Psychopharmacology-Integrated Psychotherapy

Tel: 03-3716-6624  Japanese version

The Director of the Meguro Counseling Center, Dr. Douglas Berger, M.D., Ph.D., is an American physician and Board-Certified psychiatrist, and he and the other therapists at the Meguro Counseling Center have considerable experience and knowledge on the use of psychiatric medications (anti-depressants, anti-anxiety medications, etc.) and how they can be integrated into the psychotherapy process. Medications may be recommended to persons who are having symptoms that suggest there is some stress, imbalance, or illness in their neurophysiologic functioning. Common symptoms include mood changes (panic, anxiety, depression), sleep disturbance, irritability, low energy, poor concentration, low appetite, racing thoughts, etc. Your therapist at the Meguro Counseling Center may recommend a specific medication regimen to you and refer you to a licensed Japanese physician who works closely with the Center. This physician will confirm your need for medication and provide you with a prescription that they agree is appropriate for your needs.

Medical and psychological care that is well coordinated usually leads to a smoother treatment process and more favorable outcomes, and the physicians and clinics who work closely with the Meguro Counseling Center will require a note from your therapist regarding your status each time you visit them in order to provide you with or continue your prescriptions for medications. Although your therapist can not predict the type of care you may receive if you decide to receive medications from a physician that is not the physician recommended to you by your therapist, you are free to seek medical care at the medical facility of your choice.

This page will describe a number of cautions and issues related to taking psychiatric medications. Please note that this page is for information purposes only and is not an exhaustive essay on medications, their cautions, and side-effects. Also, medical information may change over time and this page may not be fully up to date on a particular topic. If you take medications, you can also use the MediGuard web site to provide you with information on your medications, and alert you to side effects or drug interactions that may be associated with your medication regimen.

Medications on occasion can cause side effects, most are mild, but can be serious, even life-threatening in rare cases. Serious side effects can occur even when prescribed under a proper standard of medical care, i.e., it does not mean that the prescribing Dr. has made a mistake or is at fault in some way. If you decide to take medications, you need to make the final decision on taking medications after consulting with your prescribing physician on the risks and benefits of medication treatment.

Cautions When Taking Psychiatric Medications (in alphabetical order):

Allergic Reactions. Allergic reactions can range from mild rashes, to acute episodes of wheezing and shock (very low blood pressure) that can lead to seizures and even death. While these type of reactions are rare they are very serious, and of course require that you go to the nearest hospital for emergency medical care. Unfortunately, no one can predict these reactions unless you have a history of allergy to the medication in question.

Anti-Smoking Products. A nicotine patch is commonly prescribed for smoking cessation. It is possible to feel "sick" with nicotine intoxication if the dose of the patch is be too high for the amount of nicotine you intake from smoking. Be sure to discuss your exact nicotine intake and needs with your prescribing physician if you use the nicotine patch. Another drug called Chantix or Champix (generic name varenicline) is also used for smoking cessation. This may cause nausea, headache, and sleeping difficulties. There have also been reports of depression and suicidal thoughts, and one should not drive a car or bicycle while on this medication. Taking these medicines requires close follow-up with one's health care providers.

Blood and Laboratory Testing. While some sources may recommend that certain medications have blood testing before starting, this is not always an absolute clinical necessity and many Japanese physicians will prefer to check blood or other tests after medications are started. For example, persons on lithium should have their lithium levels, kidney and thyroid functions followed; those on tegretol (carbamazepine) or depakene (valproic acid) their liver function, white blood cells and drug blood levels followed; those on tricyclic antidepressants have their EKG followed; those on stimulants for depression or ADD/ADHD have their blood pressure and EKG followed, and those on betanamin (pemoline) also have their liver function followed, and those on typical or atypical (new-generation) antipsychotics should have their weight, blood glucose, and lipid levels followed as these drugs can sometimes cause abnormalities in these parameters leading to the "metabolic syndrome". There is usually no rule how early or how often to take blood tests to check for these kinds of problems. The clinic we use usually checks at the 2-week point and then monthly thereafter for a few months, then every 3-4 months. Blood testing can be done at any time if necessary, please tell your therapist and physician if you have any signs of a rash, lethargy, infection, yellowing of the white part of your eyes, or other new physical symptoms.

Your therapist can advise you and interface with your physician on these tests, but different physicians may have different styles when it comes to doing lab testing and how often to do it. To some degree you may need to take initiative with your Japanese physician in asking for the tests as the medical culture in Japan may not automatically require them. With patience, persistence, and the interface your therapist can provide you, it is possible to work with the system and receive good medical care in Japan, even if it is not exactly as you expect when in your home country.

Drinking Alcohol. Mixing any psychiatric medication with alcohol may cause dizziness, imbalance, severe sedation, confusion, etc., and should be avoided. If you take medications to treat alcohol abuse (i.e., disulfiram; brand name Nocbin in Japan, Antabuse in other countries), be sure to avoid any kind of alcohol including cold syrups, tonics, mouthwashes, alcohol containing perfume and after-shave lotions, alcohol hand sanitizer sprays, etc., and consult with your physician if you are prescribed antidepressants or stimulants along with these medications. Even moderate amounts of drinking alcohol can make depression or anxiety worse due to direct effects or from the rebound agitation of the nervous system when coming off drinking (this is what causes a "hangover"), and ongoing alcohol consumption is a common cause of persons with depression failing to respond to anti-depressant treatment or psychotherapy. If you are a heavy drinker, you also need to be careful not to stop suddenly because you may have withdrawal symptoms.

Driving Impairment. Psychiatric medications are not an absolute contraindication to driving, bicycling, or using dangerous machinery, however, these activities may be adversely affected. Especially, minor tranquilizers, also called benzodiazepines (usually the scientific name ends in -pam) such as clonazepam (brand name Rivotril in Japan) or alprazolam (brand name Solanax in Japan), and the smoking cessation product Champix (also called Chantix) are known to adversely effect driving. Mistakenly taking sleeping medications and driving is also very dangerous. You need to carefully evaluate your ability to drive or use machinery (including using cutting knives), and discuss your concerns carefully with your physician. It is probably better to avoid driving a vehicle or using machinery if you sense that your driving ability has been adversely affected. If you are in doubt, your local motor vehicle licensing center in Japan can evaluate your driving ability for you.

Drug Rash. In rare cases, a drug rash may be seen along both arms, thighs, and torso in the first few weeks after starting a new medication (i.e., lamictal, generic name lamotrigine, is a drug to be careful with). There may be an associated low-grade fever. You should contact your therapist and physician if you have a rash, probably stop the offending drug, and have a blood test to check blood cell counts, liver function, and other parameters as soon as possible.

Efficacy. Obtaining the desired effect from psychiatric medications may be rapid as in the case of sleeping medications, or for stimulants used to treat ADD/ADHD or to give energy to persons with depression. Other medications, particularly antidepressants, need to be started at low and ineffective doses and built up gradually because starting at the therapeutic doses may not be easily tolerated. Even when the dose has been raised adequately, the medication may take a few weeks to work, and in some cases that particular type of medication may not work and the type may need to be changed, another medication added, etc. Treatment with psychiatric medications requires a significant amount of effort and patience on the part of the patient in raising the dose, waiting for the treatment response, and possibly changing and/or adding different adjunctive medications.

Falling Risk. On rare occasion, psychiatric medication may make persons dizzy on standing or unsteady. This is particularly problematic with elderly persons who can break their hip on falling, but persons of any age should be aware of this and to consult with their physician if there is a concern. Especially for elderly persons, it may be helpful to make one's home "fall-proof". If you take a sleeping pill, it is best to go to bed soon after the dose.

Hot Weather, Sun, and Sweating. Psychiatric medication may impair the ability to adjust one's body temperature in hot weather, and some drugs (e.g., antipsychotics) may even make the skin sensitive to the sun. In addition, lithium toxicity can be seen in persons who sweat a lot because the sodium loss in sweat makes the body retain lithium in its place (diarrhea may also cause this). Staying cool, using a sun visor or parasol and sunscreen, and staying well-hydrated with electrolyte drinks (i.e., OS-1; not just standard sport drinks) if one does sport or manual labor and takes lithium, are important measures to take in hot weather.

Illness & Medication. In rare instances psychiatric medication may worsen a pre-existing condition. For example, tricyclic antidepressants may worsen glaucoma, antipsychotics may worsen diabetes, lithium may worsen hypothyroidism, stimulants and tricyclic antidepressants may worsen cardiac conditions, antidepressants may worsen seizure disorder or migraine headache, and various medications can worsen pre-existing obesity or liver disease. This is not a comprehensive list, however, and you should confer with your therapist and prescribing physician and/or look up specific illness and medications on a literature site like this one from the U.S. National Library of Medicine if you have a concern.

Mixing With Other Medications, Caffeine/Tobacco, and Street Drugs. Cold medicines, medications for medical problems, or other psychiatric medicines, bought either with or without a prescription, may occasionally mix badly with your psychiatric medication (causing dizziness, severe sedation, imbalance, confusion, rapid heart rate, etc.). It is also risky, however, to stop your psychiatric medication just because you take cold medications or drugs for hay fever, etc. (see the Withdrawl section below). Mixing SSRIs with each other or SNRIs may be risky, mixing most any other antidepressant within 2-weeks of an MAOI is extremely dangerous, combining the SSRI fluvoxamine (brand names luvox or depromel) with olanzapine (brand name zyprexa) can often result in a bad drug interaction, and extreme caution should be taken if one takes the pain killer tramadol (brand name ultram) with antidepressants.

Using caffeinated products may inhibit the metabolism of certain medications increasing the risk of toxicity, and use of tobacco products (but not nicotine itself) may stimulate the metabolism and thus decrease the efficacy of certain medications. Conversely, suddenly stopping the chronic use of caffeinated or tobacco containing products can potentially cause increased metabolism or risk of toxicity respectively so that caution is warranted when mixing these products with psychiatric medications.

You should consult with your physician before mixing any medications and watch yourself carefully for any symptoms suggesting a drug interaction (i.e., symptoms you did not have before you added the new drugs). You can use the MediGuard web site to alert you to side effects or drug interactions that may be associated with your particular medication regimen. If you are starting multiple medications at once, or adding a new medication or over-the-counter drug, and you do not know the English term for these drugs or their active ingredients, you can put the brand name in Japanese into Yahoo Japan and you should be able to find a web site that notes the ingredients. Then you can put the Japanese ingredient names into Yahoo Japan along with some Roman letters that seem to fit the katakana, or just as katakana into google.com, and you may find the English words for the ingredients that you can use in the MediGuard site. Note however, that while looking up drug interactions on websites or using drug interaction software may be helpful, there is a tendency of these information sources to overreport because they collate research done with these drugs in test-tubes and petri dishes not just on live people. You should follow up any concerns you have from these sources with a search of clinical research testing done in people on the U.S. National Library of Medicine research data base. Your caretakers can help you with this kind of search in a session if you request.

There are two types of drug interactions, one is the "adverse effect" type of interaction where one has some unpleasant symptom (i.e., headache, dizziness), and the other is the "loss of effect" type of a drug interaction where the expected medical effect of one of the medications may be decreased or lost. The adverse effect type of interaction can be mitigated by starting at low does etc., but many drug mixes do not absolutely need to be avoided unless there is a commonly known problem seen in people (not just a test tube). When one is concerned about the loss of effect type of interaction, the report on a web site or drug interaction software should be followed up by looking up research studies done on live persons as noted above, and discussion with one’s health care provider.

However, not every drug interaction can be expected to be registered on MediGuard, and no physician or pharmacist will know about every possible drug interaction so no professional can ever give you a definite "no-problem". Anyone can have a drug-drug interaction or just a bad reaction to a drug added to an ongoing regimen as an individual as compared with an expected drug interaction in a population as a whole. One way to approach adding new medications (whether for psychiatric issues or for a cold or hay-fever, etc.) is to start with small doses (some pills can be broken if necessary), and to refrain from increasing the dose or stop the new medication if you feel some untoward effect. Caution is required when mixing any medications. You may need to make a personal decision to avoid adding certain medications, or to stop or change ongoing medications (usually slowly) etc., if guidance on the mixture is not absolutely clear.

Note that some medications may interfere with the efficacy of contraceptive pills or devices (i.e., modafinil and oral contraceptives, vaginal rings, etc. is a reported-though questionable-interaction). While you can look up your specific contraceptive regimen on MediGuard and discuss your concerns with your caretakers, the only way to be certain you do not have a pregnancy risk from mixing medications is to use condoms or other barrier means of contraception, and this is the Meguro Counseling Center's reccomendation.

It should go without saying that using street drugs is dangerous itself, may cause psychiatric illness to worsen, and may mix badly with psychiatric medication. It is often impossible to assess the efficacy or side effects of psychiatric medication if one takes street drugs, and neither your therapist or physician can predict what will happen if you use these substances. While there are potential legal ramifications to disclose that one uses street drugs to a physician in Japan, persons who hide the fact that they use street drugs to a prescribing physician also impair that physician's ability to provide proper care. The only way out of this conundrum is to fully stop the use of street drugs.

Your therapist can help you, however, it is the policy at the Meguro Counseling Center that it is the client's responsibility to consult with their prescribing physician, as well as take the initiative to look up possible interactions on the internet, the MediGuard site, etc., in order to feel secure you are not at risk for a drug interaction. Discussing medication mixing should be done in the scheduled sessions unless there is an immediate need. The Meguro Counseling Center is a mental health consultation service and not a medical service. The Center can help clients with information about medicines, however, it is the final responsibility of the patient and their prescribing physician to deal with drug interactions even for medications suggested by your therapist.

Over/Under Dosing. Mistaken or intentional under dosing, or taking the wrong medication at the wrong time of day may result in withdrawal or loss of effect and recurrence of the symptoms of the underlying problem. Mistaken or intentional over dosing of a few pills of one's medications increases the chance of side effects and toxicity from the medications. Mistakenly taking sleeping medications in the daytime and driving, riding a bicycle, or using machinery, etc. is very dangerous. All pharmacies in Japan provide dosing instructions usually in Japanese. If you do not read Japanese, you can still ask the pharmacist, your physician, or your therapist to translate the instructions for you, but unless the pharmacy has made a mistake in the instructions, dosing of the correct medication at the correct time is the responsibility of the patient. Your caretakers can help you, but you need to ask as their primary role is not translation.

Intentional over dosing of many pills is an extremely serious matter that can result in one being brought to an emergency room, having one's stomach pumped, given iv's, etc. and may result in seizures, irregular heartbeat, coma, and death. Over or under dosing should be brought to the attention of your physician and therapist as soon as possible.

Pregnancy. You should inform your therapist and prescribing physician of any plans or risks that you might become pregnant while on psychiatric medications, and contact your therapist and prescribing physician immediately if you suddenly discover you are likely to be pregnant. The risks and benefits of each person's situation, in particular the problem(s) being treated and the type and dosage of medication, will need to be evaluated and discussed on a case-by-case basis. Do not suddenly stop or change your medication without medical advice.

Some drugs may need to be stopped only for the first trimester, some stopped altogether, and some can be taken throughout the pregnancy and tapered prior to delivery in order to prevent withdrawal and/or behavioral toxicity to the newborn. While the risk of congenital malformations for most psychiatric medications taken during pregnancy is low, it may make sense to taper and stop the medications as long as the psychiatric symptoms are tolerable. Some women who have a very serious psychiatric illness may require the medications without interruption in order to prevent a relapse of the illness that might force them to otherwise terminate the pregnancy.

There is a somewhat higher risk of a congenital problem or birth toxicity if one takes tegretol (carbamazepine), depakene (valproic acid), lithium, or paxil (paroxetine), but controlled studies have not been done on medications in pregnancy for obvious ethical reasons. Consultation on medications and breast-feeding will usually follow pregnancy discussions, and should also be brought to the attention of one's caretakers if the first visit occurs during breast-feeding. See this page on postpartum depression for further information on medications in pregnancy and breast feeding.

Male use of psychiatric medications and pregnancy. The topics of infertility, birth defects, and miscarriage related to men who take psychiatric drugs are complex. While there are no controlled clinical trials on these topics for obvious ethical reasons, there has been some clinical use data (see this paper for some details).

All psychiatric drugs are tested for sperm and chromosomal toxicity in test tubes and animals, and should not get market approval if there are significant problems, but there is no absolute guarantee any doctor can make on this issue. Men who have concerns about infertility, birth defects, or miscarriage risk while taking psychiatric medication should use a condom and discuss the if, when, and how they might change or stop medications with their prescribing physician if they wish to father a child.

Priapism (painful sustained erection). This is a rare but serious condition that can be caused by certain psychiatric medications (i.e., trazodone, trade name Deseryl; quetiapine, trade name seroquel). If you think you have this condition lasting more than an hour you should stop taking all medications and visit an emergency room near you. Do not resume taking any of the medications that you had taken before the priapism began without first discussing this with your therapist and prescribing physician. Rarely, this condition can also be seen in women who can have clitoral priapism (called clitorism), requiring the same concern for rapid intervention.

Side Effects. Your therapist and prescribing physician may discuss possible well-known side effects with you, but it is not possible for your providers to review every possible side effect. Extensive lists of side effects of medications are available on public databases, and your therapist and physician should watch you closely for the emergence of untoward effects. Not everyone experiences side effects, and most are mild, i.e., stomach upset, dizziness, sedation, etc.

Unfortunately, the Japanese medical system only provides a few minutes with the physician, and while time with your therapist can make up for this to some degree, there is no perfect system that can review every side effect or follow you continuously. You should contact your therapist and/or your physician promptly if you think you are having a concerning side effect. The therapists at the Meguro Counseling Center are aware of the more common side effects seen with psychiatric medications, can interface with your prescribing physician, and will conscientiously try to educate and watch you for any trouble you may have with medications.

The side effects of medications may negatively affect work performance (e.g., sedation) and you should contact your therapist or physician as soon as possible if you experience any concerning side effects at work. Neither your physician nor your therapist can absolutely guarantee, nor take responsibility for, how a medication may affect you in a work situation so that you will need to make a personal decision about the risks to your job of taking medications versus the risks of not taking them. It is usually possible, however, to take a test dose (or half the dose) outside of work hours, to decrease ongoing dosing, change medication types etc., if there is a problem with medications at work.

Sleeping Medication. Sleep walking, strange dreams, or next-day confusion and/or amnesia may be seen on rare occasion when taking sleeping medication. It is best to retire to bed soon after ingesting any medications for sleep as one can experience unsteady gait, speak illogically, or write e-mails with strange content if one takes sleeping medication but stays awake. Some sleep medications may cause sedation the following morning, and some may cause one to wake up after only a few hours of sleep. Taking a sleeping medication for some length of time may also impair one's natural sleep induction mechanism making it hard to stop the medication suddenly. In these cases, it would be necessary to discern whether that is due to the medication or the underlying problem. Mistakenly taking sleeping medications during the day and driving, riding a bicycle, or using machinery, is also very dangerous. You should inform your physician and therapist as soon as possible if you think you may have experienced any of the problems mentioned in this section.

Suicidal thoughts or aggression with antidepressants. These effects may be seen on rare occasion in children and adolescents but can usually be handled with close medication monitoring. Unfortunately, the warnings from various health authorities and the subsequent media coverage regarding suicidality resulted in a decreased use of these drugs and an increase in the suicide rate of young persons indicating that it is more pertinent to treat suicidality from depression itself vis-à-vis the danger from the medication. Re-analysis of the original data used for these warnings, as well as new research studies, suggest that the risk of suicide from these medications is much lower than from not using them, although there may be some relationship to age. The risk of either of these symptoms is particularly low if dosing is started low, and if the person is followed carefully at the start of dosing, when other medications are added, during smoking cessation, on stopping the medication, etc. Please read this article on antidepressants and suicide risk for a detailed description of this issue.

Tardive dyskinesia. Tardive dyskinesia (TD) is characterized by repetitive, involuntary, and purposeless movements usually of the tongue and mouth muscles, and may include rapid eye blinking, and movements of the limbs, torso, fingers and feet. Antipsychotic medication is known to be the major cause of TD, the risk seeming to be cumulative after long-term treatment. The newer "atypical" antipsychotics are thought to be less likely to result in TD but there are still cases seen, and certain anti-nausea medications i.e., metoclopromide (brand name Primperan and others in Japan), domperidone (brand name Nauzelin in Japan) may also cause TD in rare cases. The antipsychotics aripriprazole (brand name Abilify in Japan and most countries) and clozapine (brand name Clozaril in Japan and most countries) seem to be unlikely to cause TD but may have other limitations in their use. Antipsychotics are often used off-label for agitation, racing thoughts, anxiety, and insomnia, that can be seen in a number of psychiatric conditions. You should be sure to discuss the risk of TD with your prescribing Dr. and weigh your need for this medication with the condition you need treatment for, periodically look for tongue or mouth movements by yourself and with your Dr. and therapist, and let your therapist and prescribing Dr. know about any strange movements as soon as you suspect them. There are few effective treatments available for TD, however, it may get better over time on its own once the causative drugs are stopped.

Weight Gain. Moderate weight gain may be seen on occasion with SSRI or other antidepressants as well as with other psychotropic medications especially atypical or new-generation antipsychotics. You should follow your weight regularly and discuss any weight gains with your therapist and physician as weight gain may come on slowly over many weeks or months.

Withdrawal & Discontinuing Medications. Some medications may give one withdrawal symptoms (dizziness, insomnia, shock-like sensations, etc.) or rebound of the underlying symptoms if they are stopped abruptly. Be sure you visit your doctor on time so that you do not run-out of your medication, and keep a spare bottle of medication in any bags you carry in case you go on a trip and forget your medication. Many drugs and their effects persist in the body for a number of weeks after stopping them, and recurrence of one's underlying symptoms may also not return until some time after stopping the medications making the person erroneously think they do not need the medications anymore. Stopping medications should only be done under the close supervision of your physician and therapist.

Worsening of Symptoms. Medications may rarely cause a wide variety of psychiatric symptoms or worsen the underlying psychiatric problem. These symptoms may include insomnia, anxiety, depression, headache, suicidal feelings, etc. The symptoms being treated may also become worse unrelated to the medication. You need to be followed closely and discuss all symptoms carefully with your therapist and physician to determine if the worsening is due to medication or the underlying problem itself.

SUMMARY

While this page is not meant to be an exhaustive discussion of medications or side effects, it can help you to see some of the major issues involved and encourage you to receive close follow up care with your therapist and physician. The information on this page, however, should not be used in place of proper medical care. The Meguro Counseling Center strongly advises that medications should only be taken while under the care of a physician, and that any medications or herbal preparations received from your home country, the internet, or other third party, be closely followed by a licensed physician in Japan who can follow your clinical condition and laboratory testing and intervene for you quickly in the event of a problem.

Your providers and yourself have made a risk-benefit calculation that it is better to take medications than to continue to experience the psychiatric symptoms that cause you much distress. Finding the right combination of medications may take considerable patience and effort on your part in working with your physician and therapist. Many side effects will resolve themselves even if one continues taking the medications (dry mouth, stomach upset, etc.), but some will not until the medication is stopped (sweating, weight gain, sexual dysfunction, etc.). If there is a concerning side effect, your medication may be stopped, changed, or the dosage may be decreased. In the end, it is hoped that this endeavor will lead to a more enjoyable and productive life than living with the symptoms or illness that the medications are intended to treat.




Medical Responsibility

While your therapist can function as an advisor and interface closely with you and your prescribing physician, it is the prescribing physician who is responsible for any medical care you may receive (i.e., dose changes, trouble-shooting side effects, mixing medications, etc.), and these physicians and clinics are separate entities from, and have no legal, financial, or organizational relationship to your therapist or the Meguro Counseling Center.

Physicians and pharmacies in Japan who provide medical care will usually accept the Japanese National Health Insurance plan, and all fees and charges for medical care and/or medication are separate from those at the Meguro Counseling Center. In addition, the Meguro Counseling Center does not have any legal, financial, or organizational relationship with any of the pharmacies we might refer a client to use, either in Japan or abroad, and can not take any responsibility for the quality of medications you may receive, nor any problems you may have with a pharmacy you may order medications from.

If you order medication on-line without a prescription, if a pharmacist dispenses medication to you without a prescription, if you receive medication from an acquaintance, or if you buy herbal products or over-the-counter medicines and mix these on your own with prescription medication, etc., you would be doing this without licensed medical supervision at your own risk. The Meguro Counseling Center strongly recommends that all medications are received from a licensed physician who can also advise you if you mix medications with herbal or over-the-counter medicines. Our affiliated medical service can provide you with prescriptions to import medications not available in Japan, however, Japan customs only allows a 1-month amount of medications to be imported per time.




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The Meguro Counseling Center consists of Western-trained therapists able to provide face-to-face mental-health care for the international community in Tokyo. With extensive experience in Japan, these therapists have a deep understanding of the stresses of living in Japan.