The mood and anxiety disorders are tiring. It’s hard enough that fatigue hits us as a symptom. But when we have to deal with it as a side effect of a supposed remedy? That’s pretty cruel. Well, there’s plenty to learn, and options. So here’s what you’ll want to know about sedation and psych meds…
Looks like our friend is sleepy. She’s taking an antidepressant and atypical antipsychotic for her depression and anxiety. As much as they help, fatigue is a problem. She may want to read-up and think things over.
Came upon an article on Psychiatric Times that I had to bring your way. Sedation: The Ups and Downs of a Side Effect was written by psychiatrist Chris Aiken, MD. I’ve always learned a lot from Dr. Aiken. He’s also featured with Dr. Jim Phelps on a great site, Psych Education. We’ll do some links at the end.
I’ll be summarizing Dr. Aiken’s sedation article for you, as well as tossing in some tidbits of my own. I think you’ll find the information interesting as well as helpful.
Let’s get busy…
Sedation and psych meds
Dr. Aiken begins his piece by informing us that not too awful long ago “tranquilization” was an important goal of psychopharmacology. And sedation was key to the therapeutic effect.
Used to be that major tranquilizers (e.g., antipsychotics) sedated psychosis and mania, while the minor tranquilizers (e.g., benzodiazepines) handled anxiety. Even antidepressants were thought to benefit from sedation. Not only was that because insomnia is a common symptom of depression, but because of concerns that patients might act on suicidal impulses if their energy levels beat their depression to improvement.
Well, that business came to an end in the 1990s, because nonsedating meds proved just as effective as their sedative predecessors. These days, according to Dr. Aiken, sedation is sometimes desirable and sometimes not – as I’m sure you know.
Best and worst psych meds for sedation
If you were to ask Dr. Aiken, he’d tell you the simplest way to manage unwanted sedation is to choose meds that are less likely to cause it. Makes a heck of a lot of sense to me.
Of course, there’s a lot to consider. Perhaps you’re on a med that handles your core issue(s) well, but, yeah, sedation is a problem. Maybe you’ve decided to just put up with it. Or maybe you’ve come up with a creative way to minimize the sedation and/or its impact.
If you’d like to make a change, naturally, you’re going to have to work with your prescriber. I’d sure think s/he would do everything possible to accommodate you, but there may be factors you haven’t considered.
Regardless, let’s take a look at an approximation of the sedative effects of selected meds often prescribed for the mood and anxiety disorders…
- Antidepressants: HIGH: mirtazapine (Remeron), trazodone (Desyrel). HIGH-MODERATE: Tricyclics, except desipramine (Norpramin) and nortriptyline (Pamelor). MODERATE: SSRIs, particularly paroxetine (Paxil) and fluvoxamine (Luvox), SNRIs, desipramine (Norpramin), nortriptyline (Pamelor). LOW OR NONE: bupropion (Wellbutrin), vilazodone (Viibryd), vortioxetine (Trintellix/Brintellix)
- Traditional mood stabilizers: HIGH-MODERATE: carbamazepine (Tegretol), divalproex (Depakote). MODERATE: lithium. LOW OR NONE: lamotrigine (Lamictal)
- Atypical Antipsychotics: HIGH: olanzapine (Zyprexa), quetiapine (Seroquel), ziprasidone (Geodon). HIGH-MODERATE: lurasidone (Latuda), MODERATE: aripiprazole (Abilify), risperidone (Risperdal). LOW OR NONE: brexpiprazole (Rexulti), cariprazine (Vraylar), paliperidone (Invega)
For those of you using lithium, Dr. Aiken comments that it’s been reported to cause sedation in about 1 in 16 to 1 in 27 patients, depending on the study. With most atypical antipsychotics, the rate is closer to 1 in 5. He goes on to say that while lithium may not cause drowsiness, it does cause side effects that can be mistaken for sedation: motoric and cognitive slowing, especially in higher concentrations.
Now, let’s tighten our focus as we look at Dr. Aiken’s list of most and least sedating antidepressants by class…
- SSRI: Most: paroxetine (Paxil), fluvoxamine (Luvox) Least: escitalopram (Lexapro)
- SNRI: Most: venlafaxine (Effexor) Least: levomilnacipran (Fetzima)
- MAOI: Most: phenelzine (Nardil) Least: tranylcypromine (Parnate)
- Tricyclic: Most: amitriptyline (Elavil), doxepin (Sinequan) Least: desipramine (Norpramin), nortriptyline (Pamelor)
- Other: Most: trazodone (Desyrel), mirtazapine (Remeron) Least: vortioxetine (Trintellix/Brintellix)
Now, for those of you who feel as though you want to stay put with your current med, even though sedation is an issue, here are some benefits presented by Dr. Aiken that are good to know…
- quetiapine (Seroquel): Along with cariprazine (Vraylar), it’s the only antipsychotic that treats both mania and depression. It also has unique benefits for sleep and anxiety and a low risk of akathisia.
- ziprasidone (Geodon): It has the most favorable metabolic profile of the antipsychotics.
- trazodone (Desyrel) and mirtazapine (Remeron): Low risk of sexual side effects, sleep architecture benefits, low risk of weight gain with trazodone.
- Tricyclics: Potential benefits in treatment-resistant depression, melancholic depression, and chronic pain.
- clonidine (Catapres): Benefits in opioid and nicotine use disorders, autism, tic disorders, irritability, nightmares, and insomnia. Not mentioned above, but has a high-moderate sedation factor.
By the way, do you need help with antidepressant details – classes, names, etc.? Got you covered.
How to manage sedation and psych meds
Okay, sedation is definitely a problem with your med; however, since the benefits outweigh the fatigue, you’re going to stick with it. Now you’re looking for ways to manage sedation. Certainly, you’ll want to chat with your prescriber, but here are a few things to consider.
Evening dosing may be an option for you. In addition to side-stepping fatigue during the day, you may receive some much needed assistance with sleep. But keep in mind, some meds may have insomnia as a side effect, and you don’t want to sign-up for that. For instance, it’s a potential issue with fluoxetine (Prozac). I sure as heck wouldn’t evening dose it. Point is, you really have to do your research and talk with your prescriber.
Well, evening dosing didn’t work. Now what? Well, you may want to consider an added daytime med, though results can be dicey. Modafinil (Provigil) and armodafinil (Nuvigil) are options. But what about amphetamines? Nah, not significantly effective and too many associated risks.
Finally, things like a consistent and effective sleep regimen, exercise, customized food and drink intake, rest periods, activity scheduling, and supplements may provide help. You won’t know until you get creative and give them a go.
That’s gonna’ do it
I don’t have to tell you that the mood and anxiety disorders are tiring. And it’s brutal that the sedation that often accompanies med remedies makes matters worse.
As with any other side effect we’ve had to deal with, there are options. It’s such a drag that we have to find them and put them into practice; however, well, we do.
Research, get creative, and talk with your prescriber, okay? You don’t have to be sleepily miserable.
Hey, don’t forget to review the hundreds of Chipur articles available to lend a hand.