This chapter discusses the potential benefits and disadvantages of medication for body dysmorphic disorder in order to help you make an informed choice about whether or not you wish to take such medication. The discussion could also be relevant for someone who is significantly depressed (for example, as a result of a disfigurement) or if you are suffering from bulimia nervosa. However, if you have doubts and questions about medication after reading this chapter, you should discuss them with your doctor, rather than just ignoring a prescription or stopping your medication.
If you have been recommended medication and decide to take it, it is also important to take it at the correct dose and frequency. The possible side effects of medication, and what you can do to minimize them, are also discussed in this chapter. In addition, we provide advice on how to stop taking antidepressant medication. Being well informed is vital, as some people who have been prescribed medication will not get it dispensed at the pharmacy, and others might take it inappropriately (for example, at a lower dose than recommended or not daily) or not at all.
• if you have moderate to severe symptoms of BDD, as an alternative to cognitive behavior therapy (CBT) or in addition to CBT
• if you have BDD or bulimia nervosa which has persisted despite CBT being delivered competently
• if you have a body image problem and you are also significantly depressed or suicidal.
You might find it difficult to get CBT treatment because of long waiting lists or other restrictions in public medicine and insurance cover. As a result, you might be offered medication before you receive CBT. More research is needed on how to get the most out of combining treatments for BDD. We think that CBT and medication are equally effective for most people with BDD, though we don’t yet have published research evidence to support this. However, it is very important that individuals have a choice. Although CBT could be more costly to provide than drug therapy in the short term, psychological treatments are usually more cost-effective in the long term. This is because the cost of the drug continues for several months and there is a higher risk of relapse with medication alone, when the patient stops taking it, compared with an effective psychological therapy.
Some individuals do better on a combination of CBT and medication than either treatment alone. This is usually recommended if you fail to respond adequately to CBT on its own or if your BDD is more severe. The problem is that no one can predict with any certainty who will respond best to what treatment.
Taking medication is not a sign of weakness or failure. You probably wouldn’t think that taking medication was a weakness if you had heart disease or cancer. Your relatives and friends are more likely to think of your behavior as weak if you don’t take medication and will find it difficult to understand why you don’t do everything you can to get better. If some of them do criticize you for taking medication, they probably don’t understand what you are experiencing and their opinion is not worth considering. Mental disorder is no different from other medical problems in this respect, and taking medication is a practical approach.
Even if medication is of benefit, it will not work right away. Most people notice some improvement in their symptoms after about four to six weeks, while maximum benefit should occur within four to six months. Make sure you continue to take your medication at the highest dose you can tolerate for this period before judging how effective it has been.
Never stop taking medication without discussing it with your doctor first, and always ensure that you have another prescription ready before you run out of drugs. This is because, if you do not take medication regularly or stop it suddenly (for example, you forget to take it on holiday), you can be at risk of experiencing withdrawal symptoms. This is discussed in detail at the end of this chapter (see page 356).
Once you have recovered from BDD or depression and have stopped taking medication, you could have a relapse if you have had no other therapy. The risk of relapse will partly depend on the natural pattern of your BDD without treatment. For example, for a first episode of BDD, the chance of recurrence is lower if you continue to take an anti-depressant for up to a year after you have recovered. If you have a second episode of BDD, then your chances of relapse are lower if you keep taking an anti-depressant for a couple of years after you have got better. If you are someone whose BDD keeps recurring, then the risk of relapse is much higher and you will probably be advised to remain on the medication for at least five years. A few people might need to be on medication for many years to reduce the risk of relapse.
For many people, the risk of relapse is minimized by combining the medication with CBT. If you are planning to stop medication, ensure you do it after discussion with your doctor and within an agreed timeframe. Be aware that your depressive symptoms could start to return within a few weeks or months, so don’t plan to stop before predictable major stresses and life events.
The first choice of medication for most people with BDD or depression is a class of anti-depressants called selective serotonergic reuptake inhibitors or SSRIs for short (see Table 14.1, page 344). ‘Serotonergic’ means that the drugs act on serotonin nerve endings in the brain. ‘Selective’ refers to the fact that they act on serotonin nerve endings, rather than others such as noradrenaline or histamine nerve endings. ‘Reuptake inhibitor’ refers to the way the drug acts: it helps to increase the concentration of serotonin in the nerve cells. This in turn helps to increase the messages passing along certain pathways in the brain and to reduce anxiety.
Compared with older anti-depressants, SSRIs are generally safe. An overdose will not usually harm you.
For someone with BDD, an SSRI can reduce your preoccupation and distress with your feature. In BDD, a part of your nervous system might have an excessive load on it as your mind tries to make things better. SSRIs enhance this normal activity of the brain and improve its ability to dampen anxiety and reduce your preoccupation. SSRIs are also used for panic attacks, obsessive -compulsive disorder (OCD) and depression, so they are not used specifically for BDD. Afamily doctor can prescribe the drug or refer you to a psychiatrist who can discuss your issues in more detail.
In general, all SSRIs are likely to be equally effective for BDD or depression, but individuals respond differently to different drugs. The most evidence for BDD is based on trials conducted with fluoxetine. However, your doctor will help you choose the most appropriate SSRI for you, given your circumstances and history. For example, citalopram or escitalopram are usually a good choice if you are on other drugs at the same time and they are usually well tolerated.
Fluoxetine takes longer to be metabolized by the body, so it doesn’t matter so much if you forget a dose one day as it does not vanish from the blood when you stop taking it. It is also now the cheapest of the SSRIs and the easiest to come off. However, some people find fluoxetine slightly more likely to increase anxiety when they first start taking it. Some SSRIs, such as paroxetine, can be more difficult to withdraw from and other things being equal are best avoided (see ‘Stopping or reducing your medication anti-depressant’, p. 356).
If you or someone in your family did well or poorly with a medication in the past, this might influence your choice. If you have medical problems (for example, problems sleeping) or you are taking another medication, these factors will influence your doctor’s choice so that side effects and possible drug interactions are minimized. Make sure you tell your doctor if you:
• are pregnant or plan to get pregnant or are breastfeeding
• have any other medical conditions
• are taking any other medication or herbal drugs such as St John’s wort.
In general, you can drink alcohol as long as you do so in moderation and do not binge-drink. However, people’s reactions to alcohol do vary when taking medication and some people can become more aggressive or sedated. See how you respond to one drink initially.
Fluvoxamine and sertraline do not mix very well with alcohol so be aware that this mixture can impair your judgement. Also when you are on one of these medications, you should not drive or operate machinery. Excessive alcohol can also be a factor in depression and will interfere with your recovery.
The normal starting dose and suitable target doses of different SSRIs are listed in Table 14.1 overleaf. When progress is slow, you may need to increase the dose and you should check this with your doctor. If you experience significant side effects, you can always start on a lower dose, after discussion with your doctor. You can then build the dose up slowly. Tablets should be swallowed with some water while sitting or standing to make sure that they do not stick in your throat. If you miss a dose, take it as soon as you remember it. However, if it is almost time for the next dose, skip the missed dose and continue your regular dose. Do not take a double dose to make up for a missed one.
Citalopram elixir, fluoxetine elixir, clomipramine elixir, sertraline tablets and paroxetine tablets or liquid do not contain any animal products.
There is some evidence that a few anti-depressants can cause a slight increase in suicidal ideas (not acts) in young people with depression. For young adults, the increased risk of suicidal ideas is extremely small. So long as you monitor such feelings, talk about them openly with your doctor and relatives, and are seen regularly, this is something that can be managed. The thoughts of suicide will then decrease as your depression lifts.
Anti-depressant medication for children with BDD or depression is not so well studied, and CBT is recommended as the first line of treatment. This is because scientists don’t yet know the long-term effects of anti-depressants on the immature brain of a child and also because anti-depressants are often ineffective in young people or may be associated with a very slight increase in suicidal ideas (see above).
Equally, these risks need to be judged against the risk of a young person with severe BDD or depression not using medication or not responding to CBT (or refusing it). If he or she is continuing to experience severe BDD, this can have a major adverse impact on both development and education. In such cases, an anti-depressant is recommended. Only fluoxetine has been shown in controlled trials to have a favourable balance of risks and benefits for the treatment of depression in the under-18s and this is the SSRI that is usually recommended for BDD. The dose should usually start at a half the adult dose (10mg) and can be increased gradually. Therefore, a psychiatrist should supervise the use of an anti-depressant for a child or adolescent and monitor his or her mental state closely (for example, weekly for the first four weeks).
An SSRI should be offered in combination with an evidence-based psychological treatment. If treatment with fluoxetine is unsuccessful or is not tolerated because of side effects, consideration should be given to the use of another anti-depressant. In this case, sertraline or citalopram might be second-line treatments. Guidelines recommend that venlafaxine (Efexor) and paroxetine (Seroxat, Paxil) and clomipramine anti-depressants should not be used for the treatment of depression in children and young people. The side effects listed below occur in children as they do in adults. In addition, children can become over-excited, irritable or ‘silly’; if this type of reaction is severe it could be a reason to stop the medication.
Some people experience side effects with SSRIs and those who do normally find them to be minor irritations that decrease after a few weeks. The main side effects are described in this section. Most people find that they are not usually a problem in the long term. They will not alter your personality or ‘turn you into a zombie’ and they will cease when you stop taking the drug. The worst side effects usually occur in the first few days or weeks after commencing the drug. This is the time when you are most likely to stop taking the drug because you have not experienced any improvement in the symptoms of your depression. (This is because it takes four to six weeks for the full benefits of the medication to become apparent.) There is one side effect that does not tend to improve over time: sexual difficulties (see page 349). However, side effects that persist, including those of a sexual nature, will decrease when you stop taking the medication.
You are more likely to experience side effects if you are on a large dose or if your dose has been rapidly increased. If you are unable to tolerate the medication, you can try reducing the dose and then increasing it to the previous level more slowly. For example, if you find that you are feeling nauseous after a few days of taking fluoxetine or paroxetine at 20mg, you can reduce the dose to 10mg for a week or two and then increase it to 20mg again when your body has become more accustomed to the drug. This can also be done if it is a liquid and increased very slowly. Another alternative is to switch to a different SSRI altogether. Again, discuss this with your doctor beforehand.
The possible side effects of SSRIs and how to deal with them are given below. The list looks rather daunting but remember that the symptoms only occur in a minority of people. They stop if you discontinue the drug under guidance from your doctor. Alternatively, your doctor will discuss with you how to manage the side effects better. Monitoring of your mood and possible side effects is the key to all treatments – keep track of how you feel with a standardized measure and use it like a temperature chart on a weekly basis. If your mood is not improving, and especially if you are becoming more suicidal, discuss the issue with your therapist or psychiatrist and ask whether you need to change tack.
Nausea (feeling sick) is the most common but temporary side effect of an SSRI and affects about 25 per cent of patients taking an SSRI compared with about 10 per cent of those on a placebo (dummy pill). Citalopram and fluvoxamine are slightly more likely than the other SSRIs to cause nausea. The feeling can be significantly reduced by taking the drug after food. Alternatively, halve the dose for a couple of weeks and then increase it slowly back to the normal dose. If the nausea still persists, an anti-nausea drug (for example, metoclobemide) might help.
SSRIs can cause diarrhoea in up to 15 per cent of patients compared with about 5 per cent who take a placebo. Diarrhoea can be significantly reduced by drinking plenty of apple juice (which contains pectin) or the use of a drug, bismuth subsalicylate (Kaopectate). Constipation occurs in 5 per cent of patients taking an SSRI. Diarrhoea or constipation can be improved by taking bulking agents such as Fybogel or psyllium seed husk and eating plenty of bran and roughage. For both diarrhoea and constipation, you should drink at least 2 litres of water a day.
Up to 20 per cent of patients taking an SSRI find they develop headaches. Headache is a common symptom of tension and occurs in about 15 per cent of patients taking a placebo. Symptoms of headache can usually be helped by simple painkillers such as paracetamol and should decrease after a few weeks of taking an SSRI.
Excessive sweating occurs in about 10 per cent of patients taking an SSRI, compared with 5 per cent of those taking a placebo. There is no easy solution to this problem although it should decrease over time.
Dry mouth affects about 10 per cent of patients taking an SSRI, compared with 5 per cent of those taking a placebo. Sucking on sugarless gum or sugar-free boiled sweets can stimulate production of saliva, or you could try a spray that can be bought over the counter that provides artificial saliva. Again, the symptoms usually decrease over time.
Shakiness or tremor occurs in about 10 per cent of patients taking an SSRI and 3 per cent of those on a placebo. A betablocker (for example, propranolol) can be prescribed to help reduce tremor if it is severe.
Between 10 and 20 per cent of patients on SSRIs feel sedated and between 5 and 15 per cent cannot sleep. With some SSRIs, the problem can sometimes be resolved by changing the time of day you take your medication (take it at night, for example, if it makes you drowsy), temporarily reducing the dose, or taking a different SSRI altogether. Fluoxetine may be activating and should normally be taken in the mornings. Sertraline is less likely to cause sedation. Fluvoxamine and trazodone are more likely to cause sedation and are best prescribed at night. If sedation is a problem, do not drive or use machinery.
The sexual side effects of SSRIs can take the form of delayed ejaculation in men and an inability to reach an orgasm in women. They can also occasionally cause both men and women to lose libido although this is complicated to assess in the presence of depression. (However, there is one case report of an SSRI causing orgasms with yawning!)
Some atypical serotinergic anti-depressants do not cause delayed ejaculation. However, their benefit in BDD is not known. Trazodone is one example, which can very rarely cause ‘priapism’ (a persistent and painful erection) and which should be treated as an emergency at a casualty department. Nefazadone was similar to trazodone but did not cause delayed ejaculation or erectile problems; unfortunately it was withdrawn by the manufacturers for commercial reasons and is now available only on a named-patient basis. Another anti-depressant to consider if sexual dysfunction is a problem is reboxetine or dofepramine, as they act on the noradrenergic nervous system. However, they are likely to be less effective for BDD.
In the case of SSRIs generally, if you are on a relatively high dose, the problem of sexual side effects can sometimes be solved by lowering the dose or taking a ‘drug holiday’ and missing a dose on the day of sexual activity. However, this needs to be done with caution as you may experience some withdrawal symptoms (see below). Taking a drug holiday is usually safe with fluoxetine, which remains in the body for up to five weeks after stopping taking it. However, later findings suggest there are dangers in suddenly stopping some SSRI medication, so it is important you speak to your doctor before doing this.
In the past there were case reports of people finding it helpful to take cyproheptadine or buspirone (Buspar) several hours before sex. However, later studies found them to be no different from a placebo (or dummy pill). Another possible solution is ginkgo biloba. This is a herbal extract of the maiden hair tree and is sometimes used to enhance memory, particularly in the elderly. It can be purchased in healthfood shops. Ginkgo biloba has been used to treat sexual problems caused by anti-depressant drugs in a series of 14 patients. They had a variety of difficulties including erectile problems, delayed ejaculation, loss of libido and an inability to reach orgasm. The patients took a daily dose of 240mg for six weeks. The only side effect was gastric irritation (reported by two patients). Overall, the group reported improvements. Two out of the 14 patients reported no improvements and two reported that sexual functioning was completely restored. This study needs to be done as a controlled trial, but in the meantime gingko biloba could be worth trying as a natural supplement. It would also be sensible to inform your doctor.
There are also reports concerning the use of Viagra or Cialis for men and women taking SSRIs. Viagra has been reported as successful in reversing the sexual side effects of SSRIs. Again, this needs to be researched carefully. If you wish to take Viagra, try a dose of 50mg one hour before sexual activity, having first discussed it with your doctor. If this does not improve things or gives only a partial response, you could try increasing it to 100mg. Some patients with heart conditions will not be able to take it. Cialis has a possible advantage of a longer-lasting effect. The possible side effects of Viagra or Cialis include headache, flushing and dizziness. Do not buy such drugs from the Internet as you have no guarantee of quality and it could just be a dummy pill or even worse. So always go to your doctor to discuss getting a prescription. However, Viagra or Cialis are not widely regarded as reversing SSRI side effects as not enough research has been done.
Loss of appetite and weight loss occur in between 5 and 10 per cent of patients taking SSRIs (especially fluoxetine). Reducing the dose can halt this effect, though the symptoms usually fade away over time anyway. Some SSRIs can sometimes cause slight weight gain in the long term and you might need to adjust your diet and exercise program. Depression and inactivity will also contribute to weight gain.
Some people feel more anxious or ‘wired’ or more impulsive when starting an SSRI. This can be more common with fluoxetine, which then causes agitation or insomnia if taken too late in the day. Sertraline is probably less likely to cause anxiety. It is always difficult to tell whether anxiety is associated with the depression or might be caused by the drug. If it is caused by the drug, the problem might be solved by (a) trying a lower dose; (b) switching to a different SSRI; or (c) adding a different drug that may reduce anxiety. The feeling of increased anxiety is usually temporary and will subside over time. Feelings of increased agitation in some SSRIs is rarely associated with an increase in violence or suicidal ideas. This is more likely to occur in a young person. If this happens, seek urgent medical advice. The feelings will subside on gradual withdrawal from the medication and you could try a different therapy or type of anti-depressant.
Rashes are rare, but if you do get one, you should speak to your doctor and stop taking your medication. This is more likely to occur with fluoxetine.
Anti-depressants can very occasionally induce mania, especially in someone who is prone to bipolar disorder. You might be overactive, unusually uninhibited, full of energy, irritable and able to go without any sleep. This condition can involve dangerous or risky behaviors. You should seek medical attention quickly. You could be advised to stop taking the medication.
Whenever side effects are a problem, always discuss them with your doctor. The doctor is likely to advise you to do one of the following:
• reduce the dose
• try a different SSRI
• add another medication to counteract side effects such as insomnia or sexual problems, or
• wait and see, as many of the side effects tend to improve over time.
All SSRIs are equally effective overall. However, you might get a better response from a particular SSRI, or your doctor might wish to try you on another one or on a different class of antidepressant according to how well your mood improves or how troublesome your side effects are.
Tricyclics are an older class of anti-depressants: they were first developed for the treatment of depression and obsessive compulsive disorder in the 1960s. The name ‘tricyclic’ is used to describe the structure of the chemical.
They may be prescribed as second or third line drug if an SSRI has not helped.
Tricyclics lost favour to SSRIs because the former have more side effects. Clomipramine (trade name Anafranil) is a tricylic that is used for treating BDD because, compared with other tricyclics, it is a potent serotonin reuptake inhibitor. It can also be used for depression. It is normally started at a low dosage (for example, 75mg at night) and gradually increased to a maximum that you can tolerate. The minimum dose required for an effect is usually 125mg. Higher doses are sometimes used, up to 300mg a day, although the usual dose is up to 225mg. Higher doses tend to increase the frequency of side effects. Most of the side effects are related to the dose and tend to reduce over time but some may persist. They will cease if the drug is discontinued.
Clomipramine is more often prescribed at night so that the sedative side effects have worn off by the morning. Some people metabolize a tricyclic very quickly, and so, even when they are taking a high dose, they may have a relatively low level of the drug in the bloodstream. If necessary, the level of a tricyclic and its metabolite can be checked by a blood test to determine if it is safe to increase the dose to a higher level. Alternatively, you may be given a genetic test to see if you are someone who metabolizes such drugs faster than others.
• Dry mouth: At least two-thirds of patients taking clomipramine experience a dry mouth. You get a dry mouth when you produce less saliva than normal. Sucking on sugarless gum can stimulate production of saliva or you could try a spray that can be bought over the counter that provides artificial saliva. Good mouth hygiene is important, as are regular visits to your dentist.
• Dizziness: Dizziness on standing is a common side effect for about 25 per cent of patients taking clomipramine. You can reduce dizziness by rising slowly or sitting on the side of the bed and squeezing the muscles in your calf as you stand up.
• Tremor: About 15 per cent of patients taking clomipramine develop shakiness or a tremor in their arms. There are no simple remedies for tremor, although another drug (a beta blocker, such as propranolol) may reduce a tremor if it is severe.
• Weight gain: Weight gain can be a problem with clomipramine and you should therefore be especially careful to eat healthily.
• Constipation: You have a 25 per cent chance of becoming constipated if you take a clomipramine. A diet full of roughage from vegetables or bran and prunes or a bulking agent such as Fybogel or psyllium husks will help. Always remember to drink plenty of water. Laxatives that stimulate the bowel should not be used except occasionally.
• Drowsiness or fatigue: Clomipramine can cause drowsiness, which can be reduced by taking the dosage at night. Some people could still experience a hangover in the morning. If this happens with you, spread the dose over the day.
• Blurred vision, headache: Clomipramine can also cause blurring of vision or a headache. There is no good solution to this apart from switching to a different antidepressant.
• Sexual problems: Clomipramine can be a reason for delayed ejaculation or, less commonly, impotence in men. It can also cause women difficulties in reaching orgasm. For suggested solutions see under side effects of SSRIs (see page 346).
• Increased sweating: People taking clomipramine sometimes complain that they sweat more or that their hot flushes have increased. There is no easy solution to this but it should improve over time.
• Epileptic fits: There is a small risk (for about 0.5 per cent of individuals taking clomipramine) of having an epileptic fit. In this case, the drug will need to be discontinued or the dose significantly reduced. The majority of fits, however, occur in patients taking more than 250mg of clomipramine.
• Urinary problems: Occasionally, clomipramine can cause urinary retention or hesitancy in the elderly, in which case the drug will need to be discontinued.
• Heart problems: People with pre-existing heart disease treated with clomipramine should have an ECG (electrocardiogram) before beginning treatment and at regular intervals during treatment, as it could cause some individuals to develop an irregular heartbeat.
If you are already taking anti-depressant medication, then don’t stop or change the dose on your own. The reason is that you might experience withdrawal symptoms from the antidepressant and it’s best to reduce such medication slowly. Whether you experience withdrawal symptoms or not is unpredictable. Many people do not experience any or only minor ones; a small minority have marked or severe symptoms that require careful reduction of their medication. Note that some doctors may refer to withdrawal symptoms as ‘discontinuation’, which is partly a euphemism to avoid the association with an addiction or dependence. However, it is now generally recognized that, for a few people, it is a type of addiction, as the stopping of the drug causes withdrawal symptoms and craving. The body finds it difficult to adapt if a drug is removed suddenly and it is therefore sensible to taper the dose gradually over several weeks. Withdrawal symptoms can be minimized or prevented if you are warned beforehand about how to manage the situation. Always discuss what you want with your doctor and plan things together. Do not be afraid to ask for a second opinion where necessary.
In most people, these withdrawal effects are mild. For a small number of people – and no-one can predict who they might be – the effects can be unpleasant if the medication is stopped suddenly. The speed at which the discontinuation of a drug causes withdrawal symptoms is related to how fast the drug is metabolized and leaves your system. Fluoxetine is the least likely of all SSRIs to cause withdrawal symptoms. This is because it breaks down very slowly and is in your body for up to five weeks after your last dose. If it does cause withdrawal symptoms, they tend to come on within two or three weeks of stopping it. The ‘worst’ drugs linked to withdrawal symptoms are venlafaxine (Efexor) and paroxetine (Seroxat, Paxil), which can cause symptoms on the same day you miss a dose. Sertraline (Zoloft) commonly causes withdrawal symptoms within two to three days.
Possible physical withdrawal symptoms can include the following:
• flu-like symptoms (aches, fever, sweats, chills, muscle cramps)
• gastroenteritis-like symptoms (nausea, vomiting, diarrhoea, abdominal pain or cramps)
• dizziness, spinning, feeling hungover, feeling unsteady
• headache, tremor
• sensory abnormalities (numbness, sensations that feel like electric shocks, abnormal visual sensations or smells, tinnitus).
The second group of symptoms that can occur are mainly psychological:
• depression (crying, deteriorating mood, fatigue, poor concentration, loss of appetite, suicidal thoughts/ attempts)
• anxiety-like symptoms (anxious, nervous, panicky mood)
• a preoccupation and distress with your appearance
• irritability (agitation, impulsivity, aggression)
• confusion, memory problems
• mood swings (elation, mania)
• hallucinations (auditory, visual)
• feelings of dissociation (detachment, unreality, nightmares).
Another problem is deciding whether symptoms that emerge on stopping medication are those of withdrawal or whether they are a relapse of depression. The following differences may help you and your doctor to tell.
Withdrawal symptoms come on relatively suddenly, within days or weeks of lowering or stopping an anti-depressant. Symptoms of relapse of depression usually occur within one or more months of stopping.
Physical symptoms such as feeling dizzy or light-headed, having flu-like aches, sweating, nausea, numbness, electric shocks and headaches are usually part of the withdrawal state. While some of these physical symptoms can occasionally occur in relapse of depression, they would have been part of the original symptoms you had, and you might recognize them as such.
Withdrawal symptoms peak within about seven to ten days and are usually gone within three weeks; by contrast, symptoms of a relapse of depression will persist and may get worse.
Withdrawal symptoms immediately improve when you restart the drug. Symptoms of relapse may continue or get worse and take several weeks to improve when you recommence an antidepressant.
The first step is to decide when to reduce the dose. This normally depends on whether you have been well for long enough and whether you are still vulnerable to relapse. Have you had an effective psychological therapy that can now protect you? The optimum rate of reduction of an anti-depressant to a standard dose is related to the type of drug. In general, each reduction should take place over a month.
The rate at which you reduce the drug depends on the nature of the drug, the dose you are taking and the severity of any withdrawal symptoms you experience. For example, paroxetine (Seroxat or Paxil) being prescribed at 20mg daily might be reduced to 10mg for one month. Each reduction would then guide the speed at which the medication is further reduced. If withdrawal symptoms emerge, you may have to slow down. For example:
• if you experience mild or no symptoms then you need not change the rate of reduction (e.g. paroxetine from 10mg to nothing)
• if you experience moderate withdrawal symptoms, the next reduction would be smaller (e.g. paroxetine from 10mg to 5mg)
• if you have severe withdrawal symptoms your doctor will probably restore the original dose and then start smaller dose reductions (e.g. paroxetine 20mg to 15mg for a month). If this results in no symptoms or mild symptoms, it could then be reduced to 12.5mg
Most withdrawal symptoms can be minimized by reducing the drugs slowly and this should be done under the guidance of your doctor. Some patients have been advised to take the drug on alternate days, but this does not make sense unless it is long-acting like fluoxetine. It is nearly always better to reduce the dose of an anti-depressant by a small amount on a daily basis. Further discussion on withdrawing from anti-depressants can be found in the very helpful book Coming Off Antidepressants (see Appendix 1, page 383).
To obtain smaller doses for a withdrawal program or to start at a lower dose, you can cut the tablets into smaller pieces. Alternatively, if you are simply unable to tolerate a tablet, you may find it easier to have your medication in the form of a liquid (elixir), and it can be easier to reduce the dose of a liquid by successively measuring a smaller amount. The drugs available in liquid form are listed in Table 14.1 (see page 344).
Most of the SSRIs and clomipramine are generally considered safe for pregnant women. However, as no manufacturer wants to be sued, they all recommend ‘caution’ and say that their product should not be used in pregnancy or breastfeeding. No mother wants to cause harm to her baby, but in general there are no significant problems. Fluoxetine, paroxetine, sertraline and clomipramine are the most studied in pregnancy or breastfeeding, so these are the most widely prescribed drugs for pregnant women. Animal and human studies suggest a very low risk but they are not fully conclusive. The risk of ‘spontaneous abortion’ may be very slightly higher than normal but the figures are difficult to interpret. Most doctors prefer to be cautious and therefore treat BDD or depression with a psychological treatment where pregnancy is possible or planned. However, if you or your doctor believe that medication is necessary (and depression commonly gets worse during pregnancy), or if you find a psychological approach difficult, it is nearly always better for you to be functioning as a mother than suffering from depression, whatever the precise risks involved. However, you should discuss this fully with your doctor, as there might be new evidence.
There are other options if you do not get better with two or more SSRIs or clomipramine, and these are best discussed with a psychiatrist. For example, there is some evidence for the benefits of combining different anti-depressant drugs (say, an SSRI such as citalopram with clomipramine). Sometimes a very high dose of a SSRI may be used. Alternatively, your doctor might recommend a different class of anti-depressant (for example, venlafaxine) or combining an SSRI with buspirone in BDD. Buspirone is an anti-anxiety drug.
Some doctors prescribe drugs for BDD that block dopamine receptors either alone or as an additional treatment to a SSRI. These are also known as anti-psychotic drugs and include olanzapine (Zyprexa), ziprasidone (Geodon), risperidone (Risperidal), aripiprazole (Abilify), haloperidol (Haldol), quetiapine (Seroquel), sulpiride, trifluoperazine, pimozide and chlorpromazine. Some anti-psychotics (especially olanzapine and to a lesser extent risperidone) are more likely to cause weight gain and sedation.
Dopamine-blocking drugs are normally used for treating psychosis and paranoia. There is no evidence for the benefit of dopamine-blocking drugs either alone or in combination with another drug in BDD. One study suggested that adding pimozide to people who have failed to respond to an SSRI did not make any difference compared with a placebo in BDD. Anti-psychoticsmay still be prescribed in the short term if you are very agitated or, for example, have tics or have more complex problems with paranoia.
In low doses, dopamine-blocking drugs may help to reduce anxiety and do not usually cause problems. The main side effect may be tiredness. Some anti-dopamine drugs cause weight gain and loss of libido. When dopamine blockers are prescribed in higher doses, they can have side effects such as stiffness in the limbs or slurred speech that can be countered by medication such as procyclidine. A small minority of women experience hormonal changes, such as stimulation of prolactin, which stops their periods.
With a very high dose or if you are especially sensitive, such drugs may cause abnormal movements such as a tremor and you might need other tablets to counteract these effects. In general, an anti-psychotic drug is not recommended in the long term for unipolar depression. At a higher dose it can emotionally numb you and prevent you from experiencing pleasure.
If you are already taking such medication, then please don’t stop or change the dose on your own. Always discuss your wishes with your doctor and plan things together. Do not be afraid to ask for a second opinion where necessary.
Tranquillizers are drugs that aim to reduce anxiety or have a sedative effect. The most common are a group of drugs called benzodiazepines (diazepam or Valium, nitrazepam, lorazepam, clonazepam). Others are prescribed for sleep. There is no evidence for their benefit in treating BDD.
Tranquillizers used to be prescribed very commonly in the past but are less used now because of the risks of addiction. They are used for managing severe agitation in depression in the short term. The main side effects are slower reaction times, so they should not be used if you operate machinery or drive. The main problem is of dependence, so that a sudden withdrawal can lead to a short-term increase in anxiety, insomnia, irritability, headaches and many other possible symptoms. Withdrawal from such drugs therefore needs to be managed carefully.
There is no evidence that ECT helps in BDD. It might very occasionally be recommended where the person with BDD has very severe depression that has not responded to medication or a psychological treatment.
There is no evidence for the benefit of neurosurgery in BDD. There have been a few cases with mixed reports in BDD but there are no controlled trials comparing surgery with a sham treatment. Neurosurgery is generally safe, but can be followed by some rare complications such as epilepsy, haemorrhage, persistent headaches or infections.
Other medical techniques are being researched but these are still purely experimental. One, known as deep brain stimulation, passes an electric current to electrodes implanted in the brain. Because the stimulator can be switched on and off, the effects are reversible. However, in our experience, when individuals with BDD raise the possibility of neurosurgery and deep brain stimulation, they are avoiding a great deal and this needs to be the focus of the therapy.