing factors to this variability.
First, you can have liver enzyme variants. There are a group of enzymes in your liver that react with medications. This is part of how they get broken down in our body to active parts. In simple terms, people can have variance from the norm with respect to the level of activity of each enzyme, and this is separated into slow metabolizers and rapid metabolizers. Rapid metabolizers will be less likely to experience side effects, but they will commonly report feeling no effect of the drug. They are breaking down the drug so fast that it has little time to do its job. Slow metabolizers are more vulnerable to feeling overmedicated, as they do not break the drug down as fast as they're supposed to, which could leave much higher amounts of the drug floating around their bodies than expected for the stated dose.
Here's where genetic testing comes into play. There are companies like Genomind and GeneSight offering to test your liver enzymes and see if you have any of these variants, and they can give you a list of medications that would work well in your body versus a list that would not work well due to issues like your slow metabolizer. And this medication would be more likely to cause side effects because you're not breaking it down as quickly as you should, and you may be exposed to a larger dose than is safe.
Another cause of overmedication is polypharmacy. Medications often affect the rate of metabolism of those liver enzymes we just discussed. They are called inhibitors, meaning slowing the enzyme, or inducers, meaning speeding up the enzyme. Often, you may need to dose adjust if you're on two different medications and one of them affects the metabolism of the other. And this is not specific to a prescription drug. Anything we consume could affect this system. Some well-known examples are grapefruit juice and smoking.
Now, let's talk about a specific interaction. For instance, Prozac, or fluoxetine, an SSRI, can inhibit the liver enzyme CYP2D6. This enzyme has a significant effect on many psychotropic medications, including Risperdal, or risperidone, an antipsychotic. If you are taking Risperdal and then Prozac is added, you will need to decrease the dose of Risperdal because Prozac is going to limit the action of the CYP2D6 enzyme that is responsible for breaking down Risperdal. This could make it so Risperdal is acting for a longer period of time and in a higher concentration than expected at the stated dose. There is a chart on the Risperdal drug-drug interactions that discusses dosing changes for these instances.
Next, misdiagnosis and prescribing cascades. Drug effects are commonly misdiagnosed as organic psychiatric disorders, meaning something coming from the brain rather than being iatrogenic, meaning created by the medication. This can lead to a chaotic cycling of different psychiatric medications or a growing number of prescriptions. Have you ever felt like one medication was constantly substituted for another and another, but there was no improvement in your symptoms? This prescribing cascade increases your risk of developing more side effects and drug injuries, especially when these medications are just stopped abruptly when changing between each one.
Lastly, genetic SNPs, or single nucleotide polymorphisms, represent a difference in a single DNA building block called a nucleotide, which occur normally throughout a person's DNA. SNPs can predict an individual's response to certain drugs, risk of developing diseases, and susceptibility to toxins. For example, you can have yourself tested for the MTHFR SNP, which affects folate metabolism, and if you have the C677T variant, you have a risk between 35 to 75% less activity of this very important enzyme. What this translates into clinically are several downstream effects, as the active form of folate in the brain will be quite limited. Folate is necessary for the production of many neurotransmitters like serotonin and dopamine, and so there are major risks of developing many mental illnesses with these variants. People with these variants experiencing psychiatric issues are less responsive to psychiatric medications and need to be supplemented with the active form of folate to see a response to the meds.
Now that you've learned what it can look like to be overmedicated and why this happens, here is what you can do.
If you're concerned about your medication regimen, first, listen to your gut. If you feel like a symptom is coming from your medication rather than from your underlying condition, I've seen this countless times. Patients always know their bodies better than the doctors. Please speak up, and if you are dismissed, get a second opinion.
If you are starting a new medication, please consider asking for a sub-therapeutic dose. What this means is taking a dose that is lower than the official starting dose in the label, which is not supposed to have a therapeutic effect. This is a safer way to test if you're sensitive to any drug effects or side effects, and it decreases your risk for the drug effects we discussed earlier. One of the highest risk periods is when you first start the psychiatric medication, especially if the dose is started high.
Along the same lines, anytime your dose is increased, observe for any of the drug effects occurring. I would recommend informing a loved one about these risks and to monitor for any changes in your behavior during both of these time periods. It can be hard to realize what's happening, and it's easier for an outsider to observe the changes in you.
Work with your prescriber to identify any drug-drug interactions that could necessitate any dose adjustments. Make sure to tell them if you're taking any supplements or recreational drugs that may be interacting with your prescriptions. Consider collaborating on a plan to try lowering the doses one at a time and evaluate any changes in your symptoms. You may want to consider genetic testing if you're experiencing no response to the medications or you're experiencing a strong reaction to them. Also, you can explore vitamin testing with a functional medicine provider, which may reveal areas of supplementation needed. You may feel better simply after correcting those nutrient deficiencies. If not, you can improve your chances of the proper response to medications and minimize the risk of having an unwanted effect.
Consider long-term goals to minimize polypharmacy. Assess the utility of each medication you are taking. Can the doses be lowered, and is that still effective? Is there any drug effect or side effect that you don't like? Are there alternative options that you may want to try, like diet adjustment or a particular type of therapy? Reflect on how long you would like to be on these medications. Were they started during a crisis, and now that crisis has long passed, maybe you can thrive without them now? Were they started when you were a child, and now that you are an adult, do you still need the same treatment? I don't think our field spends enough time getting into these conversations. The brain is so plastic that it's always refining connections between neuronal cells in reactions to the environment. There is a massive potential for change and healing. Medication should be scrutinized frequently as you evolve because their role is bound to change as you change. I believe these medications work best when taken for the shortest amount of time at the smallest dose necessary to target the identified symptoms.
If you're familiar with my channel or my clinic, we specialize in helping people taper off psychiatric medications who are having trouble doing so on their own. I'll not go into detail about this here, but I always need to highlight the risk of tolerance with any psychiatric medication. The longer you take them, the risk increases that they will be less effective because of the opposing effects your brain is programmed to carry out. In extreme cases, withdrawal effects can occur in between doses of the same medication. The drug effect wears off quicker and quicker, and you can experience any symptoms typically seen in true withdrawal, meaning if you stop the medication abruptly, until you take the next dose. Lower your risk by safely tapering off the medication you no longer need.
I hope this provides some clarity on overmedication. Please share your experience in the comments. Many of you know the field of drug safety is often underfunded and minimized when compared to the marketing and sales of medications. What we like in clinical trial data, we learn directly from patients like you speaking up.